The Value of Improoperative Diagnostic Tests, Treatments and Procedures
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1 The Value of Improving Appropriate Diagnostic Tests, Treatments and Procedures Presented by: Dr. Eric Bohm & Dr. Thomas Mutter On behalf of the Project Team
2 Disclosure of Potential for Conflict of Interest Dr. Eric Bohm & Dr. Thomas Mutter No relevant conflicts of interest
3 Appropriate: Tests, Procedures, Treatments
4 Choosing Wisely Manitoba Choosing Wisely Manitoba has engaged with: Provincial Medical Leadership Council College of Physicians and Surgeons Manitoba Manitoba College of Family Physicians Doctors Manitoba Centre for Health Care Innovation Manitoba Centre for Health Policy University of Manitoba, Faculty of Health Sciences College of Pharmacists of Manitoba and many others To focus on opportunities specific to Manitoba.
5 Core Objectives of CW-MB Improved health outcomes Improved patient and provider experience Improved health system efficiencies Improved health system sustainability
6 Preoperative Tests Initiative ( )
7 Routine Preoperative laboratory testing Chest X-ray Electrocardiogram (ECG) Common blood tests: Complete blood count (CBC) Serum electrolytes, Creatinine, Glucose Liver function tests Coagulation profile (INR/ PTT) Thyroid function tests
8 Most preoperative lab tests are unnecessary, inefficient and potentially harmful Preoperative lab test No high level evidence of benefit Differing expectations between anesthesia providers Abnormal result False positive results Unnecessary delays in surgery Patient inconvenience Substantial cost Adverse outcomes Tests ordered FOR anesthesia BY others Clinically trivial abnormalities Change in management Cancellation/Delay insurance Unnecessary repeat and confirmative testing No change in management Prevention of postoperative complications
9 Contemporary preoperative care is multidisciplinary Primary care Surgeon Primary care PAC* SURGERY *PAC: Pre-anesthetic clinic (Anesthesiology)
10 Improving efficiencies in preoperative laboratory testing project Multidisciplinary collaborative project supported by MPAN in : Manitoba Health WRHA Administration Anesthesiologists and Pre-anesthetic clinic nursing staff Primary care providers Surgeons
11 Project objectives Design and implement a PROVINCIAL preoperative laboratory testing guideline to improve: Standardization of expectations between sites Communication between providers Efficiency in the use of preoperative testing... and evaluate guideline effectiveness
12 Our Guideline:
13 Guideline implementation: November 2010 to March 2011 Province wide: Presentations at provincial primary care conference, Grand rounds, standards committees and other information programs Distribution to each region s administration for dissemination within that region In addition, within the WRHA: Delivery by mail to all end users
14 Guideline evaluation: Audit design Retrospective chart reviews Guideline population elective, adult surgical patients All performed by one experienced auditor. Each audit a random sample typical week within the Winnipeg RHA stratified by site and surgical specialty Ethics board approval obtained to re-analyze quality assurance data collected in serial audits.
15 Guideline evaluation: Audit design
16 Chance that an unnecessary test was ordered 60.0% Baseline 50.0% 40.0% 30.0% 5 months post RRR = 14.5% p = % 10.0% 0.0%
17 Chance that an unnecessary test was ordered 60.0% RRR = 25.6% Baseline p = months post 50.0% 25 months post 40.0% 30.0% 20.0% 10.0% 0.0% RRR = 7.2% p = 0.16
18 Preoperative Tests Initiative ( )
19 Why continue the project? Nov/10 Baseline established Mar/11 Guideline implemented Sept/11 6 month audit (14.6% reduction!) May/13 2 year audit (rebound to above baseline)
20 Project Goal to ensure all Manitobans receive the necessary and appropriate preoperative diagnostic testing for elective surgeries through the sustainable implementation of a standardized, evidence informed clinical practice guideline
21 Project Framework Stakeholder Consultation Literature Review Process Mapping Barriers and Facilitators Identified Engagement with key stakeholders Strategy development Project Team Implement Evaluate Learn
22 Where are the unnecessary tests? 3 Specialties account for 70% of unnecessary tests: Ophthalmology surgery (31% of all unnecessary tests) Orthopedics surgery (23%) General surgery (17%) Note: Phase 3 Audit
23 Test ordering practice, by specialty Ophthalmology 100% Orthopedics 7% 93% General 23% 77% PCP Surgeon
24 Estimated Value of Unnecessary Tests
25 Estimated Value of Unnecessary Tests
26 High Yield Specialties
27 Ophthalmology Cataracts ~10,000 cataract procedures annually no preoperative lab test routinely required Standardized, unique History & Physical form used for cataract patients Standardized processes utilized by surgeons who operate at Misericordia Health Centre
28 Orthopedic Surgery 2 elective procedures account for 50% of the elective volume: Hip and Knee replacements Non standardized processes Different cover letters cueing unnecessary tests Some surgeons order tests, others send to PCP Multiple surgeons / offices
29 General Surgery 3 procedures = 50% of elective surgical volumes - Diagnostic / Therapeutic Intervention - large intestine (38%) - Therapeutic intervention - muscles chest & abdomen (12%) Limited awareness of the guidelines General surgeons order 55-77% of UTs Current ordering processes may not be amendable to standardization
30 What are the issues? Guidelines time-consuming to interpret Surgeon cover letters / forms do not support the guidelines Liability concerns Do not agree or unaware of guidelines Easier to order unnecessary tests than cause potential delay
31 Implementation Strategies More user friendly H&P forms / Specialist letters More user friendly Preoperative testing grid Physician Engagement EMR enhancements Process Flow Changes Communication / Education strategy Preoperative App Physician level Feedback
32 Evaluation
33 Purpose of the Evaluation Understand what is working / not working well Provide feedback and support for decision-making Understand the impact of strategies implemented on unnecessary preoperative diagnostic testing
34 Components of the Evaluation Developmental Evaluation Quantitative Document review Qualitative and surveys Chart Audit (ophthalmology and orthopedics) Administrative Data (all specialties) Project documents Interviews, consultations or surveys with: Project team members and stakeholders Users of forms and other tools developed Evaluation Platform
35 Evaluation Questions- Summary Are revised documents being used with all patients & by all providers (as appropriate)? Do stakeholders consider changes to be an improvement? Can the impact of each strategy be identified? What worked well and what could have been improved related to developing and implementing the new forms, documents & processes? Have any reductions in ordering unnecessary tests been maintained?
36 Questions? PMLC HSLC
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