Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries | Cardiology | JN Learning | AMA Ed Hub [Skip to Content]
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Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries

Educational Objective
To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.
1 Credit CME
Key Points

Question  What are the prevalence and costs of care cascades after low-value preoperative electrocardiograms for cataract surgery?

Findings  This cohort study of 110 183 fee-for-service Medicare beneficiaries found that 16% of those who received a preoperative electrocardiogram before cataract surgery experienced a potential cascade event; this was more likely among older, sicker individuals who lived in cardiologist-dense areas or had a cardiac specialist perform the electrocardiogram. There were 5 to 11 cascade events per 100 beneficiaries, costing up to $565 per beneficiary or $35 million nationally in addition to $3.3 million for the initial electrocardiograms.

Meaning  Care cascades after low-value preoperative electrocardiograms are infrequent yet costly; policy and practice interventions to mitigate such cascades could yield substantial savings.


Importance  Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.

Objective  To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.

Design, Setting, and Participants  Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019.

Exposures  Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG.

Main Outcomes and Measures  Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade.

Results  Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade.

Conclusions and Relevance  Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.

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Article Information

Accepted for Publication: April 13, 2019.

Corresponding Author: Ishani Ganguli, MD, MPH, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont St, 3rd Floor, Boston, MA 02120 (

Published Online: June 3, 2019. doi:10.1001/jamainternmed.2019.1739

Author Contributions: Dr Colla, Dr Chang, Ms Wang, and Ms Raymond had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ganguli, Mainor, Chang, Morden, Rosenthal, Colla, Sequist.

Acquisition, analysis, or interpretation of data: Ganguli, Lupo, Raymond, Wang, Orav, Chang, Morden, Rosenthal, Colla, Sequist.

Drafting of the manuscript: Ganguli, Lupo, Mainor, Morden, Sequist.

Critical revision of the manuscript for important intellectual content: Ganguli, Mainor, Raymond, Wang, Orav, Chang, Morden, Rosenthal, Colla, Sequist.

Statistical analysis: Raymond, Wang, Orav, Chang, Sequist.

Obtained funding: Rosenthal, Colla, Sequist.

Administrative, technical, or material support: Ganguli, Lupo, Mainor, Raymond, Colla.

Supervision: Ganguli, Mainor, Chang, Morden, Rosenthal, Colla, Sequist.

Conflict of Interest Disclosures: Dr Ganguli reported receiving consulting fees from Haven unrelated to this work. Dr Mainor reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study. Dr Morden reported receiving grants from NIH during the conduct of the study and is now an employee of Microsoft. Dr Rosenthal reported receiving grants from AHRQ during the conduct of the study. Dr Colla reported receiving grants from AHRQ during the conduct of the study. Dr Sequist reported receiving grants from AHRQ during the conduct of the study and personal fees from Aetna outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by the Agency for Healthcare Research and Quality grant 1R01HS023812 (Dr Ganguli, Ms Lupo, Mr Mainor, Ms Raymond, Ms Wang, Dr Chang, Dr Rosenthal, Dr Colla, Dr Sequist.

Role of the Funder: The funder 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.

Meeting Presentations: This work was presented in poster form at the 2019 Society of General Internal Medicine Annual Meeting; May 11, 2019; Washington, DC, and as an oral presentation at the 2019 Academy Health Annual Research Meeting, June 3, 2019; Washington, DC.

Additional Contributions: We thank Alice C. Lorch, MD, MPH, of the Massachusetts Eye and Ear Infirmary for her advice on the use of cataract surgery codes and Catherine L. Chen, MD, MPH, of the University of California, San Francisco, for her guidance on evaluation of preoperative testing in cataract surgery. We are grateful to Jason H. Wasfy, MD, MPhil, and Varsha Tanguturi, MD, of Massachusetts General Hospital for their review of cardiac cascade items. They were not compensated for their work on this study.

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