RITE-Size Testing

Navigating Concerns

Enacting change starts with education.

When trying to increase the appropriateness of preoperative testing across clinical care teams within the health system, it can be difficult to make progress when clinicians have concerns about how lower preoperative testing rates may impact their patients. Despite extensive research evidence of the risks of unnecessary preoperative testing prior to low-risk surgeries, many providers remain hesitant to make a shift. By addressing common provider concerns and presenting evidence-based recommendations, care teams will be empowered to ensure their patients receive appropriate preoperative testing.

Evidence + Recommendations

Common Concerns

There are several concerns commonly held by providers nationwide – see below for talking points to help discuss those concerns during conversations.

CONCERN: Preoperative testing is critical to ensure surgical safety

If a healthy patient is undergoing a low-risk surgery, evidence shows that preoperative tests do not improve surgical safety outcomes for the patient and/or alter the surgical plan for the day of surgery.

CONCERN: Not testing will result in a surgical case being cancelled

It’s common for providers to order tests just to avoid potential conflict with other providers on the case, even when they themselves do not see the merit in testing. When all perioperative team members follow the same protocol, preoperative testing can decrease without increased rates of cancellation. 

CONCERN: There are no benefits to reducing preoperative testing

There are multiple benefits to reducing preoperative tests not only for the patient, but also for the clinician. Studies show that reducing preoperative testing reduced time spent reviewing, documenting, and explaining test results that added no value and had no impact on the procedure, effectively reducing health system waste.

CONCERN: There is no harm in ordering these preoperative tests

Patients are more likely to experience stress and financial burden when undergoing medical tests. There is also evidence of patient harm when follow-up on superfluous results from preoperative testing delay care (e.g., additional falls while waiting for cataract surgery) or result in additional, more invasive tests.

CONCERN: Everyone orders preoperative tests; this is the norm

There is wide variation in average preoperative testing rates across over 100 Michigan hospitals (e.g., rates between approximately 5% to over 90%), but the majority of hospitals order tests for less than half of their low-risk procedures. Provider norms vary between hospitals, departments, and providers.

FAQs

Why do the RITE-Size partners focus on just three outpatient surgeries (i.e., lumpectomy, hernia repair, laparoscopic cholecystectomy)?

These are surgeries that have been commonly identified as low-risk in the literature and are the same surgeries that the Michigan Value Collaborative (MVC) includes in its preoperative testing reporting; therefore, data is readily available to compare hospitals for a pre- and post-intervention period. However, the same approach could be applied to other low-risk surgeries performed at your site, and spillover effects may be likely after care teams revisit their preoperative protocols.

Can this framework be applied outside of these three surgeries?

Absolutely! Refer to the Surgical Risk Estimator for examples of other low-risk surgeries for which preoperative testing may be unnecessary.  As always, clinicians will use their discretion when evaluating patients and recommending testing based on individual factors. 

What if I don’t feel comfortable not ordering a common preoperative test?

These recommendations and guidelines do not replace individual clinician medical decision making and we encourage you to make the decision that is best for each patient. However, we also acknowledge ordering preoperative tests is a practice many providers are used to, so adapting to this framework may take time. These recommendations have been in place by multiple professional societies for years and evidence from the literature shows that these unnecessary preoperative tests cause more harm than good. 

How are ASPIRE, MPrOVE, MSQC, and MVC working together?

These organizations are collaborating to improve the rate of appropriate preoperative testing by engaging with their respective audiences (e.g., anesthesiologists, surgeons, hospitals, physician organizations, implementation scientists, quality improvement staff) through different data and intervention methods that complement one another’s work. 

  • The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) curates and manages a comprehensive perioperative patient registry based on electronic healthcare data, which is used to promote safe and evidence-based perioperative care for all patients through collaboration, research, education, and quality improvement. Their leadership team reviews RITE-Size materials to ensure they align with best practices for anesthesiology.
  • The Michigan Program on Value Enhancement (MPrOVE) focuses on improving quality and demonstrating the value of care at Michigan Medicine, while at the same time catalyzing collaborative research efforts to inform state and national policy decisions. MPrOVE has aided in designing educational materials to de-implement low-value preoperative testing. 
  • The Michigan Surgical Quality Collaborative (MSQC) leads a variety of quality improvement projects, including an incentive-based project and data abstraction related to low-value preoperative testing. The serve as a key partner in designing educational materials given their knowledge of hospital practices, abstracted surgical data, and their relationships with providers.
  • The Michigan Value Collaborative (MVC) dedicates resources to claims-based reporting and incentive-based measures for preoperative testing, making them the primary source of outcome data over time. Their team also leads a preoperative testing educational workgroup series featuring expert guest speakers to support collaborative learning for hospitals across the state.

QUESTIONS?

Questions about the RITE-Size project can be directed to:

info@ritesizetesting.org

Questions about the webpage content and resources can be directed to:

info@ritesizetesting.org