Dataset Information

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

ABSTRACT:

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.

SUBMITTER: Ganguli I

PROVIDER: S-EPMC6547245 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

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

Ganguli Ishani I Lupo Claire C Mainor Alexander J AJ Raymond Stephanie S Wang Qianfei Q Orav E John EJ Chang Chiang-Hua CH Morden Nancy E NE Rosenthal Meredith B MB Colla Carrie H CH Sequist Thomas D TD

JAMA internal medicine 20190901 9

<h4>Importance</h4>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.<h4>Objective</h4>To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.<h4>Design, setting, ...[more]

PMID: 31158270

Similar Datasets

Project description:BackgroundThe amount of total knee arthroplasty (TKA) procedures performed in the United States has been increasing steadily and is projected to reach 3 million procedures annually by 2030 in patients aged ≥65 years. A rise in TKA procedures will increase spending on osteoarthritis treatments, which is currently the second highest category of spending for Medicare patients. Because TKA procedures account for a substantial amount of total osteoarthritis spending, payers and providers are examining methods to reduce spending on the procedure while improving clinical outcomes. Customized individually made implants have been shown to improve clinical outcomes, such as physical function and limb alignment, compared with off-the-shelf implants; however, the economic impact of customized implants has yet to be established.ObjectiveTo analyze TKA episode expenditures among Medicare fee-for-service (FFS) members who received a customized or an off-the-shelf implant.MethodsMembers undergoing a TKA procedure using the customized implant technology were identified in the Medicare FFS database and were propensity matched (1:5) to a cohort of members who received off-the-shelf implants. Reimbursement for the initial procedure (ie, customized and off-the-shelf procedure), a preoperative computed tomography scan, and 12-month postoperative healthcare utilization were analyzed. The overall episode expenditures were used to construct a budget impact model to calculate the per-member per-month (PMPM) spending for Medicare FFS beneficiaries.ResultsThe average total episode spending was significantly lower among the customized implant cohort ($18,585) compared with the off-the-shelf implant cohort ($20,280; a $1695 difference; P <.0001). This savings resulted in $0.08 PMPM savings for the Medicare FFS program when a portion (10%) of eligible members received the customized implant technology. A sensitivity analysis, which varied with the customized implant market penetration and the percent of customized implant-eligible procedures, indicated that the savings could be as great as $0.28 PMPM.ConclusionThe results of this analysis demonstrate that the use of customized implants in TKA procedures can achieve substantial savings versus off-the-shelf procedures for the Medicare FFS program, and this savings is primarily driven by a lower average initial procedure cost and lower postoperative spendings for inpatient services and skilled-nursing facility costs.

Project description:PurposeDelaying cataract surgery is associated with an increased risk of falls, but whether routine preoperative testing delays cataract surgery long enough to cause clinical harm is unknown. We sought to determine whether the use of routine preoperative testing leads to harm in the form of delayed surgery and falls in Medicare beneficiaries awaiting cataract surgery.DesignRetrospective, observational cohort study using 2006-2014 Medicare claims.ParticipantsMedicare beneficiaries 66+ years of age with a Current Procedural Terminology claim for ocular biometry.MethodsWe measured the mean and median number of days between biometry and cataract surgery, calculated the proportion of patients waiting ≥ 30 days or ≥ 90 days for surgery, and determined the odds of sustaining a fall within 90 days of biometry among patients of high-testing physicians (testing performed in ≥ 75% of their patients) compared with patients of low-testing physicians. We also estimated the number of days of delay attributable to high-testing physicians.Main outcome measuresIncidence of falls occurring between biometry and surgery, odds of falling within 90 days of biometry, and estimated delay associated with physician testing behavior.ResultsOf 248 345 beneficiaries, 16.4% were patients of high-testing physicians. More patients of high-testing physicians waited ≥ 30 days and ≥ 90 days to undergo surgery (31.4% and 8.2% vs. 25.0% and 5.5%, respectively; P < 0.0001 for both). Falls before surgery in patients of high-testing physicians increased by 43% within the 90 days after ocular biometry (1.0% vs. 0.7%; P < 0.0001). The adjusted odds ratio of falling within 90 days of biometry in patients of high-testing physicians versus low-testing physicians was 1.10 (95% confidence interval [CI], 1.03-1.19; P = 0.008). After adjusting for surgical wait time, the odds ratio decreased to 1.07 (95% CI, 1.00-1.15; P = 0.06). The delay associated with having a high-testing physician was approximately 8 days (estimate, 7.97 days; 95% CI, 6.40-9.55 days; P < 0.0001). Other factors associated with delayed surgery included patient race (non-White), Northeast region, ophthalmologist ≤ 40 years of age, and low surgical volume.ConclusionsOveruse of routine preoperative medical testing by high-testing physicians is associated with delayed surgery and increased falls in cataract patients awaiting surgery.

Project description:BackgroundPrevious studies have identified disparities in readmissions among Medicare beneficiaries hospitalized for the Hospital Readmissions Reduction Program's (HRRP's) priority conditions. Evidence suggests timely follow-up is associated with reduced risk of readmission, but it is unknown whether timely follow-up reduces disparities in readmission.ObjectiveTo assess whether follow-up within 7 days after discharge from a hospitalization reduces risk of readmission and mitigates identified readmission disparities.DesignA retrospective cohort study using Cox proportional hazards models to estimate the associations between sociodemographic characteristics (race and ethnicity, dual-eligibility status, rurality, and area social deprivation), follow-up, and readmission. Mediation analysis was used to examine if disparities in readmission were mitigated by follow-up.ParticipantsWe analyzed data from 749,402 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, or pneumonia, and discharged home between January 1 and December 1, 2018.Main measureAll-cause unplanned readmission within 30 days after discharge.Key resultsPost-discharge follow-up within 7 days of discharge was associated with a substantially lower risk of readmission (HR: 0.52, 95% CI: 0.52-0.53). Across all four HRRP conditions, beneficiaries with dual eligibility and beneficiaries living in areas with high social deprivation had a higher risk of readmission. Non-Hispanic Black beneficiaries had higher risk of readmission after hospitalization for pneumonia relative to non-Hispanic Whites. Mediation analysis suggested that 7-day follow-up mediated 21.2% of the disparity in the risk of readmission between dually and non-dually eligible beneficiaries and 50.7% of the disparity in the risk of readmission between beneficiaries living in areas with the highest and lowest social deprivation. Analysis suggested that after hospitalization for pneumonia, 7-day follow-up mediated nearly all (97.5%) of the increased risk of readmission between non-Hispanic Black and non-Hispanic White beneficiaries.ConclusionsImproving rates of follow-up could be a strategy to reduce readmissions for all beneficiaries and reduce disparities in readmission based on sociodemographic characteristics.

Project description:BackgroundLow-value care cascades, defined as the receipt of downstream health services potentially related to a low-value service, can result in harm to patients and wasteful healthcare spending, yet have not been characterized within the Veterans Health Administration (VHA).ObjectiveTo examine if the receipt of low-value preoperative testing is associated with greater utilization and costs of potentially related downstream health services in Veterans undergoing low or intermediate-risk surgery.DesignRetrospective cohort study using VHA administrative data from fiscal years 2017-2018 comparing Veterans who underwent low-value preoperative electrocardiogram (EKG) or chest radiograph (CXR) with those who did not.ParticipantsNational cohort of Veterans at low risk of cardiopulmonary disease undergoing low- or intermediate-risk surgery.Main measuresDifference in rate of receipt and attributed cost of potential cascade services in Veterans who underwent low-value preoperative testing compared to those who did not KEY RESULTS: Among 635,824 Veterans undergoing low-risk procedures, 7.8% underwent preoperative EKG. Veterans who underwent a preoperative EKG experienced an additional 52.4 (95% CI 47.7-57.2) cascade services per 100 Veterans, resulting in $138.28 (95% CI 126.19-150.37) per Veteran in excess costs. Among 739,005 Veterans undergoing low- or intermediate-risk surgery, 3.9% underwent preoperative CXR. These Veterans experienced an additional 61.9 (95% CI 57.8-66.1) cascade services per 100 Veterans, resulting in $152.08 (95% CI $146.66-157.51) per Veteran in excess costs. For both cohorts, care cascades consisted largely of repeat tests, follow-up imaging, and follow-up visits, with low rates invasive services.ConclusionsAmong a national cohort of Veterans undergoing low- or intermediate-risk surgeries, low-value care cascades following two routine low-value preoperative tests are common, resulting in greater unnecessary care and costs beyond the initial low-value service. These findings may guide de-implementation policies within VHA and other integrated healthcare systems that target those services whose downstream effects are most prevalent and costly.

Dataset Information

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

Importance

Objective

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Conclusions and relevance

Publications

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

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets