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.

Surgeon Perspectives on Determinants of Same-Day Mastectomy: A Roadmap for Implementing Change

BACKGROUND

Same-day discharge after mastectomy without immediate reconstruction (MwoR) has been shown to be safe, with improved patient satisfaction when compared with patients discharged 1 or more days after surgery. Nevertheless, only 16% of patients undergoing MwoR in Michigan are discharged on the day of surgery, with significant variation between facilities (3-88%). Our objective was to explore determinants of same-day discharge and offer strategies for broader implementation of this practice.

METHODS

We conducted semi-structured interviews with surgeons performing MwoR across the state of Michigan. Recruitment utilized purposeful and snowball sampling methods. The Tailored Implementation in Chronic Disease (TICD) framework was used to inform the creation of the interview guide. Interviews were transcribed and then analyzed using directed content analysis guided by the TICD framework. Salient determinants were organized into patient, provider, and system-level factors.

RESULTS

Participants (n = 26) included general surgeons, breast surgeons, and surgical oncologists. Most surgeons (n = 18, 69%) reported that they discharged fewer than 60% of patients the same day after MwoR. The most common barriers included patient knowledge at the patient level; awareness of evidence, surgeon dogma, and peer influence at the provider level; and team processes and operating room logistics at the system level.

CONCLUSION

We identified surgeon-defined determinants of same-day discharge after MwoR. For the identified barriers, potential implementation strategies could include incorporation of preoperative drain teachings for patients, utilizing consensus statements and opinion leaders to disseminate evidence supporting same-day mastectomies, and conducting workshops with relevant stakeholders to establish consistent facility practice patterns among surgical teams.