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Joo JH, Liao JM. Using peer comparisons to address low-value care: Lessons for a persistent challenge. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2023; 11:100721. [PMID: 37972418 DOI: 10.1016/j.hjdsi.2023.100721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Joseph H Joo
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, WA, USA
| | - Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, WA, USA.
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2
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Ahmadi A, Duval VF, Bartlett JD, Hofer IS, Mafi J, Villaflores CWA, Sarkisian CA. Examining patient perspectives on low-value care: Findings from a survey on preoperative testing for cataract surgery. J Am Geriatr Soc 2023; 71:3641-3644. [PMID: 37436065 PMCID: PMC11006278 DOI: 10.1111/jgs.18494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Alast Ahmadi
- Department of Internal Medicine, University of California Irvine, Irvine, California, United States
| | - Victor F. Duval
- Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - John D. Bartlett
- Department of Ophthalmology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Ira S. Hofer
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, United States
| | - John Mafi
- Division of General Internal Medicine and Health Services Research, Department of Medicine at the David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Chad Wes A. Villaflores
- Division of General Internal Medicine and Health Services Research, Department of Medicine at the David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Catherine A. Sarkisian
- Division of General Internal Medicine and Health Services Research, Department of Medicine at the David Geffen School of Medicine at UCLA, Los Angeles, California, United States
- VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, United States
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Zavodni Z, Pan LC, Mok K, Cheng H, O’Boyle D. End-to-End Impact of a Cloud-Based Surgical Planning System on Efficiency in Cataract Surgery: A Time-and-Motion Study. Clin Ophthalmol 2023; 17:1885-1896. [PMID: 37425026 PMCID: PMC10327899 DOI: 10.2147/opth.s392669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 06/14/2023] [Indexed: 07/11/2023] Open
Abstract
Purpose Inefficiencies from manual data entry and non-integration exist throughout the cataract surgery workflow. The aim of this study was to evaluate the impact of SMARTCataract, an innovative cloud-based digital surgical planning platform (SPS) on efficiency in preoperative (diagnostic workup, surgery planning), intraoperative, and postoperative phases of cataract surgery. The primary objective aimed to assess time and number of manual transcription data points (TPs) required for all pre-, intra-, and postoperative devices that integrate with the SPS and surgery planning time across three patient types (post-refractive, astigmatic, conventional). The secondary objective aimed to assess the overall efficiency impact of the SPS on the surgery workflow for the three patient types by leveraging time-and-motion methods and workflow mapping. Patients and Methods This prospective, observational, real-world, pre- and post-cohort time-and-motion study included patients undergoing evaluation for cataract surgery and/or surgery at the study site. Assessed variables included time and TPs required for clinical activities and devices associated with traditional manual methods (pre-cohort) versus the SPS (post-cohort). Statistical analyses (t-test) were performed comparing performance time using the SPS versus traditional methods for each integrated technology and surgery planning activity. Results The SPS demonstrated statistically significant time savings over traditional methods in TP data input time taken across all integrated pre-, intra-, and postoperative devices (p<0.0001). The SPS additionally demonstrated statistically significant time savings in preoperative surgery planning across post-refractive (p<0.0001), astigmatic (p=0.0005), and conventional (p=0.0004) cataract patient groups. Overall, the SPS reduced end-to-end patient workflow time and TPs for post-refractive, astigmatic, and conventional cataract patients by averages of 13.2, 12.6, and 4.3 minutes and 184, 166, and 25 TPs per patient, respectively. Conclusion Through the SPS' integration and surgery planning capabilities, substantial time efficiencies can be achieved for cataract surgery practices, clinicians, and patients compared to surgery planning with traditional manual methods.
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Ding Q, Trickey AW, Mudumbai S, Kamal RN, Sears ED, Harris AHS. Prevalence and Factors Associated With Low-Value Preoperative Testing for Patients Undergoing Carpal Tunnel Release at an Academic Medical Center. Hand (N Y) 2022; 17:28-34. [PMID: 32100568 PMCID: PMC8721789 DOI: 10.1177/1558944720906498] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Routine preoperative screening tests before low-risk surgery cannot be justified if the risks to patients are not outweighed by benefits. Several studies and professional guidelines suggest avoiding screening tests prior to minor operations. We aimed to assess the prevalence and patient characteristics associated with low-value preoperative tests (LVTs) prior to carpal tunnel release (CTR) at an academic medical center. Methods: From electronic medical records, we identified patients aged ≥18 who underwent CTR from 2015 to 2017. We determined the occurrence of 9 common LVTs, such as complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (ECG), in the 30 days prior to CTR. Multivariable logistic and Poisson regression were used to identify factors associated with receiving any LVT and the number of LVTs, respectively. Results: Among 572 patients, 248 (43.4%) had at least 1 LVT. The most common tests were ECG (31.3% of CTRs), CBC (27.3% of CTRs), and BMP (23.6% of CTRs). Patient factors associated with higher odds of receiving LVT included older age, higher Elixhauser comorbidity score, and general or regional anesthesia (vs monitored anesthesia care). Conclusions: Low-value preoperative tests were frequently received by patients undergoing CTR and were associated with anesthesia type, age, and number of comorbidities. Although our study focused on CTR, these results likely have implications for other commonly performed low-risk procedures. These findings can help guide efforts to improve the quality and value of surgery for carpal tunnel syndrome and facilitate the development of strategies to reduce LVT, such as audit feedback and provider education.
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Affiliation(s)
- Qian Ding
- Stanford University School of Medicine, CA, USA
| | | | - Seshadri Mudumbai
- Stanford University School of Medicine, CA, USA
- VA Palo Alto Health Care System, Menlo Park, CA, USA
| | | | | | - Alex H. S. Harris
- Stanford University School of Medicine, CA, USA
- VA Palo Alto Health Care System, Menlo Park, CA, USA
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Rossi T, Panozzo G, Della Mura G, Giannarelli D, Ferrari D, Alessio G, Palmisano C, Telani S, Ripandelli G. Diabetes and diabetic retinopathy in patients undergoing cataract surgery: a prevalence study-DiCat study report #2. Acta Diabetol 2020; 57:645-650. [PMID: 31912329 DOI: 10.1007/s00592-019-01466-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To report on the prevalence of diabetes, diabetic macula oedema (DME) and retinopathy and their respective grading in a large cohort of patients undergoing cataract surgery. METHODS Data on previous diagnosis of diabetes, fasting glucose, glycated haemoglobin, presence and type of retinopathy and other maculopathy of 3657 patients over 55 years of age undergoing cataract surgery in 13 centres scattered throughout Italy were analysed. RESULTS A total of 20.4% of patients were known diabetics and 27.9% of diabetics showed signs of retinopathy. Haemoglobin A1C was higher than 48 mmol/L (6.5%) in 32% of diabetics and 2.4% non-diabetics. Fasting blood glucose level was higher than 120 mg/dL in 4.3% non-diabetics and 50% diabetics. Duration of diabetes did not significantly correlate with either fasting glucose or glycated haemoglobin, while higher grades of diabetic retinopathy were significantly more prevalent as duration of disease increased. DME was present in almost 40% of diabetics and 22% of patients showed non-diabetic maculopathy. DISCUSSION Diabetic retinopathy and DME worsen after cataract extraction thus complicating long-term prognosis and requiring expensive injective therapy. Since unknown diabetics represent 2-4% of the many million cataract candidates and even known diabetics show poor metabolic control and high rates of DME, preoperative medical testing and accurate retinopathy screening may prove both ethically necessary and cost-effective.
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Affiliation(s)
- Tommaso Rossi
- IRCCS Ospedale Policlinico San Martino IRCCS - UOC Oculistica, Largo Rosanna Benzi 2, 16100, Genoa, Italy.
| | - Giacomo Panozzo
- ESASO European School of Advances Studies in Ophthalmology, Lugano, Switzerland
| | - Giulia Della Mura
- ESASO European School of Advances Studies in Ophthalmology, Lugano, Switzerland
| | - Diana Giannarelli
- Department of Biostatistics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Daniele Ferrari
- IRCCS Ospedale Policlinico San Martino IRCCS - UOC Oculistica, Largo Rosanna Benzi 2, 16100, Genoa, Italy
| | | | | | - Serena Telani
- IRCCS Ospedale Policlinico San Martino IRCCS - UOC Oculistica, Largo Rosanna Benzi 2, 16100, Genoa, Italy
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Golozar A, Chen Y, Lindsley K, Rouse B, Musch DC, Lum F, Hawkins BS, Li T. Identification and Description of Reliable Evidence for 2016 American Academy of Ophthalmology Preferred Practice Pattern Guidelines for Cataract in the Adult Eye. JAMA Ophthalmol 2019; 136:514-523. [PMID: 29800249 DOI: 10.1001/jamaophthalmol.2018.0786] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Trustworthy clinical practice guidelines require reliable systematic reviews of the evidence to support recommendations. Since 2016, the American Academy of Ophthalmology (AAO) has partnered with Cochrane Eyes and Vision US Satellite to update their guidelines, the Preferred Practice Patterns (PPP). Objective To describe experiences and findings related to identifying reliable systematic reviews that support topics likely to be addressed in the 2016 update of the 2011 AAO PPP guidelines on cataract in the adult eye. Design, Setting, and Participants Cross-sectional study. Systematic reviews on the management of cataract were searched for in an established database. Each relevant systematic review was mapped to 1 or more of the 24 management categories listed under the Management section of the table of contents of the 2011 AAO PPP guidelines. Data were extracted to determine the reliability of each systematic review using prespecified criteria, and the reliable systematic reviews were examined to find whether they were referenced in the 2016 AAO PPP guidelines. For comparison, we assessed whether the reliable systematic reviews published before February 2010 the last search date of the 2011 AAO PPP guidelines were referenced in the 2011 AAO PPP guidelines. Cochrane Eyes and Vision US Satellite did not provide systematic reviews to the AAO during the development of the 2011 AAO PPP guidelines. Main Outcomes and Measures Systematic review reliability was defined by reporting eligibility criteria, performing a comprehensive literature search, assessing methodologic quality of included studies, using appropriate methods for meta-analysis, and basing conclusions on review findings. Results From 99 systematic reviews on management of cataract, 46 (46%) were classified as reliable. No evidence that a comprehensive search had been conducted was the most common reason a review was classified as unreliable. All 46 reliable systematic reviews were cited in the 2016 AAO PPP guidelines, and 8 of 15 available reliable reviews (53%) were cited in the 2011 PPP guidelines. Conclusions and Relevance The partnership between Cochrane Eyes and Vision US Satellite and the AAO provides the AAO access to an evidence base of relevant and reliable systematic reviews, thereby supporting robust and efficient clinical practice guidelines development to improve the quality of eye care.
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Affiliation(s)
- Asieh Golozar
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yujiang Chen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kristina Lindsley
- Department of Epidemiology, Center for Clinical Trials and Evidence Synthesis, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Benjamin Rouse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David C Musch
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor.,Department of Epidemiology, University of Michigan, Ann Arbor
| | - Flora Lum
- American Academy of Ophthalmology, San Francisco, California
| | - Barbara S Hawkins
- Department of Epidemiology, Center for Clinical Trials and Evidence Synthesis, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
| | - Tianjing Li
- Department of Epidemiology, Center for Clinical Trials and Evidence Synthesis, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Alabi RO, Turnbull ZA, Coombs PG, Wu Y, Orlin A, Chan RP, Kiss S, D'Amico DJ, Gupta MP. Assessing the value of preoperative medical clearance in patients with primary rhegmatogenous retinal detachment. Clin Ophthalmol 2019; 13:1711-1718. [PMID: 31564820 PMCID: PMC6732513 DOI: 10.2147/opth.s209681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/03/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine rates of intraoperative and postoperative systemic and ocular adverse events and establish the value of preoperative medical assessment in patients undergoing surgery for primary rhegmatogenous retinal detachment repair at a single academic center. Patients and methods Retrospective cohort study of 185 patients undergoing surgery for repair of primary rhegmatogenous retinal detachment (RRD) at a single academic center. Medical records were reviewed for medical comorbidities, completion of preoperative medical examination, anesthesia used during surgery, intraoperative adverse medical events, intraoperative ocular complications, and systemic and ocular postoperative complications. The main outcome of interest was the association of comorbidities and preoperative medical evaluation with intraoperative and postoperative complications. Results Approximately 48% of the patients presented with no medical comorbidities of interest. Formal preoperative evaluation by an independent medical provider was completed in 36% of the patients. Overall, intraoperative and postoperative systemic complications (5.7% and 1%, respectively) and intraoperative and postoperative ocular complications (0.5% for both) were uncommon. Patients with a history of chronic heart failure (OR 24.5, P=0.02) or who received general anesthesia (OR 9.56, P<0.001) had increased risk of having experienced any intraoperative or postoperative complication. No relationship between preoperative medical evaluation and intraoperative and postoperative complications was observed. Conclusion Patients undergoing surgery for RRD repair presented with fewer medical comorbidities than previously reported in patients undergoing all vitreoretinal surgeries. Intraoperative and postoperative complications were uncommon and were increased in patients with chronic heart failure or who received general anesthesia. Complications were not significantly associated with preoperative evaluation by an independent medical provider.
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Affiliation(s)
- Rolake O Alabi
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Zachary A Turnbull
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Peter G Coombs
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Yiyuan Wu
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Anton Orlin
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Rv Paul Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
| | - Szilard Kiss
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Donald J D'Amico
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Mrinali P Gupta
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
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Harris AHS, Meerwijk EL, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn H, Mudumbai S. Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesth Analg 2019; 129:804-811. [PMID: 31425223 PMCID: PMC6760302 DOI: 10.1213/ane.0000000000004291] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA). METHODS Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression. RESULTS From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT. CONCLUSIONS Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.
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Affiliation(s)
- Alex H S Harris
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Surgery, Stanford-Surgical Policy Improvement Research and Education Center, Stanford University School of Medicine, Stanford, California
| | - Esther L Meerwijk
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Robin N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Erika D Sears
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Surgery, Michigan Medicine
| | - Mary Hawn
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Surgery, Stanford-Surgical Policy Improvement Research and Education Center, Stanford University School of Medicine, Stanford, California
| | - Dan Eisenberg
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Surgery, Stanford-Surgical Policy Improvement Research and Education Center, Stanford University School of Medicine, Stanford, California
| | - Andrea K Finlay
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Hildi Hagedorn
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Seshadri Mudumbai
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Mafi JN, Godoy-Travieso P, Wei E, Anders M, Amaya R, Carrillo CA, Berry JL, Sarff L, Daskivich L, Vangala S, Ladapo J, Keeler E, Damberg CL, Sarkisian C. Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System. JAMA Intern Med 2019; 179:648-657. [PMID: 30907922 PMCID: PMC6503569 DOI: 10.1001/jamainternmed.2018.8358] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE 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. OBJECTIVE 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. INTERVENTIONS 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. RESULTS 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. 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.
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Affiliation(s)
- John N Mafi
- 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
| | - Patricia Godoy-Travieso
- Department of Quality, Patient Safety and Risk Management, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Eric Wei
- Department of Quality, Patient Safety and Risk Management, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Malvin Anders
- Department of Ophthalmology, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Rodolfo Amaya
- Department of Anesthesiology, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Carmen A Carrillo
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles
| | - Jesse L Berry
- Department of Ophthalmology, Los Angeles County and University of Southern California Medical Center, Los Angeles.,University of Southern California Roski Eye Institute, Keck School of Medicine, Los Angeles
| | - Laura Sarff
- Department of Quality, Patient Safety and Risk Management, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Lauren Daskivich
- Ophthalmology and Eye Health Programs, Los Angeles County Department of Health Services, Los Angeles, California
| | - Sitaram Vangala
- 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
| | - Joseph Ladapo
- 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
| | | | | | - Catherine Sarkisian
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles.,Geriatric Research Education and Clinical Center, Greater Los Angeles Veterans Administration Healthcare System, Los Angeles, California
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10
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Abstract
BACKGROUND Cataract surgery is practiced widely, and substantial resources are committed to an increasing cataract surgical rate in low- and middle-income countries. With the current volume of cataract surgery and future increases, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management. OBJECTIVES 1. To investigate the evidence for reductions in adverse events through preoperative medical testing2. To estimate the average cost of performing routine medical testing SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); Ovid MEDLINE; Embase.com; PubMed; LILACS BIREME, the metaRegister of Controlled Trials (mRCT) (last searched 5 January 2012); ClinicalTrials.gov and the WHO ICTRP. The date of the search was 29 June 2018, with the exception of mRCT which is no longer in service. We searched the references of reports from included studies for additional relevant studies without restrictions regarding language or date of publication. SELECTION CRITERIA We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed risk of bias. MAIN RESULTS We identified three randomized clinical trials that compared routine preoperative medical testing versus selective or no preoperative testing for 21,531 cataract surgeries. The largest trial, in which 19,557 surgeries were randomized, was conducted in Canada and the USA. Another study was conducted in Brazil and the third in Italy. Although the studies had some issues with respect to performance and detection bias due to lack of masking (high risk for one study, unclear for two studies), we assessed the studies as at overall low risk of bias.The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pre-testing group and 354 occurred in the no-testing group (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.86 to 1.16; high-certainty evidence). Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 0.99, 95% CI 0.71 to 1.38) or postoperative ocular adverse events (OR 1.11, 95% CI 0.74 to 1.67) when compared to selective or no testing (2 studies; 2281 cataract surgeries; moderate-certainty evidence). One study evaluated cost savings, estimating the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing (1 study; 1005 cataract surgeries; moderate-certainty evidence). There was no difference in cancellation of surgery between those with preoperative medical testing and those with selective or no preoperative testing, reported by two studies with 20,582 cataract surgeries (OR 0.97, 95% CI 0.78 to 1.21; high-certainty evidence). No study reported outcomes related to clinical management changes (other than cancellation) or quality of life scores. AUTHORS' CONCLUSIONS This review has shown that routine preoperative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in low- and middle-income settings. Unfortunately, in these settings, medical history questionnaires may be useless to screen for risk because few people have ever been to a physician, let alone been diagnosed with any chronic disease.
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Affiliation(s)
- Lisa Keay
- The University of SydneyThe George Institute for Global HealthLevel 24, Maritime Trade Towers207 Kent StreetSydneyNSWAustralia2000
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, Mail Room E6132BaltimoreMarylandUSA21205
| | - James Tielsch
- George Washington UniversityDepartment of Global Health, Milken Institute of Public Health950 New Hampshire Avenue, NW, Suite 400Washington DCUSA20052
| | - Joanne Katz
- Johns Hopkins Bloomberg School of Public HealthDepartment of International Health615 N. Wolfe StreetBaltimoreMarylandUSA21209
| | - Oliver Schein
- Johns Hopkins University School of MedicineWilmer Eye Institute600 N. Wolfe Street, Wilmer 116BaltimoreMarylandUSA21287‐9019
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11
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Peto T, Sandi F, Kumar V. Making the most of cataract surgery in patients with diabetes. COMMUNITY EYE HEALTH 2019; 31:80-81. [PMID: 31086435 PMCID: PMC6390521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tunde Peto
- Professor of Clinical Ophthalmology: Queen's University Belfast, Institute of Clinical Sciences Building A, Belfast, Ireland, UK
| | - Frank Sandi
- Ophthalmologist and Clinical Instructor: The University of Dodoma, College of Health Sciences, Tanzania
| | - Vineeth Kumar
- Consultant Ophthalmologist and Vitreoretinal Surgeon: Wirral University Teaching Hospital NHS trust, Wirral, UK
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Hanna KL, Hepworth LR, Rowe FJ. The treatment methods for post-stroke visual impairment: A systematic review. Brain Behav 2017; 7:e00682. [PMID: 28523224 PMCID: PMC5434187 DOI: 10.1002/brb3.682] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 12/23/2022] Open
Abstract
AIM To provide a systematic overview of interventions for stroke related visual impairments. METHOD A systematic review of the literature was conducted including randomized controlled trials, controlled trials, cohort studies, observational studies, systematic reviews, and retrospective medical note reviews. All languages were included and translation obtained. This review covers adult participants (aged 18 years or over) diagnosed with a visual impairment as a direct cause of a stroke. Studies which included mixed populations were included if over 50% of the participants had a diagnosis of stroke and were discussed separately. We searched scholarly online resources and hand searched articles and registers of published, unpublished, and ongoing trials. Search terms included a variety of MESH terms and alternatives in relation to stroke and visual conditions. Article selection was performed by two authors independently. Data were extracted by one author and verified by a second. The quality of the evidence and risk of bias was assessed using appropriate tools dependant on the type of article. RESULTS Forty-nine articles (4142 subjects) were included in the review, including an overview of four Cochrane systematic reviews. Interventions appraised included those for visual field loss, ocular motility deficits, reduced central vision, and visual perceptual deficits. CONCLUSION Further high quality randomized controlled trials are required to determine the effectiveness of interventions for treating post-stroke visual impairments. For interventions which are used in practice but do not yet have an evidence base in the literature, it is imperative that these treatments be addressed and evaluated in future studies.
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Affiliation(s)
- Kerry Louise Hanna
- Department of Health Services ResearchUniversity of LiverpoolLiverpoolUK
| | | | - Fiona J. Rowe
- Department of Health Services ResearchUniversity of LiverpoolLiverpoolUK
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13
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Gualandro DM, Yu PC, Caramelli B, Marques AC, Calderaro D, Fornari LS, Pinho C, Feitosa ACR, Polanczyk CA, Rochitte CE, Jardim C, Vieira CLZ, Nakamura DYM, Iezzi D, Schreen D, Adam EL, D'Amico EA, Lima EQD, Burdmann EDA, Mateo EIP, Braga FGM, Machado FS, Paula FJD, Carmo GALD, Feitosa-Filho GS, Prado GF, Lopes HF, Fernandes JRC, Lima JJGD, Sacilotto L, Drager LF, Vacanti LJ, Rohde LEP, Prada LFL, Gowdak LHW, Vieira MLC, Monachini MC, Macatrão-Costa MF, Paixão MR, Oliveira MTD, Cury P, Villaça PR, Farsky PS, Siciliano RF, Heinisch RH, Souza R, Gualandro SFM, Accorsi TAD, Mathias W. 3rd Guideline for Perioperative Cardiovascular Evaluation of the Brazilian Society of Cardiology. Arq Bras Cardiol 2017; 109:1-104. [PMID: 29044300 PMCID: PMC5629911 DOI: 10.5935/abc.20170140] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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14
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Alboim C, Kliemann RB, Soares LE, Ferreira MM, Polanczyk CA, Biolo A. The impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery: a cohort study. Eye (Lond) 2016; 30:1614-1622. [PMID: 27636228 DOI: 10.1038/eye.2016.203] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 08/15/2016] [Indexed: 01/13/2023] Open
Abstract
PurposeAmbulatory surgery is a major area of surgical and anesthetic practice, and preoperative clinics are being increasingly used for low-risk surgical procedures. This study investigated the impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery.MethodsThis was a retrospective cohort study of 968 consecutive patients undergoing cataract surgery. Details of medical conditions, surgical, anesthetic, and postoperative information were collected from medical records. A logistic regression model was developed using propensity score adjustment for baseline characteristics.ResultsOut 968 patients included, 240 (24.7%) underwent outpatient preoperative evaluation. There were no perioperative major cardiovascular events. Hypertension occurred in 319 (33%) patients, accounting for 79.7% of all adverse events. Preoperative evaluation resulted in a lower hypertension rate after adjustment for propensity score (OR=0.6; 95% CI 0.41-0.93); no effects were observed on posterior capsule rupture and emergency visits/hospitalization within 7 days of surgery. Eighty-nine patients (9.3%) had an initial systolic pressure ≥180 mm Hg, which was not associated with higher risk of posterior capsule rupture (P=0.158) or postoperative adverse events (P=0.902). Median waiting time to surgery was 6 and 2 months for evaluated and non-evaluated patients, respectively (P<0.001).ConclusionsIn the context of low-risk surgery and no major perioperative and postoperative outcomes, it appears that outpatient preoperative evaluation has no role in reducing adverse events in cataract surgery candidates. Despite fewer hypertensive episodes observed in evaluated patients, these episodes were not associated with any medical or surgical outcomes.
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Affiliation(s)
- C Alboim
- Department of Anaesthesiology, Perioperative and Pain Medicine (SAMPE), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - R B Kliemann
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - L E Soares
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - M M Ferreira
- Department of Anaesthesiology, Perioperative and Pain Medicine (SAMPE), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - C A Polanczyk
- Department of Internal Medicine, Division of Cardiology, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Post - Graduate Program in Cardiology, School of Medicine, UFRGS, Porto Alegre, Brazil.,Institute for Health Technology Assessment (IATS), HCPA, Porto Alegre, Brazil
| | - A Biolo
- Department of Internal Medicine, Division of Cardiology, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Post - Graduate Program in Cardiology, School of Medicine, UFRGS, Porto Alegre, Brazil.,Institute for Health Technology Assessment (IATS), HCPA, Porto Alegre, Brazil
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15
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Jastrzebski A, Villafranca A, Sethi S, Bellan L. Safety and comparative costs of preoperative assessments for cataract surgery: traditional mandatory assessment versus a novel graded assessment system. Can J Anaesth 2016; 63:842-50. [PMID: 26943645 DOI: 10.1007/s12630-016-0626-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 02/03/2016] [Accepted: 02/29/2016] [Indexed: 01/17/2023] Open
Abstract
PURPOSE We conducted this study to evaluate the safety and costs of traditional mandatory preoperative assessment for cataract surgery patients compared with a novel graded preoperative assessment system. METHODS Patients were recruited at a high-volume surgical centre from May to November 2013. Patients completed a health-related questionnaire which allowed for a graded preoperative assessment of all participants. Based on responses to the questionnaire, patients were classified preoperatively into a) low-risk patients not requiring a preoperative assessment and b) high-risk patients requiring this assessment. Anesthesiologists still assessed all patients immediately before surgery but with staff blinded to preoperative assessment information for low-risk patients. Observed complication rates and costs were compared with those expected in the mandatory assessment system. RESULTS We examined 3,347 cataract surgeries on 2,766 patients and categorized 59.9% of patients as low risk. In the graded system cohort, there were no major complications and a low rate of minor complications occurred. Wherever a complication occurred in a low-risk patient, the anesthesiologist doubted that the preoperative assessment information would have prevented the complication. If implemented, the graded system would save approximately 4,414 preoperative assessments per year in our region, with an associated cost of approximately $40.00 per surgery, or $359,000 in total. The cost to prevent a single minor complication with the mandatory system was approximately $8,976, with a number needed to treat of 223. CONCLUSION The graded system resulted in no major complications and a low rate of minor complications. The information obtained from the mandatory assessment is unlikely to prevent complications. Additionally, the cost effectiveness of the mandatory system was poor. This novel graded preoperative assessment system for cataract surgery patients can save time and resources by eliminating unnecessary patient visits.
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Affiliation(s)
- André Jastrzebski
- Department of Ophthalmology, University of Manitoba and Misericordia Health Centre, Room M264, 99 Cornish Avenue, Winnipeg, MB, R3T 2N2, Canada.
| | - Alex Villafranca
- Department of Anesthesia, University of Manitoba and Misericordia Health Centre, Winnipeg, MB, Canada
| | - Subash Sethi
- Department of Anesthesia, University of Manitoba and Misericordia Health Centre, Winnipeg, MB, Canada
| | - Lorne Bellan
- Department of Ophthalmology, University of Manitoba and Misericordia Health Centre, Room M264, 99 Cornish Avenue, Winnipeg, MB, R3T 2N2, Canada
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16
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Abstract
Routine preoperative testing is not cost-effective, because it is unlikely to identify significant abnormalities. Abnormal findings from routine testing are more likely to be false positive, are costly to pursue, introduce a new risk, increase the patient's anxiety, and are inconvenient to the patient. Abnormal findings rarely alter the surgical or anesthetic plan, and there is usually no association between perioperative complications and abnormal laboratory results. Incidental findings and false positive results may lead to increased hospital visits and admissions. Preoperative testing needs to be done based on a targeted history and physical examination and the type of surgery.
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Affiliation(s)
- Matthias Bock
- Department of Anesthesia and Intensive Care Medicine, Central Hospital, Via Lorenz Boehler 5, Bolzano 39100, Italy; Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Muellner Hauptrstrasse 48, Salzburg 5020, Austria
| | - Gerhard Fritsch
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Muellner Hauptrstrasse 48, Salzburg 5020, Austria; Department of Anesthesiology and Intensive Care, UKH Lorenz Boehler, Donaueschingerstrasse 3, Vienna 1220, Austria
| | - David L Hepner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02459, USA.
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Onuoha OC, Hatch MB, Miano TA, Fleisher LA. The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study. Perioper Med (Lond) 2015; 4:14. [PMID: 26677410 PMCID: PMC4681056 DOI: 10.1186/s13741-015-0023-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/24/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Despite existing evidence and guidelines advocating for appropriate risk stratification, ambulatory surgery in low-risk patients continues to be accompanied by a battery of routine tests prior to surgery. Using a single-center retrospective cohort study, we aimed to quantify the incidence of un-indicated preoperative testing in an academic ambulatory center by utilizing recommendations by the recently developed American Society of Anesthesiology (ASA) "Choosing Wisely" Top-5 list. METHODS We utilized data from the EPIC medical records of 3111 patients who had ambulatory surgery at the Hospital of the University of Pennsylvania during a 6-month period. Data were abstracted from laboratory studies- complete blood count, electrolyte panel, coagulation studies, and cardiac studies-stress test, and echocardiogram obtained within 30 days prior to surgery. Preoperative tests obtained from each patient were categorized into "indicated" (ASA ≥ 3) and "un-indicated" (ASA 1 and 2) tests, and percentages were reported. RESULTS During the study period, 52.9 % (95 % confidence interval (CI) 37.6-66.4) of all patients had at least one un-indicated laboratory test performed preoperatively. Further analysis revealed variation in the incidence of preoperative ordering between tests; 73 % of all complete blood counts (CBCs), 70 % of all metabolic panels, and 49 % of all coagulation studies were considered un-indicated by "Top-5 List" criteria. Stated differently, of the patients included in the sample, 51 % of patients received an un-indicated CBC, 41 % an un-indicated metabolic panel, and 16 % un-indicated coagulation studies. Twelve percent of "any un-indicated preoperative test" were obtained from ASA 1 healthy patients. Of the 587 patients less than 36 years old, 331 (56 %) had at least one test that was deemed un-indicated. Forty-one patients had either an echocardiogram or stress test ordered and performed within 30 days of surgery. Of these, eight (19.5 %) studies were un-indicated as determined by chart review. CONCLUSIONS The incidence of ordering "at least one un-indicated preoperative test" in low-risk patients undergoing low-risk surgery remains high even in academic tertiary institutions. In the emerging era of optimizing patient safety and financial accountability, further studies are needed to better understand the problem of overuse while identifying modifiable attitudes and institutional influences on perioperative practices among all stakeholders involved. Such information would drive the development of feasible interventions.
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Affiliation(s)
- Onyi C Onuoha
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street Dulles 680, Philadelphia, PA 19104 USA
| | - Michael B Hatch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street Dulles 680, Philadelphia, PA 19104 USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania USA
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, Senior Scholar, Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania USA
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Chen CL, Lin GA, Bardach NS, Clay TH, Boscardin WJ, Gelb AW, Maze M, Gropper MA, Dudley RA. Preoperative medical testing in Medicare patients undergoing cataract surgery. N Engl J Med 2015; 372:1530-8. [PMID: 25875258 PMCID: PMC5536179 DOI: 10.1056/nejmsa1410846] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Routine preoperative testing is not recommended for patients undergoing cataract surgery, because testing neither decreases adverse events nor improves outcomes. We sought to assess adherence to this guideline, estimate expenditures from potentially unnecessary testing, and identify patient and health care system characteristics associated with potentially unnecessary testing. METHODS Using an observational cohort of Medicare beneficiaries undergoing cataract surgery in 2011, we determined the prevalence and cost of preoperative testing in the month before surgery. We compared the prevalence of preoperative testing and office visits with the mean percentage of beneficiaries who underwent tests and had office visits during the preceding 11 months. Using multivariate hierarchical analyses, we examined the relationship between preoperative testing and characteristics of patients, health system characteristics, surgical setting, care team, and occurrence of a preoperative office visit. RESULTS Of 440,857 patients, 53% had at least one preoperative test in the month before surgery. Expenditures on testing during that month were $4.8 million higher and expenditures on office visits $12.4 million higher (42% and 78% higher, respectively) than the mean monthly expenditures during the preceding 11 months. Testing varied widely among ophthalmologists; 36% of ophthalmologists ordered preoperative tests for more than 75% of their patients. A patient's probability of undergoing testing was associated mainly with the ophthalmologist who managed the preoperative evaluation. CONCLUSIONS Preoperative testing before cataract surgery occurred frequently and was more strongly associated with provider practice patterns than with patient characteristics. (Funded by the Foundation for Anesthesia Education and Research and the Grove Foundation.).
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Affiliation(s)
- Catherine L Chen
- From the Departments of Anesthesia and Perioperative Care (C.L.C., A.W.G., M.M., M.A.G.), Pediatrics (N.S.B.), and Medicine and Epidemiology and Biostatistics (W.J.B., R.A.D.), Center for Healthcare Value (C.L.C., G.A.L., N.S.B., R.A.D.), Division of General Internal Medicine (G.A.L.), and Philip R. Lee Institute for Health Policy Studies (G.A.L., R.A.D.), University of California, San Francisco, San Francisco; and Clay Software and Statistics, Ashland, OR (T.H.C.)
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Schlitzkus LL, Melin AA, Johanning JM, Schenarts PJ. Perioperative management of elderly patients. Surg Clin North Am 2015; 95:391-415. [PMID: 25814114 DOI: 10.1016/j.suc.2014.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The older population only represents 13.7% of the US population but has grown by 21% since 2002. The centenarian population is growing at a faster rate than the total US population. This unprecedented growth has significantly increased surgical demand. The establishment of quality and performance improvement data has allowed researchers to focus attention on the older patient population, resulting in an exponential increase in studies. Although there is still much work to be done in this field, overlying themes regarding the perioperative management of elderly patients are presented in this article based on a thorough literature review.
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Affiliation(s)
- Lisa L Schlitzkus
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
| | - Alyson A Melin
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
| | - Paul J Schenarts
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
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20
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Fong R, Sweitzer BJ. Preoperative Optimization of Patients Undergoing Ambulatory Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0082-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Flamm M, Fritsch G, Hysek M, Klausner S, Entacher K, Panisch S, Soennichsen AC. Quality improvement in preoperative assessment by implementation of an electronic decision support tool. J Am Med Inform Assoc 2013; 20:e91-6. [PMID: 23599223 PMCID: PMC3715339 DOI: 10.1136/amiajnl-2012-001178] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 01/24/2013] [Accepted: 03/24/2013] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To evaluate the impact of the electronic decision support (eDS) tool 'PReOPerative evaluation' (PROP) on guideline adherence in preoperative assessment in statutory health care in Salzburg, Austria. MATERIALS AND METHODS The evaluation was designed as a non-randomized controlled trial with a historical control group (CG). In 2007, we consecutively recruited 1363 patients admitted for elective surgery, and evaluated the preoperative assessment. In 2008, PROP was implemented and available online. In 2009 we recruited 1148 patients preoperatively assessed using PROP (294 outpatients, 854 hospital sector). Our analysis includes full blood count, liver function tests, coagulation parameters, electrolytes, ECG, and chest x-ray. RESULTS The number of tests/patient without indication was 3.39 in the CG vs 0.60 in the intervention group (IG) (p<0.001). 97.8% (CG) vs 31.5% (IG) received at least one unnecessary test. However, we also observed an increase in recommended tests not performed/patient (0.05±0.27 (CG) vs 0.55±1.00 (IG), p<0.001). 4.2% (CG) vs 30.1% (IG) missed at least one necessary test. The guideline adherence (correctly tested/not tested) improved distinctively for all tests (1.6% (CG) vs 49.3% (IG), p<0.001). DISCUSSION PROP reduced the number of unnecessary tests/patient by 2.79 which implied a reduction of patients' burden, and a relevant cut in unnecessary costs. However, the advantage in specificity caused an increase in the number of patients incorrectly not tested. Further research is required regarding the impact of PROP on perioperative outcomes.
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Affiliation(s)
- Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine; Paracelsus Medical University, Salzburg, Austria.
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