Behavioral Intervention for Preoperative Care in Surgery

(Pre-Op Trial)

Recruiting at 3 trial locations

Overseen By Andrea Patey, PhD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Ottawa Hospital Research Institute

Disqualifiers: Emergency elective chest X-rays, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Approved in 1 Jurisdiction This treatment is already approved in other countries

Compensation: Varies

Number of Visits: Unknown

22 Participants Needed

Trial Summary

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications.

What data supports the effectiveness of the treatment Reducing preoperative low-value test ordering?

Research shows that reducing unnecessary preoperative tests can save significant healthcare costs without negatively impacting patient care. For example, one study found that eliminating unwarranted tests saved over $320 million annually, suggesting that minimizing low-value tests can be both cost-effective and safe for patients. ^{1 2 3 4 5}

Is the behavioral intervention for reducing unnecessary preoperative tests safe for humans?

The research does not provide specific safety data for the behavioral intervention itself, but it focuses on reducing unnecessary preoperative tests, which are generally considered low-value and not harmful. The intervention aims to improve care quality and reduce waste without introducing new risks. ^{1 4 6 7 8}

How is the treatment for reducing preoperative low-value test ordering different from other treatments?

This treatment is unique because it focuses on changing surgeons' behavior to reduce unnecessary preoperative tests, which are often costly and provide little benefit. Unlike other treatments that might involve medications or procedures, this approach aims to improve decision-making and adherence to guidelines, ultimately reducing waste and improving care quality. ^{1 2 9 10 11}

What is the purpose of this trial?

The purpose of this study is to evaluate if a multi-component behavioral intervention given to anesthesiologists and surgeons is associated with decreasing low value preoperative testing orders in patients undergoing low risk surgery. The objectives of this trial are to evaluate a) the overall rate of low-value preoperative test (electrocardiogram and chest X-ray) in patients undergoing low risk surgery, b) to conduct an economic and c) process evaluation of the implementation The investigators will assess these outcomes in a sample of 22 Hospitals in Ontario, Canada.

Research Team

Jeremy Grimshaw, PhD

Principal Investigator

Ottawa Hospital Research Institute

Kyle Kirkham, MD

Principal Investigator

Department of Anaesthesia, Toronto Western Hospital, University of Toronto

Eligibility Criteria

This trial is for hospitals in Ontario, Canada that frequently order routine preoperative tests and patients aged 18 or older undergoing low-risk surgeries like endoscopy, eye surgery, knee arthroscopy, or hernia repair. Hospitals with emergency elective chest X-rays and/or electrocardiograms are excluded.

Inclusion Criteria

Cluster Level: Hospitals in Ontario, Canada within the 26-100th centile for routine preoperative tests for 2019

I am 18 or older and having a low-risk surgery like endoscopy or hernia repair.

Exclusion Criteria

I am scheduled for an urgent chest X-ray or ECG.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Intervention

A multi-behaviour technique will be used along with theoretical domains framework to increase accountability for preoperative test ordering in patients having low risk surgeries.

6 months

Evaluation

Evaluation of the theory-informed intervention to determine if preoperative testing ordered by anesthesiologist can decrease the use of low-value preoperative tests.

1 month

Follow-up

Participants are monitored for safety and effectiveness after the intervention.

30 days

Treatment Details

Interventions

• Reducing preoperative low-value test ordering

Trial Overview The study is testing a behavioral intervention aimed at anesthesiologists and surgeons to see if it reduces unnecessary preoperative tests (like ECGs and chest X-rays) in patients having low-risk surgeries. It's being conducted across 22 hospitals.

Participant Groups

Group I: De-implementation Experimental Treatment 1 Intervention

A multi-behaviour technique will be used along with theoretical domains framework. Clinicians will be provided with continuing multi-behaviour component intervention to increase accountability for preoperative test ordering in patients having low risk surgeries.

Group II: Comparator Active Control 1 Intervention

Standard of care

Reducing preoperative low-value test ordering is already approved in Canada for the following indications:

Approved in Canada as Preoperative Test Reduction Strategy for:

• Reduction of low-value preoperative tests in low-risk surgeries

Who Is Running the Clinical Trial?

Ottawa Hospital Research Institute

Lead Sponsor

Trials

585

Recruited

3,283,000+

Canadian Institutes of Health Research (CIHR)

Collaborator

Trials

1,417

Recruited

26,550,000+

Findings from Research

The 2002 professional guidance on routine preoperative testing led to a significant decrease in the use of electrocardiograms (EKGs) during preoperative visits, dropping from 19.4% to 14.3% between 1997-2002 and 2003-2010, indicating a positive shift towards more appropriate testing practices.

Despite the guidance, there were no significant changes in the use of other routine tests like plain radiography, hematocrit, urinalysis, or cardiac stress testing, suggesting that further efforts are needed to improve adherence to guidelines and reduce unnecessary preoperative testing.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Use of Preoperative Testing and Physicians' Response to Professional Society Guidance. Sigmund, AE., Stevens, ER., Blitz, JD., et al.[2022]

A review of 1,402 women undergoing gynecologic surgery revealed that while 95% adhered to guideline-recommended preoperative tests, 90% also received at least one unnecessary test, indicating poor adherence to evidence-based recommendations.

Inappropriate preoperative testing resulted in over $418,000 in unnecessary healthcare costs, with many tests showing abnormalities that rarely influenced patient management.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Adherence to evidence-based guidelines for preoperative testing in women undergoing gynecologic surgery. St Clair, CM., Shah, M., Diver, EJ., et al.[2021]

The study reviewed 2,093 medical records and found that the ordering of unwarranted preoperative tests decreased from 32.2% to 25.9% between 1979 and 1987, indicating a 19.6% reduction in unnecessary testing.

However, there was also a concerning decrease in medically indicated tests, from 92.9% to 80.9%, suggesting that while some unnecessary tests were eliminated, the overall approach to preoperative testing may need improvement to ensure patient safety and health benefits.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Reassessment of preoperative laboratory testing has changed the test-ordering patterns of physicians. Macario, A., Roizen, MF., Thisted, RA., et al.[2015]

A study involving 30 healthcare professionals identified that unnecessary preoperative testing before low-risk surgeries is influenced by shared values prioritizing patient safety, knowledge gaps about testing guidelines, and communication breakdowns among interdisciplinary teams.

Addressing these knowledge gaps and improving communication through consensus guidelines could help reduce unnecessary testing and align practices with evidence-based recommendations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Targets for De-implementation of Unnecessary Testing Before Low-Risk Surgery: A Qualitative Study. Richburg, CE., Pesavento, CM., Vastardis, A., et al.[2023]

About 60% of preoperative tests are unnecessary and can be eliminated without harming patient care, which can reduce risks and costs associated with surgery.

Unnecessary testing can lead to false-positive results, increased medicolegal risks, and inefficient use of operating room time, highlighting the need for a more effective method of ordering preoperative tests.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Preoperative laboratory testing for the oral and maxillofacial surgery patient. Wagner, JD., Moore, DL.[2019]

A qualitative study involving 35 perioperative clinicians from 29 Veterans Health Administration facilities identified effective strategies to reduce unnecessary preoperative testing for low-risk surgeries, such as building consensus among stakeholders and using evidence-based education.

Successful institutions implemented innovative care delivery methods, like pre-screening evaluations and dedicated preoperative clinics, to streamline the testing process and improve overall efficiency in patient care.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing. Harris, AHS., Finlay, AK., Hagedorn, HJ., et al.[2023]

The implementation of a Nurse Practitioner and Physician Assistant clinic for preoperative evaluations significantly reduced unnecessary testing rates from 36% to 4% within 3 months, demonstrating improved efficiency in the assessment process.

Despite the success of the dedicated preoperative clinic, overall testing rates in the General Internal Medicine division did not show significant change, indicating that broader systemic factors may need to be addressed for widespread improvement.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Choosing Wisely: A Quality Improvement Initiative to Decrease Unnecessary Preoperative Testing. Matulis, J., Liu, S., Mecchella, J., et al.[2020]

In a study of 906,902 patients undergoing low-risk surgeries in Ontario, 30.1% had preoperative blood work, with significant variation in testing rates across institutions (0.0% to 98.1%).

Factors such as atrial fibrillation, preoperative medical consultations, previous mitral valve replacements, and liver disease were strong predictors for preoperative testing, indicating that clinical history significantly influences testing practices.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Preoperative Laboratory Investigations: Rates and Variability Prior to Low-risk Surgical Procedures. Kirkham, KR., Wijeysundera, DN., Pendrith, C., et al.[2022]

Over 50% of patients undergoing surgery had at least one unnecessary preoperative test, indicating a persistent issue despite previous efforts to reduce such testing.

Anesthesiologists were significantly less likely to order unnecessary tests compared to surgeons, suggesting that involving anesthesiologists in the preoperative testing process could help reduce unnecessary procedures.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Survey study of anesthesiologists' and surgeons' ordering of unnecessary preoperative laboratory tests. Katz, RI., Dexter, F., Rosenfeld, K., et al.[2011]

A scoping review of 1460 articles identified 17 studies that tested behavioral interventions aimed at improving surgeons' preoperative decision-making, highlighting a small but growing field focused on reducing low-value surgical care.

The review found that effective strategies often included multidisciplinary preoperative conferences and clinical decision support tools, primarily targeting knowledge gaps and enhancing communication among providers.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Behavioral Interventions on Surgeons' Preoperative Decision-Making: A Scoping Review and Critical Analysis. Antunez, AG., Rowe, KA., Bain, PA., et al.[2023]

A scoping review of 11 studies identified that low-value care in low-risk preoperative settings often includes unnecessary screening tests for asymptomatic patients, which can lead to false positives and psychological distress.

The review highlights the need to redefine low-value care in preoperative contexts to reduce unnecessary costs and delays in surgery, paving the way for improved surgical care pathways.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Definition of low-value care in a low-risk preoperative population: A scoping review. F John, J., B S Etges, AP., A Z Marcolino, M., et al.[2023]

References

1. United States pubmed.ncbi.nlm.nih.gov

Use of Preoperative Testing and Physicians' Response to Professional Society Guidance. [2022]

2. United States pubmed.ncbi.nlm.nih.gov

Adherence to evidence-based guidelines for preoperative testing in women undergoing gynecologic surgery. [2021]

3. United States pubmed.ncbi.nlm.nih.gov

Reassessment of preoperative laboratory testing has changed the test-ordering patterns of physicians. [2015]

4. United States pubmed.ncbi.nlm.nih.gov

Targets for De-implementation of Unnecessary Testing Before Low-Risk Surgery: A Qualitative Study. [2023]

5. United States pubmed.ncbi.nlm.nih.gov

Preoperative laboratory testing for the oral and maxillofacial surgery patient. [2019]

6. United States pubmed.ncbi.nlm.nih.gov

Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing. [2023]

7. England pubmed.ncbi.nlm.nih.gov

Choosing Wisely: A Quality Improvement Initiative to Decrease Unnecessary Preoperative Testing. [2020]

8. United States pubmed.ncbi.nlm.nih.gov

Preoperative Laboratory Investigations: Rates and Variability Prior to Low-risk Surgical Procedures. [2022]

9. United States pubmed.ncbi.nlm.nih.gov

Survey study of anesthesiologists' and surgeons' ordering of unnecessary preoperative laboratory tests. [2011]

10. United States pubmed.ncbi.nlm.nih.gov

Behavioral Interventions on Surgeons' Preoperative Decision-Making: A Scoping Review and Critical Analysis. [2023]

11. England pubmed.ncbi.nlm.nih.gov

Definition of low-value care in a low-risk preoperative population: A scoping review. [2023]