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    Original Investigation
    Less Is More
    March 25, 2019

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

    Author Affiliations
    • 1Division 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
    • 2RAND Health, RAND Corporation
    • 3Department of Quality, Patient Safety and Risk Management, Los Angeles County and University of Southern California Medical Center, Los Angeles
    • 4Department of Ophthalmology, Los Angeles County and University of Southern California Medical Center, Los Angeles
    • 5Department of Anesthesiology, Los Angeles County and University of Southern California Medical Center, Los Angeles
    • 6Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles
    • 7University of Southern California Roski Eye Institute, Keck School of Medicine, Los Angeles
    • 8Ophthalmology and Eye Health Programs, Los Angeles County Department of Health Services, Los Angeles, California
    • 9Geriatric Research Education and Clinical Center, Greater Los Angeles Veterans Administration Healthcare System, Los Angeles, California
    JAMA Intern Med. 2019;179(5):648-657. doi:10.1001/jamainternmed.2018.8358
    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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