Determinants of Low-Value Testing Before Low-Risk Operation

Abstract

INTRODUCTION: Routine testing (ie EKG and laboratory tests) before low-risk operation does not prevent adverse events and can lead to harm, including risky care cascades and operative delay. Despite multiple surgical, anesthesia, and general medicine professional societies recommending against routine testing, unnecessary testing remains common and de-implementation has proven difficult. This study describes determinants of such testing. METHODS: We conducted focused ethnography at one academic institution. We directly observed two preoperative clinics and one outpatient surgery center, conducted semi-structured interviews, and collected artifacts including preoperative testing protocols related to low-risk operation. Structured notes were written after each observation and interviews were audio-recorded and transcribed. Themes were identified through narrative thematic analysis. RESULTS: We had conversations with 22 stakeholders including 2 surgeons, 5 anesthesiologists, 3 perioperative nurses, 11 advanced practice providers (certified registered nurse anesthetists and physician’s assistants), and 1 medical assistant. We identified three major themes: highly varied testing preferences illustrated by surgeon- and service-specific protocols, confusion around “intentional” vs “automated” orders leading to verbal verification of orders, and the belief that other providers or services want testing that the ordering provider does not necessarily desire, thus incentivizing reflexive ordering to avoid conflict or confrontation. CONCLUSION: When viewed in its entirety, the preoperative system is cumbersome. However, individual stakeholders behave rationally given roles and associated pressures. Unnecessary preoperative testing is a human problem based in culture and convention. Efforts to reduce low-value testing before low-risk operation should take on a systems lens to optimize each input for efficiency and value.