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Original Investigation
Less Is More
June 3, 2019

Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries

Author Affiliations
  • 1Department of Medicine, Harvard Medical School, Boston, Massachusetts
  • 2Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Partners HealthCare, Boston, Massachusetts
  • 4The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
  • 5Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 6Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
  • 7Department of Health Care Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 8Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
JAMA Intern Med. 2019;179(9):1211-1219. doi:10.1001/jamainternmed.2019.1739
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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    2 Comments for this article
    Additional cost
    Mark Mc Connell |
    I may have missed it but it does not seem like the cost of distraction has been fully accounted for. Part of that cost is the downstream time taken from primary care providers with which they have been seeing other patients. And the cost to the system of having cardiologist, echocardiogram technicians and others occupied by visits regarding these patients negatively impacts the ability for other patients who do have active cardiology issues to be cared for.
    Drivers of cost- supply or demand?
    narendra javadekar, M.D.(Med),M.A.(Economics) | Consultant Physician and health economist
    In a complex medical system bound by medicolegal ,regulatory and re- embursement issues ,and patients highly empowered with medical information, it's difficult to say whether it is supply or demand that drives these cascades.
    However,such information will surely empower both physician and patient groups committed to low cost but quality care.