From the 2024 HVPA National Conference
Valerie Gavrila MPH (University of Michigan), Anthony Cuttitta MPH, Ruby Kazemi BA, Erin Kim BS, Alexis Antunez MD, MS, Lesly Dossett MD, MPH
Background:
Multiple national societies recommend against routine preoperative testing before low-risk surgery; however, it is still common-practice as demonstrated by various trials. Not only are unnecessary preoperative tests a waste of healthcare resources, but they can lead to false-positive results that delay operations, lead to a cascade of additional care, and rarely change the surgical plan.
Objective:
Prior claims data analysis identified our institution as a high utilizer of low-value tests. To address this, our team coordinated a multicomponent de-implementation strategy aim to decrease the ordering of unnecessary preoperative tests for three target surgeries: breast lumpectomy, inguinal hernia repair, and laparoscopic cholecystectomy.
Methods:
Utilizing prior ethnography work identifying barriers to reducing unnecessary preoperative testing, our team designed and deployed various de-implementation strategies over the course of an intervention period. These strategies included a provider-facing preoperative testing decision aid, facilitated discussions with stakeholder groups (preoperative physician assistants, surgeons, and anesthesiologists), and revisions to the electronic medical record to streamline pre-operative ordering. We conducted a chart review of patients undergoing one of three low-risk surgeries to determine the use of preoperative testing before and after the intervention. Testing appropriateness was determined via ASA class, comorbidities, and testing recommendations. Overall testing rates and testing appropriateness were measured. Testing rates were analyzed as a proportion of operations performed, as well as by appropriateness within a given type of test. An interrupted time series analysis accounted for patient age, sex, operation, and ASA class, as well as existing trends in testing appropriateness over time.
Results:
Preoperative testing for a total of 1,143 low-risk surgeries were reviewed. A significant decrease in the use of preoperative testing was detected in the data after the intervention period as evidenced from overall testing rates falling from 51.3% to 27.4%. The proportion of patients receiving any unnecessary test decreased significantly after the intervention period, from 36.8% (N=96) to 14.0% (N=52, p<0.001 on chi square test).
Prior to the de-implementation strategy, 72.2% of patients received an inappropriate CBC, while afterwards this proportion decreased to 56.4% (N=31). Rates of unnecessary BMP and EKG saw similar decreases, 60.2% to 45.3%, and 52.5% to 44.7%, respectively. Safety data were also reviewed for this cohort of patients and it was found that there was no increase in seven-day emergency department visits nor in 30-day readmission rates. This increase in testing appropriateness remained significant when accounting for patient factors and temporal testing trends (Figure 1).
Conclusion:
This evaluation of a multicomponent de-implementation strategy demonstrates a successful decrease in unnecessary preoperative testing prior to three low-risk operations without any adverse impact on patient safety. This modifiability of the gap between evidenced based practices and real-world application highlights the need for targeted quality improvement efforts to translate guidelines into common practice. Convening all stakeholders (anesthesiology, surgery, and preoperative clinic staff) for discussion and consensus on patient risk level and appropriate tests achieved measurable improvement in rates of unnecessary testing.
Clinical Implications:
Aligning national guidelines to local practice patterns have an effect on multiple stakeholder levels. Patients are not subjected to unnecessary tests that could lead to care cascades causing inconvenience, undue stress, and potential iatrogenic harm. For the clinicians and the institution, decreasing unnecessary testing has the potential to increase efficiency of the preoperative process in a safe manner and contributes to overall resource and healthcare savings.