Department of Anesthesiology and Pain Medicine, University of Washington, Seattle.
Department of Anesthesiology and Pain Medicine, University of Washington, Seattle2Department of Epidemiology, University of Washington, Seattle.
JAMA Intern Med. 2014 Mar;174(3):380-8. doi: 10.1001/jamainternmed.2013.13426.
Low-risk elective surgical procedures are common, but there are no clear guidelines for when preoperative consultations are required. Such consultations may therefore represent a substantial discretionary service.
To assess temporal trends, explanatory factors, and geographic variation for preoperative consultation in Medicare beneficiaries undergoing cataract surgery, a common low-risk elective procedure.
DESIGN, SETTING, AND PARTICIPANTS: Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556,637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89,817 individuals who underwent surgery from 2005 to 2006.
Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery.
The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75-84 years vs 66-74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04-1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65-0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49-1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05-1.15]), anesthesia provider (anesthesiologist vs non-medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10-1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI, 2.33-4.10]). The burden of comorbidity was associated with consultation, but the effect size was small (<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0-69%]), even after accounting for differences in patient-level, anesthesia provider-level, and facility-level characteristics.
Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.
低风险的择期手术很常见，但何时需要进行术前咨询尚无明确的指导方针。因此，此类咨询可能代表了一项大量的可自由裁量的服务。
评估 Medicare 受益患者接受白内障手术时术前咨询的时间趋势、解释因素和地理差异，白内障手术是一种常见的低风险择期手术。
设计、设置和参与者：使用 Medicare 部分 B 索赔数据的全国 5%随机样本进行队列研究，该样本包括了一个队列，队列中共有 556637 名 66 岁或以上的患者在 1995 年至 2006 年期间接受了白内障手术。在整个队列中评估了咨询的时间趋势，而在 2005 年至 2006 年期间接受手术的 89817 名患者中评估了解释因素和地理差异。
在指数手术前 42 天内，分别计费的术前咨询（由家庭医生、普通内科医生、肺科医生、内分泌科医生、心脏病专家、执业护士或麻醉师进行）。
术前咨询的频率从 1998 年的 11.3%增加到 2006 年的 18.4%。在 2005 年至 2006 年期间接受手术的患者中，分层逻辑回归模型发现了几个与术前咨询相关的因素，包括年龄增加（75-84 岁比 66-74 岁：调整后的优势比[OR]，1.09[95%置信区间，1.04-1.13]）、种族（非裔美国人比其他种族：OR，0.71[95%置信区间，0.65-0.78]）、城市居住（城市居住比孤立的农村城镇：OR，1.64[95%置信区间，1.49-1.81]）、医疗机构类型（门诊医院比门诊外科设施：OR，1.10[95%置信区间，1.05-1.15]）、麻醉提供者（麻醉师比非医学指导的注册护士麻醉师：OR，1.16[95%置信区间，1.10-1.24]）和地理区域（东北地区比南部地区：OR，3.09[95%置信区间，2.33-4.10]）。合并症负担与咨询有关，但效应大小较小（<10%）。医院转诊区域之间咨询频率的差异很大（中位数[范围]，12%[0-69%]），即使考虑到患者水平、麻醉提供者水平和医疗机构水平的特征差异也是如此。
1995 年至 2006 年间，白内障手术术前咨询的频率大幅增加。咨询的转诊似乎主要由非医疗因素驱动，存在大量的地理差异。
