Impact of end user involvement in implementing guidelines on routine pre-operative tests.

Objectives: To assess the impact of health professionals' involvement in the implementation of practice guidelines aimed at reducing the use of pre-operative tests in patients at low anaesthetic risk undergoing elective surgery.

Intervention: A 6 month (September 1997 to February 1998) strategy based upon organization of local meetings involving health professionals from six hospitals of Canton Ticino (Switzerland).

Design: Observational study (pre/post) of pre-operative test utilization between March 1996 and December 1998.

Subjects And Methods: A total of 17,978 patients admitted for elective surgery over the study period. The latter was modelled in six intervals, three before (baseline), one during, and two after (adoption) guidelines implementation, respectively. For each time interval the proportion of patients undergoing pre-operative tests was estimated. Multilevel logistic regression analysis was used to assess patient likelihood [expressed as the odds ratio (OR)] of undergoing a diagnostic test in each period, using the implementation interval as the reference category.

Main Outcome Measure: Change in patient probability of undergoing pre-operative tests in the adoption interval.

Results: Adoption of the recommendations was associated with 81% [OR = 0.19; 95% confidence interval (CI) 0.15-0.23] reduction of patient probability of undergoing coagulation test, 73% (OR = 0.27; 95% CI 0.23-0.33) for glycaemia, 62% (OR = 0.38; 95% CI 0.33-0.44) for azotaemia, 57% (OR = 0.43; 95% CI 0.36-0.51) for chest X-ray, 49% (OR = 0.51; 95% CI 0.44-0.60) for creatinemia, and 43% (OR = 0.57; 95% CI 0.48-0.69) for ECG. Overall, these findings corresponded to a cost saving of 67,890 Swiss francs (US$42,000) for the last quarter under study.

Conclusions: This study indicates that an implementation strategy based upon direct involvement of end users in the identification of possible barriers to change can be successful in promoting the use of practice guidelines.