Customize your JAMA Network experience by selecting one or more topics from the list below.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Mafi JN, Godoy-Travieso P, Wei E, et al. 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(5):648–657. doi:10.1001/jamainternmed.2018.8358
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?
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.
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.
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.
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.
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.
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.
Create a personal account or sign in to: