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Measuring and Improving the Quality of Preprocedural Assessments

Manji, Farah MD, MPH*; McCarty, Kelsey MS, MBA; Kurzweil, Vanessa PhD; Mark, Eden MPH§; Rathmell, James P. MD; Agarwala, Aalok V. MD, MBA

doi: 10.1213/ANE.0000000000001834
Patient Safety: Original Clinical Research Report

BACKGROUND: Preprocedural assessments are used by anesthesia providers to optimize perioperative care for patients undergoing invasive procedures. When these assessments are performed in advance by providers who are not caring for the patient during the procedure, there is an additional layer of complexity in ensuring that the workup meets the needs of the primary anesthesia care team. In this study, anesthesia providers were asked to rate the quality of preprocedural assessments prepared by other providers to evaluate anesthesia care team satisfaction.

METHODS: Quality ratings for preprocedural assessments were collected from anesthesia providers on the day of surgery using an electronic quality assurance tool from January 9, 2014 to October 21, 2014. Users could rate assessments as “exemplary,” “satisfactory,” or “unsatisfactory.” Free text comments could be entered for any of the quality ratings chosen. A reviewer trained in clinical anesthesia categorized all comments as “positive,” “constructive,” or “neutral” and conducted in-depth chart reviews triggered by 67 “constructive” comments submitted during the first 3 months of data collection to further subcategorize perceived deficiencies in the preprocedural assessments. In May 2014, providers were asked to participate in a midpoint survey and provide general feedback about the preprocedural process and evaluations.

RESULTS: 37,611 procedures requiring anesthesia were analyzed. Of the 17,522 (46.6%) cases with a rated preprocedural assessment, anesthesia providers rated 3828 (21.8%) as “exemplary,” 13,454 (76.8%) as “satisfactory,” and 240 (1.4%) as “unsatisfactory.” The monthly proportion of “unsatisfactory” ratings ranged from 3.1% to 0% over the study period, whereas the midpoint survey showed that anesthesia providers estimated that the number of unsatisfactory evaluations was 11.5%. Preprocedural evaluations performed on inpatients received significantly better ratings than evaluations performed on outpatients by the preadmission testing clinic or phone program (P < .0001). The most common reason given for “unsatisfactory” ratings was a perception of “missing information” (49.2%). Chart reviews revealed that inadequate documentation was in reality the most common deficiency in preprocedural evaluations (35 of 67 reviews, 52.2%).

CONCLUSIONS: The overwhelming majority of preprocedural assessments performed at our institution were considered satisfactory or exemplary by day-of-surgery anesthesia providers. This was demonstrated by both the case-by-case ratings and midpoint survey. However, the perceived frequency of “unsatisfactory” evaluations was worse when providers were asked to reflect on the quality of preprocedural evaluations generally versus rate them individually. Analysis of comments left by providers allowed us to identify specific and actionable areas for improvement. This method can be used by other institutions to identify systemic deficiencies in the preprocedural evaluation process.

From the *Department of Anesthesia, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Department of Medicine, Boston Medical Center, Boston, Massachusetts; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; §Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Accepted for publication November 21, 2016.

Funding: No external funding.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Aalok V. Agarwala, MD, MBA, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Gray Jackson 446, 55 Fruit St, Boston, MA 02114. Address e-mail to

All US hospitals are responsible for ensuring that patients are adequately prepared for surgical procedures. Preprocedural assessments are typically the responsibility of anesthesiologists and are considered to be a fundamental element of anesthesia care. The American Society of Anesthesiologists Task Force on Preanesthesia Evaluation defines these assessments as “the process of clinical assessment that precedes the delivery of anesthesia care for surgery and nonsurgical procedures.”1 Preprocedural assessments usually involve the consolidation of information from various sources including medical records, patient history, physical examination, and the results of preoperative laboratory tests and imaging. This information allows anesthesia providers to determine their patients’ surgical risk and intervene preoperatively to optimize patient safety and postsurgical outcomes.

Historically, patients were brought into the hospital as inpatients the night before surgery to be assessed and optimized. The expansion of ambulatory and same-day admission surgery has necessitated the development of preoperative clinics that facilitate preprocedural patient evaluations in advance of the day of surgery (DOS) or procedure. The adoption of preoperative clinics in hospitals has been shown to reduce surgical cancellations and delays,2–5 hospital length of stay,6–9 and costs,10,11 while also increasing operating room efficiency12 and quality of care.8 In order for preoperative clinics to yield these benefits for patients and hospitals, the preprocedural assessments produced at the clinic must be of acceptable quality. There are, however, no defined quality standards to guide anesthesia practitioners regarding the optimal performance of preprocedural assessments.

As reimbursement for health care in the United States moves toward value-based models, the ability to measure the quality of perioperative care will become increasingly important. Our institution, like other US hospitals, struggles with the challenge of ensuring that our preoperative evaluation clinic produces consistently high-quality assessments. Similar to many other practices, evaluations done by our preadmission testing (PAT) program are not performed by the anesthesia provider present on the DOS, but instead by a nurse practitioner or an anesthesiologist. Therefore, it is important to determine whether these evaluations are of sufficient quality and value to meet the needs of the clinicians using them on the DOS. When DOS anesthesia providers perceive clinic evaluations as unsatisfactory, they redo the assessments; this creates system inefficiency and can lead to delays in operating room flow.

In this study, we hypothesized that the 90% of preoperative evaluations would be perceived by DOS providers as satisfactory or better (as defined by each individual provider) and that the quality ratings would not differ based on the source of the evaluation (evaluations conducted during an outpatient clinic visit, evaluations conducted over the telephone, or inpatient evaluations). To test this, we developed a highly specific and real-time measurement tool to evaluate the perceived quality of preprocedural assessments performed by the PAT program. A secondary aim of this study was to identify specific, actionable, recurrent deficiencies with preprocedural evaluations in order to focus improvement efforts.

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This project was undertaken as a quality improvement initiative within the Department of Anesthesia, Critical Care, and Pain Medicine at Massachusetts General Hospital, and as such was not formally supervised by the Institutional Review Board per their policies.

This study included all surgical, interventional, and diagnostic procedures requiring anesthesia performed between January 9, 2014 and October 21, 2014 at the Massachusetts General Hospital (Boston, MA). For patients evaluated preoperatively through the hospital’s PAT program, the preprocedural assessment was made available through the hospital’s electronic medical record.

Surgeons are responsible for referring high-risk ambulatory and same-day admission patients (defined as a high-complexity procedure, high expected blood loss, and/or high-acuity patient) to the PAT clinic for preprocedural evaluation. During the study period, patients having orthopedic surgery were referred to a separate branch of the PAT clinic referred to as the “Ortho Clinic.” The PAT clinic preprocedural assessments are performed primarily by nurse practitioners, but also by attending anesthesiologists and supervised anesthesia residents. Surgeons may also refer their low-risk patients (defined as a low-complexity procedure and low-acuity patient) for evaluation by a registered nurse through the PAT phone-screening program. Inpatients are evaluated in-house on the day before the DOS by an anesthesia resident, certified registered nurse anesthetist, or anesthesia attending.

During the study period, quality ratings for the PAT preprocedural assessments were collected from anesthesia providers on the DOS using an electronic quality assurance tool accessed through the institution’s anesthesia information management system previously described by Peterfreund et al.13 Before the end of each anesthetic encounter, providers were required, through forced entry programming, to rate the preprocedural assessment for the case (Figure 1). Each preprocedural evaluation was rated as “exemplary,” “satisfactory,” “unsatisfactory,” or “patient not evaluated before the DOS.” For all “unsatisfactory” assessments, the tool required the provider to select at least 1 of 9 subcategory reasons. Optional free text comments could also be submitted with any of the selections. We analyzed these data using a mixed-methods approach, combining quantitative and qualitative techniques.14

Figure 1.

Figure 1.

Proportions and frequencies were calculated to describe the quantitative data. Free text comments were qualitatively categorized by 2 reviewers. Comments that consisted of only positive feedback regarding the quality of the assessment were labeled as “positive.” Comments that indicated problems with the assessment or suggested changes to current practice were labeled as “constructive.” Comments that simply stated facts about the assessment (eg, “phone assessment”) or the case (eg, “emergency case”) were labeled “neutral.”

Chart reviews were performed by a single reviewer, who was a fourth year anesthesia resident in a Canadian residency program, during the first 3 months of data collection (January 13, 2014 to March 9, 2014) for all patients whose preprocedural evaluations received a “constructive” free text comment, irrespective of the assessment’s quality rating. Qualitative data analysis was then performed on the findings of the review. Patients who were marked as “patient not evaluated before the DOS” were excluded from the chart review. For each review, the patient’s preprocedural assessment, preoperative consultations and reports, and intraoperative record were examined. For the reviewed “unsatisfactory” assessments, the comment was investigated in the context of the subcategory selected indicating the reason for this rating. Specific reasons for the problem identified in the comment were documented based on the findings of the review. Thematic analysis was used to categorize all the reasons found for unsatisfactory ratings.

In May 2015, providers were asked to participate in a midpoint review of the PAT evaluation improvement effort. Using an online survey tool (SurveyMonkey, Palo Alto, CA), all anesthesia providers in the department were asked to estimate the frequency that preoperative evaluations received from the PAT program in the past month were exemplary, satisfactory, or unsatisfactory. They also had the opportunity to provide more general feedback about the PAT process and quality of work.

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Statistical Analysis

Categorical variables are presented as numbers and proportions where appropriate. For the results of the midpoint survey, the average, standard deviation, and 95% confidence intervals were calculated. Interrater reliability for characterization of the comments was determined by calculating the Cohen unweighted κ coefficient with 95% confidence interval (CI); κ = 0.77 (CI, 0.69–0.85). The Pearson χ2 test for goodness-of-fit was used to compare the observed proportion of satisfactory and exemplary evaluations with the hypothesized proportion. The Pearson χ2 test of independence was used to analyze differences in quality ratings by source of preoperative evaluation based on a 4×3 contingency table. Statistical analysis was performed using Stata/SE 11.0 (StataCorp, College Station, TX) and R version 3.2.2 (The R Foundation for Statistical Computing, Vienna, Austria).

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During the study period, 37,611 procedures requiring anesthesia were performed. This includes patients evaluated in the PAT clinics and phone program, inpatients, and those not scheduled for an evaluation, including emergency patients.

Providers marked 20,089 (53.4%) cases as “patient not evaluated before the DOS.” Of the remaining 17,522 (46.6%) cases, anesthesia providers rated 3828 (21.8%) as “exemplary,” 13,454 (76.8%) as “satisfactory,” and 240 (1.4%) as “unsatisfactory” (Figure 2A). The 98.6% of rated evaluations considered satisfactory or better was significantly higher than the 90% we hypothesized (P < .0001; CI, 98.4–98.8). These proportions remained stable over the study period (Figure 2B).

Figure 2.

Figure 2.

The most frequently selected reason for an “unsatisfactory” rating (49.2%) was “missing information” (Table 1). In 17.5% of “unsatisfactory” evaluations, providers selected “inadequate assessment” or “incomplete/missing assessment,” indicating perceived deficiencies with the portion of the evaluations in which comorbidities, anesthetic concerns, and perioperative plan are summarized.

Table 1.

Table 1.

We next examined whether the source of preprocedural evaluations was associated with the perceived quality of the evaluations. Patient identifiers in this group were checked against the lists of completed clinic and phone appointments (no-shows and unsuccessful calls were excluded) to determine if a preprocedural assessment was performed through the PAT. We identified the source of 12,811 of the 17,522 cases and analyzed these to determine whether quality ratings differed among them (Figure 3). Quality ratings were significantly associated with the source of the evaluations (P < .0001). Notably, inpatient evaluations had the highest rate of “exemplary” ratings (30.1%) and lowest rate of “unsatisfactory” ratings (0.7%) of all preprocedural evaluation sources. Significant differences between all pairwise comparisons of evaluation source were also observed, including substantial differences between the PAT Phone Program and in-person clinics. Excluded were 4711 cases in which a preprocedural evaluation was rated by the DOS provider but no record of a corresponding PAT appointment was available. The distribution of quality ratings in this group was similar to the distribution of quality ratings in the analysis group. Further interrogation revealed that assigning these cases to any of the preoperative evaluation sources in the analysis group did not alter the results of significance testing (data not shown).

Figure 3.

Figure 3.

During the data collection period, providers left 432 free text comments. Of those, 183 (42.4%) were classified as “constructive,” 41 (9.5%) were classified as “positive,” and 208 (48.1%) were classified as “neutral” (Figure 4).

Figure 4.

Figure 4.

A total of 67 chart reviews were performed (Table 2); these charts denoted every case in which the DOS anesthesiologist left a “constructive” comment regarding the preoperative evaluation during the first 3 months of data collection, and served as a sample of the entire study population. Of those 67 charts, 52 (77.6%) received an “unsatisfactory” rating, 14 (20.9%) were “satisfactory,” and 1 (1.5%) was “exemplary.” All assessments were qualitatively divided into subcategories based on the issues identified in the review, with 3 of 67 falling into 2 categories. There were 35 (52.2%) cases of inadequate documentation of medical or anesthesia issues. The most common poorly documented types of information were anesthesia histories (n = 9), allergies (n = 6), cardiac histories (n = 6), and diabetic histories (n = 5). In 9 of the 35 cases (25.7%), the anesthesia provider stated that important information was missing from the assessment; however, during the chart review, the desired information was found to be present in the assessment.

Table 2.

Table 2.

The 20,089 (53.4%) cases marked by providers as “patient not evaluated before the DOS” were excluded from the quality analysis and reviewed separately. This review showed that 50.3% of patients had no record of an evaluation before the surgery, 25.5% were inpatients, 20.2% had been evaluated over the phone program, and 4.0% had been evaluated in the PAT clinic. Among all the completed phone evaluations during the study period (n = 6381), 63.6% had been marked by DOS providers as “patient not evaluated before the DOS” (data not shown).

In order to assess the accuracy of ratings of inpatient preprocedural evaluations, we reviewed 100 random inpatient cases from the study period (Table 3). Of the 59 cases marked “patient not evaluated before the DOS,” 49 (83.1%) were indeed missing an evaluation. Of the 41 cases that had received a quality rating, 28 (68.3%) had a record of an evaluation performed before the DOS. In all cases in which an evaluation was not performed before the DOS, it was instead performed on the DOS.

Table 3.

Table 3.

Table 4.

Table 4.

One hundred twenty-five anesthesia providers participated in the midpoint survey (Table 4). On average, the group reported a perception that 25.9% (95% CI, 21.0%–30.9%) of assessments were “exemplary,” 62.6% (95% CI, 57.9%–67.2%) were “satisfactory,” and 11.5% (95% CI, 8.9%–14.1%) were “unsatisfactory.”

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Poor-quality preprocedural assessments have been associated with negative outcomes including operating room cancellations and delays.15 Moreover, inadequate or incomplete assessments have been associated with anesthesia-related morbidity and mortality.16–18 As such, the process of improving the quality of preprocedural assessments can not only affect operating room efficiency but can also have a valuable effect on patient safety.

This study developed a formal method to measure the quality of, and identify common deficiencies in, preprocedural assessments at a high-volume academic medical center. Almost 99% of preprocedural evaluations were rated by DOS anesthesia providers to be of sufficient quality. These findings are consistent with a similar examination of the quality of preoperative assessments at a large academic medical center in the Netherlands.19 In addition, it is notable that the PAT phone program, which employs registered nurses supervised by anesthesia attendings, produces only slightly less satisfactory results than the clinic, based on assessments by the DOS providers. Staffing models that primarily employ registered nurses in place of nurse practitioners are typically less costly, as are programs that replace in-person clinic visits with phone evaluations. To fully characterize the costs and benefits of such models, future studies should evaluate whether the source of the preoperative evaluation affects outcomes such as case cancellations, anesthesia-related complications, and unnecessary medical tests.

Analysis of preprocedural assessments by source revealed that anesthesia providers perceived inpatient evaluations to be of higher quality than those performed in the PAT clinic or phone program. This may reflect the fact that inpatient evaluations are performed by anesthesia providers, whereas PAT evaluations are mostly performed by nurse practitioners and registered nurses. It may be that anesthesia providers are better able to anticipate the needs of the operative team. Alternatively, inpatient evaluations may be more thorough because inpatients are more likely to have recent notes and medical tests available at the time of the assessment than outpatients seen in the clinic or over the phone.

A difference was also observed within outpatients, indicating better overall ratings for PAT Clinic visits compared with PAT Phone Program appointments. Although several factors are likely to have contributed to this difference, inappropriate triage and patient compliance with laboratory draws are worth noting. When “inappropriate method of evaluation” was identified as an issue (Table 2), all cases involved complex and/or anxious patients whom the DOS providers believed required in-person evaluations. In addition, while surgeons are asked to instruct patients to obtain required laboratory tests (eg, Complete Blood Count or Basic Metabolic Panel) before any PAT appointment, not all patients do so. In those cases, the PAT clinic will usually draw required laboratory tests during the appointment, while patients evaluated by phone are reminded to have the laboratory test done. Thus, although patients appropriately triaged to the phone program require fewer laboratory tests than those evaluated in the clinic (Supplemental Digital Content, Figure 1,, they may be less likely to have these laboratory tests done before the DOS.

This study identified systemic problems with our institution’s preoperative evaluation program that can be targeted for process improvement. This provided us with specific, actionable, and timely information about quality issues with our preoperative evaluation process that could be further investigated with a chart review. If we had gathered only quality ratings without free text comments, we would not have obtained the level of detail needed to make rapid improvements.

The chart reviews revealed that there are recurring problems with adequate documentation of medical and anesthesia issues, the consent and counseling process in our preanesthesia clinic, appropriate referrals to the preprocedural phone program, missing preoperative laboratory results, and DOS medication management. The method we used to identify these issues can be applied at any institution to obtain information about these types of themes and also the specificity needed to make improvements. For example, 3 of the 10 constructive comments about missing laboratory results were related to a missing blood bank sample. This allowed us to improve our staff education and guidelines about when to obtain a blood bank sample. Without the granular feedback, the request of the PAT staff would have been to always obtain necessary laboratory tests, which would likely not have been as effective in improving the collection of blood bank samples.

The findings of our chart review underscore the need to continue to standardize the preprocedural evaluation process and develop more robust institutional practice guidelines. It was interesting to find that in almost 26% of assessments where the provider indicated missing pertinent information, the desired information was in the assessment, but was missed by the DOS anesthesia provider. Perhaps just as important as ensuring that sufficient information is documented is ensuring that the documentation is clearly organized in a standard format, with essential information easily identifiable.

As patient and surgical complexity increases, standardization has the potential to reduce medical error in the evaluation process.20 The implementation of a checklist or standardized preprocedural evaluation form in the clinic can reduce differences between the practices of individual clinicians21 and improve the quality and completeness of the information collected and documented at each visit.22–24 Moreover, standardized forms ensure that DOS providers know where in the assessment to find essential information and facilitate the integration of alerts or flags to draw the provider’s attention to critical facts. This strategy may have avoided the “near miss” described in a free text comment where a spinal anesthetic was planned for an anticoagulated patient. In response to this finding, the PAT phone assessment template (Supplemental Digital Content 2, Figure 2A, was updated to a new version (Supplemental Digital Content 3, Figure 2B, that is similar to the template used for inpatient assessments (Supplemental Digital Content 4, Figure 2C,

Other areas in which documentation can be improved are anesthesia-specific histories, diabetic histories, cardiac histories, allergies, home medications, and airway assessments. The electronic template used for evaluations in our preanesthesia clinic may benefit from the integration of more detailed questions or checklists that address these areas. The problems identified in the chart reviews that relate to evaluation of complex patients, the consent and counseling process, missing preoperative tests, and preoperative medication management may be improved with a combination of institutional guidelines and focused education for clinicians who work in the preoperative evaluation clinic.

Of the 20,089 cases where the provider marked the case as “preop not completed before the DOS,” a preprocedural evaluation had indeed been completed in 24.2% of these instances, and mostly by the PAT phone program. Upon discussion with providers, it became evident that these results were partly because of misconceptions regarding the legitimacy of phone assessments conducted by a registered nurse. Providers were not aware that phone evaluation data could be used as part of the preoperative assessment, and as a result, many were redocumenting large amounts of information before bringing patients into the operating room rather than making updates and additions as needed. Identifying this misperception gave us an opportunity to educate providers about the usefulness of phone evaluations and reduce their workload.

The midpoint survey was another source of important data about provider perceptions. Over the first 4 months of the study, “unsatisfactory” evaluations were consistently between 1% and 3%. At the end of the 4-month mark, when asked to think back about the quality of the preoperative evaluations as a whole, providers said that evaluations were unsatisfactory 11.5% of the time. This is consistent with cognitive psychology research that shows increased or exaggerated recall of negative compared with neutral events.25–27 It also highlights that making improvements to our preoperative assessment process alone was not sufficient; we also needed to improve perceptions and attitudes about the preoperative assessment process to obtain our desired level of provider satisfaction. Furthermore, the finding that almost 99% of assessments were rated as satisfactory by anesthesia providers positively impacted the relationship between providers and PAT staff. The results served to improve morale among PAT staff and cultivate a sense of mutual respect and appreciation between the 2 groups.

This study has several limitations. First, the metric of the anesthesia provider’s satisfaction with the preprocedural assessment is subjective and could be influenced by a number of personal biases resulting from past experiences with particular types of patients or procedures or personal interactions with clinic practitioners. Second, providers were asked to provide a quality rating at the end of each case, rather than at the start of the case immediately after reviewing the preprocedural assessment. This was a limitation of our anesthesia information management system; however, the benefit of rating the assessment at the end of the case is that providers would likely be best able to globally evaluate the relevance of the assessment once the case is over. This method, however, could reasonably have contributed to outcome bias, because the outcome of the case, whether positive or negative, could have influenced the quality rating of the assessment for that case. Third, in a small number of cases, the provider who used the assessment to start the case may not have been the provider who finished the case and entered the feedback. Fourth, because this process yielded 432 comments from 37,611 cases, a comment rate of only 1.2%, the voluntary comments received may not be representative of the entire scope of the quality issues that challenge our preoperative evaluation process. Moreover, we only conducted chart reviews on the “constructive” comments received during the first 3 months of data collection; the use of this convenience sample could have further contributed to problems with the evaluation process being missed. The findings of the reviewer who performed chart reviews are also considered subjective, because they were not corroborated by a second reviewer or based on any institutional guidelines for quality measurement. Finally, we were unable to identify the source of the preoperative evaluation in 4711 of 17,522 cases in which a preprocedural evaluation was rated by the DOS provider. Although this did not appear to affect the results of our analysis, the potential causes for this discrepancy highlight 3 potential limitations of the data. First, appointments added to the PAT clinic schedule on the same day as the appointment (“add-ons”) were not reflected in the appointment list used to identify evaluation source. Second, although providers were instructed that preoperative evaluations are only valid for 30 days, some may have nevertheless rated the quality of older preoperative evaluations instead of indicating that the patient had not been properly evaluated before the DOS. Similarly, providers were instructed to choose “patient not evaluated” if the preoperative evaluation was not completed before the DOS, but some may have instead rated the quality of evaluations performed the morning of surgery.

Future studies should explore the clinical implications of provider ratings, such as time spent revising incomplete evaluations and case delays due to inadequate preoperative optimization. It would also be interesting to compare the results of studies in hospitals with different models for conducting preoperative evaluations.

In summary, 98.6% of preprocedural assessments performed at our institution are of adequate quality (rated as “satisfactory” or “exemplary”) for anesthesia providers on the day of surgery. Potential solutions to the specific quality issues identified through the chart review process include template standardization, clinician education, and the further development and implementation of practice guidelines for preoperative testing, consent and counseling, and the clinic referral process. The efficacy of these interventions will be examined in future studies.

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The authors would like to acknowledge K. Trudy Poon, MS, from the DACCPM CRC for her assistance with statistical analysis; Brian Bateman for helpful discussion; and Shaji Anupama, Bill Driscoll, Gopi Golgada, Milcho Nikolov, and Kalpan Tolia for development of the feedback tool and data reports.

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Name: Farah Manji, MD, MPH.

Contribution: This author helped perform data collection, analysis, and manuscript preparation.

Name: Kelsey McCarty, MS, MBA.

Contribution: This author helped contribute to study design and manuscript preparation.

Name: Vanessa Kurzweil, PhD.

Contribution: This author helped perform data collection, analysis, and manuscript preparation.

Name: Eden Brand, MPH.

Contribution: This author helped with study design and manuscript preparation.

Name: James P. Rathmell, MD.

Contribution: This author helped with study design and manuscript preparation.

Name: Aalok V. Agarwala, MD, MBA.

Contribution: This author helped with study design and manuscript preparation.

This manuscript was handled by: Richard C. Prielipp, MD.

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