Choosing Wisely: A Quality Improvement Initiative to Decrease Unnecessary Preoperative Testing.

Area of Science:

• Health Services Research
• Quality Improvement in Healthcare
• Primary Care Medicine

Background:

• Routine preoperative testing is often considered a low-value service in primary care settings.
• Baseline data indicated approximately 36% of preoperative evaluations at Dartmouth-Hitchcock Medical Center involved unnecessary testing.
• A multidisciplinary team aimed to reduce low-value care in preoperative assessments.

Purpose of the Study:

• To analyze the existing preoperative evaluation process and implement a rapid cycle improvement strategy.
• To reduce unnecessary preoperative testing rates through a novel Associate Provider-led clinic.
• To evaluate the effectiveness of standardized protocols and electronic health record (EHR) tools in preoperative care.

Main Methods:

• A micro-systems approach and Plan-Do-Study-Act (PDSA) cycles were employed for process analysis and improvement.
• A dedicated Nurse Practitioner and Physician Assistant (Associate Provider) clinic was established with standardized protocols.
• Statistical Process Control (SPC) methods were used to compare testing rates between the new clinic and usual care.

Main Results:

• The Associate Provider preoperative clinic achieved unnecessary testing rates of 4%, compared to 23% in the usual care cohort (p<.001).
• Significant reduction in unnecessary testing was observed within three months of the clinic's implementation.
• No significant change in overall testing rates across the entire General Internal Medicine division was noted.

Conclusions:

• An Associate Provider-staffed preoperative clinic effectively reduced unnecessary testing in a primary care setting.
• Key success factors included dedicated leadership, multidisciplinary team input, and balancing innovation with clinical needs.
• Further improvements may be achieved by optimizing clinical time, scheduling processes, and EHR tool support.