Background and Anticipated Impacts on VA Patient Care: Pre-operative testing practices have received considerable scrutiny over the past decade as sensitivity to risks and costs of unnecessary testing have increased. Preoperative tests can only be justified if they reveal actionable data that alters clinical management in a way that improves patient safety and outcomes. A recent Cochrane review of three randomized trials including over 21,000 cataract surgeries concluded that pre- operative testing does not reduce the risk of intraoperative or postoperative adverse events compared to no testing. Other studies indicate that routine testing, especially in patients without significant systemic disease undergoing low risk procedures, often does not change perioperative management, may lead to follow-up testing and invasive interventions with normal results, and can unnecessarily delay surgery or other procedures. Accordingly, the American Society of Anesthesiologists' recent “Top-5 Activities to Avoid” include the following recommendation: “Specific pre-operative laboratory studies should not be obtained in patients without significant systemic disease undergoing low-risk surgery.” Because they do not alter clinical management or improve patient outcomes, we define routine preoperative testing of any patients before cataract surgery and routine preoperative testing of patients without significant systemic disease undergoing other low-risk procedures as low value tests. Even in light of these research results and professional standards, several descriptive studies in diverse settings outside the Veterans Health Administration (VHA) have found that low value testing is still very common. Despite the large numbers of surgeries conducted within VHA (e.g. >50,000 cataract surgeries annually), little data exists on associated patterns of preoperative testing. If patterns of low value preoperative testing are found within VHA, an important practice improvement or “de-implementation” target exists that could afford significant opportunities to redirect resources to other organizational priorities, such as improved access and the provision of evidence-supported treatments. Therefore, in order to ensure that VHA patients receive the highest value care, are not subjected to low value testing with little or no benefit and potential unintended harm, and to ensure that VHA uses its resources to produce the largest possible positive impact on health outcomes, this study has the following aims: Aim 1: Describe system-wide and facility-level rates and associated costs of low value pre-operative testing in the 30 and 60 days before high-frequency low-risk procedures including cataract surgery (>50,000 annually), carpal tunnel release (>9,500 annually), and upper and lower digestive tract endoscopy (>500,000 annually). Aim 2: Examine the patient factors (e.g., comorbidities), clinician factors (e.g., ordering clinician specialty), and facility-level factors (e.g., surgical volume) that may be associated with the ordering of low value preoperative tests. Aim 3: Identify VHA sites with the highest rates and total expenditures on low value pre-operative testing in common low risk procedures, as well as sites that have recently switched from high to low use of low value testing. Using the Theoretical Domains Framework (TDF), we will interview key informants at these sites in order to understand which TDF constructs are drivers of low value testing, as well as barriers to and facilitators of de-implementing low value tests.

Surgeons and anesthesiologists previously thought that routine preoperative testing, even for patients undergoing low risk procedures, had no downsides. The goal of testing was to reveal serious medical issues, and thus allow for better management of risks. The zeitgeist was that more testing was consistent with better care. However, decades of experience have taught us that, in many cases, preoperative tests have very low value. Preoperative testing did not necessarily alter clinical management in a way that improves patient safety and outcomes. Low value testing also can have unintended harms, such as follow-up testing and invasive interventions, and unnecessary delays in surgery. Therefore, the purpose of this study is to describe and understand drivers of low value preoperative testing in the Veterans Health Administration, to inform the future development of a de-implementation strategy. Our goal is to ensure that VHA patients receive the highest value care, are not subjected to the harms of low value testing, and that VHA uses its resources wisely.