Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System
Published in: JAMA Internal Medicine, Volume 179, Issue 5, pages 648–657 (2019). doi: 10.1001/jamainternmed.2018.8358
Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems.
To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives.
Design, Setting, and Participants
This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n=469) and Harbor-UCLA (University of California, Los Angeles) (control, n=585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n=1002; control, n=511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used.
Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care.
Main Outcomes and Measures
Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives.
Of 1,054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, –71%; 95% CI, –80% to –62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, –75%; 95% CI, –86% to –65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, –56%; 95% CI, –64% to –48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, –74%; 95% CI, –83% to –65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42,241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67,241 in savings. In a simulation of a FFS health system at 3 years, $88,151 in losses were estimated, and for societal 3-year perspectives, $217,322 in savings were estimated.
Conclusions and Relevance
This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.