Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries
Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries
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DOI：
10.1001/jamainternmed.2019.1739
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发表时间：
2019-09-01
影响因子：
39
通讯作者：
Sequist, Thomas D.
中科院分区：
文献类型：
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作者：
Ganguli, Ishani;Lupo, Claire;Sequist, Thomas D.
低价值医疗在美国很普遍，但人们对低价值服务引发的下游医疗使用知之甚少。测量这种护理级联对于理解低价值护理的全部后果至关重要。目的（测试、治疗、就诊、住院和新诊断）后的一项共同的低价值服务，术前心电图（EKG）的患者接受白内障手术。设计，设置，观察性队列研究，使用付费-2013年4月1日期间连续登记的66岁或以上无已知心脏病的受益人的服务Medicare索赔数据，2014年7月1日至2015年6月30日期间接受白内障手术。分析了2018年3月12日至2019年4月9日的数据。暴露接收术前EKG。对照组包括接受白内障手术但未接受术前EKG.Main结局和指标的患者，在术前EKG后90天或对照组匹配的时间范围内，级联事件发生率和相关支出。次要结果是患者，医生，和区域水平的特点与经历一个潜在的cascad.Results在110183白内障手术收件人，12408（11.3%）接受了术前心电图（65.6%的人是女性），其中，1978（15.9%）有至少1个潜在的级联事件。对照组包括97775名参与者（63.1%为女性）。与对照组相比，接受术前EKG检查的患者每100名受益人发生的事件增加了5.11（95%CI，3.96-6.25）至10.92（95%CI，9.76-12.08）起。这包括2.18（95% CI，1.34-3.02）和7.98（95% CI，7.12-8.84）次检查、0.33（95% CI，0.19-0.46）次治疗、1.40（95% CI，1.18-1.62）次新患者心脏病学访视和1.21（95% CI，0.62-1.79）次新心脏诊断。每个医疗保险受益人的额外服务支出高达565美元（95% CI，342 - 775美元），或所有医疗保险受益人每年估计为35 025 923美元，加上术前心电图支付的3 275 712美元。在术前EKG接受者中，年龄较大的患者（75 - 84岁患者与66 - 74岁患者的校正比值比[aOR]为1.42; 95% CI为1.28-1.57），（每增加一个Elixhauser条件的aOR，1.18; 95% CI，1.14-1.22），居住在心脏病专家密集的地区（aOR，1.05; 95% CI，1.02-1.09），或由心脏专科医生而非初级保健医生进行术前EKG检查（aOR，1.26; 95%可信区间，（1.10-1.43）更有可能经历潜在的级联反应。结论和相关性白内障手术术前心电图后的护理级联反应并不常见但代价高昂减少低价值服务的政策和实践干预措施以及随之而来的级联效应可以产生大量节省。
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 110183 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 97775 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.