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

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. 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. 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 preoperative 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)

Ultra low-dose naloxone and tramadol/acetaminophen in elderly patients undergoing joint replacement surgery: A pilot study

OBJECTIVE: A pilot study was conducted to assess whether both the rationale and feasibility exist for future randomized clinical trials to evaluate the combined use of naloxone infusion and tramadol/acetaminophen as opioid-sparing drugs in elderly patients undergoing lower extremity joint replacement surgery

Knowledge for the West, Production for the Rest?

This article develops the argument that a ‘knowledge economy,’ despite its cheerful optimism, is also an elegant incarnation of the demise of Western economies. An analysis of policy documents, research statements, and national accounts reveals this paradoxical coexistence of anxiety and progress in the discourse on knowledge economies. While the concept is often hailed as a temporal concept (superseding other forms of economic production), this article argues that a knowledge economy is best understood as a spatial concept – it is a way of contending with global reorganizations of production. This spatial approach is elaborated to tackle three paradoxes. (1) A knowledge economy enfolds defeat with progress. (2) A knowledge economy downplays the importance of industrial labor and simultaneously depends on it to materialize its ideas. (3) While seemingly intangible and ephemeral, a knowledge economy is fixed in place in national economies through government and corporate policy (including through the emergent phenomenon of ‘knowledge-adjusted gross domestic products’). A spatial approach provides a view of the tenuous global interconnections and specific conditions that prop up a knowledge economy, and shows how the concept is mobilized to redraw the map so that endangered economies can regain their challenged sense of centrality in a world economy