What is the impact of «Do not do» recommendations in a hospital surgical department?

Zambrana-Luque, José Luis; Sánchez-Benítez, Almudena; Rodríguez-Galán, Juan; Zambrana-García, José Luis
doi:10.1016/j.redare.2019.11.004
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2013&#44; the Ministry of Health launched the initiative &#8220;Commitment to the quality in Scientific Societies in Spain&#8221; with the main aim of reducing the use of unnecessary health interventions&#44; i&#46;e&#46;&#44; non-priority interventions that are not cost-effective&#44; have no proven efficacy&#44; and minimal or questionable effect&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the case of the Spanish Society of Anaesthesiology&#44; the Ministry selected 5 &#8220;Don&#8217;t do&#8221; recommendations&#44; including&#58; 1&#41; Do not perform preoperative chest radiography in patients under 40 years of age with ASA I or II physical status&#44; and 2&#41; Do not systematically perform preoperative tests in cataract surgery&#44; unless indicated based on clinical history and physical examination&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Seven years on&#44; few investigators have evaluated the impact of these recommendations on daily practice&#46; This prompted us to undertake a study to analyse the impact of these 2 recommendations in the surgical block of a local hospital&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The Hospital de Montilla Montilla&#44; Cordoba is a public hospital attending a population of approximately 64&#44;000 individuals&#46; Our staff includes 6 doctors specialized in anaesthesiology and critical care&#46; Our hospital performs around 3100 surgeries per year&#44; of which around 60&#37; correspond to major outpatient surgery&#44; 18&#37; to scheduled surgery&#44; and the rest to minor surgery&#46; In 2015&#44; we raised awareness of the &#8220;Don&#8217;t do&#8221; initiative in our hospital by holding a clinical session in the anaesthesiology service&#44; putting the documentation and references at the disposal of our staff&#44; and including the &#8220;Don&#8217;t do&#8221; objectives in our management contract&#46; We conducted an observational&#44; retrospective study in all patients undergoing in-hospital scheduled surgery or major outpatient surgery between 2017 and 2018 and collected data on the number of preoperative tests performed&#44; and the number of chest radiographs performed in patients under 40 years of age&#44; with ASA status I or II&#44; and the reason for such radiographs&#46; The results are expressed as the absolute number of surgeries by specialty in 2017 and 2018&#44; and the number of radiography studies performed in patients under 40 years in both periods&#46; The study was approved by our hospital&#8217;s Ethics Committee&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows our results&#46; A total of 2101 scheduled surgeries were performed in 2017&#44; and 2218 in 2018&#46; We observed a 1&#37; decrease in the number of preoperative studies performed&#44; mainly in ophthalmology &#8722;7&#37;&#41;&#44; with little change in other specialties&#46; Twenty three studies in patients under 40 years with ASA status I or II were considered unnecessary in 2017 &#40;3&#46;5&#37; of the total&#41; compared to 3 in 2018 &#40;&#8722;3&#46;1&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Our results show that raising awareness among anaesthesiologists of the &#8220;Don&#8217;t do&#8221; recommendations successfully reduced the number of unnecessary studies&#46; The practice of performing chest radiographs in patients under 40 years with no lung disease has been practically eliminated&#44; although the overall reduction in preoperative studies has been more modest&#44; and mostly limited to ophthalmology&#46; These results are not as satisfactory as we had hoped&#46; We believe the main reasons for this poor response has been unwillingness to accept certain recommendations&#44; unwillingness to change standard practices&#44; a desire to avoid litigation for alleged negligence or malpractice&#44; and the relative short interval between the 2 measurements&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There is scant mention in the literature on the impact of the &#34;Don&#8217;t do&#34; recommendations on clinical practice&#46; Early trends in some of the few studies published have shown that such campaigns have a modest effect on the number of radiological and cardiological tests performed&#44; while other types of diagnostic and therapeutic interventions actually increased&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In Spain&#44; studies in the context of laboratory studies have observed a 19&#37; reduction in testing following awareness raising campaigns&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; active dissemination of &#8220;Don&#8217;t dos&#8221; among anaesthesiologists effectively reduces unnecessary testing&#44; although more time and other actions are probably needed to improve results&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Zambrana-Luque J&#46;L&#46;&#44; S&#225;nchez-Ben&#237;tez A&#46;&#44; Rodr&#237;guez-Gal&#225;n J&#46;&#44; Zambrana-Garc&#237;a J&#46;L&#46; &#191;Cu&#225;l es el impacto de la implantaci&#243;n de recomendaciones &#171;No hacer&#187; en un bloque quir&#250;rgico hospitalario&#63; Rev Esp Anestesiol Reanim&#46; 2019&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.redar.2019.11.007">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;redar&#46;2019&#46;11&#46;007</span></p>"
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