The Institute of Medicine (IOM) suggests that up to 30% of healthcare is considered low-value, defined as 'a test or treatment for which there is no evidence of benefit to the patient or where there is evidence of more harm than benefit'. The investigators have previously found that more than 31% of Ontario patients, who go home the same day as their surgery, receive unnecessary cardiac testing and/or chest x-rays. In addition, the investigators identified an almost 30-fold variability in how tests are ordered between different hospitals. While identification of low-value care is an important first step, additional efforts are required to reduce this waste. The investigators previously explored the reasons behind low value test ordering through a qualitative study of surgeons and anesthesiologists. This work has informed the development of a theory-based intervention to reduce wasteful ordering. The proposed project will conduct a hospital level randomized controlled trial to determine if preoperative testing ordered by anesthesiologist and supported by a focused implementation strategy can decrease the use of low-value investigations before elective surgery where patients will go home the same day.

The Institute of Medicine's (IOM) quality improvement framework includes the three pillars of underuse, overuse and misuse, though misuse and underuse have largely been the historical focus of quality improvement efforts (1). More recently, there is increasing recognition of the problem of overuse relating to "low-value care", defined as 'a test or treatment for which there is no evidence of patient benefit or where there is evidence of more harm than benefit'. The IOM suggests that as much as 30% of healthcare qualifies as low-value, which can lead to: poor patient outcomes due to adverse events of treatments or secondary unwarranted tests (with potential for over-treatment of incidental findings); and inefficient use of scarce healthcare resources threatening the sustainability of healthcare systems. In the context of Ontario, this would equate to over $15 billion wasted on low-value care in 2014 representing a major threat to the sustainability of the Ontario healthcare system. Unfortunately, recent studies have demonstrated similar levels of low-value care in Ontario currently, and suggest that there are considerable opportunities to reduce this waste within the province. For example, the investigators found previously that approximately 30% of patients received unnecessary cardiac testing and/or chest x-rays prior to ambulatory surgery (with almost 30-fold variability in ordering between institutions) (2,3).

Within Canada, provincial governments have made reducing low-value care a priority. Choosing Wisely Canada (CWC) (4,5) is a professionally led campaign to rally the medical professional to address this issue and make declarative statements about low-value care that physicians and patients should avoid or question across a broad range of specialties. To date, 37 Canadian medical specialty societies have developed over 150 recommendations pertaining to unnecessary tests, treatments and procedures.

Whilst the identification of potential areas of low-value care is an important first step in addressing this problem, additional efforts are required to ensure implementation of CWC recommendations. Before now, internationally and in Canada, the issue of implementing Choosing Wisely like recommendations has not received adequate attention. This project directly addresses this key priority for healthcare systems bringing together Ontarian experts from CWC, implementation science, relevant clinical content areas and knowledge users to develop and evaluate programs to implement CWC recommendations. The investigators will use state-of-the-art approaches from implementation science to develop and evaluate a major initiative to reduce low-value care in Ontario. Knowledge users include Health Quality Ontario, the Ontario Hospital Association and Choosing Wisely Canada.

Inclusion Criteria:

• Hospitals in the 26th - 100th percentile for routine preoperative tests

Exclusion Criteria:

• Hospitals in the 0 - 25th percentile for routine preoperative tests