Overuse in surgery by deviation from the “Choosing Wisely” campaign recommendations: a surrogate of unnecessary surgery and low-value care

BACKGROUND: Inappropriate health care reduces the quality of care and efficiency of the health system. The goal of this study was to analyze the frequency of overuse of five surgical procedures while also determining the epidemiological characteristics of both patients and interventions. METHODS: This is a retrospective observational cohort study performed in a tertiary referral center in Spain. Surgical Overuse was analyzed according to five "Choosing Wisely" recommendations related to both interventions and perioperative care. The association between overuse and the characteristics of patients and procedures was assessed by bivariate and multivariate predictive analysis. Costs were calculated for each clinical episode using data from the hospital's accounting department; total hospitalization costs from the index procedure to hospital discharge were used for intervention-related overuse, and average unit cost for perioperative practices. RESULTS: A total of 895 clinical episodes were analyzed over one year. Low-value surgery was identified in 9.7% (N: 87; 95% CI: 7.9 to 11.9). Specifically, overuse was identified in 59.6% (53 out of 89; 48.6 to 69.7)) of the echocardiograms performed after valve replacement, 15.7% (26 out of 166; 10.6 to 22.3) of podiatric surgeries, and 2.0% (8 out of 400; 0.9 to 4.1) of cholecystectomies for asymptomatic cholelithiasis. No overuse was found among Mohs surgeries or in the perioperative use of opioids for pediatric patients. The risk of overuse was higher in patients with the following characteristics: increased age (OR [95% CI]: 1.1 [1.1 to 1.2] for each additional year); ≥1 intrinsic risk factor (IRF) (3.5 [1.5 to 8.0] versus absence of IRF); and hospitalized patients (12.8 [4.5 to 37.1] versus ambulatory surgery). Overuse represented an overall cost of €86,858.05. CONCLUSION: Applying five "Choosing Wisely" recommendations, low-value surgical practices were identified, mainly involving echocardiograms after valve replacement, podiatric surgery, and cholecystectomies. Such practices were more frequent among older and hospitalized patients and were associated with direct economic costs.