National clinician societies in Canada representing anesthesiologists, cardiologists, surgeons, and transfusion specialists recommend not performing regular preoperative testing for healthy patients before minor surgery. Preoperative tests, such as chest X-rays, electrocardiograms, and blood work, for patients undergoing minor surgery can cause significant harm, including false–positive or borderline results requiring further investigation as well as delaying surgery.
Choosing Wisely Manitoba (CWMB) is a partnership between Shared Health Manitoba and the George and Fay Yee Centre for Healthcare Innovation (CHI) in Manitoba, a central Canadian province of 1.4 million people. CWMB chose to focus on reducing unnecessary preoperative tests as a result of audits that found unnecessary preoperative testing was common in practice and quite costly. The tests were estimated to cost the province more than $2 million annually, with four types of preoperative tests accounting for 62 percent of these costs.
To develop an effective implementation strategy, CWMB launched a multiphase project to identify the barriers and facilitators to the sustainable adoption of preoperative testing guidelines. The goal was to reduce unnecessary preoperative testing in Manitoba by 25 percent, using baseline data from 2013 to 2017.
All patients undergoing minor or low-risk surgeries (e.g., cataract surgery) in Manitoba since the project was launched in 2016 have been affected by this effort. The targeted stakeholders included surgeons, anesthesiologists, family physicians, and other clinicians such as surgical office assistants and preadmission clinic nursing staff.
Key Features of the Innovation
Through stakeholder consultations, literature reviews, and an analysis of surgical audits, the barriers and facilitators to guideline uptake were identified. Using these results, a multidisciplinary team of stakeholders developed a tailored implementation strategy. This included:
- Tools for clinicians, including revised preoperative lab test guidelines, decision-support aids embedded in the electronic medical record, and preoperative history and physical form
- Audit and feedback of data from surgeons across all surgical specialties (excluding cardiac and caesarian surgeries) to measure ongoing sustainability and uptake.
Audits of preoperative testing at six hospitals and one surgical center in Winnipeg demonstrated a 35% reduction in preoperative diagnostic testing after implementation, as well as an average savings of $31.59 per person.
Evidence of Impact
Audits of preoperative testing at six hospitals and one surgical center in Winnipeg (Manitoba’s largest city and main referral center, population 700,000) demonstrated a 35 percent reduction in preoperative diagnostic testing after implementation, as well as an average savings of $31.59 per person (from 2013 to 2017). Based on conservative estimates of the average weekly volume of 500 to 600 surgeries, this corresponds to approximately $821,000 to $985,000 in savings each year in Winnipeg alone. Separate audits of cataract surgery showed a 76% reduction in preoperative testing representing an annual savings of $118,000.
Sharing and Spreading the Innovation
CWMB clinician leaders have shared the results of this work through national webinars and presentations. While the results reveal that the majority of surgical offices are using the revised guidelines and the amount of preoperative testing has decreased significantly, audits of all surgeons revealed a large range in test ordering. This, along with the postimplementation survey results, underscores the need to encourage adoption of standardized cover letters within surgical offices.
Contact for Further Information
Sarah Kirby, Research Project Manager, Choosing Wisely Manitoba [email protected]