Antunez Alexis G, Kazemi Ruby J, Richburg Caroline, Pesavento Cecilia, Vastardis Andrew, Kim Erin, Kappelman Abigail L, Nanua Devak, Pediyakkal Hiba, Jacobson-Davies Faelan, Smith Shawna N, Henderson James, Gavrila Valerie, Cuttitta Anthony, Nathan Hari, Dossett Lesly A
Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
Center for Surgery and Public Health, Boston, Massachusetts.
JAMA Surg. 2025 Mar 1;160(3):304-311. doi: 10.1001/jamasurg.2024.6063.
Routine preoperative blood tests and electrocardiograms before low-risk surgery do not prevent adverse events or change management but waste resources and can cause patient harm. Given this, multispecialty organizations recommend against routine testing before low-risk surgery.
To determine whether a multicomponent deimplementation strategy (the intervention) would reduce low-value preoperative testing before low-risk general surgery operations.
DESIGN, SETTING, AND PARTICIPANTS: This study had a pre-post quality improvement interventional design using interrupted time series and difference-in-difference analytic approaches. The setting was a single academic, quaternary referral hospital with 2 freestanding ambulatory surgery centers and a central preoperative clinic. Included in the study were adult patients undergoing nonurgent outpatient inguinal hernia repairs, lumpectomy, or laparoscopic cholecystectomy between June 2022 and August 2023. Eligible clinicians included those treating at least 1 patient during both the preintervention and postintervention periods.
All clinicians were exposed to the multicomponent deimplementation intervention, and their testing practices were compared before and after the intervention. The strategy components were evidenced-based decisional support, multidisciplinary stakeholder engagement, educational sessions, and consensus building with surgeons and physician assistants staffing a preoperative clinic.
The primary end point of the trial was the rate of unnecessary preoperative tests across each trial period.
A total of 1143 patients (mean [SD] age, 58.7 [15.5] years; 643 female [56.3%]) underwent 261 operations (23%) in the preintervention period, 510 (45%) in the intervention period, and 372 (33%) in the postintervention period. Unnecessary testing rates decreased over each period (intervention testing rate, -16%; 95% CI, -4% to -27%; P = .01; postintervention testing rate, -27%; 95% CI, -17% to -38%; P = .003) and within each test category. The decrease in overall testing was not observed at other hospitals in the state on adjusted difference-in-difference analysis.
In this quality improvement study, a multicomponent deimplementation strategy was associated with a reduction in unnecessary preoperative testing before low-risk general surgery operations. The resulting changes in testing practice patterns were not associated with temporal trends within or outside the study hospital. Results suggest that this intervention was effective, applicable to common general surgery operations, and adaptable for expansion into appropriate clinical settings.
低风险手术前的常规术前血液检查和心电图检查并不能预防不良事件或改变治疗方案，反而会浪费资源并可能对患者造成伤害。鉴于此，多专业组织建议不进行低风险手术前的常规检查。
确定多组分去实施策略（干预措施）是否会减少低风险普通外科手术前的低价值术前检查。
设计、设置和参与者：本研究采用中断时间序列和差异分析方法进行前后质量改进干预设计。研究地点为一家拥有2个独立门诊手术中心和一个中央术前诊所的单一学术性四级转诊医院。纳入研究的是2022年6月至2023年8月期间接受非紧急门诊腹股沟疝修补术、乳房切除术或腹腔镜胆囊切除术的成年患者。符合条件的临床医生包括在干预前和干预后期间至少治疗1名患者的医生。
所有临床医生都接受了多组分去实施干预措施，并比较了干预前后他们的检查实践。策略组成部分包括基于证据的决策支持、多学科利益相关者参与、教育课程以及与术前诊所的外科医生和医师助理达成共识。
试验的主要终点是每个试验期间不必要的术前检查率。
共有1143名患者（平均[标准差]年龄，58.7[15.5]岁；643名女性[56.3%]）在干预前期进行了261例手术（23%），干预期进行了510例（45%），干预后期进行了372例（33%）。每个时期不必要检查率均有所下降（干预期检查率，-16%；95%置信区间，-4%至-27%；P = .01；干预后期检查率，-27%；95%置信区间，-17%至-38%；P = .003），且在每个检查类别中均如此。在对该州其他医院进行调整后的差异分析中，未观察到总体检查的下降情况。
在这项质量改进研究中，多组分去实施策略与低风险普通外科手术前不必要的术前检查减少相关。检查实践模式的变化与研究医院内部或外部的时间趋势无关。结果表明，该干预措施有效，适用于常见的普通外科手术，并且可扩展应用于合适的临床环境。
