Project: Appropriate Preoperative Diagnostic Testing: A Choosing Wisely Manitoba Initiative


Project: Appropriate Preoperative Diagnostic Testing: A Choosing Wisely Manitoba Initiative

[img]

Team: Health Systems Performance
Posted on July 14, 2017

CHIMb.ca
[img]

Project: Appropriate Preoperative Diagnostic Testing: A Choosing Wisely Manitoba Initiative

Team: Health Systems Performance

Date: This is not a timed event.

Description


Choosing Wisely Canada is a national campaign aimed to help engage clinicians and patients in conversations about unnecessary tests and treatments, and make smart and effective care choices. Inappropriate preoperative diagnostic testing has been identified as a priority. Routine preoperative tests for low risk surgeries results in unnecessary delays, potential distress for patients and significant cost for the health care system https://choosingwiselycanada.org/internal-medicine/.

In 2014 the Centre for Healthcare Innovation and our partner Diagnostic Services Manitoba, with funding from the Manitoba Patient Access Network, set out to identify and remove barriers to the sustainable adoption of previously developed pre-operative testing guidelines, in order to reduce unnecessary preoperative diagnostic testing.

An examination of the barriers and facilitators to guideline adoption and implementation of the guidelines, including further analysis of 3 audits completed previously, meetings with administrators and stakeholders from primary care, surgery, anesthesia, preadmission clinics and eHealth, focus groups with family physicians, and a review of the literature all informed the development of a revised guideline and implementation strategy.

The implementation of a revised Cataract Surgery History and Physical (H&P) Form emphasized that tests are not usually required for cataract surgery and eliminated cueing for unnecessary pre-operative tests. At the same time a Red-Green project eliminated pre-operative History and Physicals for ~60% of cataract surgery patients. Pre and post-implementation audits showed a 77.5% reduction in patients undergoing pre-operative testing from pre to post-implementation of these 2 projects.  

Building on what we learned through the cataract project, on July 11, 2016, five revised documents were implemented to help reduce cues that prompt unnecessary testing for all other types of surgery. The revised documents were the result of collaborations with key partners including representatives from Preoperative Assessment Clinics (PAC), anesthesiologists, primary care providers, surgeons, and hospital and lab staff. The revised documents were implemented in eight surgical sites across Winnipeg.

Five Documents:

  1. Revised Routine Preoperative Lab Tests Guidelines
  2. WRHA Preoperative History & Physical Form
  3. Patient Quick Reference Cover Letter
  4. Preoperative Care Cover Letter
  5. Web-based decision support aid

Our primary outcome, to reduce preoperative diagnostic testing by 25%, was evaluated through retrospective chart reviews of two random samples of surgical patients during typical weeks in the WRHA.  The results demonstrated a significant (p<0.0001) 35% reduction in preoperative diagnostic testing.  

In order to review adherence to the guidelines and to support implementation by providing feedback and supporting materials, we have conducted approximately 10 audits of surgeons in each of the 8 surgical sites in Winnipeg (excluding cataract and pediatrics).  The results revealed that the majority of surgeries were compliant with the guidelines (60%) but that there is a large range in the number of unnecessary tests ordered between surgical specialties from 24% of tests ordered are unnecessary to 72% are unnecessary. Based on these results our next step is to provide feedback to individual surgeons including supporting materials to increase adherence to the guidelines.

Join us on October 3, 2018, for Drop the Pre-op: Choosing Wisely to reduce unnecessary preoperative testing in Manitoba, to hear more about this project. 

Click here for a summary of the evaluation results.

To request the full report, please email info@chimb.ca

Documents and Photos