Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles.
RAND Health, RAND Corporation.
JAMA Intern Med. 2019 May 1;179(5):648-657. 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.
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 1054 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.
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.
白内障手术的术前检查是低价值医疗的典型代表，尽管在全美最大的医疗保障体系之一中，这种情况仍频繁发生。
评估一项多管齐下的干预措施，以减少接受白内障手术患者的低价值术前护理，并从各种财政角度分析成本。
设计、设置和参与者：这项研究在洛杉矶县和南加州大学 (LAC-USC)（干预组，n=469）和 Harbor-UCLA（加州大学洛杉矶分校）（对照组，n=585）这两个学术性医疗保障机构进行，时间为 2015 年 4 月 13 日至 2016 年 4 月 12 日，额外增加 12 个月（2016 年 4 月 13 日至 2017 年 4 月 13 日）以评估可持续性（干预组，n=1002；对照组，n=511）。为了比较干预前、干预后与对照组的利用情况和成本变化，使用评估时间与组间交互作用的逻辑回归进行比较。
利用计划-执行-研究-行动循环，一名质量改进护士审查病历，并与麻醉学和眼科学主任一起分析过度使用的情况；这三个人共同向员工和学员传授减少常规术前护理的知识。
接受白内障手术的患者术前医疗访问、胸部 X 光检查、实验室检查和心电图的比例。成本是根据 LAC-USC 的财务补贴角度进行估算的，成本是根据按服务收费（FFS）医疗系统和社会角度进行模拟的。
在 1054 名患者中，546 名（51.8%）为女性（平均[标准差]年龄，60.6[11.1]岁）。在干预组中，术前访问从 93%降至 24%，而在对照组中，术前访问从 89%增至 91%（组间差异，-71%；95%CI，-80%至-62%）。胸部 X 光检查从 90%降至 24%，在对照组中，胸部 X 光检查从 75%增至 83%（组间差异，-75%；95%CI，-86%至-65%）。实验室检查从 92%降至 37%，在对照组中，实验室检查从 98%降至 97%（组间差异，-56%；95%CI，-64%至-48%）。心电图检查从 95%降至 29%，在对照组中，心电图检查从 86%增至 94%（组间差异，-74%；95%CI，-83%至-65%）。在 12 个月的随访中，干预组的访问量增加到 67%，但胸部 X 光检查（12%）、实验室检查（28%）和心电图检查（11%）仍然较低（两个时期所有时间-组间交互作用的 P 值均<.001）。在 LAC-USC，第一年的损失为 42241 美元，归因于干预成本，而 3 年的预测显示节省 67241 美元。在 FFS 医疗系统 3 年的模拟中，预计损失为 88151 美元，而从社会 3 年的角度来看，预计节省 217322 美元。
该干预措施与白内障手术患者的低价值术前检查持续减少以及医疗系统的适度成本节约有关。研究结果表明，减少低价值护理可能与财务补贴健康系统和社会的成本节约有关，但也可能导致按服务收费健康系统的损失，这突出了消除低价值护理的潜在障碍。
