1. From PDF to Practice The Gap Between What We Know and What We Do
uOttawa.ca
From PDF to Practice
The Gap Between What We Know and What We Do
Presented by: Gregory L Bryson, Toronto Interactive Anesthesia
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Département d'anesthésiologie | Department of Anesthesiology

2. David Fear Lecture
Community anesthesia practice 1970 to 1985, Sick Kids , continuing professional development, standards,

3. Diffusion of knowledge
How long does it take to get evidence to practice?
1 year
5 years
10 years
15 years

4. The long and winding road
Original Research
Publication + Indexing (1.5 yrs)
Citation (6 to 13 years)
Implementation (9 years)
9 clinical procedures, everything from flu shots to thrombolysis for MI. Date of landmark publication identified. Date when 50% use identified recorded.

5. Disclosures Deputy Editor-in-Chief, Canadian Journal of Anesthesia5
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.
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6. 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

7. Preoperative testing (SR)
“For all the tests reviewed, a policy of routine
testing in apparently healthy individuals is likely
to lead to little, if any, benefit.”
Systematic review, largely of observational trials. CXR, ECG, CBC, coags, chemistry and urine.

8. Testing before cataract surgery
No Testing
N = 9624
RR (95% CI)
Events
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
1.00 (0.9 to 1.2)
“perioperative morbidity and mortality are not reduced by routine use of commonly ordered preoperative medical tests”
Schein O. N Engl J Med 2000; 342(3):

9. NICE guideline

10. Ontario Preoperative Testing Grid

11. Testing before ambulatory surgery
No Testing
N=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):
Randomly assigned to testing per Ontario grid or NOTHING.
Mixture of roughly 25% each ortho, plastics, ophthalmology.
Intraop events difficult intubation (4) arrythmia (3), laryngospasm (2)
Postoperative events pain (8), PONV (7), HTN (3), dizziness (3)

12. Abnormal tests before herniorrhaphy
Cohort
N = 73,596
% Abn
Major Complications
(OR 95% CI)
Wound Complications
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)
NSQIP data day outcomes.
Major complications unplanned intubation, pulmonary embolism, stroke, coma for greater than 24 hours, renal failure requiring dialysis, my- ocardial infarction, cardiac arrest, sepsis, septic shock, blood trans- fusions, or death.
Wound complications superficial and deep surgical site infections, organ space infections, and wound dehiscence.
“Physician and/or facility preference and not only patient condition currently dictate use.”
Benarroch-Gampel J. Ann Surg 2012;256(3):

13. Preop Testing in Ontario (2008-13)
% Endo
(95% CI)
N = 892,644
% Ophth
N = 759,906
% Low-Risk
N = 571,520
% Total
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)
2.9
(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)
30% of OPHTH patients get an ECG that’s 228K ECGs.
10% of all outpatients get a CXR that’s 222K CXRs.
Kirkham K. CMAJ DOI: /cmaj

14. Indirect standardized rates of preoperative electrocardiography (ECG).
Indirect standardized rates of preoperative electrocardiography (ECG). Each point represents the indirect standardized rate of preoperative ECG for a single institution, and the associated vertical line represents the institution’s 95% confidence interval for the testing rate. The dashed horizontal line denotes the mean rate of testing across all institutions.
Kyle R. Kirkham et al. CMAJ 2015;187:E349-E358
©2015 by Canadian Medical Association

15. Indirect standardized rates of preoperative chest radiography.
Indirect standardized rates of preoperative chest radiography. Each point represents the indirect standardized rate of preoperative chest radiography for a single institution, and the associated vertical line represents the 95% confidence interval for the testing rate. The dashed horizontal line denotes the mean rate of testing across all institutions.
Kyle R. Kirkham et al. CMAJ 2015;187:E349-E358
©2015 by Canadian Medical Association

16. 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 DOI: /cmaj

18. 4 Elements of Knowledge Translation
Synthesis
Dissemination
Exchange
Ethically-sound application
Synthesis – drawing together individual study data into a coherent body of knowledge (not necessarily meta-analysis).
Dissemination – tailoring the message and the medium to the audience
Exchange – intearction between researcher and knowledge user
Ethical application – compliant with norms, values and regulation.

20. 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.”

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

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

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

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

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

26. Preop Testing in Ontario (2008-13)
% Endo
(95% CI)
N = 892,644
% Ophth
N = 759,906
% Low-Risk
N = 571,520
% Total
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)
2.9
(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)
30% of OPHTH patients get an ECG that’s 228K ECGs.
10% of all outpatients get a CXR that’s 222K CXRs.
Kirkham K. CMAJ DOI: /cmaj

27. Exchange with Knowledge Users
Anesthesiologists
Surgeons
Administration
Patients

28. 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

29. Somebody Else’s Solution
Patey AF, Implement Sci, 2012;7(1):52

30. 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

31. 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

32. 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.

33. Work with patients

34. The long and winding road
Original Research
Publication + Indexing (1.5 yrs)
Citation (6 to 13 years)
Implementation (9 years)
9 clinical procedures, everything from flu shots to thrombolysis for MI. Date of landmark publication identified. Date when 50% use identified recorded.

35. Conclusion Synthesis of observational studies in 1997
Dissemination in guideline form in 2003
In Ontario , we ordered ECGs
30% of low risk surgeries
3 – 80% rates in different institutions
There is work to do.
Engagement
Ethical application

36. Questions, for you …
What is the greatest barrier to reducing testing in your practice?
What would it take to make your most conservative colleague happy?
Would your surgeons and administration buy in?
Will your patients feel undertreated?
How will you react if your patient questions why they are being tested?