Reducing Low-Value
Preoperative Testing
Welcome & Introductions
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Hari Nathan, MD, PhD
Director, Michigan Value Collaborative (MVC);
Associate Professor of Surgery,
Division of Surgical Oncology
Michigan Medicine
Lesly Dossett, MD, MPH
Co-Director, Michigan Program on Value
Enhancement (MPrOVE);
Associate Professor of Surgery,
Chief, Division of Surgical Oncology,
Michigan Medicine
Disclosures
▸ Agency for Healthcare
Research and Quality
R01HS029306
▸ Dossett & Nathan (co-PI)
▸ “De-Implementation of Low-
Value Testing in Patients
Undergoing Low-risk
Surgery
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Agenda
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▸ What is RITE-Size?
▸ Why Preop Testing?
▸ Successes & Barriers
▸ Material Resources
▸ Next Steps
▸ Q&A
Preoperative Testing Collaboration
Expertise
• Expertise in identifying
areas of low-
value care and
understanding the reasons
for persistent use
• Expertise in designing
behavioral interventions
• Engagement of statewide
site champions in QI
• Statewide claims data and
quantitative expertise
• Reporting structure
• Engagement of
statewide clinical
champions, hospitals,
and key stakeholders to
facilitate practice
change
Partnership Role
•
Lead design of intervention
strategies
• Support for measure
development
• Lead measurement and
reporting of testing rates
• Integration with MVC P4P
and QI infrastructure
• Integration with MSQC
P4P and QI infrastructure
• Data abstraction
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Why Preop Testing?
Making the case for de-implementation of
preoperative testing before low-risk surgery
What Does Evidence
Tell Us?
▪ Routine testing in
asymptomatic patients does
not avoid adverse events
▪ Tests are costly to the
healthcare system
▪ Cascade events risk patient
harm
▪ Multiple medical societies (e.g.,
ASA, ACS, AAO, ACP, etc.)
recommend against this
practice
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Rates Vary
Between
and
Within
Hospitals
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Berlin et al. JAMA Internal Medicine. 2021
Identifying areas of opportunity
using unblinded data with new MVC
preoperative testing cohort definitions
Successes & Barriers
Strategic approaches to de-implementation of
low-value testing and common points of resistance
“
“We all know
complications can occur
regardless of the preop
evaluation, it’s better to
be safe and just have
everyone go through it
[preoperative testing].”
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“
“I think one of the big
barriers [to de-
implementation] would
just be making sure that
everybody knows that
that's the policy.“
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Common Barriers Observed
▸ Concerns for safety
▸ Testing culture / Current policies
▸ Provider habits and workflows
▸ Conflicting EMR processes
▸ Communication breakdowns between providers
▹ Testing triad: Anesthesiologist, Surgeon, PCP
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MM Pilot Interventions
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MM Pilot Timeline
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NOVNOVOCTOCTSEPTSEPTAUGAUGJULYJULYJUNEJUNEMAYMAYAPRAPRMARMARFEBFEBJANJANDECDEC
Met with Anesthesia
Met with Minimal
Invasive Surgery Unit CHART REVIEW
Met with Surgical
Oncology Division
Met with Preop Clinic Procedure Pass
Enhancements
EHR Enhancements: Procedure Pass
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Unnecessary Preoperative Testing Decreased Overall
Proportion of
patients receiving
at least one
unnecessary test
Pre-Intervention
October-
December 2022
Intervention
January-
March 2023
(data collection)
Post-Intervention
April-August 2023
Material Resources
Decision Aid, Testing Chart, PCP Package,
and more
New domain name
and redesigned
web pages to
support preop
testing initiatives
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Announcing
ritesizetesting.org
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Decision Aid &
Testing Chart
Updated
Version 1.4 has
been modified
slightly and now
also endorsed by
ASPIRE/MPOG
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INPUT REQUESTED: Our team will reach out for feedback on these materials after the meeting
Sites with experience reducing
preop testing commonly cite PCPs
as the source of test orders
▸ We recommend engaging PCPs as
partners, and are developing a PCP
Package to engage them
Engaging Primary
Care Physicians
Connect with RITE-Size & Hospital Peers
CURRENT:
▸ Leverage resources on
ritesizetesting.org
▸ Attend MVC preop testing
workgroups
▹ May 14, 12-1pm
▹ Aug. 6, 12-1pm
▹ Nov. 5, 12-1pm
RSVP and event details available at
https://michiganvalue.org/upcoming-events
FUTURE:
▸ Select preop testing for future
MSQC and/ or MVC P4P cycles
▸ Contact RITE-Size team about
joining study program in 2025
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Thank
You!
Any questions?
You can reach us at:
▸ drnathan@umich.edu
▸ ldossett@med.umich.edu
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