Right-Sizing Testing Before Elective Surgery for Patients With Low Risk.

Abstract

Guidelines recommend against testing before low-risk surgery in healthy patients because it offers no benefit and may cause harm. However, testing remains prevalent, highlighting the need for a deimplementation strategy that can be broadly applied across health care settings. To assess the feasibility of a multifaceted, multicomponent deimplementation strategy entitled Right-Sizing Testing Before Elective Surgery (RITE-Size), hypothesizing it would be feasible to execute with 80% of milestones met on time. This quality improvement study was conducted from March 1 to August 31, 2024, at 3 hospitals of varying characteristics in Michigan. The intervention was structured into 3 phases (baseline, preparation, and active deimplementation) and further divided into 6 milestones (ie, key steps in the deimplementation process). Eligible preoperative tests included bloodwork and cardiopulmonary evaluations (eg, blood cell counts, metabolic panels, chest radiography, and electrocardiography) performed within 30 days of elective laparoscopic cholecystectomy, inguinal hernia repair, or breast lumpectomy in healthy adults. The intervention included site visits, coaching sessions, data review, initiation of consensus processes for deimplementation, and distribution of strategy components (eg, decision support tools). The primary outcome was milestone completion. Secondary outcomes included acceptability and appropriateness, as assessed by the Acceptability of Intervention Measure (AIM) and the Intervention Appropriateness Measure (IAM). Additionally, barriers and facilitators to implementation were evaluated through semistructured interviews, along with testing rates derived from claims data. A total of 203 patients (mean [SD] age, 57 [17] years; 117 [57.6%] female) who underwent procedures of interest were identified. All milestones were achieved on time. The intervention had high acceptability and appropriateness among stakeholders (median [IQR], 20 of 20 [18-20] for AIM and 20 of 20 [16-20] for IAM). Key facilitators included small, cohesive, perioperative teams and the incorporation of the intervention into policy, supported by auditing and feedback systems. Barriers included the need for ongoing education and coordination across large health care systems. Testing rates significantly decreased across all sites from 68.0% (51 of 75) to 40.3% (25 of 62) (P = .001). This quality improvement study of a multifaceted, multicomponent deimplementation strategy to reduce unnecessary preoperative testing at diverse hospital sites demonstrated feasibility of expanding this work in a stepped-wedge cluster randomized trial. These results suggest that hospital systems can use this deimplementation strategy in the future to reduce unnecessary preoperative testing.