Mechanisms of decision-making in preoperative assessment for older adult prostate cancer patients – a qualitative study

Abstract

Background and Objective

Little research exists which investigates the contextual factors and hidden influences that inform surgeons and surgical teams decision-making in preoperative assessment when deciding whether to or not to operate on older adult prostate cancer patients living with aging-associated functional declines and illnesses. The aim of this study is to identify and examine the underlying mechanisms that uniquely shape preoperative surgical decision-making strategies concerning older adult prostate cancer patients.

Methods

Qualitative methodologies were used that paired ethnographic field observations with semi-structured interviews for data collection. An inductive thematic analysis approach was used to identify, analyze, and describe patterns in the data.

Results

Factors underlining surgical decision-making originated from the context of two categories: (1) clinical and surgery-specific factors; and (2) non-patient factors. Thematic subcategories included personal experiences, methods of assessment during medical encounters, anticipation of outcomes, perceptions of preoperative assessment instruments for frailty and multimorbidity, routines and workflow patterns, micro-cultures, and indirect observation & second-hand knowledge.

Conclusion

Surgeon’s personal experiences has a significant impact on the decision-making processes during preoperative assessments. However, non-patient factors such as institutional micro-cultures passively and actively influence decision-making process during preoperative assessment.

INTRODUCTION

Prostate cancer is the second most common form of cancer diagnosed among men in the United States [1]. It is projected that there will be 164,690 new cases and 29,430 deaths in 2018 as a result of the disease [2], and older men represent the majority of prostate cancer diagnoses and mortalities [3]. In general, radical prostatectomy is considered one of the primary treatments available with curative intent for men diagnosed with clinically localized prostate cancer and a life expectancy of more than 10 years [4–8]. Given that older adults (defined herein as age 65 years or more [11, 12]) account for a significant ratio of the patient population, special attention and consideration must be given by surgeons and surgical teams during the stages of preoperative assessment when deciding whether or not to operate.

However, the decision to operate in older adults is a complex task since the rate of adverse postoperative outcomes increases proportionally with age due to aging-associated functional declines and illnesses [9–11]. In particular, frailty and multimorbidity are among the most prevalent conditions that burden older adults, which lead to adverse postoperative outcomes [12–18]. Although decision-aids are available to assist in evaluating risk for patients living with aging-associated functional declines and illnesses [19–27], providers largely prefer to utilize traditional preoperative assessments [28–30]. This method involves surgeons relying on their ‘clinical judgement’ to recognize individual risk factors and predict postoperative outcomes [31, 32]. It is largely based on an unstructured approach (also referred to as ‘clinical gestalt’), which relies on surgeons using a combination of their individually acquired knowledge, expertise, and critical analysis to assess a patient’s surgical risk and postoperative outcomes [33]. Thus, the subjective nature of clinical gestalt implies that there is an inherent risk of variation in assessment among surgeons when engaging in the decision-making process to make a clinical judgment [34]. As surgeons’ general preference is to use gestalt for preoperative assessment, there is an increasing need to better understand the underlying mechanisms that uniquely shape decision-making strategies in preoperative assessment for older adult prostate cancer patients. Furthermore, research concerning surgical decision-making strategies for older adult prostate cancer patients living with co-existing conditions has been surprisingly limited and the existing studies investigating the intersection between prostate cancer and aging-associated declines and illnesses have largely focused on quantitative trends to study treatment outcomes [20, 35–38].

The present study seeks to address this gap in the literature by using qualitative research methodologies to identify and examine the strategies that surgeons and their surgical teams use during the stages of preoperative assessment for older adult prostate cancer patients. More specifically, this study will examine the mechanisms and often hidden processes in clinic practices that inform the decision-making strategies of surgeons and their surgical teams when assessing older adult prostate cancer patients living with aging-associated functional declines and illnesses. The results of this study provide new insight into the complex and subjective processes that shape preoperative assessments for older adult prostate cancer patients.

MATERIALS AND METHODS

We used a qualitative research approach to address our research objectives, which paired ethnographic field observations with semi-structured interviews. The rationale for using qualitative research in this study was to identify the strategies used by urologists and members their surgical teams during the preoperative assessment encounters with prostate cancer patients living with co-existing conditions and then to investigate the extent to which different factors affect their clinical judgment. Qualitative methods can reveal information from the perspective of those experiencing it, such as how behaviors are influenced by internalized notions of norms, traditions, roles, and values [39]. All study participants were in-full time practice working at the Urologic Oncology Clinic of a major academic medical center that serves a mix of government- and privately insured patients.

Participant Recruitment

We recruited purposive samples of fellowship-trained urologic oncologists, advanced practice providers (physician assistants and nurse practitioners), and nurses with experience in the treatment of patients with prostate cancer and multiple co-existing conditions. Study recruitment was halted once systematic initial coding of interview transcripts and observational field notes revealed data collection had reached “saturation” (e.g. new interviews and observations were not revealing additional themes or information) [40]. All participants in the study were given a brief project overview, and they provided written consent for both direct observation and interviews. No clinicians declined to participate in either the field observations or the interview portion of the study. The institutional review board at the University of Michigan approved this study.

Data Collection

We collected data using both direct observations and semi-structured interviews. We observed workflow and medical encounters for over 186 hours with particular attention to observing interactions among patients and providers. Using this approach, we observed 158 clinical encounters in total. The typical length of these encounters ranged from 15 to 20 minutes between patients and advanced practice providers and 10 to 15 minutes between patients and urologists, reflecting the average 30-minute time slot allocated for consultations. As time allowed, we also conducted informal interviews to clarify our observations. We transcribed all field notes after observation and stored them in an electronic document during fieldwork periods. We used our initial notes to refine observations and formulate topics to consider during additional observations in the clinics.

In addition to direct observation, we conducted semi-structured interviews with five urologists and four advanced practice providers. Lasting between 20 and 60 minutes, all interviews were conducted using an interview guide that covered topics concerning a provider’s day-to-day interactions with colleagues and patients, perceptions of different approaches in medical decision-making, managing incoming and outgoing patient referrals, and interpretations of sample cases. The language used in the sample cases was tailored to match the terminology used by the providers. We piloted the guide for content and length with another urologist prior to interviewing our study participants. All interviews were conducted in person, using offices and conference rooms located in the clinic. Interviews were audio recorded, professionally transcribed verbatim (including all the interviewer’s interjections), and anonymized. All interview participants were compensated $50 for their time.

Data Analysis

Fieldwork notes and interview transcripts were transferred to the qualitative analysis software program NVivo 11 (QSR International) for analysis. We used an inductive thematic analysis approach as described by Braun and Clarke to identify, analyze, and describe patterns in the data in order to investigate a diversity and range of our study participants experiences [41]. Three authors (PK, MDV, SG) independently coded each interview and field note observations to develop, then validate, our codebook. The preliminary version of the codebook comprising both structural and contextual codes in reading the first three transcripts and was iteratively refined over the coding process. Key concepts, ideas and notes were discussed between members of the study team. Ideas which recurred across the entire dataset or which represented an important idea in relation to the research questions were identified as categories. The research study team engaged in reflective note-taking during all stages of the study. Transcripts were read, re-read, and coded line-by-line by multiple study team members. Discrepancies in coding were resolved by adopting a consensus approach. We remained open to new codes and categories when appropriate [42]. As new categories were identified, previous transcripts were re-examined for relevant material. After coding all transcripts, content was grouped into common themes and discussed among the full study team.

RESULTS

Study Participants

In total, five surgical urologists, four advanced practice providers, and one mid-level provider agreed to participate in this study. All urologists were men, had more than 10 years of clinical experience, and were active in urologic research. All advanced practice providers were women with more than 10 years of clinical experience, and had specialized training degrees (e.g. nurse practitioner, physician assistant). The registered nurse was a woman with more than 10 years of clinical experience.

Qualitative Themes

The results here include the main themes identified through the data analysis. We defined mechanisms of decision-making in this study as factors that directly or indirectly affected urologists, advanced practice providers, and the registered nurse’s medical decision-making activities. These were identified as meaningful and observable events that contained an implicit or explicit choice of action, which influenced evaluation of the patient’s surgical candidacy (e.g. interpretation of patient’s health and prediction of their postoperative outcomes). Factors underlining decision-making originated from the context of two core categories: (1) clinical and surgery-specific factors (Table 1); (2) and non-patient factors (Table 2). These categories were further divided into thematic subcategories to further elaborate the reasoning behind the provider’s decision-making behaviors in preoperative assessment of older adult prostate cancer patients.

Table 1:

Clinical and surgery-specific factors - Emerged themes, and their subcategories

Clinical and surgery-specific factors
Subcategories	Definition
Personal experiences	Having a good level of knowledge-based reasoning developed through constructive processes.
Methods of assessment during medical encounters	Approaches used by clinicians to measure the risks and benefits of operative and non-operative procedures for patients as part of the medical encounter.
Anticipation of outcomes	Situations of patterned intuition concerning clinicians’ inclination to predict the outcomes of a surgical intervention.
Perceptions of preoperative assessment instruments for frailty and multimorbidity	Clinicians view on validated scoring systems, risk indices, and other decision-aids designed to measure the level of frailty and morbidities present in a surgical candidate.

Table 2:

Non-patient factors - Emerged themes and their subcategories

Non-patient-factors
Subcategories	Definition
Routines and workflow patterns	The arrangements and sequence of tasks consistently established in the individual clinic practices.
Micro-cultures	The relationships established between clinicians in the individual teams in terms of clinic workflow structures and productivity.
Indirect observation & second-hand knowledge	Clinical information that was observed, collected, and delivered by the mid-level provider to the attending surgeon.

Clinical and surgery-specific factors

Clinical and surgery-specific factors were defined as the catalysts motivating individual decision-making behaviors in terms of preferred evaluation methods to assess surgical risk and candidacy during clinical encounters.

Personal Experiences

In the interviews, the majority of the clinicians identified the importance of relying on their personal experience in the clinical setting when asked about the significant factors that underlined the processes of their medical decision-making. We defined “personal experience” as knowledge-based reasoning that clinicians developed through constructive processes — the pulling together of information and knowledge from events that happened in the past.

Urologists emphasized that their ability to determine whether a patient was a candidate for radical prostatectomy developed through accumulated professional knowledge and experiences. These factors assisted them in forming a comprehensive understanding of the clinical picture during the medical encounter in order to make clinical judgements. Two explained:

“It’s kind of a gestalt observing the patient, and based on clinical experience, and knowing from experience” (Urologist 04).

“Good surgeons are good at selecting … Part of it, I think, is innate” (Urologist 05).

Methods of assessment

The methods of assessment used to evaluate patients during medical encounters were generally homogenous across a surgeon’s surgical team members. We defined methods of assessment as the strategies used to measure the risks/benefits of both operative and non-operative procedures.

Urologists stated in the interviews that they often relied on the ‘eyeball test’ to determine whether surgery would be in the best interest of the patient. The eyeball test was favored for two reasons: (1) visual examinations were perceived to be efficient; and (2) its validation of the experiential knowledge of the provider. One urologist explained,

“In prostate cancer, it’s less of an issue [validated preoperative assessment tools], only because we rely on the crude eyeball test” (Urologist 03).

Our observations confirmed that for the majority of urologists, their approach to assessment was situational and patient specific. Also, we observed that the eyeball test was used as a follow-up to confirm the initial impressions that they had developed of the patient based upon reviewing the medical record, imaging files, and summary of observation and reporting delivered to them by the advanced practice providers. For example, in a case involving a 66-year patient with idiopathic pulmonary fibrosis, the urologist decided that surgery was not in the best interest of the patient after reviewing the medical record and learning from the advanced practice provider that the patient was on home oxygen. He clarified:

“(T)he lung transplant patient was not a candidate for surgery or radiation oncology, and (we) need to send this information to the patient’s lung doctors. The goal … is to get the focus back on the patient’s lung disease, which is looking bad.” (Observation, Sep 7, 2017).

Similarly, advanced practice providers explained that the eyeball test is part of assessing the patients’ functional status prior to relaying their findings to the urologist:

“How I assess people is functional status, and just the total picture, and what they’re able to do” (Advanced practice provider 01).

Anticipation of outcomes

In several instances, urologists generally anticipated poorer outcomes when encountering older men considered at an elevated risk or not suitable for surgery due to factors such a significantly advanced age or limited life expectancy. Anticipation of outcomes was defined as a situation where urologists predicated an elevated risk concerning poor and/or non-beneficial postoperative outcomes.

During the observations, urologists often concluded that older men who were in a significantly higher age bracket would not benefit from surgery because: (a) postoperative outcomes generally lead to poorer functional outcomes; and (b) surgery would not be beneficial for men with limited life expectancy. For example:

“He is 83 and will likely lose urinary control following any kind of surgical intervention. He has low-grade Gleason-6 disease and would likely do well on active surveillance” (Observation, Jan 24, 2018).

“He went into detail describing radiation, and noted surgery is not an option given [the patient’s] other medical issues. He wouldn’t be able to take his medication and would be at risk of a stroke … At 76 years old,” [Urologist 05] added, “you don’t need a 30-year fix.” (Observation, April 13, 2017)

Perceptions of decision-aids for preoperative assessment

From our observations, providers did not integrate decision-aids into clinical practice and did not view them as beneficial in their practice. Perceptions of decision-aids for preoperative assessment were defined as providers’ view on validated scoring systems, risk indices, and other decision-aids designed to measure risk and predict postoperative outcomes.

Urologists emphasized that decision-aids were not part of clinic practice. The most frequently cited reason for not integrating instruments into clinic practice was the perceived lack of benefit of preoperative assessment instruments. For example:

“We don’t routinely use in prostate cancer in particular” (Urologist 03).

“It just is not practical. I mean, there’s a lot of nomograms out there and various tools available, but the majority of it is dependent upon our clinical experience” (Urologist 04).

Non-patient factors

Non-patient factors were defined as situations where decision-making behaviors were influenced by the unique, complex, and social environments of individual clinics, which led to distinctive patterns in workflow and productivity.

Routines and workflow patterns

Clinics broadly shared similar routines and workflow patterns in terms of assessing new patients referred to the clinic for assessment. Routines and workflow patterns were defined as the arrangements and sequence of tasks consistently established in the individual clinic practices.

Mid-level providers and urologists generally shared similar patterns of work distribution across practices. Mid-level providers served as the first point of contact for the patient to collect information concerning the patient’s medical history as well as perform a physical exam. They would then summarize and discuss their findings with the urologist in the staff room. Routines and workflow patterns were generally developed over an extended period of time with the overall aim of improving clinic efficiency:

“One thing [Urologist 05] and I have learned over the years is how to be very efficient, because we have a high-volume clinic. He knows what I do and I know what he does. We have worked out a system that has worked very well... I tend to try to spend more time with the patients and do a lot of counseling so that he can go in, talk about the surgery very efficiently and get out” (Advanced practice provider 05).

Furthermore, these periods of extended collaboration led to increases in relationship trust between urologists and advanced practice providers. One urologist explained that the establishment of trust was a positive outcome of working together regularly:

“(W)e sit down at the end of every clinic. We go through the list of patients, and we make sure that we dot our I’s and cross our T’s for each patient, and we have a game plan” (Urologist 01).

“I think we have a nice, solid team, and we’ve been together for the majority of the time to build relationships” (Advanced practice provider 03).

We also observed deviations from the standard work patterns and roles. There were several instances where urologists would take the initiative to meet with the patients first if the advanced practice provider was preoccupied, or if they wanted to mitigate any potential delays to the schedule:

“I notice that [Urologist 04] isn’t there but that he has already taken multiple charts and crossed off patients from the appointment list … sometimes he just goes straight into the next room to see patients back-to-back” (Observation, January 25, 2017).

Others were comfortable with the advanced practice providers also entering data into the electronic medical record.

Micro-cultures

The micro-cultures of individual clinics affected routines and workflow patterns. Micro-cultures were defined as the relationships established between providers in the individual teams in terms of clinic workflow structures and productivity. Important components of workflow structure and productivity included authority and autonomy to execute roles and tasks within the practice environment.

Practice cultures determined by individual urologists had implications for whether members of their practice team took on a more passive or active role in both their working relationship with the urologist and in patient care. This can lead to differences in perceived authority and autonomy between advanced practice providers in terms of their roles at the clinic. In some clinics, advanced practice providers took on a more restrained role and often reiterated to patients that the urologist was the provider most qualified to discuss their treatment options with them.

Whereas in another clinic, an advanced practice provider working with a different urologist took on a more proactive role in recommending treatment to patients prior to the involvement of the urologist. For example, one advanced practice provider told the patient:

“Surgery doesn’t sound good [for you]. Also, there are many quality of life issues after” (Observation, June 26, 2017).

Additionally, individual clinic practices generated differences in autonomy among advanced practice providers with respect to referral practices: in particular, providers’ ability to make referral decisions for patients who required additional care outside the prostate cancer clinic. As one advanced practice provider explained:

“Independently I typically, for most everything else, make referrals. With the PSAs, it just depends on what their pathology was, too. I mean not everyone with a Gleason six needs to go to radiation. That depends on if there is (a) focal positive margin, extraprostatic extension, pT3a (disease) … that kind of thing. Well, you would want to refer them sooner rather than later. I usually just refer those folks” (Advanced practice provider 05)

In contrast, another advanced practice provider explained that she would only create a referral if asked by the urologist:

“I will put the referrals in based on what the doctor asks, verbal from the doctor” (Advanced practice provider 03).

Indirect observation and second-hand knowledge

As part of the workflow, urologists’ initial impressions about patients’ surgical candidacy were influenced by the information provided to them via indirect observation and second-hand knowledge. We define indirect observation and second-hand knowledge as clinical information that was observed, collected, and delivered by the advanced practice provider to the attending urologist.

Urologists’ initial impressions were generally shaped by their advanced practice providers’ summary of the clinical findings. Prior to meeting with the patient, urologists review the observations compiled by their advanced practice provider concerning patients’ functional status and character. There were several instances where advanced practice providers would deliver their findings along with a reflection on the potential diagnoses or accompanied by other information not documented in the patient’s charts:

“[Advanced practice provider 01] further explains how ‘the patient was disappointed by his PSA.’ She also mentions the patient’s pain and says that it could be sciatic pain” (Observation, January 16, 2017).

Advanced practice providers both actively and passively influenced medical decision-making activities in cases where they made diagnosis and treatment recommendations to the urologist. For example, when discussing a patient with stroke history and high blood pressure, an advanced practice provider suggested to the urologist that radiation would be the better option:

“[Advanced practice provider 05] briefed [Urologist 05], noting she’d recommend radiation. [Urologist 05] agreed they should try to get him [patient] to see radiation oncology today.” (Observation, April 13, 2017).

We also found that some advanced practice providers believed that their opinions influenced urologists’ decisions:

“I think my assessment will play into some of his opinion of when he walks in the room, what he’s (going to) see when he goes in there” (Advanced practice provider 01).

“(I) get input from what other providers are managing their care to try to make that assessment as to whether they’re a surgical patient or not” (Advanced practice provider 02).

This dynamic between urologists and advanced practice providers was also reflected in the instances where urologists’ initial thoughts about outgoing patient referrals were influenced by advanced practice providers. For example, one urologist summarized how the advanced practice provider’s knowledge of previous referrals had implications for his referral decision-making:

“I could just see over time where I would need to refer somebody to the local medical oncologist, and she [Advanced practice provider 01] would say, actually, I know from working with another provider that there’s a medical oncologist in Grand Rapids named so-and-so that we’ve used. Then I say, ‘Great.’” (Urologist 01)

DISCUSSION

In this study, we used qualitative research methods to examine variations in surgeon and surgical team decision-making strategies used during preoperative assessments to inform clinical judgement of prostate cancer patients with co-existing conditions. Findings from our study imply that clinician’s ‘personal experience’ has a significant impact on the decision-making processes during preoperative assessments. At the same time, our study suggests that these variations in decision-making for preoperative assessment may be shaped by non-patient factors. In particular, institutional micro-cultures and the organization of surgeon and advanced practice provider relationships both directly and indirectly play a role in the decision-making process.

This paper addresses the processes of surgeons and surgical teams decision-making strategies—an important issue which has been under explored in previous research. Similar to other studies, a factor that significantly informs surgical decision-making is the provider’s personal experience [43–45]. Surgeons in our study were confident that they could intuitively make decisions based on their individually accumulated clinical experience. Although surgeons prefer this method, it can lead to inaccuracies and inconsistencies such as: (1) diagnostic errors as a result of cognitive biases [46–48]; (2) variations between surgeons decision-making [34]; (3) poor estimation of operative risk [49]; and (4) risk of biased approaches by surgeons when assessing older adult vulnerable patients [50]. Preoperative assessment decision-based aids are available to minimize inaccuracy and inconsistency; however, our findings suggest a lack of incorporation of these tools into clinical practice. Potential reasons for this may be that these tools require changes in routines, as well as additional time and resource investment [51, 52]. Alternatively, some surgeons may perceive that these tools compare unfavorably to gestalt [53].

A significant issue uniquely identified in this study are the antecedent circumstances that shape individual cognitive experiences and perceptions in decision-making behavior. In line with studies on idioculture [54], where the cultural context of social interactions influence how employees conceptualize a system of knowledge, beliefs, behaviors, and customs, our observations and interviews found that antecedent circumstances consisted of processes in clinic workflow structures and productivity patterns. That is, individual clinic practices developed unique, complex, and social environments, which led to distinctive workflow and productivity patterns, each of which affected how “personal experience” was conceptualized and shaped by the providers in question. In particular, ‘micro-cultures’ in surgeon and advanced practice provider relationships played a clear role as a precursor in provider decision-making. In our observations, advanced practice providers primarily served to assist in obtaining the clinical risk profiles of patients, which involved performing the initial patient assessment (obtaining and crosschecking medical histories, performing physical examinations, and interpreting diagnostic tests) and providing the summary of their findings to the surgeon prior to the surgeon meeting the patient.

Advanced practice providers roles have been well-documented in several other studies detailing their high-level of clinical competency [55, 56] and the role that they play in assisting physicians’ productivity [57]. Differing dynamics of autonomy in clinical practice teams also led to situations where some advanced practice providers could independently manage internal and external patient referrals (both inside and outside surgeons’ professional network). Apart from their functional activities, we observed that they influenced a surgeon’s decision-making. Advanced practice providers’ interpretations of the patient’s background information, health status, and overall clinical risk profile also informed surgeons’ initial preoperative assessments. Advanced practice providers in this study articulated their opinions concerning the surgical suitability of patients; they also anticipated challenges to their reasoning, based on the patient’s medical background, as well as surgeons’ opinions concerning the referring provider.

There are several avenues for further exploration arising from this study. There is a need to further examine the relationships between the components that make up personal experience and surgical decision-making for high-risk patients living with multimorbidity and frailty in a variety of clinical settings. While this paper presents a study within a urologic oncology setting, physicians and advanced practice providers from other units can use the findings to examine what factors lead to variations in between their staff in preoperative assessment for high-risk patients. As this study has also shown, focusing on the micro-culture between clinicians allowed us to develop some understanding of the dynamic of relationships between clinicians and how it can shape surgeons’ decisions. Future studies could explore aspects related to professional identify, complexities of power, the social relations that exist in the clinical context, and the administrative and institutional factors affecting clinic culture.

Limitations

These findings are subject to limitations. This study captures only a small portion of a rich culture within prostate cancer care teams. Because ethnographic research reflects phenomena as they were experienced during a specific time-period and under certain conditions, the replicability of our findings are inherently limited. Furthermore, the study participants observed and the experiences related by our interviewees may not reflect the perceptions and experiences of all clinicians working in urologic oncology. Although a concentrated effort was made to present an accurate account of the staff experiences, this study may be biased by the researcher’s interpretations. As with any observational study, the Hawthorne effect was a potential data confounder [58]. The research team met frequently to discuss and jointly code collected data to increase the credibility of the data.

CONCLUSIONS

Given the growing burden and prevalence of prostate cancer in the aging population, understanding the variances between clinicians in the preoperative assessment of patients living with a combination of co-existing conditions has increasing public health significance. The population of this patient cohort is expected to increase along with the growing demand for patients seeking to qualify for curative treatment such as radical prostatectomy. Because this patient population is at a heightened risk of significant adverse health outcomes often beyond the effects of a singular condition, the prevention of postoperative complications and mortality is an important issue in surgery. Clinicians have to carefully engage in a series of intricate evaluation processes to assess a patient’s surgical candidacy. Because information is critical as an input into the decision-making process, surgeons’ cognitive processing could unintentionally be influenced without them being aware of it. The extent of these incidences vary between clinics as a result of varying interprofessional boundaries that shape the practice culture. Because of the diverse and evolving dynamics of inter-professional relationships, we conclude that the type and culture of interaction between surgeons and their surgical team members can both passively and actively introduce variation into the decision-making process.

Synopsis.

This paper addresses the processes of surgeons and surgical teams decision-making strategies. Our study suggests that ‘personal experience’ has a significant impact on the decision-making processes during preoperative assessments. At the same time, we found that variations in decision-making for preoperative assessment are shaped by non-patient factors, such as institutional micro-cultures and the organization of surgeon and advanced practice provider relationships.