Surgeons' views on preoperative medical evaluation: a qualitative study

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

INTRODUCTION

Despite multispecialty recommendations to avoid routine preoperative testing before low-risk surgery, the practice remains common and de-implementation has proven difficult. The goal of this study as to elicit determinants of unnecessary testing before low-risk surgery to inform de-implementation efforts.

METHODS

We conducted focused ethnography at a large academic institution, including semi-structured interviews and direct observations at two preoperative evaluation clinics and one outpatient surgery center. Themes were identified through narrative thematic analysis and mapped to a comprehensive and integrated checklist of determinants of practice, the Tailored Implementation for Chronic Diseases framework (TICD).

RESULTS

Thirty individuals participated (surgeons, anesthesiologists, primary care physicians, physician assistants, nurses, and medical assistants). Three themes were identified: (1) Shared Values (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). Shared Values describe core tenets expressed by all groups of clinicians, namely prioritizing patient safety and utilizing evidence-based medicine. Clinicians had Gaps in Knowledge related to existing data and preoperative testing recommendations. Communication Breakdowns within interdisciplinary teams resulted in unnecessary testing ordered to meet perceived expectations of other providers.

CONCLUSIONS

Clinicians have knowledge gaps related to preoperative testing recommendations and may be amenable to de-implementation efforts and educational interventions. Consensus guidelines may streamline interdisciplinary communication by clarifying interdisciplinary needs and reducing testing ordered to meet perceived expectations of other clinicians.

Development and Validation of an Electronic Health Record-based Score for Triage to Perioperative Medicine

OBJECTIVE

To develop an electronic health record-based risk model for perioperative medicine (POM) triage and compare this model with legacy triage practices that were based on clinician assessment.

SUMMARY OF BACKGROUND DATA

POM clinicians seek to address the increasingly complex medical needs of patients prior to scheduled surgery. Identifying which patients might derive the most benefit from evaluation is challenging.

METHODS

Elective surgical cases performed within a health system 2014- 2019 (N = 470,727) were used to develop a predictive score, called the Comorbidity Assessment for Surgical Triage (CAST) score, using split validation. CAST incorporates patient and surgical case characteristics to predict the risk of 30-day post-operative morbidity, defined as a composite of mortality and major NSQIP complications. Thresholds of CAST were then selected to define risk groups, which correspond with triage to POM appointments of different durations and modalities. The predictive discrimination CAST score was compared with the surgeon's assessments of patient complexity and the American Society of Anesthesiologists class.

RESULTS

The CAST score demonstrated a significantly higher discrimination for predicting post-operative morbidity (area under the receiver operating characteristic curve 0.75) than the surgeon's complexity designation (0.63; P < 0.001) or the American Society of Anesthesiologists (0.65; P < 0.001) ( Fig. 1 ). Incorporating the complexity designation in the CAST model did not significantly alter the discrimination (0.75; P = 0.098). Compared with the complexity designation, classification based on CAST score groups resulted a net reclassification improvement index of 10.4% ( P < 0.001) ( Table 1 ).

CONCLUSION

A parsimonious electronic health record-based predictive model demonstrates improved performance for identifying pre-surgical patients who are at risk than previously-used assessments for POM triage.

Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis

BACKGROUND

Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use.

QUESTIONS/PURPOSES

(1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not?

METHODS

In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use.

RESULTS

When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually.

CONCLUSION

Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Hospital doctors' attitudes to brief educational messages that aim to modify diagnostic test requests: a qualitative study

Background

Avoidable use of diagnostic tests can both harm patients and increase the cost of healthcare. Nudge-type educational interventions have potential to modify clinician behaviour while respecting clinical autonomy and responsibility, but there is little evidence how this approach may be best used in a healthcare setting. This study aims to explore attitudes of hospital doctors to two nudge-type messages: one concerning potential future cancer risk after receiving a CT scan, another about the financial costs of blood tests.

Methods

We added two brief educational messages to diagnostic test results in a UK hospital for one year. One message on the associated long-term potential cancer risk from ionising radiation imaging to CT scan reports, and a second on the financial costs incurred to common blood test results. We conducted a qualitative study involving telephone interviews with doctors working at the hospital to identify themes explaining their response to the intervention.

Results

Twenty eight doctors were interviewed. Themes showed doctors found the intervention to be highly acceptable, as the group had a high awareness of the need to prevent harm and optimise use of finite resources, and most found the nudge-type approach to be inoffensive and harmless. However, the messages were not seen as personally relevant because doctors felt they were already relatively conservative in their use of tests.

Cancer risk was important in decision-making but was not considered to represent new knowledge to doctors. Conversely, financial costs were considered to be novel information that was unimportant in decision-making. Defensive medicine was commonly cited as a barrier to individual behaviour change. The educational cancer risk message on CT scan reports increased doctors’ confidence to challenge decisions and explain risks to patients and there were some modifications in clinical practice prompted by the financial cost message.

Conclusion

The nudge-type approach to target avoidable use of tests was acceptable to hospital doctors but there were barriers to behaviour change. There was evidence doctors perceived this cheap and light-touch method can contribute to culture change and form a foundation for more comprehensive educational efforts to modify behaviour in a healthcare environment.

Surgeons' Views on Shared Decision-Making

PURPOSE

Shared decision-making (SDM) has a significant role in surgical encounters, where decisions are influenced by both clinician and patient preferences. Herein, we sought to explore surgeons' practices and beliefs about SDM.

METHODS

We performed a qualitative study consisting of semi-structured individual interviews with 18 surgeons from private practice and academic surgery practices in Baltimore, Maryland. We purposively sampled participants to maximize diversity of practice type (academic vs private), surgical specialty, gender, and experience level. Interview topics included benefits and challenges to patient involvement in decision-making, communicating uncertainty to patients, and use of decision aids. Interviews were audio-recorded and transcribed. Transcripts were analyzed using content analysis to identify themes.

RESULTS

Surgeons were supportive of patients being involved in decision-making, particularly in cases with uncertainty about treatment options. However, surgeons identified SDM as being more appropriate for patients whom surgeons perceived as interested in decision-making involvement and for decisions in which surgeons did not have strong preferences. Additionally, surgeons reported typically presenting only a subset of available options, remaining confident in their ability to filter less suitable options based on intuitive risk assessments. Surgeons differed in their approach to making recommendations, with some guiding patients towards what they saw as the correct or optimal decision while others sought to maintain neutrality and support of the patients' chosen decision.

CONCLUSIONS

Many surgeons do not believe SDM is universally optimal for every surgical decision. They instead use assessments of patient disposition or potential clinical uncertainty to guide their perceived appropriateness of using SDM.

Factors influencing day surgery patients' quality of postoperative recovery and satisfaction with recovery: a narrative review

The aim of healthcare services is to provide a high quality of care. One way to ensure that this aim has been fulfilled is to assess patients' satisfaction with their care. Although satisfaction is a complex concept, it is an important outcome in perioperative care. The objective of this paper is to discuss and reflect on factors that can affect patients' quality of postoperative recovery and satisfaction with recovery after day surgery. Involving patients in shared decision-making (SDM) and providing sufficient preoperative and postoperative information can improve their satisfaction. It is important to assess whether patients experience poor recovery, which can be both distressing and dissatisfying. We suggest that patients' age, sex, mental health status, and health literacy (HL) skills should be assessed preoperatively, since these factors seem to have a negative impact on patients' postoperative recovery. Identifying factors that have a negative impact on patients' quality of postoperative recovery and satisfaction with recovery after day surgery will assist healthcare professionals in supporting vulnerable patients, such as those with limited HL and poor mental health. Treating patients with respect and dignity and providing SDM can increase their quality of postoperative recovery and satisfaction with recovery.

Role of Patient- and Surgery-Specific Risk in Receipt of Outpatient Preoperative Testing

Objective

To determine the independent association of patient- and surgery-specific risk with receipt of outpatient preoperative testing.

Methods

Using administrative data from 2010-2013 (Marketscan^® Commercial Claims and Encounters), we constructed a retrospective cohort of 678,368 privately-insured, non-elderly US adults who underwent one of ten operations, including one lower-risk and one higher-risk operation from five surgical specialties. Outcomes were receipt of nine outpatient tests in the 30 days before surgery and cost of those tests. Patient-specific risk was based on Revised Cardiac Risk Index (RCRI) and, alternatively, the Charlson Comorbidity Index (CCI). Surgery-specific risk was based on operation (higher- versus lower-risk within each specialty). Multivariable logistic regression models were constructed to measure the independent association of patient- and surgery-specific risk with the receipt of tests.

Results

Receipt of tests ranged from 0.9% (pulmonary function tests) to 46.8% (blood counts), and 65.2% of patients received at least one test. Mean cost per patient for all tests was $124.38. Higher RCRI was strongly associated (Odds Ratio (OR) >2) with receipt of stress tests and echocardiograms, and more modestly associated [OR <2] with receipt of most other tests. Undergoing higher-risk operations was strongly associated with receipt of most tests. Results were similar using the CCI for patient-specific risk.

Conclusion

Surgery-specific risk is strongly associated with receipt of most preoperative tests, which is consistent with preoperative testing protocols based as much or more on the planned operation as on patient-specific risk factors. Whether this pattern of preoperative testing represents optimal care is uncertain.