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

背景和对退伍军人管理局患者护理的预期影响：术前测试实践有 在过去十年中，由于对不必要的风险和成本的敏感性而受到相当多的审查 测试增加了。术前测试只有在揭示可操作的数据的情况下才能被证明是合理的 改变临床管理，提高患者的安全性和预后。最近的一款Cochrane 对包括21,000多例白内障手术在内的三项随机试验的审查得出结论，Pre-Pre 手术测试并不能降低术中或术后不良事件的风险 为了不做测试。其他研究表明，常规检测，特别是在没有显著差异的患者中 接受低风险手术的系统性疾病通常不会改变围手术期的处理， 可能导致后续检测和侵入性干预，结果正常，并可能不必要地 延迟手术或其他程序。因此，美国麻醉学家协会最近 “五大应避免的活动”包括以下建议：“具体的术前实验室 研究不应该在没有重大系统性疾病的低风险患者中进行。 外科手术。“因为它们不会改变临床管理或改善患者结果，我们定义 任何患者在白内障手术前的常规术前检查和常规的术前检查 没有重大系统性疾病的患者接受其他低风险手术的价值较低 测试。 即使根据这些研究结果和专业标准，几项描述性研究 退伍军人健康管理局(VHA)以外的各种设置发现，低价值检测 仍然很常见。尽管在VHA内进行了大量手术(例如&>50,000 每年的白内障手术)，关于术前检测的相关模式的数据很少。如果 在VHA中发现了低值的术前测试模式，这是一项重要的实践改进 或者“取消实施”目标的存在，可以提供将资源重定向到 其他组织优先事项，如改善准入和提供证据支持 治疗。因此，为了确保VHA患者得到最高价值的护理， 接受低价值测试，但好处很少或没有好处，并可能造成意外伤害，并确保 VHA利用其资源对健康结果产生最大可能的积极影响，这 研究的目的如下： 目标1：描述手术前低价值的全系统和设施水平的费率和相关费用 在包括白内障手术在内的高频低风险手术前30天和60天进行测试 (&gt；每年50,000)，腕管释放(&gt；每年9,500)，上、下消化道 内窥镜检查(每年50万英镑)。 目标2：检查患者因素(例如，合并症)、临床因素(例如，预约临床医生 专科)，以及可能与订购 低值的术前检查。 目标3：确定VHA站点的使用率和术前低价值总支出最高 在常见的低风险程序以及最近从高风险切换到低风险的站点中进行测试 使用低值测试。使用理论领域框架(TDF)，我们将采访关键 这些站点的告密者为了了解哪些TDF结构是低价值测试的驱动因素， 以及取消实施低价值测试的障碍和促进者。

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.