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From PDF to PracticeThe Gap Between What We Know and What We Do

Presented by: Gregory L Bryson, Toronto Interactive Anesthesia 2015-11-21

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Département d'anesthésiologie | Department of Anesthesiology

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David Fear Lecture

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Diffusion of knowledge

How long does it take to get evidence to practice?

a. 1 yearb. 5 yearsc. 10 yearsd. 15 years

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The long and winding road

Original Research

Publication + Indexing (1.5 yrs)

Citation (6 to 13 years)

Implementation (9 years)

http://www.ihi.org/resources/Pages/Publications/Managingclinicalknowledgeforhealthcareimprovement.aspx

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Disclosures

• Deputy Editor-in-Chief, Canadian Journal of Anesthesia• National Co-Chair, Choosing Wisely Canada – CAS• Supported by

– The Department of Anesthesiology, uOttawa– Ottawa Hospital Anesthesia Alternate Funds Assoc.

5

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Objectives• 1. Identify the four elements of knowledge translation• 2. Appraise the evidence regarding effectiveness and

utilization of preoperative tests.• 3. Identify Choosing Wisely Canada – Canadian

Anesthesiologists’ Society recommendations • 4. Advise me on means to communicate-implement

these recommendations.

For references and links follow me @glbryson

Download my slides from

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Preoperative testing (SR)

“For all the tests reviewed, a policy of routinetesting in apparently healthy individuals is likelyto lead to little, if any, benefit.”

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Testing before cataract surgery

TestingN = 9626

No TestingN = 9624

RR (95% CI)Events per

1000Events per

1000

Death 2 0.2 1 0.1 2.00 (0.2 to 22.0)

Hospital 33 3.4 28 2.9 1.17 (0.7 to 2.0)

Other 266 27.6 272 28.3 0.97 (0.8 to 1.2)

Total 301 31.3 301 31.3 1.00 (0.9 to 1.2)

Schein O. N Engl J Med 2000; 342(3): 168-175

“perioperative morbidity and mortality are not reduced by routine use of commonly ordered preoperative medical tests”

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NICE guideline

http://www.nice.org.uk/guidance/cg3

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Ontario Preoperative Testing Grid

www.gacguidelines.ca/site/GAC_Guidelines/.../Projects_Preop_Grid.doc

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Testing before ambulatory surgery

TestingN=527

No TestingN=499

RR (95% CI)

Intraoperative 7 (13.3) 7 (14.0) 0.95 (0.33 to 2.68)

Postoperative 21 (4.0) 16 (3.2) 1.24 (0.66 to 2.35)

Readmission 30 days 3 (0.6) 2 (0.4) 1.42 (0.24 to 8.46)

Chung F. Anesth Analg 2009; 108(2):467-475

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Abnormal tests before herniorrhaphyCohortN = 73,596

% Abn Major Complications(OR 95% CI)

Wound Complications

(OR 95% CI)

Hematology (n = 43,153)

39.3 1.29 (0.95 to 1.75) 0.96 (0.76 to 1.20)

Biochemistry(n = 39,402)

40.2 1.28 (0.93 to 1.75) 1.15 (0.90 to 1.45)

Coagulation(n = 13,746

11.3 1.52 (0.86 to 2.65) 1.16 (0.66 to 2.05)

Liver Function(n = 17,433)

22.8 1.50 (0.90 to 2.49) 1.14 (0.79 to 1.65)

Benarroch-Gampel J. Ann Surg 2012;256(3): 518-28

“Physician and/or facility preference and not only patient condition currently dictate use.”

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Preop Testing in Ontario (2008-13)

% Endo(95% CI)

N = 892,644

% Ophth(95% CI)

N = 759,906

% Low-Risk(95% CI)

N = 571,520

% Total(95% CI)

N = 2,224,070

ECG 15.1(15.0 to

15.2)

32.0(31.9 to 32.1)

54.6(54.5 to 54.7)

31.0(30.9 to 31.1)

ECHO 2.7(2.7 to 2.7)

3.2(3.2 to 3.2)

2.7(2.7 to 2.7)

2.9(2.9 to 2.9)

Stress 2.2 (2.2 to 2.2)

1.8(1.8 to 1.8)

2.5(2.5 to 2.5)

2.1(2.1 to 2.1)

CXR 9.0(8.9 to 9.1)

6.7(6.6 to 6.8)

19.0(18.9 to 19.1)

10.8 (10.8 to 10.8)

Kirkham K. CMAJ 2015. DOI:10.1503 /cmaj.150174

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Indirect standardized rates of preoperative electrocardiography (ECG).

Kyle R. Kirkham et al. CMAJ 2015;187:E349-E358©2015 by Canadian Medical Association

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Indirect standardized rates of preoperative chest radiography.

Kyle R. Kirkham et al. CMAJ 2015;187:E349-E358©2015 by Canadian Medical Association

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That’s you, and me, and that guy.

“Despite existing recommendations — testing before low-risk procedures was common … significant regional and institution-level variation was present, with a 30-fold difference between institutions with the lowest and highest rates of ordering tests.”

Kirkham K. CMAJ 2015. DOI:10.1503 /cmaj.150174

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http://imgur.com/gallery/iWKad22

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4 Elements of Knowledge Translation

• Synthesis• Dissemination• Exchange• Ethically-sound application

http://www.cihr-irsc.gc.ca/e/29418.html

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http://www.choosingwiselycanada.org/recommendations/anesthesiology/

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Choosing Wisely Canada

“Choosing Wisely Canada (CWC) is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care.”

http://www.choosingwiselycanada.org/about/what-is-cwc/

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Don’t order baseline laboratory studies (complete blood count, coagulation testing, or serum biochemistry) for asymptomatic patients undergoing low-risk non-cardiac surgery.

http://www.choosingwiselycanada.org/recommendations/anesthesiology/

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Don’t order a baseline electrocardiogram for asymptomatic patients undergoing low-risk non-cardiac surgery.

http://www.choosingwiselycanada.org/recommendations/anesthesiology/

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Don’t order a baseline chest X-ray in asymptomatic patients, except as part of surgical or oncological evaluation.

http://www.choosingwiselycanada.org/recommendations/anesthesiology/

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Don’t perform resting echocardiography as part of preoperative assessment for asymptomatic patients undergoing low to intermediate-risk non-cardiac surgery.

http://www.choosingwiselycanada.org/recommendations/anesthesiology/

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Don’t perform cardiac stress testing for asymptomatic patients undergoing low to intermediate risk non-cardiac surgery.

http://www.choosingwiselycanada.org/recommendations/anesthesiology/

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Preop Testing in Ontario (2008-13)

% Endo(95% CI)

N = 892,644

% Ophth(95% CI)

N = 759,906

% Low-Risk(95% CI)

N = 571,520

% Total(95% CI)

N = 2,224,070

ECG 15.1(15.0 to

15.2)

32.0(31.9 to 32.1)

54.6(54.5 to 54.7)

31.0(30.9 to 31.1)

ECHO 2.7(2.7 to 2.7)

3.2(3.2 to 3.2)

2.7(2.7 to 2.7)

2.9(2.9 to 2.9)

Stress 2.2 (2.2 to 2.2)

1.8(1.8 to 1.8)

2.5(2.5 to 2.5)

2.1(2.1 to 2.1)

CXR 9.0(8.9 to 9.1)

6.7(6.6 to 6.8)

19.0(18.9 to 19.1)

10.8 (10.8 to 10.8)

Kirkham K. CMAJ 2015. DOI:10.1503 /cmaj.150174

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Exchange with Knowledge Users

• Anesthesiologists• Surgeons• Administration• Patients

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Theoretical Domains of Testing

• 11 anesthesiolgists, 5 surgeons• 6 health regions in Ontario• Structured interview

– Healthy patient– Minor surgery (cataract, hernia, arthroscopy)

• Theoretical Domains Framework– 12 domains that influence decision-making– Knowledge, skills– Professional role – identity– Beliefs about consequences

Patey AF, Implement Sci, 2012;7(1):52

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Somebody Else’s Solution

Patey AF, Implement Sci, 2012;7(1):52

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Everyone is Choosing Wisely

• Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery. Cardiology

• Don’t order annual electrocardiograms (ECGs) for low-risk patients without symptoms. Cardiology

• Don’t routinely perform preoperative testing (such as chest X-rays, echocardiograms, or cardiac stress tests) for patients undergoing low risk surgeries. Internal Medicine

• Don’t order screening chest X-rays and ECGs for asymptomatic or low risk outpatients. Family Medicine

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Even These Guys are Choosing Wisely

• Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present. Nuclear Medicine

• Avoid routine preoperative laboratory testing for low risk surgeries without a clinical indication. Pathology

• Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam. General Surgery

http://www.choosingwiselycanada.org/recommendations/

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Work with your administration

• North York General Hospital– Adopted CWC in June 2014– Focus in ED– 40% reduction in laboratory costs– No change in outcome.

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Work with patients

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The long and winding roadOriginal Research

Publication + Indexing (1.5 yrs)

Citation

(6 to 13 years)

Implementation (9 years)

http://www.ihi.org/resources/Pages/Publications/Managingclinicalknowledgeforhealthcareimprovement.aspx

uOttawa.ca

Conclusion

• Synthesis of observational studies in 1997• Dissemination in guideline form in 2003• In Ontario 2008-2013, we ordered ECGs

– 30% of low risk surgeries– 3 – 80% rates in different institutions

• There is work to do.• Engagement• Ethical application

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Questions, for you …

1. What is the greatest barrier to reducing testing in your practice?

2. What would it take to make your most conservative colleague happy?

3. Would your surgeons and administration buy in?

4. Will your patients feel undertreated?5. How will you react if your patient questions

why they are being tested?