Beyond guideline knowledge: a theory-based qualitative study of low-value preoperative testing

Area of Science:

• Health Services Research
• Medical Decision Making
• Behavioral Science in Medicine

Background:

• Major anesthesia and preoperative guidelines advise against routine preoperative tests for low-risk procedures.
• Despite recommendations, low-value preoperative test ordering remains prevalent.
• The theoretical domains framework (TDF) is utilized to explore factors influencing preoperative test ordering.

Purpose of the Study:

• To understand the drivers of preoperative electrocardiogram (ECG) and chest X-ray (CXR) ordering for low-risk surgeries.
• To identify influencing factors among anesthesiologists, internal medicine specialists, nurses, and surgeons.
• To inform interventions aimed at reducing low-value preoperative testing.

Main Methods:

• Semi-structured interviews were conducted with preoperative clinicians in a Canadian health system.
• Snowball sampling was used for participant recruitment.
• The interview guide was based on the TDF to probe influences on ECG and CXR ordering; content was deductively coded.

Main Results:

• Eight TDF domains were identified as drivers of preoperative test ordering.
• Clinicians expressed distrust in guideline evidence and faced unclear role responsibilities.
• Ease of ordering tests, fear of surgery cancellation, and preventing intraoperative issues influenced ordering decisions.

Conclusions:

• Key factors influencing preoperative test ordering by various specialists were identified.
• Interventions should move beyond knowledge dissemination to address local behavioral drivers.
• Targeted changes at individual, team, and institutional levels are necessary to reduce low-value testing.