Behavioral Intervention for Preoperative Care in Surgery

(Pre-Op Trial)

Not currently 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

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial explores whether a special program for doctors can reduce unnecessary medical tests before certain low-risk surgeries. Tests like electrocardiograms and chest X-rays often don't add value for surgeries such as endoscopies or hernia repairs. The researchers aim to determine if fewer tests can save money and streamline processes in hospitals across Ontario, Canada. Patients scheduled for low-risk procedures, such as knee arthroscopy or eye surgery, might participate in this research. This approach is called "Reducing preoperative low-value test ordering." As an unphased study, this trial allows patients to contribute to improving healthcare efficiency and reducing unnecessary procedures.

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 prior data suggests that this behavioral intervention is safe for preoperative care?

Research shows that reducing unnecessary pre-surgery tests, such as ECGs and chest X-rays, can be safe and effective. Studies have found that educating surgeons and aligning healthcare teams on best practices reduces these unneeded tests before low-risk surgeries.

Previous research has not identified any major safety concerns with these methods. Instead, they aim to improve care quality and reduce unnecessary medical procedures. As a result, the treatment is generally well-tolerated, with few to no side effects reported. Therefore, participating in a trial like this one likely poses minimal risk to participants. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about this trial because it explores a behavioral intervention aimed at reducing unnecessary preoperative tests for patients undergoing low-risk surgeries. Unlike typical protocols that may not scrutinize the necessity of each test, this trial uses a multi-behavior technique and the theoretical domains framework to increase accountability among clinicians. By potentially reducing low-value test ordering, the intervention could streamline preoperative care, minimize patient stress, and cut healthcare costs without compromising safety.

What evidence suggests that this behavioral intervention is effective for reducing low-value preoperative tests?

This trial will compare a behavioral intervention aimed at reducing preoperative low-value test ordering with standard care. Research has shown that reducing unnecessary pre-surgery tests, such as heart and chest exams, is effective. One study found that educating surgeons reduced these low-value tests by about 40%. Another project with a similar approach demonstrated that these tests often don't improve patient care. These findings suggest that when surgeons and anesthesiologists change their habits, they can significantly reduce unnecessary testing. By focusing on responsibility and making informed choices, the use of these tests can be minimized in low-risk surgeries. ^{1 2 3 4 6}

Who Is on the 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

Are You a Good Fit for This Trial?

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 for a Trial Participant

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

What Are the Treatments Tested in This Trial?

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.

How Is the Trial Designed?

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+

Published Research Related to This Trial

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]

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]

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 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 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 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]

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]

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]

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]

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]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC10651557/

Identifying Strategies to Reduce Low-Value Preoperative ... Studies of strategies to reduce low-value screening and testing outside the preoperative setting suggest other possible ideas worth considering.

2. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/37407767/

Identifying Strategies to Reduce Low-Value Preoperative ... Conclusions: We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions ...

3. facs.org facs.org/for-medical-professionals/news-publications/news-and-articles/acs-brief/january-28-2025-issue/low-value-preoperative-testing-can-be-reduced-with-deimplementation-strategy/

Low-Value Preoperative Testing Can be Reduced with ... This study described a before and after multicomponent quality improvement initiative designed to educate surgeons and reduce preoperative testing.

4. bcbsm.mibluedaily.com bcbsm.mibluedaily.com/stories/affordabilitycontent/reducing-tests-that-don-t-add-value-to-health-care

Reducing Tests That Don't Add Value to Health Care A pilot program cut unnecessary preoperative testing in low-risk surgeries by about 40%, showing that routine labs, EKGs and imaging often add ...

5. researchgate.net researchgate.net/publication/372154208_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

Identifying Strategies to Reduce Low-Value Preoperative ... Conclusions: We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to ...

6. hvpaa.org hvpaa.org/de-implementing-low-value-preoperative-testing-prior-to-low-risk-operations-results-from-a-multicomponent-intervention/

De-implementing low-value preoperative testing prior to ... To address this, our team coordinated a multicomponent de-implementation strategy aim to decrease the ordering of unnecessary preoperative tests for three ...