Over‐ordering of ultrasound and pre‐operative investigations for inguinal hernia repair at Northern Health: a Choosing Wisely audit

• Published in: ANZ journal of surgery 2019-12, Vol.89 (12), p.1626-1630
• Main Authors: Chmiel, Edward, Pearson, Kristen, Mori, Krinal
• Format: Article
• Language: English
• Subjects: Blood; Coagulation; Creatinine; EKG; Electrocardiography; Electrolytes; Guidelines; Health; Hernia; Hernias; Indication; inguinal hernia; Signs and symptoms; Surgery; Ultrasonic imaging; Ultrasound; Urea; Ureas
• ISSN: 1445-1433; 1445-2197
• DOI: 10.1111/ans.15495

Background Choosing Wisely Australia is an initiative aimed at reducing the incidence of unnecessary investigations. This study is an audit of Northern Health's adherence to two Choosing Wisely recommendations in the context of inguinal hernia repair. Recommendation 1: Avoid routinely performing pre‐operative investigations in patients, but instead order in response to patient factors, signs and symptoms, disease or planned surgery. Recommendation 2: Do not order ultrasound for clinically apparent inguinal hernias. Methods Records of 264 patients who underwent elective inguinal hernia repair at Northern Health in 2016 were reviewed. Results Recommendation 1: Results demonstrated over‐ordering of coagulation studies. Thirty‐four percent of patients received coagulation studies, 86% of which were unindicated. There was better adherence to Choosing Wisely guidelines for other investigations: 38% of patients received a full blood examination (42% unindicated), 38% received a urea, electrolytes and creatinine (14% unindicated), 7% received a glycated haemaglobin (0% unindicated) and 38% received an electrocardiogram (11% unindicated). Recommendation 2: Seventy percent (n = 186) of patients received an ultrasound of which 25% (n = 46) had a documented indication. Correlation with surgical findings showed a positive predictive value of 95.6% and sensitivity of 97.8% for ultrasound. Conclusion Recommendation 1: Most pre‐operative coagulation studies were unindicated, while adherence to Choosing Wisely guidelines was better for pre‐operative full blood examination, urea, electrolytes and creatinine, glycated haemaglobin and electrocardiogram. Recommendation 2: The majority of patients received an inguinal hernia ultrasound, most of which had no documented indication. This article examines the incidence of non‐indicated inguinal hernia ultrasounds and pre‐operative investigations before elective inguinal hernia repair at a single health institution. The study found significant over‐ordering of hernia ultrasound and coagulation studies prior to inguinal hernia repair.