Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration.
Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration.
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DOI：
10.1001/jamanetworkopen.2021.7470
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发表时间：
2021-05-03
影响因子：
13.8
通讯作者：
Harris AHS
中科院分区：
文献类型：
--
作者：
Mudumbai SC;Pershing S;Bowe T;Kamal RN;Sears ED;Hawn MT;Eisenberg D;Finlay AK;Hagedorn H;Harris AHS
美国退伍军人健康管理局在白内障手术前使用低价值术前检查的程度如何？这些检查的可变性和成本如何？在这项队列研究中，50106例患者中进行了69070例白内障手术，几乎一半患者在手术前进行了至少1次低值检查。与低复杂性设施相比，较高的设施水平的复杂性与接受4测试捆绑的几率较高。尽管在一个大型的综合医疗保健系统中传播了围绕白内障手术的明智选择指南，但这些结果表明，低价值的检查仍然很普遍，需要采取更密集的去实施方法。这项退伍军人健康管理局记录的队列研究检查了低价值的眼白内障手术术前检查的患病率，以及与患者人口统计学特征、手术类型和设施规模的相关性。《明智选择指南》指出，对于接受白内障手术的患者来说，术前检查通常是不必要的，也是浪费。然而，很少有人知道这些广泛传播的指南在美国退伍军人健康管理局（VHA）系统的影响。检查VHA白内障手术前低值检查（LVT）的程度、变异性、相关因素和成本。这项队列研究检查了2017财年（2016年10月1日至2017年9月31日）在VHA内接受白内障手术的所有患者的记录。来自全国135个支持门诊和住院手术的机构的记录被包括在内。在白内障手术前30天内和临床评估后30天内进行的实验室检查。在白内障手术前30天内接受8种常见LVT中任何一种的总体国家和机构级比率和相关费用。与接受至少1次检测相关的患者特征、手术类型和机构水平因素、接受的检测次数以及接受4次检测（全血细胞计数、基本代谢特征、胸片和心电图）。在50106例患者中共确定了69070例白内障手术（66282例[96.0%]男性;平均[SD]年龄，71.7 [8.1]岁; 53837例[77.9%]白色，10292例[14.9%]黑人）。大多数患者人群为超重（23 292例[33.7%]患者）或肥胖（27 799例[40.2%]患者）。大约49%的外科手术（33424例手术）之前进行了1次或多次LVT，总LVT成本为2597623美元。在接受LVT的患者中，心电图（7434例患者[29.9%]）是最常见的，一些患者还接受了更昂贵的检查，包括胸片（489例患者[8.2%]）和肺功能检查（127例患者[3.4%]）。对于接受任何LVT，在设施水平上的组内相关系数为0.61（P < .001），在外科医生水平上的组内相关系数为0.06（P < .001），表明设施对所给予的测试量的实质性贡献。尽管有现有的指南，在一个大型的国家综合卫生保健系统中，白内障手术前使用LVT既常见又昂贵。我们的研究结果表明，单独发布循证指南-如明智选择指南-可能不足以影响个体医生的行为，因此，系统层面的努力，直接取消左室功能测试可能需要实现持续的变化。
To what extent are low-value preoperative tests used before cataract surgery in the US Veterans Health Administration, and what is the variability and cost of these tests? In this cohort study including 69 070 cataract procedures performed among 50 106 patients, almost half were preceded by at least 1 low-value test. Compared with low-complexity facilities, higher facility-level complexity was associated with higher odds of receiving a 4-test bundle. Despite the dissemination of Choosing Wisely guidelines surrounding cataract surgery within a large, integrated health care system, these results suggest that low-value tests continue to be widespread, and that more intensive deimplementation approaches are required. This cohort study of Veterans Health Administration records examines the prevalence of low-value preoperative tests for eye cataract operations and associations with patient demographic characteristics, procedure type, and facility size. The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system. To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA. This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included. A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation. Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram). A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given. Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone—such as the Choosing Wisely campaign—may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.
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影响因子：
2.2
作者：
Wu S;Crespi CM;Wong WK
通讯作者：
Wong WK
DOI：
10.1056/nejmsa1410846
发表时间：
2015-04-16
期刊：
The New England journal of medicine
影响因子：
--
作者：
Chen CL;Lin GA;Bardach NS;Clay TH;Boscardin WJ;Gelb AW;Maze M;Gropper MA;Dudley RA
通讯作者：
Dudley RA
影响因子：
2.6
作者：
Grocott, Michael P. W.;Plumb, James O. M.;Levett, Denny Z. H.
通讯作者：
Levett, Denny Z. H.
影响因子：
39
作者：
Ganguli, Ishani;Lupo, Claire;Sequist, Thomas D.
通讯作者：
Sequist, Thomas D.
影响因子：
120.7
作者：
KAPLAN, EB;SHEINER, LB;NICOLL, CD
通讯作者：
NICOLL, CD