Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco.
Center for Healthcare Value, University of California, San Francisco.
JAMA Ophthalmol. 2018 Mar 1;136(3):231-238. doi: 10.1001/jamaophthalmol.2017.6372.
Routine preoperative medical testing is not recommended for patients undergoing low-risk surgery, but testing is common before surgery. A 30-day preoperative testing window is conventionally used for study purposes; however, the extent of routine testing that occurs prior to that point is unknown.
To improve on existing cost estimates by identifying all routine preoperative testing that takes place after the decision is made to perform cataract surgery.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study assessed preoperative care in a 50% sample of Medicare beneficiaries older than 66 years who underwent ambulatory cataract surgery in 2011. Data analysis was completed from March 2016 to October 2017.
Using ocular biometry as a procedure-specific indicator to mark the start of the routine preoperative testing window, we measured testing rates in the interval between ocular biometry and cataract surgery and compared this with testing rates in the 6 months preceding biometry. We estimated the total cost of testing that occurred between biometry and cataract surgery.
A total of 440 857 patients underwent cataract surgery. A total of 423 710 (96.1%) had an ocular biometry claim before index surgery, of whom 264 514 (60.0%) were female; the mean (SD) age of the cohort was 76.1 (6.2) years. A total of 111 998 (25.4%) underwent surgery more than 30 days after biometry. Among patients with a biometry claim, the mean number of tests/patient/month increased from 1.1 in the baseline period to 1.7 in the interval between biometry and cataract surgery. Although preoperative testing peaked in all patients in the 30 days preceding surgery (1.8 tests/patient/month), the subset of patients with no overlap between postbiometry and presurgery periods experienced increased testing rates to 1.8 tests per patient per month in the 30 days after biometry, regardless of the elapsed time between biometry and surgery. The total estimated cost of routine preoperative testing in the full cohort was $22.7 million; we estimate that routine preoperative testing costs Medicare up to $45.4 million annually.
In this study of Medicare beneficiaries, routine preoperative medical testing occurs more often and is costlier than has been reported previously. Extra costs are attributable to testing that occurs prior to the 30-day window preceding surgery. As a cost-cutting measure, routine preoperative medical testing should be avoided in patients with cataracts throughout the interval between ocular biometry and cataract surgery.
对于接受低风险手术的患者，不建议进行常规术前医学检查，但手术前通常会进行检查。传统上使用 30 天的术前检查窗口来进行研究；然而，在此之前常规检查的程度尚不清楚。
通过确定在决定进行白内障手术后发生的所有常规术前检查，来改进现有的成本估算。
设计、设置和参与者：这项横断面研究评估了 2011 年在接受门诊白内障手术的 50%的 Medicare 受益人中，年龄在 66 岁以上的患者的术前护理情况。数据分析于 2016 年 3 月至 2017 年 10 月完成。
使用眼部生物测量作为特定于程序的指标来标记常规术前检查窗口的开始，我们测量了眼部生物测量和白内障手术之间的间隔内的检查率，并将其与眼部生物测量前 6 个月的检查率进行比较。我们估计了眼部生物测量和白内障手术之间发生的所有检查的总费用。
共有 440857 例患者接受了白内障手术。共有 423710 例（96.1%）在指数手术前有眼部生物测量索赔，其中 264514 例（60.0%）为女性；队列的平均（SD）年龄为 76.1（6.2）岁。共有 111998 例（25.4%）在眼部生物测量后 30 天以上进行了手术。在有眼部生物测量索赔的患者中，每位患者每月的平均检查次数从基线期的 1.1 次增加到眼部生物测量和白内障手术之间的 1.7 次。尽管所有患者在手术前 30 天的术前检查率最高（每位患者每月 1.8 次检查），但在眼部生物测量和手术之间没有重叠的患者亚组中，无论眼部生物测量和手术之间的时间间隔如何，每月每位患者的检查次数仍增加到 1.8 次。在全体患者中，常规术前检查的总估计费用为 2270 万美元；我们估计常规术前检查每年使医疗保险支出增加高达 4540 万美元。
在这项对 Medicare 受益人的研究中，常规术前医学检查比以前报道的更频繁，也更昂贵。额外的费用归因于在手术前 30 天窗口之前进行的检查。作为一项节约成本的措施，在眼部生物测量和白内障手术之间的整个间隔内，应避免对白内障患者进行常规术前医学检查。
