Abstract
Background:
Consensus is lacking regarding the optimal strategy to influence surgeons’ behaviors to reduce low-value surgical care. Comprehensively describing the existing body of literature that seeks to intervene on surgeons’ preoperative decision-making may aid in structuring future behavior change strategies.
Methods:
We performed a scoping review using four databases (MEDLINE, Embase, Web of Science, and CINAHL) for articles that tested the effect of behavioral-based interventions on any aspect of surgeons’ decision-making in the preoperative setting. Abstracted data were characterized by summative descriptions and analyzed using the Tailored Implementation for Chronic Disease (TICD) framework, mapping aspects of de-implementation strategies in the studies onto the determinant(s) that they altered. Data abstraction and mapping tools were piloted and iteratively revised prior to two researchers independently assessing studies and categorizing determinants, and then meeting to discuss their decisions.
Results:
There were 1,460 articles identified from the initial search, with 17 full text articles ultimately included in the scoping review. Eight studies relied on a multidisciplinary preoperative conference to accomplish their aims, while five were multi-faceted in their approach to de-implementation, and four studies used only a clinical decision support tool to accomplish their aims. Mapping determinants addressed in these studies onto the TICD framework demonstrated that most strategies attempted to close knowledge gaps, leverage communication between providers, and broadcast institutional prioritization of change.
Conclusion:
There is a small but growing field of implementation and de-implementation strategies in preoperative surgical decision-making, and different approaches may be equally effective in varied clinical contexts. Deliberate measurement and comparison of outcomes, as well as selection of control groups, are areas for improvement in future work.
Keywords: Preoperative, surgical, decision-making, de-implementation
Introduction
Low-value care, which is comprised of medical services without a clinically meaningful benefit, costs the United States over $100 billion dollars per year.1 Specific instances of low-value care were identified by the Choosing Wisely guidelines through partnership with subspecialty organizations. These recommendations have generated scholarship and clinical efforts since they were first published in 2012, but the full promise of this initiative has failed to materialize despite widespread dissemination and recognition across fields.2,3 A potential solution to close the gap between guidelines and practice has emerged via de-implementation, a process that seeks to modify individual and institutional behaviors to decrease the provision of low-value care.
While the persistence of low-value care is multi-factorial, there is strong evidence that clinician decision-making plays a role.4-6 Surgical decision-making has emerged as an important target for de-implementation work, given the heightened risks and costs associated with such care.7 In particular, preoperative, as compared to intra- and post-operative choices, deserve consideration.8 It is at this stage of decision-making that many evidence-based practices are brought to bear, choices have the potential to set patients and surgeons on established care pathways, and decision-making is subject to less urgency. Salient examples include the widespread use of preoperative testing prior to low-risk surgeries, the prevalence of total thyroidectomy instead of lobectomy for low-risk papillary thyroid cancer, and sentinel lymph node biopsy in older breast cancer patients.9-11 Despite recognition of low-value practices across specialties, means of effecting behavior change in surgeons via implementation and deimplementation strategies continue to be heterogenous.12 There has not been a comprehensive cataloging of existing interventions to address low-value surgical care.13
There are limited data to support which behavioral based interventions bring about consistent results. This scoping review summarizes the literature on strategies to change behaviors to improve the value of surgical care in the preoperative setting. There are actionable insights that may be gained from comprehensively describing the existing body of work that seeks to intervene on surgeons’ preoperative decision-making. By categorizing interventions using an established framework, we aimed to identify the most effective behavior change strategies. This scoping review will inform ongoing efforts to reduce low-value surgical care.
Methods
We performed a scoping review using Peters et al. as guide, following a protocol that was created before searching commenced (Supplement 1).14 This report was created following the PRISMA-ScR checklist (Supplement 2).15
Electronic database searches
We identified studies reporting the effect of behavior-based de-escalation strategies on surgeon decision-making in the preoperative setting by searching the electronic databases MEDLINE (Ovid), Embase (Elsevier), Web of Science Core Collection (Clarivate), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL, EBSCO). The searches were iteratively developed with an experienced librarian (PAB). The searches included controlled vocabulary terms (when available) and synonyms for decision making, the preoperative period, and de-escalation (Supplement 3). The final search was carried out on September 2nd, 2022. We searched the references of included articles and utilized the “similar articles” feature to increase the search’s yield.
Selection of studies
We included studies testing the effect of behavioral-based interventions on any aspect of surgeon decision-making in the preoperative setting. Studies that collected primary data, were peer reviewed, and had their full text available in English were included. We limited our results to those published after 2011 to capture the state of the field after the initiation of the Choosing Wisely campaign. Studies that involved intraoperative events and those evaluating shared decision-making tools were excluded, as were systematic reviews, editorials, and meta-analyses. Intraoperative decision-making is dynamic in a way that makes it less amenable to behavioral interventions, and shared decision-making applies to clinical scenarios where patient preference may modify care, so clinical guidelines are not universally applicable. We stipulated that at least one of the subjects of the intervention was a surgeon or surgical trainee but did not exclude those studies that intervened on both surgical providers and non-surgeons. Search results were downloaded and imported into Covidence systematic review software (Veritas Health Innovation).16 All records were screened by title and abstract by one researcher (AGA), and then 57 full text articles were reviewed by two researchers (AGA and KAR) to determine whether they met inclusion criteria.
Data extraction
A data abstraction tool was utilized by two researchers (KAR and AGA) to compile studies meeting inclusion criteria. A standardized approach was used to extract the salient characteristics of each study’s intervention for ease of direct comparison. Data collected included study design, analytic approaches, details of the intervention, outcome variables, and whether the study achieved its stated intended effect. Multifaceted studies were defined as those that used more than one means of putting their strategy into action, e.g., via an educational session and a decision support tool. Through iterative assessment, two additional characteristics of intervention strategies were assessed after initial review- whether the activities described in the study were interactive or asynchronous, and whether the content of the strategy was static or dynamic over time (Table 1). Interactive describes activities where participants can speak to one another in real time, either in person or virtually, whereas asynchronous activities take place whenever the target audience chooses to engage with the material.17 Static content does not change over time, while dynamic content evolves with the intervention. This allowed for a more detailed, yet summative description of the studies captured in the review.
Table 1:
17 scoping review articles and their attributes
| Article Information | Multi- faceted? |
Aspects of Intervention | Achieved Desired Effect? |
Interactive or asynchronous? |
Content over time/interactions? |
|---|---|---|---|---|---|
| Quality improvement in preoperative assessment by implementation of an electronic decision support tool (Flamm et al., Journal of the American Medical Informatics Association, 2013) | N | Electronic decision support (eDS) tool ‘PReOPerative evaluation’ (PROP) | Y | Asynchronous | Static |
| Reduced Red Blood Cell Transfusion in Cardiothoracic Surgery after Implementation of a Novel Clinical Decision Support Tool (Razavi et al., Journal of the American College of Surgeons, 2014) | N | Clinical decision support tool | Y | Asynchronous | Static |
| A Partnership Model Between High- and Low-Volume Hospitals to Improve Results in Hepatobiliary Pancreatic Surgery (Ravaioli et al., Annals of Surgery, 2014) | Y | Preoperative phone/email discussions | Y | Interactive | Dynamic |
| Operative assistance | |||||
| Postoperative phone/email conversations | |||||
| Improving blood transfusion practice by educational emphasis of the blood utilization committee: The experience of one hospital (Vrotsos et al., Transfusion Clinique et Biologique, 2015) | Y | Blood Utilization Committee/Surgeon-champion | Y | Both | Dynamic |
| Utilization Protocol | |||||
| In-Person Communication Between Radiologists and Acute Care Surgeons Leads to Significant Alterations in Surgical Decision Making (Dickerson et al., Clinical Practice Management, 2016) | Y | Semiweekly multidisciplinary case review | Y | Interactive | Dynamic |
| An easy-to-follow algorithm to improve pre-operative diagnosis for appendicitis in children (Podevin et al., Journal of Visceral Surgery, 2017) | Y | Interactive education session | Y | Both | Static |
| Diagnostic algorithm for appendicitis | |||||
| Decreasing 30-day surgical mortality in a VA Medical Center utilizing the ACS NSQIP Surgical Risk Calculator (Kuy et al., Journal of Surgical Research, 2017) | Y | ACS Surgical Risk Calculator | Y | Both | Dynamic |
| Multidisciplinary Pre-Operative Consultation Committee | |||||
| Improved utilization of resources as an improvement of outcome: The effect of multidisciplinary team for rectal cancer in a district hospital (Maurizi et al., Clincs in Oncoloy, 2017) | N | Multidisciplinary team for rectal cancer patients | N | Interactive | Dynamic |
| The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial (Voorn et al., Implementation Science, 2017) | Y | Information letter/email | N | Both | Both |
| Interactive education session | |||||
| Pocket cards | |||||
| Feedback visits | |||||
| Follow up newsletters | |||||
| Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study (Yanamadala et al., Spine, 2017) | N | Multidisciplinary conference | Y | Interactive | Dynamic |
| Influence of a Preoperative Conference on Surgeons’ Decision-making for Adult Spinal Disorders- A Prospective Clinical Study From a Spine Hospital (Erken et al., Clinical Spine Surgery, 2018) | N | Daily preoperative conference | Y | Interactive | Dynamic |
| DECIDE: a cluster-randomized controlled trial to reduce unnecessary caesarean deliveries in Burkina Faso (Kaboré et al., BMC Medicine, 2019) | Y | Clinical algorithms | Y | Both | Both |
| On-site training | |||||
| Text reminders | |||||
| Audit and feedback | |||||
| Implementing a Pediatric Perioperative Surgical Home Integrated Care Coordination Pathway for Laryngeal Cleft Repair (Leahy et al., Anesthesia & Analgesia, 2019) | N | Pediatric Perioperative Surgical Home (PPSH) integrative care model | Y | Both | Static |
| The effects of a preoperative multidisciplinary conference on outcomes for high-risk patients with challenging surgical treatment options: a retrospective study (Koike et al., BMC Anesthesiology, 2021) | N | Multidisciplinary High-Risk Conferences | Y | Interactive | Dynamic |
| Improving smoking cessation referrals among elective surgery clinics through electronic clinical decision support (Stonesifer et al., Tobacco Prevention & Cessation, 2021) | N | Clinical decision support tool | Y | Asynchronous | Static |
| A Multidisciplinary Spine Surgical Indications Conference Leads to Alterations in Surgical Plans in a Significant Number of Cases: A Case Series (Benton, et al., Spine, 2021) | N | Multidisciplinary spine surgery indications conference (MSSIC) | Y | Interactive | Dynamic |
| A tailored intervention does not reduce low value MRI's and arthroscopies in degenerative knee disease when the secular time trend is taken into account: a difference-in-difference analysis (Rietbergen et al., Knee Surgery, Sports Traumatology, Arthroscopy, 2022) | Y | Clinical champions | N | Both | Both |
| Education on the Dutch Choosing Wisely recommendations | |||||
| Training of orthopedic surgeons to manage patient expectations | |||||
| Performance feedback | |||||
| Patient brochure |
Abstracted data were characterized and analyzed using the Tailored Implementation for Chronic Disease (TICD) framework.18 This framework synthesizes determinants of healthcare practice, such as “attitudes towards guidelines” and “financial incentives and disincentives.” Aspects of de-implementation strategies in the studies were mapped onto the determinant(s) that they altered, in a quasi-qualitative process of systematic categorization. This type of synthesis was modeled after published scoping reviews of deimplementation of low-value care.19 Determinants were mapped onto studies if the intervention strategy led to improvement in that domain or if it leveraged techniques in a domain to accomplish its aims. Both data abstraction and mapping tools were piloted with a single study and then iteratively revised. Two researchers independently categorized determinants to strategies and documented their processes using a codebook (Supplement 4). Consensus was reached via discussion of each study, with a third researcher available to resolve discrepancies. Certain aspects of the TICD were not applicable to the strategies included in the scoping review, like cultural appropriateness, patient factors, and those relating to corruption/political stability, and so were omitted from the analytical framework. The quality of evidence and conclusions in the included studies were assessed using the JBI checklist for the appraisal of quasi-experimental studies.20 This checklist examines studies’ methodological approaches, confounding conditions, and whether the conclusions were supported by the data.
Results
Electronic database searching yielded 1,460 unique records (Figure 1). From these, 57 articles underwent full-text examination. Seventeen studies in 17 articles were included in the analysis. The most common reason for exclusion (28/44) was for study or intervention designs that were not congruent with the review, e.g., utilizing imaging characteristics alone to change preoperative decisions, or descriptions of the development of preoperative prediction scores without implementation efforts. Eight studies intervened on non-surgical providers, five studies could not be found in English, two collected an outcome related to postoperative surgical decision-making, and one was a duplicate. 13 articles remained, and four additional studies were obtained via citation review and related literature review outside of the search, for a final total of 17 full text articles included.
Figure 1:
Preferred Reporting Items for Systematic Reviews and Meta-analyses Flow Diagram
General surgery patients were the target population in seven studies, orthopedic, neurosurgical, or spine surgery patients were studied in five, pediatric and cardiothoracic populations each accounted for two studies, with the remaining study focusing on obstetric patients. Nine studies targeted low-value operations, while eight focused on low-value perioperative processes. Seven studies relied on a multidisciplinary preoperative conference. One study used an additional strategy, a clinical decision support tool, to identify those patients who were discussed at the preoperative conference. Eight studies were multi-faceted in their approaches to de-implementation, meaning they used a combination of two or more approaches in their strategy to influence behaviors. Four studies used only a clinical decision support tool.
Three studies were unsuccessful in accomplishing their desired effects (Table 1). Of these, two were well-designed, multi-site, pragmatic trials in orthopedic surgery. Effectiveness of the strategies was not dependent on the means of delivery or whether the content of their message changed over time or multiple interactions. Asynchronous and static strategies were as successful in bringing about the desired change in behavior as interactive, dynamic ones, in different contexts. The overall quality was the studies was variable, as assessed using the JBI checklist for quasi-experimental studies (Table 2). The baseline characteristics of patients in comparison groups were often different in significant ways, and very few studies utilized a control group in their analyses.
Table 2:
Study type, specialty, outcomes, and JBI appraisal of evidence
| Article | Study Type | Specialty | Outcomes | Is it clear in the study what is the ‘cause’ and what is the ‘effect’? |
Were the participants included in any comparisons similar? |
Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? |
Was there a control group? |
Were there multiple measurements of the outcome both pre and post the intervention/exposure? |
Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed? |
Were the outcomes of participants included in any comparisons measured in the same way? |
Were outcomes measured in a reliable way? |
Was appropriate statistical analysis used? |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Y/N/NA/Unclear | ||||||||||||
| Quality improvement in preoperative assessment by implementation of an electronic decision support tool (Flamm) | Pre-post study | General Surgery | Guideline adherence, unnecessary tests, recommended tests omitted | Y | N | Y | N | Y | Y | Y | Y | Y |
| Reduced Red Blood Cell Transfusion in Cardiothoracic Surgery after Implementation of a Novel Clinical Decision Support Tool (Razavi) | Pre-post study | Cardiothoracic Surgery | Pretransfusion HGB level, units transfused, postoperative/ICU LOS, SSI, mortality | Y | Y | Y | N | Y | Y | Y | Y | Y |
| A Partnership Model Between High- and Low-Volume Hospitals to Improve Results in Hepatobiliary Pancreatic Surgery (Ravaioli) | Pre-post study | General Surgery | Postoperative complications | Y | Y | Y | N | Y | Y | Y | Y | Y |
| Improving blood transfusion practice by educational emphasis of the blood utilization committee: The experience of one hospital (Vrotsos) | Pre-post study | Cardiothoracic Surgery | Crossmatch to transfusion ratio | Y | Unclear | Y | N | Y | Y | Y | Y | Unclear |
| In-Person Communication Between Radiologists and Acute Care Surgeons Leads to Significant Alterations in Surgical Decision Making (Dickerson) | Cross-sectional pilot study | General Surgery | Changes to surgical plan | Y | NA | NA | N | Y | Y | NA | Y | Y |
| An easy-to-follow algorithm to improve pre-operative diagnosis for appendicitis in children (Podevin) | Randomized controlled trial (cluster) | Pediatric Surgery | Algorithm adherence, "poor results" composite endpoint, unnecessary appendectomy | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| Decreasing 30-day surgical mortality in a VA Medical Center utilizing the ACS NSQIP Surgical Risk Calculator (Kuy) | Pre-post study | General Surgery | Mortality (observed:expected) | Y | Unclear | N | N | Y | Unclear | Y | Y | Y |
| Improved utilization of resources as an improvement of outcome: The effect of multidisciplinary team for rectal cancer in a district hospital (Maurizi) | Pre-post study | General Surgery | Clinical and pathological stage discordance | Y | N | Unclear | N | Y | Y | Y | Y | Y |
| The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial (Voorn) | Randomized controlled trial (cluster) | Orthopedic Surgery | Blood salvage use; EPO use | Y | N | N | Y | Y | Y | Y | Y | Y |
| Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study (Yanamadala) | Cross-sectional pilot study | Neurosurgery | Spinal fusion surgery | Y | NA | NA | N | Y | Y | NA | Y | Y |
| Influence of a Preoperative Conference on Surgeons’ Decision-making for Adult Spinal Disorders- A Prospective Clinical Study From a Spine Hospital (Erken) | Cross-sectional pilot study | Spine Surgery | Changes to surgical plan | Y | NA | NA | N | Y | Y | NA | Y | Y |
| DECIDE: a cluster-randomized controlled trial to reduce unnecessary caesarean deliveries in Burkina Faso (Kaboré) | Randomized controlled trial | Obstetrics/Gynecology | Change in percentage of unnecessary C-sections | Y | N | Y | Y | Y | Y | Y | Y | Y |
| Implementing a Pediatric Perioperative Surgical Home Integrated Care Coordination Pathway for Laryngeal Cleft Repair (Leahy) | Pre-post study | Pediatric Surgery | ICU admissions, cost of care | Y | Y | Unclear | N | Y | Y | Y | Y | Y |
| The effects of a preoperative multidisciplinary conference on outcomes for high-risk patients with challenging surgical treatment options: a retrospective study (Koike) | Cross-sectional pilot study | General Surgery | Changes to surgical plan | Y | NA | NA | N | N | N | NA | Y | Y |
| Improving smoking cessation referrals among elective surgery clinics through electronic clinical decision support (Stonesifer) | Pre-post study | General Surgery | Number of encounters when tool was used, smoking cessation referrals | Y | Unclear | Y | N | Y | Y | Y | Y | Y |
| A multidisciplinary spine surgical indications conference leads to alterations in surgical plans in a significant number of cases (Benton) | Cross-sectional pilot study | Neurosurgery | Compliance rates, invasiveness scores, changes in surgical plan | Y | NA | NA | N | N | Y | NA | Y | Y |
| A tailored intervention does not reduce low value MRI's and arthroscopies in degenerative knee disease when the secular time trend is taken into account: a difference-in-difference analysis (Rietbergen) | Non-randomized controlled trial | Orthopedic Surgery | Monthly percentage of patients receiving a MRI or knee arthroscopy | Y | N | Y | Y | Y | Y | Y | Y | Y |
Mapping the study interventions onto the TICD framework domains demonstrated a few common intervention strategies (Table 3). Several interventions targeted Clinician Knowledge (Individual Provider Factors) via conferences and clinical decision support tools. This was a common component of nearly all studies and, similarly, most strategies improved overall Awareness of Recommendations (Guideline Factors) and Awareness and Familiarity with Recommendations (Individual Provider Factors). The commonality of these three domains amongst most strategies demonstrates a propensity for including education and information sharing as a component of preoperative decision-making strategies.
Table 3:
TICD domains with examples from included studies
| TICD Domain | Commonly Identified Determinant |
Example Strategy | Study Utilizing this Strategy |
|---|---|---|---|
| Guideline Factors | Accessibility of recommendation | Text message reminders | DECIDE: a cluster-randomized controlled trial to reduce unnecessary caesarean deliveries in Burkina Faso (Kaboré) |
| Individual Provider Factors | Knowledge about own practice | Performance feedback | A tailored intervention does not reduce low value MRI's and arthroscopies in degenerative knee disease when the secular time trend is taken into account: a difference-in-difference analysis (Rietbergen) |
| Professional Interactions | Communication and influence | Preoperative phone and email discussions | A Partnership Model Between High- and Low-Volume Hospitals to Improve Results in Hepatobiliary Pancreatic Surgery (Ravaioli) |
| Incentives and Resources | Availability of necessary resources | Regular case review with radiologists | In-Person Communication Between Radiologists and Acute Care Surgeons Leads to Significant Alterations in Surgical Decision Making (Dickerson) |
| Capacity for Organizational Change | Mandate, authority, accountability | Mandatory multidisciplinary preoperative consultation committee | Decreasing 30-day surgical mortality in a VA Medical Center utilizing the ACS NSQIP Surgical Risk Calculator (Kuy) |
| Social, Political, and Legal Factors | Economic constraints on the healthcare budget | Pediatric Perioperative Surgical Home integrative care model protocols | Implementing a Pediatric Perioperative Surgical Home Integrated Care Coordination Pathway for Laryngeal Cleft Repair (Leahy) |
Another frequently used approach was to leverage Communication and Influence (Professional Interactions). Many of the strategies were publicized, well-known initiatives within surgical departments and involved in-person dialogue between providers, so participants were both directly and indirectly guided towards the strategies’ goals. Sometimes Communication and Influence was also employed alongside Team Processes (Professional Interactions), but not always. Another frequently used strategy was utilization of the Priority of Necessary Change and Mandate, Authority, and Accountability (both within the domain of Capacity for Organizational Change). These strategies encouraged behavior change by demonstrating institutional commitment to new patterns of action. Targeting these determinants demonstrates a shared emphasis on discussion, interpersonal interactions, and leadership as means of effecting change across the final cohort of studies.
There were several determinants that were targeted less commonly but were shared across multiple strategies. Monitoring and Feedback (Capacity for Organizational Change) were regularly employed to assess and reinforce behaviors. Additionally, surgeons were prompted to develop Knowledge of Their Own Practice (Individual Provider Factors). This expanded on purely educational strategies to also include reflective and applied knowledge. And finally, many strategies also improved the Feasibility of the Recommended Intervention (Guideline Factors) by addressing logistical obstacles to surgeons providing recommended care.
Discussion
This scoping review identified 17 studies that evaluated strategies seeking to improve surgeons’ preoperative decision-making in a variety of patient populations. Many strategies were multi-faceted; common strategies included multidisciplinary preoperative conferences and clinical decision aids. There was not a single strategy that tended to change behavior more reliably than another. Singular clinical decision support tools performed as well as multifaceted study designs in different contexts, as described eslewhere.21 There were common attributes amongst the successful studies, and these conclusions are shared with other systematic reviews on related topics.19,22 Making relevant information available to clinicians in different contexts and over time was a strategy present in nearly all studies. Fostering dialogue and appraisal between providers is another consistent practice. These are both in line with the surgical and implementation literature; educational implementation strategies are the most common approaches, and preoperative, multidisciplinary collaboration is already known to improve surgical outcomes.12,23
The final commonality amongst most studies, institutional prioritization of change, may initially seem imprecise, but the public knowledge and gradual buy-in that occurs from leadership engagement and purposeful messaging is a tangible way to exert influence.24 The first announcement and public discussion of new initiatives in clinical practice often occurs via emails from leaders, grand rounds presentations, and regular divisional meetings. This domain also relates to the pivotal step of engaging multiple stakeholders in de-implementation efforts, a step which continues to be seldomly included in implementation efforts in healthcare systems.25 Preoperative surgical care often involves providers from different specialties and facilities, staff, and administrators who can impact the uptake of new practices, so stakeholder engagement should be one of the first phases of any strategy. The original TICD checklist describes one way of accomplishing institutional prioritization as “persuading those responsible to change their priorities.”26 Partnerships between leaders and those at the forefront of care are a durable means of bringing about behavior change. Efforts from national organizations can parallel the local endeavors described in this strategy; they may consider collaborations with affected groups or customizing guidelines to be more user-friendly for specific providers, e.g., thyroid nodule management guidelines for the general surgeon, or preoperative anesthesia practices for the primary care provider.27,28 De-implementation efforts in particular, where existing incentives are sustaining low-value care, benefit from interpersonal efforts and those that leverage multiple interactions over time.
Finally, the scientific rigor of all included studies could be of higher quality. Identifying a control population, even if it is historical, allows implementation researchers to better address the impact of confounding conditions and permits more rigorous analyses, like interrupted time series or stepped wedge designs.29 The frequently employed “cross-sectional pilot study” design compares the decision made prior to a conference (or other intervention) to the final decision after the strategies are enacted, which is inherently vulnerable to multiple sources of bias. The two pragmatic, randomized-controlled trials with null results exemplify the deeper insights that can be gained by comparing trends across populations. Even more fundamental to assessing the impact of these strategies was selection of a measurable outcome, which was present in most studies, but nonetheless not universally adopted. There was also a lack of measurement of impact over time and after active strategies have concluded, which is commonly absent from implementation designs in medicine.30,31 Long-term sustainability is a separate but impactful aspect of implementation science that is inadequately addressed by the studies in this review.
One limitation of this study is in its generalizability. While we purposefully conducted a broad scoping review so that the included articles represented as much of the field as possible, the conclusions drawn from our evaluation of their content are only applicable to studies in surgical preoperative decision-making. Other specialties or contexts for de-implementation initiatives likely have characteristics that differ from those we describe. Additionally, publication bias is likely to be especially problematic in the field of implementation science, but the prominence of two large, high profile, well designed negative trials in this cohort belies that concern. Finally, although our review did include several multidisciplinary preoperative conferences, the literature concerning these sorts of reviews is vast. It is likely that more were not captured in our search because they tend to review both medical and surgical patients to determine the best course of treatment, while this review limited itself to preoperative surgical populations. Often, these conferences are not framed in an implementation lens, which may be an additional reason for their omission from our search.
There is a well-established and growing body of work that seeks to improve and support surgeons’ preoperative decision-making via behavioral interventions. Most strategies attempted to close knowledge gaps, encourage communication between providers, and broadcast institutional prioritization of change across specialties and leadership hierarchies. While largely effective, the means of bringing about such change is heterogenous and context-specific. Interventions could be better measured and improved via more consistent outcomes and comparison groups. Surgeons initiating such endeavors should consult the existing body of work advising best practices for designing, disseminating, and assessing implementation and de-implementation strategies.
Supplementary Material
Disclosures/Funding statement:
Dr. Antunez is supported by the University of Michigan Surgical Oncology Research Training Program (NIH T32 CA009672). The authors have no conflicts of interest to disclose.
Footnotes
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References:
- 1.Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019;322(15):1501–1509. doi: 10.1001/JAMA.2019.13978 [DOI] [PubMed] [Google Scholar]
- 2.Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801–1802. doi: 10.1001/JAMA.2012.476 [DOI] [PubMed] [Google Scholar]
- 3.Anderson TS, Leonard S, Zhang AJ, et al. Trends in Low-Value Carotid Imaging in the Veterans Health Administration From 2007 to 2016. JAMA Netw Open. 2020;3(9). doi: 10.1001/JAMANETWORKOPEN.2020.15250 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Mafi JN, Parchman M. Low-value care: an intractable global problem with no quick fix. BMJ Qual Saf. 2018;27(5):333–336. doi: 10.1136/BMJQS-2017-007477 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Embrett M, Randall GE. Physician perspectives on Choosing Wisely Canada as an approach to reduce unnecessary medical care: a qualitative study. Health Res Policy Syst. 2018;16(1):95. doi: 10.1186/s12961-018-0370-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Wang T, Baskin A, Miller J, et al. Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study. Ann Surg Oncol. 2021;28(2):902–913. doi: 10.1245/S10434-020-08823-W [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Weissman JS, Kelz RR, Lee CN. Appropriateness, Health Care Reform, and the Surgeon: Perspectives From the Surgical Outcomes Club. JAMA Surg. 2017;152(9):813–814. doi: 10.1001/JAMASURG.2017.1572 [DOI] [PubMed] [Google Scholar]
- 8.Antunez AG, Telem DA, Dossett LA. Assessment of Surgical Specialty Societies’ Choosing Wisely Recommendations. JAMA Surg. 2019;154(10):971–973. doi: 10.1001/JAMASURG.2019.2309 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Berlin NL, Yost ML, Cheng B, et al. Patterns and Determinants of Low-Value Preoperative Testing in Michigan. JAMA Intern Med. 2021;181(8):1115–1118. doi: 10.1001/JAMAINTERNMED.2021.1653 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Conroy PC, Wilhelm A, Calthorpe L, et al. Endocrine surgeons are performing more thyroid lobectomies for low-risk differentiated thyroid cancer since the 2015 ATA guidelines. Surgery. Published online August 21, 2022. doi: 10.1016/J.SURG.2022.06.031 [DOI] [PubMed] [Google Scholar]
- 11.Dossett LA, Wang T, Baskin AS. Deimplementation of the Choosing Wisely Recommendations for Low-Value Breast Cancer Surgery: A Systematic Review. JAMA Surg. 2020;155(8):759–770. doi: 10.1001/JAMASURG.2020.0322 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Peters S, Sukumar K, Blanchard S, et al. Trends in guideline implementation: an updated scoping review. Implement Sci. 2022;17(1). doi: 10.1186/S13012-022-01223-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Grimshaw JM, Patey AM, Kirkham KR, et al. De-implementing wisely: developing the evidence base to reduce low-value care. BMJ QualSaf. 2020;29(5):409–417. doi: 10.1136/BMJQS-2019-010060 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Peters MD, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Chapter 11: Scoping reviews. JBI Manual for Evidence Synthesis. Published online 2020. doi: 10.46658/JBIMES-20-12 [DOI] [PubMed] [Google Scholar]
- 15.Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467–473. doi: 10.7326/M18-0850 [DOI] [PubMed] [Google Scholar]
- 16.Covidence - Better systematic review management. Accessed April 18, 2023. https://www.covidence.org/
- 17.Theodorou CM, Joshi ART, Chahine AA, et al. Multi-institutional Collaborative Surgery Education Didactics: Virtual Adaptations During a Global Pandemic. J Surg Educ. 2021;78(4):1340–1344. doi: 10.1016/J.JSURG.2020.12.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Jager C, Freund T, Steinhauser J, et al. Tailored Implementation for Chronic Diseases (TICD): A protocol for process evaluation in cluster randomized controlled trials in five European countries. Trials. 2014;15(1). doi: 10.1186/1745-6215-15-87 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Ingvarsson S, Hasson H, von Thiele Schwarz U, et al. Strategies for de-implementation of low-value care—a scoping review. Implementation Science 2022 17:1. 2022;17(1):1–15. doi: 10.1186/S13012-022-01247-Y [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.McArthur A, Klugarova J, Yan H, Florescu S. Chapter 4: Systematic reviews of text and opinion. JBI Manual for Evidence Synthesis. Published online 2020. doi: 10.46658/JBIMES-20-05 [DOI] [Google Scholar]
- 21.Harvey G, Kitson A. Single Versus Multi-Faceted Implementation Strategies – Is There a Simple Answer to a Complex Question? A Response to Recent Commentaries and a Call to Action for Implementation Practitioners and Researchers. Int J Health Policy Manag. 2016;5(3):215. doi: 10.15171/IJHPM.2015.214 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Colla CH, Mainor AJ, Hargreaves C, Sequist T, Morden N. Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review. https://doi.org/101177/1077558716656970. 2016;74(5):507–550. doi: 10.1177/1077558716656970 [DOI] [PubMed] [Google Scholar]
- 23.Rogers SO, Ayanian JZ, Ko CY, et al. Surgeons’ volume of colorectal cancer procedures and collaborative decision-making about adjuvant therapies. Ann Surg. 2009;250(6):895–900. doi: 10.1097/SLA.0B013E3181AFE0C6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science. 2015;10(1):1–14. doi: 10.1186/S13012-015-0209-1/TABLES/3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Petkovic J, Riddle A, Akl EA, et al. Protocol for the development of guidance for stakeholder engagement in health and healthcare guideline development and implementation. Syst Rev. 2020;9(1). doi: 10.1186/S13643-020-1272-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Flottorp SA, Oxman AD, Krause J, et al. A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Science. 2013;8(1):1–11. doi: 10.1186/1748-5908-8-35/TABLES/1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implementation Science. 2011;6(1):1–11. doi: 10.1186/1748-5908-6-26/TABLES/6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26(1):1. doi: 10.1089/THY.2015.0020 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Miller CJ, Smith SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Psychiatry Res. 2020;283. doi: 10.1016/J.PSYCHRES.2019.06.027 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Seers K, Rycroft-Malone J, Cox K, et al. Facilitating Implementation of Research Evidence (FIRE): An international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Implementation Science. 2018;13(1):1–11. doi: 10.1186/S13012-018-0831-9/TABLES/8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implement Sci. 2008;3(1). doi: 10.1186/1748-5908-3-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
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