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Cited by 237Healthcare cost, quality, practicesHealth Policy Implementation ScienceBehavioral Health and Interventions

Anesthesiologists’ and surgeons’ perceptions about routine pre-operative testing in low-risk patients: application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians’ decisions to order pre-operative tests

Open access
the Canada PRIME Plus Team, Patey, Andrea M, Islam, Rafat, Francis, Jill J, Bryson, Gregory L, Grimshaw, Jeremy M·2012·Implementation Science
DOI 10.1186/1748-5908-7-52PMC PMC3522997
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Abstract

BACKGROUND: Routine pre-operative tests for anesthesia management are often ordered by both anesthesiologists and surgeons for healthy patients undergoing low-risk surgery. The Theoretical Domains Framework (TDF) was developed to investigate determinants of behaviour and identify potential behaviour change interventions. In this study, the TDF is used to explore anaesthesiologists' and surgeons' perceptions of ordering routine tests for healthy patients undergoing low-risk surgery. METHODS: Sixteen clinicians (eleven anesthesiologists and five surgeons) throughout Ontario were recruited. An interview guide based on the TDF was developed to identify beliefs about pre-operative testing practices. Content analysis of physicians' statements into the relevant theoretical domains was performed. Specific beliefs were identified by grouping similar utterances of the interview participants. Relevant domains were identified by noting the frequencies of the beliefs reported, presence of conflicting beliefs, and perceived influence on the performance of the behaviour under investigation. RESULTS: Seven of the twelve domains were identified as likely relevant to changing clinicians' behaviour about pre-operative test ordering for anesthesia management. Key beliefs were identified within these domains including: conflicting comments about who was responsible for the test-ordering (Social/professional role and identity); inability to cancel tests ordered by fellow physicians (Beliefs about capabilities and social influences); and the problem with tests being completed before the anesthesiologists see the patient (Beliefs about capabilities and Environmental context and resources). Often, tests were ordered by an anesthesiologist based on who may be the attending anesthesiologist on the day of surgery while surgeons ordered tests they thought anesthesiologists may need (Social influences). There were also conflicting comments about the potential consequences associated with reducing testing, from negative (delay or cancel patients' surgeries), to indifference (little or no change in patient outcomes), to positive (save money, avoid unnecessary investigations) (Beliefs about consequences). Further, while most agreed that they are motivated to reduce ordering unnecessary tests (Motivation and goals), there was still a report of a gap between their motivation and practice (Behavioural regulation). CONCLUSION: We identified key factors that anesthesiologists and surgeons believe influence whether they order pre-operative tests routinely for anesthesia management for a healthy adults undergoing low-risk surgery. These beliefs identify potential individual, team, and organisation targets for behaviour change interventions to reduce unnecessary routine test ordering.

AI snapshot

Written from the paper’s full text.

TL;DR

This interview study applied the Theoretical Domains Framework to explore why anesthesiologists and surgeons order routine pre-operative tests for healthy patients undergoing low-risk surgery. It identified seven potentially relevant domains, especially social/professional role and identity, beliefs about capabilities and consequences, environmental context and resources, and social influences, as targets for reducing unnecessary testing.

Key findings

  • Seven of the 12 TDF domains were judged likely relevant to changing pre-operative test-ordering behaviour: Social/professional role and identity, Beliefs about capabilities, Beliefs about consequences, Environmental context and resources, Social influences, Behavioural regulation, and Nature of the behaviour. Five domains were reported as less relevant: Knowledge, Motivation and goals, Skills, Memory/attention/decision processes, and Emotion.
  • Among 16 participants (11 anesthesiologists, 5 surgeons), 459 utterances were coded into the 12 domains, with almost perfect interrater agreement (κ = 0.84; 95% CI 0.807–0.878). Beliefs included that ordering tests was very easy (16/16), confidence in assessing a low-risk patient without pre-op tests (11/16), that reducing routine tests would save money (11/16), little or no change in outcomes (10/16), and possible delay or cancellation of surgery (9/16).
  • Clinicians reported conflicting views about who was responsible for ordering tests. Anesthesiologists described difficulty or reluctance cancelling tests ordered by surgeons and noted tests were often completed before they saw the patient; they sometimes ordered tests they felt unnecessary because a more conservative colleague might be the attending anesthesiologist. Surgeons reported ordering tests they thought anesthesiologists might need.
  • Most agreed they were motivated to reduce unnecessary tests, but a gap between motivation and practice was reported. Suggested changes included policy taking test ordering out of surgeons’ hands and better evidence that testing is unnecessary in low-risk patients.

Methods

  • Semi-structured interview study using an interview topic guide based on the Theoretical Domains Framework. The behaviour of interest was ordering pre-operative chest x-ray and electrocardiograph for anesthesia management in healthy patients having low-risk surgery (e.g., knee arthroscopy, laparoscopic cholecystectomy, cataract removal/lens replacement, and similar surgeries).
  • Sixteen clinicians in Ontario were recruited: 11 anesthesiologists (9 male; 2 female) and 5 surgeons (all male), from community (n = 3) and academic hospitals (n = 5) in six health regions. Recruitment used snowball sampling supplemented with purposive sampling; interviews lasted 14–46 minutes; data saturation occurred after 16 interviews.
  • Two researchers coded 459 utterances into the 12 TDF domains, calculated Fleiss’s kappa, and resolved disagreements by consensus. Specific beliefs were grouped, and relevant domains were identified by frequency of beliefs, presence of conflicting beliefs, and perceived influence on the behaviour.

Limitations

  • The paper states that saturation could have been reached prematurely if participants recommended others with similar opinions; that identified themes are clinicians’ views about what might influence practice, not evidence of actual influences; and that the interview guide mixed descriptive and diagnostic questions, requiring interpretation by the research team.
  • Evident from the text: the sample was small (16 clinicians), all surgeons and most anesthesiologists were male, recruitment was from a single Canadian province, surgeons were not purposively sampled by subspecialty, and the data are self-reported interview accounts, limiting generalizability.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/1748-5908-7-52

Cites

47 of 47 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 39 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Key beliefs identified included the problem with tests being completed before the anesthesiologists see the patient (Beliefs about capabilities and Environmental context and resources).

    “and the problem with tests being completed before the anesthesiologists see the patient (Beliefs about capabilities and Environmental context and resources).”
    Quote in the paperSubstantial claim
  • Findingown data

    All respondents interviewed stated that their own emotions would not influence whether they ordered pre-operative tests or not.

    “all respondents interviewed stated that their own emotions would not influence whether they ordered pre-operative tests or not”
    Quote in the paperNot a substantial claim
  • Findingown data

    Some anesthesiologists and surgeons stated that routinely ordering tests was not an important part of their pre-operative evaluation.

    “some stated that routinely ordering tests was not an important part of their pre-operative evaluation”
    Quote in the paperNot a substantial claim
  • Findingown data

    The existence of hospital directives varied from hospital to hospital throughout the province.

    “Further, the existence of hospital directives varied from hospital to hospital throughout the province”
    Quote in the paperSubstantial claim
  • Findingown data

    Evidence of the inter-professional influences among the attending surgeon performing the surgery, the anesthesiologist at pre-admission ordering the tests, and attending anesthesiologist providing intraoperative care was reported by the vast majority of respondents.

    “Second, evidence of the inter-professional influences among the attending surgeon performing the surgery, the anesthesiologist at pre-admission ordering the tests, and attending anesthesiologist providing intraoperative care was reported by the vast majority of respondents”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 68
  • May combine two claims. 34

  • Classified as probably not a substantial claim. May combine two claims.

    Findingown data

    After six interviews with anesthesiologists, it became apparent that surgeons had a strong influence on the test ordering practice of the anesthesiologists, and surgeons were added to the sampling.

    “It became apparent after these six interviews the strong influence surgeons had on the test ordering practice of the anesthesiologists and we decided to include them in the study.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that the medical directive at their hospital is that the surgeon orders the tests.

    “The medical directive at our hospital is that the surgeon orders the tests.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Some surgeons noted that pre-operative test ordering was the responsibility of the anesthesiologists.

    “some surgeons noted that pre-operative test ordering was the responsibility of the anesthesiologists”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Although anesthesiologists and surgeons greatly influence whether pre-operative test are ordered by another team member, these clinicians rarely have direct contact with one another and communication is difficult.

    “The interesting thing about the team influence is that although anesthesiologists and surgeons greatly influence whether pre-operative test are ordered by another team member, these clinicians rarely have direct contact with one another and communication is difficult.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that reducing routine tests would save money.

    “Reducing routine tests would save money.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that there is nothing in their clinic environment that influences whether they order tests or not.

    “There is nothing in my clinic environment that influences whether I order tests or not.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingown data

    Both anesthesiologists and surgeons stated that routine testing may result in false positives that require investigation, and reducing test ordering would avoid unnecessary investigations and delays.

    “They stated that routine testing may result in false positives that require investigation, and reducing test ordering would avoid unnecessary investigations and delays.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that reducing tests may delay or cancel a patient's surgery.

    “Reducing tests may delay or cancel a patient's surgery.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Sixteen participants, eleven anesthesiologists (9 male; 2 female) and five surgeons (all males), from community (n = 3) and academic hospitals (n = 5) in six health regions throughout Ontario were recruited.

    “Sixteen participants, eleven anesthesiologists (9 male; 2 female) and five surgeons (all males), from community (n = 3) and academic hospitals (n = 5) in six health regions throughout Ontario were recruited to participate in the semi-structured interviews.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Participants reported the belief that they don't need to see an ECG or CXR to do their job.

    “I don't need to see an ECG or CXR to do my job.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    While most agreed that they are motivated to reduce ordering unnecessary tests (Motivation and goals), there was still a report of a gap between their motivation and practice (Behavioural regulation).

    “Further, while most agreed that they are motivated to reduce ordering unnecessary tests (Motivation and goals), there was still a report of a gap between their motivation and practice (Behavioural regulation).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Respondents reported that hospitals commonly either failed to identify which group was specifically responsible for test ordering or identified surgeons as the group responsible for test ordering.

    “Respondents reported that hospitals commonly either failed to identify which group was specifically responsible for test ordering or identified surgeons as the group responsible for test ordering.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Participants reported the belief that the opinions of others do/do not influence their decision to order routine tests.

    “The opinions of others do/do not influence my decision to order routine tests.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that it's difficult to cancel because it's time consuming to track down the doctor.

    “It's difficult to cancel because it's time consuming to track down the doctor.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Several anesthesiologists stated that they should have complete autonomy as to what tests should be ordered.

    “several anesthesiologists stated that they should have complete autonomy as to what tests should be ordered”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Surgeons stated that they rely on the anesthesiologists to order the necessary pre-operative tests and listen to their other team member before making a decision regarding what tests to order.

    “They stated that they rely on the anesthesiologists to order the necessary pre-operative tests and listen to their other team member before making a decision regarding what tests to order”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Some surgeons mentioned that they were the most responsible physician in the operating room and as such had the ultimate responsibility to understand the whole picture.

    “others mentioned that they were the most responsible physician in the operating room and as such had the ultimate responsibility to understand the whole picture”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that they are reluctant to cancel tests ordered by other physicians.

    “I'm reluctant to cancel test ordered by other physicians.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Anesthesiologists noted that because they work with a team there is often an understanding among their colleagues as to what tests are required and they tend to be conservative and order more, to cater for majority views.

    “They also noted that because they work with a team there is often an understanding among their colleagues as to what tests are required and they tend to be conservative and order more, to cater for majority views”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that reducing routine tests would result in little or no change in outcomes.

    “Reducing routine tests would result in little or not change in outcomes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Participants reported the belief that time is/is not a factor in their decision to not order tests.

    “Time is/is not a factor in my decision to not order tests.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    The anesthesiologists and surgeons interviewed report this finding as accurate and is further supported by evidence documented by Bryson et al.

    “Yet, the anesthesiologists and surgeons interviewed report this finding as accurate and is further supported by evidence documented by Bryson et al.[29].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Bryson GL, Wyand A, Bragg PR: Preoperative testing is inconsistent with published guidelines and rarely changes management. Canadian Journal of Anesthesia/Journal canadien d'anesthqsie. 2006, 53: 236-41. 10.1007/BF03022208. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Findingown data

    Participants reported the belief that reducing routine tests may result in missing an underlying condition that may complicate surgery/recovery.

    “Reducing routine tests may result in missing an underlying condition that may complicate surgery/recovery.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The majority of anesthesiologists and surgeons were aware of the guidelines and knew they were supported by evidence-based research.

    “The majority of anesthesiologists and surgeons were aware of the guidelines and knew they were supported by evidence-based research”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

    Findingown data

    Participants reported the belief that we need policy that takes the test ordering out of the hands of the surgeons.

    “We need policy that takes the test ordering out of the hands of the surgeons.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that tests are ordered routinely because they're pretty cheap.

    “Tests are ordered routinely because there pretty cheap.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Both anesthesiologists and surgeons agreed that routine tests are a waste of time and money, unnecessary, and rarely provide any useful information.

    “Both anesthesiologist and surgeons agreed that routine tests are a waste of time and money, unnecessary, and rarely provide any useful information.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The clinicians' experience as a specialist ranged in years from 2.5 to 22 (mean ± SD, 10.72 ± 5.16).

    “The clinicians’ experience as a specialist ranged in years from 2.5 to 22 (mean ± SD, 10.72 ± 5.16).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Both anesthesiologists and surgeons mentioned that routine testing saves patients' time and if routine tests are not ordered, a patient's surgery may get cancelled or miss an underlying condition that may complicate surgery and ensures the patient is fit for the surgery.

    “Yet, they also mentioned that routine testing saves patients' time and if routine tests are not ordered, a patient's surgery may get cancelled or miss an underlying condition that may complicate surgery and ensures the patient is fit for the surgery.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that reducing routine tests would save patients' time.

    “Reducing routine tests would save patients' time.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Both anesthesiologists and surgeons mentioned that if hospitals made sure that all pre-operative testing was conducted by only anesthesiologists and took the ordering out of the hands of the surgeons, unnecessary routine testing could be reduced.

    “Both anesthesiologists and surgeons mentioned if hospitals made sure that all pre-operative testing was conducted by only anesthesiologists and took the ordering out of the hands of the surgeons, unnecessary routine testing could be reduced.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    A total of 459 utterances from the 16 interviews were coded into the 12 domains.

    “A total of 459 utterances from the 16 interviews were coded into the 12 domains.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that they don't play a role in the ordering of tests.

    “I don't play a role in the ordering of tests.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that the medical directive at their hospital dictates that no routine testing/routine testing for low-risk surgeries.

    “The Medical directive at this hospital dictates that no routine testing/routine testing for low-risk surgeries.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that because you work with a group you have to come to an agreement as to what tests are required.

    “Because you work with a group we have to come to an agreement as to what test are required.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Often, tests were ordered by an anesthesiologist based on who may be the attending anesthesiologist on the day of surgery, while surgeons ordered tests they thought anesthesiologists may need (Social influences).

    “Often, tests were ordered by an anesthesiologist based on who may be the attending anesthesiologist on the day of surgery while surgeons ordered tests they thought anesthesiologists may need (Social influences).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that they are confident that they can perform a pre-op assessment on a low-risk patient without pre-op tests.

    “I am confident that I can perform a pre-op assessment on a low-risk patient without pre-op tests.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that if tests are ordered they never/sometimes/always review them.

    “If tests are ordered I never/sometimes/always review them.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Surgeons mentioned that no one would question their request for certain tests; staff would just follow the surgeons' requests.

    “but mentioned that no one would question their request for certain tests; staff would just follow the surgeons’ requests”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Participants reported the belief that they order tests they feel are unnecessary because their conservative colleague may be in the OR the day of the surgery and want to see the routine test that they would not.

    “I order test I feel are unnecessary because my conservative colleague may be in the OR the day of the surgery and want to see the routine test that I would not.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that they can't cancel tests that were ordered by another physician.

    “I can't cancel tests that were ordered by another physician.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that reducing routine testing would avoid unnecessary investigation.

    “Reducing routine testing would avoid unnecessary investigation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Anesthesiologists and surgeons made conflicting comments as to who exactly was responsible for ordering the pre-operative tests, and responses within each professional group varied.

    “they made conflicting comments as to who exactly was responsible for ordering the pre-operative tests and responses within each professional group varied”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Participants reported the belief that patient emotions do/do not influence whether or not they order routine tests.

    “Patient emotions do/do not influence whether or not I order routine tests.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that it's very easy for them to cancel/not order tests.

    “It's very easy for me to cancel/not order tests.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that they prefer to have routine tests for patients having general anesthesia.

    “I prefer to have routine tests for patient having general anesthesia.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Participants reported the belief that their colleagues agree or do not agree with their opinion about pre-op testing.

    “My Colleagues agree/do not agree with my opinion about Pre-op testing.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Anesthesiologists and surgeons stated that there was no set of specific skills required to order pre-operative test and that nurses, general practitioners, and other physicians (internists) can order them if appropriately trained.

    “they stated that there was no set of specific skills required to order pre-operative test and that nurses, general practitioners, and other physicians (internists) can order them if appropriately trained”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that it's very easy for them to order tests.

    “It's very easy for me to order tests.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants reported the belief that it's difficult to cancel/not order because most often the tests are completed before they see the patient.

    “It's difficult to cancel/not order because most often the tests are completed before I see the patient.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Findingnone given

    The anesthesiologists and surgeons interviewed appear to lend credence to this report.

    “Further the anesthesiologists and surgeons interviewed appear to lend credence to this report.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The Theoretical Domains Framework can be used to inform the choice of potential behaviour change techniques to develop interventions as well as to investigate determinants of behaviour.

    “The Theoretical Domains Framework (TDF) can be used to inform the choice of potential behaviour change techniques to develop interventions as well as to investigate determinants of behaviour [20].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A: Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005, 14: 26-10.1136/qshc.2004.011155. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Two pilot interviews were used to formulate a coding strategy; the first was coded by two researchers in tandem, and the second ensured the two coders were comfortable with the strategy.

    “Two pilot interviews were used to formulate a coding strategy. The first pilot interview was coded by two researchers in tandem to develop the coding strategy, and the second was used to ensure the two coders were comfortable with the strategy developed from the first.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Two researchers coded interview participants' responses into the relevant theoretical domains.

    “Two researchers (AMP, RI) coded interview participants’ responses into the relevant theoretical domains.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Participants were asked to recommend additional anesthesiologists with differing opinions in an attempt to avoid premature saturation.

    “Additionally, in an attempt to avoid premature saturation, we asked the participants to recommend additional anesthesiologists with differing opinions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A randomized control study of over 19,000 cataract patients found no benefit to routine pre-operative medical testing when stratified according to age, gender, or race of the patient, and most abnormalities in laboratory values could be predicted from patient's history and physical exam.

    “A randomized control study (RCT) of over 19,000 cataract patients found no benefit to routine pre-operative medical testing when stratified according to age, gender, or race of the patient, and most abnormalities in laboratory values could be predicted from patient’s history and physical exam [4].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [4] Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, Petty BG, Steinberg EP: The value of routine preoperative medical testing before cataract surgery. N Engl J Med. 2000, 342 (3): 168-175. 10.1056/NEJM200001203420304. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Many pre-operative tests are routinely ordered for apparently healthy patients without any clinical indication, and the subsequent test results are rarely used.

    “However, many pre-operative tests are routinely ordered for apparently healthy patients without any clinical indication, and the subsequent test results are rarely used [2].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] Thanh NX, Rashiq S, Jonsson E: Routine preoperative electrocardiogram and chest x-ray prior to elective surgery in Alberta, Canada. Canadian Journal of Anesthesia/Journal canadien d’anesthqsie. 2010, 57: 127-33. 10.1007/s12630-009-9233-4. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Michie et al. applied a systematic consensus approach to develop a framework grounded in psychological theory that simplifies theories relevant to behaviour change; the consensus identified 12 theoretical domains from 33 theories and 128 constructs that may explain health-related behaviour change.

    “Michie et al. [20] applied a systematic consensus approach to develop a framework grounded in psychological theory that simplifies theories relevant to behaviour change. The consensus identified 12 theoretical domains from 33 theories and 128 constructs that may explain health-related behaviour change.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A: Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005, 14: 26-10.1136/qshc.2004.011155. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Subsequent coding of the remaining interviews was completed independently and Fleiss's Kappa was calculated for all domains and interviews to assess whether the two researchers coded the same response into the same domain.

    “Subsequent coding of the remaining interviews was completed independently and Fleiss’s Kappa (κ) was calculated for all domains and interviews to assess whether the two researchers coded the same response into the same domain [26,27].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [26] Fleiss JL: Measuring nominal scale agreement among many raters. Psychol Bull. 1971, 76: 378- source

      Not checked in the free run.

    • cites [27] Fleiss JL: The measurement of interrater agreement. Statistical methods for rates and proportions. 1981, 2: 212-36.

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    The Canadian Anesthesiologists' Society guidelines advocate that investigations should not be ordered on a routine basis, but should be based on the patient's health status, drug therapy, and with consideration to the proposed surgical intervention.

    “They advocate that investigations should not be ordered on a routine basis, but should be based on the patient’s health status, drug therapy, and with consideration to the proposed surgical intervention [7].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] Merchant R, Bosenberg C, Brown K, Chartrand D, Dain S, Dobson J, Kurrek M, LeDez K, Morgan P, Penner M: Guidelines to the Practice of Anesthesia Revised Edition 2011 - Guide d’exercice de l'anesthésie Édition révisée 2011. Canadian Journal of Anesthesia. 2011, 58: 74-107. 10.1007/s12630-010-9416-z. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The interview topic guide was pilot tested with two anesthesiologists, and wording of some questions was modified to fit the context of the behaviour; subsequent piloting with a further two anesthesiologists resulted in additional wording changes to enhance clarity of one question.

    “After pilot testing with two anesthesiologists, wording of some questions from the original TDF had to be modified to fit the context of the behaviour. Subsequent piloting with a further two anesthesiologists resulted in additional wording changes to enhance clarity of one question”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In an RCT of 1,057 ambulatory patients, there was no significant difference between rates of perioperative adverse events and rates of adverse events 30 days after surgery between patients who received pre-operative tests ordered according to the Ontario Pre-operative Testing Grid and those who received no pre-operative tests routinely ordered for anesthesia management.

    “They reported no significant difference between rates of perioperative adverse events and the rates of adverse events 30 days after surgery between groups [6].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT: Elimination of preoperative testing in ambulatory surgery. Anesth Analg. 2009, 108: 467-10.1213/ane.0b013e318176bc19. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Bryson reported that surgeons were responsible for 80% of the test ordering that were in non-compliance with the Ontario Pre-operative Testing Grid at the Ottawa Hospital.

    “Bryson reported that surgeons were responsible for 80% of the test ordering that were in non-compliance with the Ontario Pre-operative Testing Grid at the Ottawa Hospital [10].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Bryson GL, Wyand A, Bragg PR: Preoperative testing is inconsistent with published guidelines and rarely changes management [Les tests preoperatoires ne correspondent pas aux directives publiees et modifient rarement la ligne de conduite]. Canadian Journal of Anesthesia. 2006, 53: 236-41. 10.1007/BF03022208. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    Three factors were considered when identifying key domains: frequency of the beliefs across interviews; presence of conflicting beliefs; and perceived strength of the beliefs impacting the behaviour.

    “Briefly, three factors were considered when identifying key domains: frequency of the beliefs across interviews; presence of conflicting beliefs; and perceived strength of the beliefs impacting the behaviour.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    A surgeon may order the tests 'in case' the attending anesthesiologist needs it and in hopes that the patient will move smoothly through the pre-admission assessment process.

    “A surgeon may order the tests ‘in case’ the attending anesthesiologist needs it and in hopes that the patient will move smoothly through the pre-admission assessment process.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    These beliefs identify potential individual, team, and organisation targets for behaviour change interventions to reduce unnecessary routine test ordering.

    “These beliefs identify potential individual, team, and organisation targets for behaviour change interventions to reduce unnecessary routine test ordering.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Changing the beliefs identified in this study would change clinicians' pre-operative test-ordering behaviour.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Responses coded in different domains by the researchers were discussed to establish consensus; where single domain allocation agreement could not be reached, researchers agreed the response could be placed in both domains.

    “Responses that were coded in different domains by the researchers were discussed to establish consensus. In instances where single domain allocation agreement could not be reached, researchers agreed that the response could be placed in both domains.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A study by Lingard et al. found marked differences in the professionals' perceptions around issues of role authority, motivation, and value with respect to communication among team members.

    “They found marked differences in the professionals’ perceptions around issues of role authority, motivation, and value with respect to communication among team members.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Lingard L, Reznick R, DeVito I, Espin S: Forming professional identities on the health care team: discursive constructions of the ‘other’ in the operating room. Medical education. 2002, 36: 728-34. 10.1046/j.1365-2923.2002.01271.x. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The anesthesiologist who sees the patient prior to the surgery orders the tests 'in case' the attending anesthesiologist needs them and could not cancel tests ordered by the surgeon because they have not identified the reason for ordering the tests.

    “The anesthesiologist who sees the patient prior to the surgery orders the tests ‘in case’ the attending anesthesiologist needs them and could not cancel tests ordered by the surgeon because they have not identified the reason for ordering the tests.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    The likelihood that an alternative professional group would review another's guidelines is rare because they struggle to keep up-to-date with their own ever-changing evidence-based practice.

    “The likelihood that an alternative professional group would review another’s guidelines is rare because they struggle to keep up-to-date with their own ever-changing evidence-based practice.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    All disagreements between researchers were resolved through consensus.

    “Further, although initial interrater reliability was calculated, all disagreements between researchers were resolved through consensus.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The strategy for generating and grouping belief statements was reviewed by the second researcher to ensure accurate representation of content.

    “This strategy was reviewed by the second researcher (RI) to ensure accurate representation of content.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    A directive by hospital management that is supported by the professional groups involved, as to which group holds the role and responsible for ordering the tests required for anesthesia management would likely reduce confusion and encourage greater consistency in test ordering practices.

    “A directive by hospital management that is supported by the professional groups involved, as to which group holds the role and responsible for ordering the tests required for anesthesia management would likely reduce confusion and encourage greater consistency in test ordering practices.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    One researcher generated statements representing specific beliefs from each participant's responses.

    “One researcher (AMP) generated statements that represented the specific beliefs from each participant’s responses that captured the core thought and continued this process for every response.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Relevant domains were identified through consensus discussion between the two researchers and confirmed by a health psychologist.

    “Relevant domains were identified through consensus discussion between the two researchers (AMP, RI) and confirmed by a health psychologist (JJF).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There has been a large body of work reporting pre-operative testing practices.

    “There has been a large body of work reporting pre-operative testing practices [2,4,6,10,31-33].”
    Quote in the paperNot a substantial claim0 of 7 sources checked
    • cites [2] Thanh NX, Rashiq S, Jonsson E: Routine preoperative electrocardiogram and chest x-ray prior to elective surgery in Alberta, Canada. Canadian Journal of Anesthesia/Journal canadien d’anesthqsie. 2010, 57: 127-33. 10.1007/s12630-009-9233-4. source

      Not checked in the free run.

    • cites [4] Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, Petty BG, Steinberg EP: The value of routine preoperative medical testing before cataract surgery. N Engl J Med. 2000, 342 (3): 168-175. 10.1056/NEJM200001203420304. source

      Not checked in the free run.

    • cites [6] Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT: Elimination of preoperative testing in ambulatory surgery. Anesth Analg. 2009, 108: 467-10.1213/ane.0b013e318176bc19. source

      Not checked in the free run.

    • cites [10] Bryson GL, Wyand A, Bragg PR: Preoperative testing is inconsistent with published guidelines and rarely changes management [Les tests preoperatoires ne correspondent pas aux directives publiees et modifient rarement la ligne de conduite]. Canadian Journal of Anesthesia. 2006, 53: 236-41. 10.1007/BF03022208. source

      Not checked in the free run.

    • cites [31] Imasogie N, Wong DT, Luk K, Chung F: Elimination of routine testing in patients undergoing cataract surgery allows substantial savings in laboratory costs. A brief report [L'elimination des tests de routine, avant l'operation de la cataracte, permet de reduire de facon importante les depenses de laboratoire. Un rapport sommaire.]. Canadian Journal of Anesthesia. 2003, 50: 246-8. 10.1007/BF03017792. source

      Not checked in the free run.

    • cites [32] Finegan BA, Rashiq S, McAlister FA, O'Connor P: Selective ordering of preoperative investigations by anesthesiologists reduces the number and cost of tests. Canadian Journal of Anesthesia/Journal canadien d'anesthqsie. 2005, 52: 575-80. 10.1007/BF03015765. source

      Not checked in the free run.

    • cites [33] Archer C, Levy AR, McGregor M: Value of routine preoperative chest x-rays: a meta-analysis. Canadian Journal of Anesthesia/Journal canadien d'anesthqsie. 1993, 40: 1022-7. 10.1007/BF03009471. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Bryson et al. was the only paper reviewed to suggest a need to change 'established behaviour' that should include not only anesthesiologists but surgical colleagues and clinic personnel.

    “Bryson et al. was the only paper reviewed to suggest a need to change ‘established behaviour’ that should include not only anesthesiologists but surgical colleagues and clinic personnel [10].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Bryson GL, Wyand A, Bragg PR: Preoperative testing is inconsistent with published guidelines and rarely changes management [Les tests preoperatoires ne correspondent pas aux directives publiees et modifient rarement la ligne de conduite]. Canadian Journal of Anesthesia. 2006, 53: 236-41. 10.1007/BF03022208. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    This study is one of the first to attempt to examine why anesthesiologists and surgeons order routine pre-operative tests when no clinical indicators exist.

    “This study is one of the first to attempt to examine why anesthesiologists and surgeons order routine pre-operative tests when no clinical indicators exist.”
    • Also stated in: § Conclusion · plain
      “This study is one of the first to attempt to examine why anesthesiologists and surgeons order routine pre-operative tests.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    A systematic review by Munro et al. reported that the value of pre-operative ECGs in predicting postoperative cardiac complications seems to be very small, and the indirect evidence suggests that routinely recorded pre-operative ECGs as a baseline measure are likely to be of little or no value.

    “A systematic review by Munro et al. reported that the value of pre-operative ECGs in predicting postoperative cardiac complications seems to be very small, and the indirect evidence suggests that routinely recorded pre-operative ECGs as a baseline measure are likely to be of little or no value [34].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] Munro J, Booth A, Nicholl J: Routine preoperative testing: a systematic review of the evidence. Health Technology Assessment (Winchester, England). 1997, 1 (12): 1-62.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Their findings are consistent with ours in identifying a problem in the lack of clarity relating to roles of surgeons and anesthesiologists.

    “Although their study looked at four professional groups, their findings are consistent with ours in identifying a problem in the lack of clarity relating to roles of surgeons and anesthesiologists.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    They suggest that communications of these team members are probably motivated by some combination of concern for the patient, the day's schedule, ethical issues, economic implications, and many other factors.

    “They suggest that communications of these team members are probably motivated by some combination of concern for the patient, the day’s schedule, ethical issues, economic implications, and many other factors [30]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Lingard L, Reznick R, DeVito I, Espin S: Forming professional identities on the health care team: discursive constructions of the ‘other’ in the operating room. Medical education. 2002, 36: 728-34. 10.1046/j.1365-2923.2002.01271.x. source

      Not checked in the free run.

81 of 81

  • The paper relies on this without support.

    Changing the beliefs identified in this study would change clinicians' pre-operative test-ordering behaviour.

    “These beliefs identify potential individual, team, and organisation targets for behaviour change interventions to reduce unnecessary routine test ordering.”

  • The paper relies on this without support.

    The TDF domains and specific beliefs elicited in interviews capture the determinants of pre-operative test-ordering behaviour.

    “In this study, we used the TDF to systematically examine the beliefs of anaesthesiologists and surgeons about the use of pre-operative testing routinely ordered for anesthesia management in healthy patients undergoing low-risk surgical procedures.”

  • The paper relies on this without support.

    Participants' self-reported beliefs accurately reflect their actual test-ordering behaviour.

    “An interview topic guide was developed based on the Theoretical Domains Framework to elicit beliefs about each domain for the behaviour”

  • The paper relies on this without support.

    Translating guidelines into clinical practice is difficult when one healthcare professional has decision-making autonomy, and even more so when a group of professionals are responsible, as with pre-operative test ordering.

    “Translating guidelines into clinical practice is notoriously difficult when one healthcare professional has decision-making autonomy; it can be even more so when a group of professionals are responsible, as is the case with pre-operative test ordering.”

  • The paper relies on this without support.

    The frequency with which a domain is mentioned by participants reflects its importance as an influence on test-ordering behaviour.

    “Of the seven identified the five that appeared to be the most influential, based on the frequency of utterances coded and content of the responses, were Social/professional role and identity, Beliefs about capabilities, Beliefs about consequences, Environmental context and resources, and Social influences.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Cites

Flagged first, then by citations

2 of the 49 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. Badner N, Bryson G, Kashin B, Mensour M, Riegert D, van Vlymen J, Wong D: Ontario Preoperative testing grid. 2004, Available from URL; http://gacguidelines.ca/pdfs/tools/Ontario%20Preoperative%20Testing%20Grid.pdf , Endorsed by the Ontario Guidelines Advisory Committee,
  2. Hux J: Preoperative testing prior to elective surgery. Hospital Quarterly. 2003, 6: 27-
  3. Bryson GL, Wyand A, Bragg PR: Preoperative testing is inconsistent with published guidelines and rarely changes management. Canadian Journal of Anesthesia/Journal canadien d'anesthqsie. 2006, 53: 236-41. 10.1007/BF03022208. · DOI · Paper page

Cited by

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Related

Authors
the Canada PRIME Plus Team, Patey, A. M., Islam, R., Francis, J. J., Bryson, G. L., & Grimshaw, J. M.
Affiliations
  • Ottawa Hospital Research Institute (CA)
  • University of Aberdeen (GB)
  • University of Ottawa (CA)
Corresponding author
Patey, Andrea M
ORCID
Venue
Implementation Science
Publisher
Springer Science and Business Media LLC
Published
2012-06-09
Volume
7
Issue
1
Pages
52-52
ISSN
1748-5908 (ISSN-L)
DOI
10.1186/1748-5908-7-52
PMC
PMC3522997
OpenAlex
W2094924948
Semantic Scholar
cee40a4133c9a22af3d2838f9ea7aa7b73e1c6b2
Cited by
237
References
49
Citations by year
2026: 10 · 2025: 15 · 2024: 34 · 2023: 26 · 2022: 26 · 2021: 25 · 2020: 13 · 2019: 23 · 2018: 13 · 2017: 17 · 2016: 10 · 2015: 9 · 2014: 12 · 2013: 4
FWCI
14.20
Type
journal article
Language
en
Open access
Licence
Locations
  • Implementation Science (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • City Research Online (City University London) (acceptedVersion)
  • Minerva Access (University of Melbourne) (submittedVersion, cc-by)
  • Aberdeen University Research Archive (Aberdeen University) (submittedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
  • uO Research (University of Ottawa) (submittedVersion, public-domain)
Funders
Canadian Institutes of Health Research
Topics
  • Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Social Sciences › Psychology › Applied Psychology › Behavioral Health and Interventions
Keywords
preoperative screening, low-risk surgery, Theoretical Domains Framework, clinician behavior change, anesthesiologists, surgeons, clinician perceptions, behaviour change interventions, overuse of diagnostic tests
MeSH terms
Anesthesiology, Clinical Competence, Decision Making, Environment, Female, Humans, Interprofessional Relations, Interviews as Topic, Health Knowledge, Attitudes, Practice, Male, Medicine, Motivation, Ontario, Perception, Physicians, Preoperative Care, Risk Factors, Professional Role

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

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