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IIR 16-216 – HSR Study

IIR 16-216
Choosing Wisely: Barriers to De-Implementation, Patterns, and Costs of Low Value Preoperative Testing for Veterans Undergoing Low Risk Procedures
Alexander H.S. Sox-Harris, PhD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: January 2018 - December 2020
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. 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.

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 aims to describe the burden of low value testing within VHA and understand drivers of low value 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.

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.

In FY17, 70,306 cataract surgeries were performed. Overall, 44.4% of cataract surgeries were preceded by at least one low value preoperative test. The most common were ECG (26.4%), followed by complete blood count (26.1%), basic metabolic profile (17.5%), urinalysis (8.8%), chest x-ray (7.4%), and PFT (3.0%). Perhaps more interesting from a quality improvement perspective, large facility-level variation was found. In 126 major VHA facilities, the facility-level range of receiving at least one low value test was 6.3% to 98.4%, with 16 sites providing at least one low value test prior to 75% of cataract surgeries.

The principles of high-value, patient-centered health care demand that we avoid testing procedures that do not inform a patient's clinical management or outcomes, that can cause unintended harm, that waste their time, and that consume resources that might be used to improve the access and quality of care for them and other patients. This study has already identified an important de-implementation target, providing an opportunity to improve patient care while conserving resources for more beneficial uses.

External Links for this Project

NIH Reporter

Grant Number: I01HX002314-01A1

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Journal Articles

  1. Shanafelt TD, Wang H, Leonard M, Hawn M, McKenna Q, Majzun R, Minor L, Trockel M. Assessment of the Association of Leadership Behaviors of Supervising Physicians With Personal-Organizational Values Alignment Among Staff Physicians. JAMA Network Open. 2021 Feb 1; 4(2):e2035622. [view]
  2. Harris AHS, Hagedorn HJ, Finlay AK. Delta Studies: Expanding the Concept of Deviance Studies to Design More Effective Improvement Interventions. Journal of general internal medicine. 2021 Feb 1; 36(2):280-287. [view]
  3. Tamboli M, Leng JC, Hunter OO, Kou A, Mudumbai SC, Memtsoudis SG, Walters TL, Lochbaum GM, Mariano ER. Five-year follow-up to assess long-term sustainability of changing clinical practice regarding anesthesia and regional analgesia for lower extremity arthroplasty. Korean journal of anesthesiology. 2020 Oct 1; 73(5):401-407. [view]
  4. Harris AHS, Bowe T, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn HJ, Mudumbai S. Frequency and costs of low-value preoperative tests for patients undergoing low-risk procedures in the veterans health administration. Perioperative medicine (London, England). 2022 Sep 13; 11(1):33. [view]
  5. Korndorffer JR, Wren SM, Pugh CM, Hawn MT. From Listening to Action: Academic Surgical Departmental Response to Social Injustice Through Curricular Development. Annals of surgery. 2021 Dec 1; 274(6):921-924. [view]
  6. Harris AHS, Finlay AK, Hagedorn HJ, Manfredi L, Jones G, Kamal RN, Sears ED, Hawn M, Eisenberg D, Pershing S, Mudumbai S. Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing. Journal of general internal medicine. 2023 Nov 1; 38(14):3209-3215. [view]
  7. Titan A, Doyle A, Pfaff K, Baiu I, Lee A, Graham L, Shelton A, Hawn M. Impact of policy-based and institutional interventions on postoperative opioid prescribing practices. American journal of surgery. 2021 Oct 1; 222(4):766-772. [view]
  8. Saraswathula A, Chen MM, Mudumbai SC, Whittemore AS, Divi V. Persistent Postoperative Opioid Use in Older Head and Neck Cancer Patients. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2019 Mar 1; 160(3):380-387. [view]
  9. Gustavson AM, Gordon AJ, Kenny ME, McHenry H, Gronek J, Ackland PE, Hagedorn HJ. Response to coronavirus 2019 in Veterans Health Administration facilities participating in an implementation initiative to enhance access to medication for opioid use disorder. Substance Abuse. 2020 Sep 16; 41(4):413-418. [view]
  10. Harris AHS, Meerwijk EL, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn H, Mudumbai S. Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesthesia and analgesia. 2019 Sep 1; 129(3):804-811. [view]
  11. Mudumbai SC, Pershing S, Bowe T, Kamal RN, Sears ED, Hawn MT, Eisenberg D, Finlay AK, Hagedorn H, Harris AHS. Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration. JAMA Network Open. 2021 May 3; 4(5):e217470. [view]
Online News Media Articles

  1. Neil J, Tighe P, Mudumbai S. Artificial Intelligence: Coming to rescue you? Or replace you? ASA Monitor: The Newsletter of the American Society of Anesthesiologists, INC. [Internet]. 2018 Jun 1:82(6):12-16. Available from: [view]
  2. Mudumbai S, Chan L, Banoub M. Committee News: Electronic Health Records - Pros and Cons. ASA Monitor: The Newsletter of the American Society of Anesthesiologists, INC. [Internet]. 2017 Oct 1:81(10):74-78. Available from: [view]

DRA: Health Systems
DRE: Treatment - Implementation
Keywords: Best Practices, Implementation
MeSH Terms: none

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