Does a theory-based intervention to improve accountability reduce low-value preoperative tests for patients undergoing low-risk surgery? A pragmatic cluster randomized controlled trial protocol.

Abstract Background: Low value preoperative tests ordered for patients without any clinical indication undergoing low-risk surgery can lead to further unnecessary investigations or treatments of false-positives. Identified drivers of ordering such low value preoperative tests include uncertainty about who should be responsible for test ordering, perceived inability to cancel tests ordered by fellow physicians and tests being completed before anesthesiologists assess patients. These findings informed a theory-based intervention increasing accountability in the hospital for preoperative test ordering. The objective of the proposed randomised trial is to evaluate whether this intervention reduces unnecessary preoperative tests (ECGs and Chest X-Rays) in patients undergoing low-risk surgery. Methods: A cluster randomized trial in 22 Ontario hospitals is planned. Eligible hospitals, those falling between the 26th-100th centile for their rate of routine low value preoperative test ordering, will be randomly allocated into the intervention arm (a multicomponent intervention including changing hospital policy, identification of a local champion, delivering an education workshop, and restructuring patient flow and responsibility) or control arm (usual care). A process evaluation will determine whether the intervention is delivered as designed and local champions’ experiences of the delivering the intervention (fidelity). An economic evaluation will determine if the intervention offers good value for money from the perspective of Canada’s health care system. The primary outcome, defined at the level of the hospital, is the proportion of patients receiving one or more low-value preoperative tests within 60 days before surgery. Secondary outcomes are proportions of patients with overnight admission, re-operation in 24 hours, and 30-day all-cause mortality from the date of surgery, in addition to the proportion of patients receiving each of the above preoperative tests individually. Discussion: Designing interventions to target the de-implementation of low-value care, is critical to improving healthcare for Canadians. Systematically addressing the barriers in a theory-informed manner, and by identifying the most appropriate intervention components for those barriers, increases the likelihood that the intervention will reduce unnecessary care delivered to patients. Trial registration: ClinicalTrials.gov Identifier: NCT05526495; Registered September 2, 2022