Abstract：
BACKGROUND: Choosing Wisely Canada and most major anesthesia and preoperative guidelines recommend against obtaining preoperative tests before low-risk procedures. However, these recommendations alone have not reduced low-value test ordering. In this study, the theoretical domains framework (TDF) was used to understand the drivers of preoperative electrocardiogram (ECG) and chest X-ray (CXR) ordering for patients undergoing low-risk surgery (\'low-value preoperative testing\') among anesthesiologists, internal medicine specialists, nurses, and surgeons.
METHODS: Using snowball sampling, preoperative clinicians working in a single health system in Canada were recruited for semi-structured interviews about low-value preoperative testing. The interview guide was developed using the TDF to identify the factors that influence preoperative ECG and CXR ordering. Interview content was deductively coded using TDF domains and specific beliefs were identified by grouping similar utterances. Domain relevance was established based on belief statement frequency, presence of conflicting beliefs, and perceived influence over preoperative test ordering practices.
RESULTS: Sixteen clinicians (7 anesthesiologists, 4 internists, 1 nurse, and 4 surgeons) participated. Eight of the 12 TDF domains were identified as the drivers of preoperative test ordering. While most participants agreed that the guidelines were helpful, they also expressed distrust in the evidence behind them (knowledge). Both a lack of clarity about the responsibilities of the specialties involved in the preoperative process and the ease by which any clinician could order, but not cancel tests, were drivers of low-value preoperative test ordering (social/professional role and identity, social influences, belief about capabilities). Additionally, low-value tests could also be ordered by nurses or the surgeon and may be completed before the anesthesia or internal medicine preoperative assessment appointment (environmental context and resources, beliefs about capabilities). Finally, while participants agreed that they did not intend to routinely order low-value tests and understood that these would not benefit patient outcomes, they also reported ordering tests to prevent surgery cancellations and problems during surgery (motivation and goals, beliefs about consequences, social influences).
CONCLUSIONS: We identified key factors that anesthesiologists, internists, nurses, and surgeons believe influence preoperative test ordering for patients undergoing low-risk surgeries. These beliefs highlight the need to shift away from knowledge-based interventions and focus instead on understanding local drivers of behaviour and target change at the individual, team, and institutional levels.
METHODS: Using snowball sampling, preoperative clinicians working in a single health system in Canada were recruited for semi-structured interviews about low-value preoperative testing. The interview guide was developed using the TDF to identify the factors that influence preoperative ECG and CXR ordering. Interview content was deductively coded using TDF domains and specific beliefs were identified by grouping similar utterances. Domain relevance was established based on belief statement frequency, presence of conflicting beliefs, and perceived influence over preoperative test ordering practices.
RESULTS: Sixteen clinicians (7 anesthesiologists, 4 internists, 1 nurse, and 4 surgeons) participated. Eight of the 12 TDF domains were identified as the drivers of preoperative test ordering. While most participants agreed that the guidelines were helpful, they also expressed distrust in the evidence behind them (knowledge). Both a lack of clarity about the responsibilities of the specialties involved in the preoperative process and the ease by which any clinician could order, but not cancel tests, were drivers of low-value preoperative test ordering (social/professional role and identity, social influences, belief about capabilities). Additionally, low-value tests could also be ordered by nurses or the surgeon and may be completed before the anesthesia or internal medicine preoperative assessment appointment (environmental context and resources, beliefs about capabilities). Finally, while participants agreed that they did not intend to routinely order low-value tests and understood that these would not benefit patient outcomes, they also reported ordering tests to prevent surgery cancellations and problems during surgery (motivation and goals, beliefs about consequences, social influences).
CONCLUSIONS: We identified key factors that anesthesiologists, internists, nurses, and surgeons believe influence preoperative test ordering for patients undergoing low-risk surgeries. These beliefs highlight the need to shift away from knowledge-based interventions and focus instead on understanding local drivers of behaviour and target change at the individual, team, and institutional levels.
摘要：
背景：明智选择加拿大和大多数主要的麻醉和术前指南建议不要在低风险程序之前进行术前检查。然而,这些建议本身并没有降低低价值测试顺序。在这项研究中,理论领域框架（TDF）用于了解麻醉医师中接受低风险手术（“低值术前测试”）的患者的术前心电图（ECG）和胸部X射线（CXR）排序的驱动因素，内科专家，护士,还有外科医生.
方法：使用雪球采样，我们招募了在加拿大单一卫生系统中工作的术前临床医生,对低价值术前检测进行半结构化访谈.使用TDF开发了访谈指南，以确定影响术前ECG和CXR排序的因素。使用TDF域对采访内容进行演绎编码，并通过对相似的话语进行分组来识别特定的信念。领域相关性是基于信念陈述频率建立的，存在冲突的信念，以及对术前测试订购实践的感知影响。
结果：16名临床医生（7名麻醉师，4个内科医生，1名护士,和4名外科医生)参与。12个TDF域中的8个被确定为术前测试排序的驱动因素。虽然大多数参与者都认为指南是有帮助的，他们还对背后的证据(知识)表示不信任。既不清楚术前过程中涉及的专业的责任，也不容易让任何临床医生订购，但不能取消测试,是低价值术前测试顺序的驱动因素(社会/职业角色和身份，社会影响,关于能力的信念)。此外,低价值测试也可以由护士或外科医生订购，并且可以在麻醉或内科术前评估预约之前完成(环境背景和资源，关于能力的信念)。最后,虽然参与者同意他们不打算常规订购低价值测试，并理解这些不会有利于患者的结果，他们还报告了订购测试，以防止手术取消和手术期间的问题(动机和目标，关于后果的信念，社会影响)。
结论：我们确定了麻醉医师的关键因素，内科医生,护士,和外科医生认为影响患者的术前检查顺序接受低风险手术。这些信念突出表明，需要摆脱基于知识的干预措施，而将重点放在理解当地的行为驱动因素和针对个人的改变上。团队,和机构层面。
方法：使用雪球采样，我们招募了在加拿大单一卫生系统中工作的术前临床医生,对低价值术前检测进行半结构化访谈.使用TDF开发了访谈指南，以确定影响术前ECG和CXR排序的因素。使用TDF域对采访内容进行演绎编码，并通过对相似的话语进行分组来识别特定的信念。领域相关性是基于信念陈述频率建立的，存在冲突的信念，以及对术前测试订购实践的感知影响。
结果：16名临床医生（7名麻醉师，4个内科医生，1名护士,和4名外科医生)参与。12个TDF域中的8个被确定为术前测试排序的驱动因素。虽然大多数参与者都认为指南是有帮助的，他们还对背后的证据(知识)表示不信任。既不清楚术前过程中涉及的专业的责任，也不容易让任何临床医生订购，但不能取消测试,是低价值术前测试顺序的驱动因素(社会/职业角色和身份，社会影响,关于能力的信念)。此外,低价值测试也可以由护士或外科医生订购，并且可以在麻醉或内科术前评估预约之前完成(环境背景和资源，关于能力的信念)。最后,虽然参与者同意他们不打算常规订购低价值测试，并理解这些不会有利于患者的结果，他们还报告了订购测试，以防止手术取消和手术期间的问题(动机和目标，关于后果的信念，社会影响)。
结论：我们确定了麻醉医师的关键因素，内科医生,护士,和外科医生认为影响患者的术前检查顺序接受低风险手术。这些信念突出表明，需要摆脱基于知识的干预措施，而将重点放在理解当地的行为驱动因素和针对个人的改变上。团队,和机构层面。
