1. In this quality improvement study carried out in Southern California, educational interventions to prevent low-value care before cataract surgery lead by a single quality improvement nurse yielded societal savings estimated at $217,322 over 3 years.
2. In a fee-for-service system, the estimated loss of earnings was $88,151 over 3 years, highlighting a potential barrier.
Evidence Rating Level: 2 (Good)
Study Rundown: Despite increasing awareness, a large amount of healthcare spending is still directed at interventions without proven benefit. With rising health care costs and economic uncertainty, these are opportunities for intervention and savings. Preoperative care for cataract surgery is one example, as the existing literature has shown no clinical benefit.
In this multi-component quality improvement project run at two academic safety-net health systems in California, the educational interventions yielded cost savings of $42,241 after 1 year at LAC-USC (Los Angeles County and University of Southern California) Medical Center with 3 year estimate at $67,241. In a fee-for-service system, 3 year loss of earnings was estimated at $88,151 however societal cost savings were $217,322. Pre-operative visits, chest x-rays, lab testing, and electrocardiograms all decreased from roughly 85-95% to 20-40% in frequency. Apart from pre-operative visits, the reductions were sustained for one year after intervention.
While the tangible aspects of this intervention could be applied at other institutions, limitations of the study included the non-randomized, observational design and the inability to separate the efficacy of the individual components of the intervention.
Relevant Reading: Measuring Low-Value Care in Medicare
In-Depth [prospective cohort study]: This was a multi-component quality improvement project run at two academic safety net health systems in California. All adult patients undergoing cataract surgery at both sites between April 2015 and April 2016 were included (6 months before and after the interventions). Data was collected for an additional 1 year for information on sustainability of effect. The interventions included a quality improvement nurse reviewing medical records and presenting overuse data to physician leadership, educating residents and nursing staff to stop routinely ordering tests and routinely scheduling preoperative visits, a resident champion helping craft new preoperative protocols, and continued reminders from physician leadership to clinicians. The quality improvement nurse spent 20% of her time leading the initiative for one year. Primary outcome was percentage of patients with preoperative medical visits, chest x-rays, laboratory tests, or electrocardiograms within 80 days of surgery. Secondary outcomes included serious 30-day postoperative adverse events (e.g. myocardial infarction, stroke, or hypoglycemia). A cost analysis was also performed. Cost analysis was from the perspective of LAC-USC (Los Angeles County and University of Southern California) Medical Center. Total sample size was 2567, with 469 intervention patients and 585 control patients during the first year and 1002 intervention patients and 511 control patients in the 12 month sustainability analysis. In the first year of analysis, preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group. Chest x-rays decreased from 90% to 24% versus an increase from 75% to 83%, lab testing decreased from 92% to 37% versus a decrease from 98% to 97%, and electrocardiograms decreased from 95% to 29% versus an increase of 86% to 94%. All time-by-group interactions had a p<0.001. In the 12 months of additional follow up pre-operative visits increase back to 67% however the remainder of improvements were stable. Serious 30-day events remained rare in all groups. Cost savings were $42,241 after 1 year with estimated health system savings of $67,241 at 3 years. Extrapolating to a fee-for-service system suggested losses of $88,151 at 3 years but societal cost savings of $217,322 at 3 years.
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