Choosing Wisely: Barriers to De-Implementation, Patterns, and Costs of Low Value Preoperative Testing for Veterans Undergoing Low Risk Procedures

背景和对VA患者护理的预期影响：术前测试实践 在过去十年中，由于对不必要的风险和成本的敏感性， 测试增加了。只有当术前检查显示出可采取行动的数据时，才能证明其合理性， 以改善患者安全和结局的方式改变临床管理。最近的科克伦 回顾三项随机试验，包括超过21，000例白内障手术，得出结论， 手术测试并不能降低术中或术后不良事件的风险， 没有测试。其他研究表明，常规检测，特别是对于没有明显症状的患者， 全身性疾病接受低风险手术，通常不会改变围手术期管理， 可能导致后续测试和侵入性干预，结果正常， 延迟手术或其他程序。因此，美国麻醉学家协会最近 "应避免的前5项活动"包括以下建议："特定的术前实验室检查 不应在无显著全身性疾病的低风险患者中进行研究 手术"因为它们不会改变临床管理或改善患者结局，我们定义 白内障手术前对任何患者进行常规术前检测， 接受其他低风险手术的无显著全身性疾病的患者为低价值 试验. 即使根据这些研究结果和专业标准， 退伍军人健康管理局（VHA）以外的各种环境发现， 仍然很常见。尽管在VHA内进行了大量手术（例如> 50，000例 白内障手术每年），很少有数据存在的相关模式的术前测试。如果 在VHA中发现了低价值术前检测模式，这是一项重要的实践改进 或"取消执行"的目标，可以提供重大机会，将资源转用于 其他组织优先事项，如改善获取和提供证据支持的 治疗。因此，为了确保VHA患者获得最高价值的护理， 进行低价值测试，几乎没有或没有受益和潜在的非预期伤害，并确保 VHA利用其资源对健康结果产生尽可能大的积极影响， 研究的目的如下： 目标1：描述全系统和机构一级的低价值术前手术率和相关成本 在包括白内障手术在内的高频率低风险手术前30天和60天进行检测 （每年> 50，000例）、腕管松解（每年> 9，500例）以及上下消化道 内窥镜检查（每年> 500，000）。 目的2：检查患者因素（例如，合并症），临床医生因素（例如，指令的临床医生 专业）和设施级因素（例如，手术体积），其可以与以下命令相关联 术前检查值低。 目标3：确定低价值术前治疗发生率和总支出最高的VHA部位 在常见的低风险程序中进行测试，以及最近从高风险转为低风险的地点 使用低值测试。使用理论领域框架（TDF），我们将采访关键 为了了解哪些TDF结构是低价值测试的驱动因素， 以及取消低价值测试的障碍和促进因素。

Background and Anticipated Impacts on VA Patient Care: Pre-operative testing practices have received considerable scrutiny over the past decade as sensitivity to risks and costs of unnecessary testing have increased. Preoperative tests can only be justified if they reveal actionable data that alters clinical management in a way that improves patient safety and outcomes. A recent Cochrane review of three randomized trials including over 21,000 cataract surgeries concluded that pre- operative testing does not reduce the risk of intraoperative or postoperative adverse events compared to no testing. Other studies indicate that routine testing, especially in patients without significant systemic disease undergoing low risk procedures, often does not change perioperative management, may lead to follow-up testing and invasive interventions with normal results, and can unnecessarily delay surgery or other procedures. Accordingly, the American Society of Anesthesiologists' recent “Top-5 Activities to Avoid” include the following recommendation: “Specific pre-operative laboratory studies should not be obtained in patients without significant systemic disease undergoing low-risk surgery.” Because they do not alter clinical management or improve patient outcomes, we define routine preoperative testing of any patients before cataract surgery and routine preoperative testing of patients without significant systemic disease undergoing other low-risk procedures as low value tests. Even in light of these research results and professional standards, several descriptive studies in diverse settings outside the Veterans Health Administration (VHA) have found that low value testing is still very common. Despite the large numbers of surgeries conducted within VHA (e.g. >50,000 cataract surgeries annually), little data exists on associated patterns of preoperative testing. If patterns of low value preoperative testing are found within VHA, an important practice improvement or “de-implementation” target exists that could afford significant opportunities to redirect resources to other organizational priorities, such as improved access and the provision of evidence-supported treatments. Therefore, in order to ensure that VHA patients receive the highest value care, are not subjected to low value testing with little or no benefit and potential unintended harm, and to ensure that VHA uses its resources to produce the largest possible positive impact on health outcomes, this study has the following aims: Aim 1: Describe system-wide and facility-level rates and associated costs of low value pre-operative testing in the 30 and 60 days before high-frequency low-risk procedures including cataract surgery (>50,000 annually), carpal tunnel release (>9,500 annually), and upper and lower digestive tract endoscopy (>500,000 annually). Aim 2: Examine the patient factors (e.g., comorbidities), clinician factors (e.g., ordering clinician specialty), and facility-level factors (e.g., surgical volume) that may be associated with the ordering of low value preoperative tests. Aim 3: Identify VHA sites with the highest rates and total expenditures on low value pre-operative testing in common low risk procedures, as well as sites that have recently switched from high to low use of low value testing. Using the Theoretical Domains Framework (TDF), we will interview key informants at these sites in order to understand which TDF constructs are drivers of low value testing, as well as barriers to and facilitators of de-implementing low value tests.