Development of strategies to de-implement low-value pre-operative testing: the use of a research-practice partnership as a model to design & deliver high-value care

From the 2023 HVPA National Conference

Anthony Cuttitta MPH (Michigan Medicine), Caroline Richburg BS, Cecilia Pesavento MBA, Alexis Antunez MD, Valerie Gavrila MPH, Shawna Smith PhD, Lesly Dossett MD, MPH

Background:
De-implementation of low-value care represents an opportunity to reduce patient burden, re-purpose limited clinician time, and increase healthcare system efficiency. This is particularly true in the pre-operative space, where testing utilization is highly variable across providers, does not prevent adverse events, and can lead to burdensome care cascades & financial waste. Despite recommendations to avoid it, unnecessary testing remains common and de-implementation efforts have been limited.

Objective:
This research-practice partnership applied research methods to the development of a multi-component quality improvement intervention to de-implement low-value pre-operative tests before three low-risk surgeries (lumpectomy, inguinal hernia repair, and laparoscopic cholecystectomy). The goal was to intervene first at a single hospital, creating tools that could be expanded to additional low-risk surgeries and at additional hospital sites.

Methods:
This model employed multiple information gathering methods to inform intervention design (Figure 1). First, clinician input was gathered regarding current pre-operative testing practices. Second, common pre-operative tests (CBCs, BMP/CMPs, EKGs) and low-risk surgeries (lumpectomy, inguinal hernia repair, laparoscopic cholecystectomy) were identified as candidates for intervention. Third, statewide claims data was analyzed to assess testing utilization & variation. Fourth, research methods were used to gain knowledge of practice patterns; methods included an ethnographic study that engaged 30 clinicians and a medical chart review that assessed testing appropriateness. Fifth, the intervention was designed based on these learnings, available data, identification of Tailored Implementation in Chronic Diseases (TICD) factors, implementation mapping to align strategies with barriers, and the creation of tools & resources.

Results:
Analyses of statewide utilization data & clinician input confirmed low-value pre-operative testing before the three target procedures was common. The ethnographic study identified three themes: 1) Shared Values of patient safety and utilizing evidence-based medicine (TICD Social, Political, and Legal Factors), 2) Gaps in Knowledge (TICD Individual Health Professional Factors, Guideline Factors), and 3) Communication Breakdown (TICD Professional Interactions, Incentives and Resources, Capacity for Organizational Change). The chart review found a large proportion of pre-operative tests to be low-value: 69% of CBCs, 59% of BMP/CMPs, and 43% of EKGs were unnecessary. The comprehensive & strategic intervention design based on learnings & data led to a multi-component intervention, including: detailed testing guidelines, provider education, coordination across clinicians/stakeholders, and the potential for peer led audit & feedback among any providers who continue to order low-value tests. Figure 2 summarizes results.

Conclusions:
De-implementation of low-value pre-operative testing before low-risk surgery continues to present an opportunity to improve the value of care. Research-practice partnerships facilitate collaborative alignment of local quality improvement efforts with more robust analytical concepts & implementation science strategies. Clinical Implications

Specifically, this intervention has the potential to significantly reduce the rate of low-value pre-operative testing before low-risk surgery. The scalability potential is high, as the tools, collaboration, & practice improvement developed here can be easily applied to a) additional low-risk surgeries at the local site, and b) additional hospital facilities.

Generally, when established strategically, research-practice partnerships maximize the impact of both small & large scope de-implementation interventions. Locally, the research & implementation science methods enhance quality improvement efforts through background research, enhanced learnings about practice patterns, and the identification of barriers, determinants, & strategies defined by implementation science (that increase the likelihood of designing effective interventions). When considering broader implementation, the practice perspective provides local knowledge to help more efficiently adapt spread to other sites.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog