Barriers to reducing preoperative testing for low-risk surgical procedures: A qualitative assessment guided by the Theoretical Domains Framework

Abstract

Introduction While numerous guidelines do not recommend preoperative tests for low risk patients undergoing low risk surgeries, they are often routinely performed. Canadian data suggests preoperative tests (e.g. ECGs and chest x-rays) preceded 17.9%-35.5% of low-risk procedures. Translating guidelines into clinical practice can be challenging and it is important to understand what is driving behaviour when developing interventions to change it. Aim Thus, we completed a theory-based investigation of the perceived barriers and enablers to reducing unnecessary preoperative tests for low-risk surgical procedures in Newfoundland, Canada. Method We used snowball sampling to recruit surgeons, anaesthesiologists, or preoperative clinic nurses. Interviews were conducted by two researchers using an interview guide with 31 questions based on the theoretical domains framework. Data was transcribed and coded into the 14 theoretical domains and then themes were identified for each domain. Results We interviewed 17 surgeons, anaesthesiologists, or preoperative clinic nurses with 1 to 34 years’ experience. Overall, while respondents agreed with the guidelines they described several factors, across seven relevant theoretical domains, that influence whether tests are ordered. The most common included uncertainty about who is responsible for test ordering, inability to access patient records or to consult/communicate with colleagues about ordering decisions and worry about surgery delays/cancellation if tests are not ordered. Other factors included workplace norms that conflicted with guidelines and concerns about missing something serious or litigation. In terms of enablers, respondents believed that clear institutional guidelines including who is responsible for test ordering and information about the risk of missing something serious, supported by improved communication between those involved in the ordering process and periodic evaluation will reduce any unnecessary preoperative testing. Conclusion These findings suggest that both health system and health provider factors need to be addressed in an intervention to reduce pre-operative testing.

Definition of low‐value care in a low‐risk preoperative population: A scoping review

“…This detailed definition complements the currently existing, general LVC definition but also considers the specificities and complexity of preoperative care. 5,13,16,25,35 There is a consensus among the included studies that routine preoperative tests represent a major example of LVC in the preoperative setting. 6,8,18 The consequences reported have a wide spectrum of both clinical and nonclinical implications, mostly represented by false-positive results from tests, psychological distress to the patient, surgical delays, and added costs.…”

“…9,10,14,15 The most challenging obstacles to eliminating LVC are cultural behaviours and economic interests. 13,39,40 Several important research questions have emerged during this scoping review. For example, what are the reasons why LVC in the preoperative field continues to result in waste?…”

“…Through a scoping review of theoretical studies, we summarized various definitions of LVC from different studies into a more personalised definition of preoperative LVC for low‐risk procedures and described their possible LVC clinical and nonclinical consequences. This detailed definition complements the currently existing, general LVC definition but also considers the specificities and complexity of preoperative care 5,13,16,25,35 …”

“…[10][11][12] This period is complex and presents a variety of situations and interpretations that may or may not be considered LVC and that need to be detailed. 3,5,13,14 LVC in the preoperative setting has many gaps: there is a few studies with the types of services and/or care beyond preoperative exams that do not add value; it is unknown whether this care positively or negatively impacts clinical outcomes in patients with intermediate or high-risk surgery; the scientific evidence at this moment is not comprehensive enough for LVC in this field and this problem has seen only moderate improvements over the last few decades. 10,[13][14][15][16][17][18][19] Given this knowledge gap, a deeper understanding of how conceptual studies defined and described the consequences setting associated with LVC in preoperative of low-risk surgeries can be the first step to discuss this topic from different points of view and promote high-value care.…”

“…Furthermore, this generic definition needs to be detailed in the preoperative field to guide the de‐implementation of LVC 10‐12 . This period is complex and presents a variety of situations and interpretations that may or may not be considered LVC and that need to be detailed 3,5,13,14 . LVC in the preoperative setting has many gaps: there is a few studies with the types of services and/or care beyond preoperative exams that do not add value; it is unknown whether this care positively or negatively impacts clinical outcomes in patients with intermediate or high‐risk surgery; the scientific evidence at this moment is not comprehensive enough for LVC in this field and this problem has seen only moderate improvements over the last few decades 10,13‐19 …”