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Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System

Educational Objective
To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives.
1 Credit CME
Key Points

Question  Can a multipronged quality improvement initiative reduce low-value preoperative care for patients undergoing cataract surgery and save costs at a large safety-net health system?

Findings  In this study at 2 academic safety-net medical centers in California, the quality improvement initiative was associated with reduced preoperative testing compared with the control health system. Also, 3-year projections estimated a modest amount of cost savings associated with the initiative; simulating fee-for-service health system perspective estimated losses and a societal perspective estimated savings.

Meaning  These findings suggest that reducing low-value care is associated with cost savings for financially capitated health systems and society but also with losses for fee-for-service health systems, highlighting a potential barrier to eliminating low-value care.

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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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: December 7, 2018.

Corresponding Author: John N. Mafi, MD, MPH, Division of General Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, 911 Broxton Ave, Ste 301, Los Angeles, CA 90024 (jmafi@mednet.ucla.edu).

Published Online: March 25, 2019. doi:10.1001/jamainternmed.2018.8358

Author Contributions: Dr Mafi and Mr Vangala had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mafi, Godoy-Travieso, Wei, Anders, Amaya, Berry, Sarkisian.

Acquisition, analysis, or interpretation of data: Mafi, Godoy-Travieso, Wei, Carrillo, Sarff, Daskivich, Vangala, Ladapo, Keeler, Damberg, Sarkisian.

Drafting of the manuscript: Mafi, Carrillo, Vangala, Damberg.

Critical revision of the manuscript for important intellectual content: Mafi, Godoy-Travieso, Wei, Anders, Amaya, Berry, Sarff, Daskivich, Vangala, Ladapo, Keeler, Damberg, Sarkisian.

Statistical analysis: Mafi, Carrillo, Vangala, Ladapo, Keeler.

Obtained funding: Wei, Sarkisian.

Administrative, technical, or material support: Godoy-Travieso, Wei, Amaya, Carrillo, Berry, Sarff, Daskivich.

Supervision: Mafi, Berry, Sarkisian.

Conflict of Interest Disclosures: Dr Mafi reported receiving grants from the American Board of Internal Medicine Foundation Choosing Wisely, grants from the Robert Wood Johnson Foundation, and grant KL2TR001882 from the National Institutes of Health (NIH)/National Center for Advancing Translational Science Institute. Drs Godoy-Travieso and Wei reported receiving grants from American Board of Internal Medicine Foundation Choosing Wisely during the conduct of the study. Dr Berry reported receiving support not directly related to the scope of this work from grant K08CA232344 from the National Cancer Institute, NIH, the Wright Foundation, Knights Templar Eye Foundation, the Larry and Celia Moh Foundation, and the Institute for Families Inc at Children’s Hospital Los Angeles and an unrestricted departmental grant from Research to Prevent Blindness. Dr Damberg reported receiving grant 1U19HS024067-01 from the Agency for Healthcare Quality and Research. Dr Sarkisian reported receiving grants from the American Board of Internal Medicine Foundation, the NIH/National Institute on Aging, grant 1K24AG047899-01 from the National Institute on Aging Midcareer Investigator Awards in Patient-Oriented Research, grant 2P30AG081684 from the NIH/National Institute on Aging UCLA Resource Center for Minority Aging Research/Center for Health Improvement of Minority Elders, and grants from the NIH/National Center for Advancing Translational Sciences during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by an American Board of Internal Medicine Foundation Choosing Wisely grant to reduce low-value care. Dr Mafi was supported by a National Institutes of Health/National Center for Advanced Translational Science Institute KL2TR001882 award. Dr Sarkisian was supported by a National Institute on Aging 1K24AG047899-01 award. Dr Damberg was supported by the RAND Center of Excellence on Health System Performance funded by grant 1U19HS024067-01 from the Agency for Healthcare Research and Quality.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Toktam Sadralodabai, PhD, and Vichuda Matthews, DrPH, both affiliated with Los Angeles County Department of Health Services, assisted with electronic health record data extraction and data management. They were not financially compensated for their contribution.

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