A Revised Estimate of Costs Associated With Routine Preoperative Testing in Medicare Cataract Patients With a Procedure-Specific Indicator

Importance

Routine preoperative medical testing is not recommended for patients undergoing low-risk surgery, but testing is common before surgery. A 30-day preoperative testing window is conventionally used for study purposes; however, the extent of routine testing that occurs prior to that point is unknown.

Objective

To improve on existing cost estimates by identifying all routine preoperative testing that takes place after the decision is made to perform cataract surgery.

Design, Setting, and Participants

This cross-sectional study assessed preoperative care in a 50% sample of Medicare beneficiaries older than 66 years who underwent ambulatory cataract surgery in 2011. Data analysis was completed from March 2016 to October 2017.

Main Outcomes and Measures

Using ocular biometry as a procedure-specific indicator to mark the start of the routine preoperative testing window, we measured testing rates in the interval between ocular biometry and cataract surgery and compared this with testing rates in the 6 months preceding biometry. We estimated the total cost of testing that occurred between biometry and cataract surgery.

Results

A total of 440 857 patients underwent cataract surgery. A total of 423 710 (96.1%) had an ocular biometry claim before index surgery, of whom 264 514 (60.0%) were female; the mean (SD) age of the cohort was 76.1 (6.2) years. A total of 111 998 (25.4%) underwent surgery more than 30 days after biometry. Among patients with a biometry claim, the mean number of tests/patient/month increased from 1.1 in the baseline period to 1.7 in the interval between biometry and cataract surgery. Although preoperative testing peaked in all patients in the 30 days preceding surgery (1.8 tests/patient/month), the subset of patients with no overlap between postbiometry and presurgery periods experienced increased testing rates to 1.8 tests per patient per month in the 30 days after biometry, regardless of the elapsed time between biometry and surgery. The total estimated cost of routine preoperative testing in the full cohort was $22.7 million; we estimate that routine preoperative testing costs Medicare up to $45.4 million annually.

Conclusions and Relevance

In this study of Medicare beneficiaries, routine preoperative medical testing occurs more often and is costlier than has been reported previously. Extra costs are attributable to testing that occurs prior to the 30-day window preceding surgery. As a cost-cutting measure, routine preoperative medical testing should be avoided in patients with cataracts throughout the interval between ocular biometry and cataract surgery.

Revisit rates and associated costs after an emergency department encounter: a multistate analysis

BACKGROUND

Return visits to the emergency department (ED) or hospital after an index ED visit strain the health system, but information about rates and determinants of revisits is limited.

OBJECTIVE

To describe revisit rates, variation in revisit rates by diagnosis and state, and associated costs.

DESIGN

Observational study using the Healthcare Cost and Utilization Project databases.

SETTING

6 U.S. states.

PATIENTS

Adults with ED visits between 2006 and 2010.

MEASUREMENTS

Revisit rates and costs.

RESULTS

Within 3 days of an index ED visit, 8.2% of patients had a revisit; 32% of those revisits occurred at a different institution. Revisit rates varied by diagnosis, with skin infections having the highest rate (23.1% [95% CI, 22.3% to 23.9%]). Revisit rates also varied by state. For skin infections, Florida had higher risk-adjusted revisit rates (24.8% [CI, 23.5% to 26.2%]) than Nebraska (10.6% [CI, 9.2% to 12.1%]). In Florida, the only state with complete cost data, total revisit costs for the 19.8% of patients with a revisit within 30 days were 118% of total index ED visit costs for all patients (including those with and without a revisit).

LIMITATION

Whether a revisit reflects inadequate access to primary care, a planned revisit, the patient's nonadherence to ED recommendations, or poor-quality care at the initial ED visit remains unknown.

CONCLUSION

Revisits after an index ED encounter are more frequent than previously reported, in part because many occur outside the index institution. Among ED patients in Florida, more resources are spent on revisits than on index ED visits.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Preoperative medical testing in Medicare patients undergoing cataract surgery

BACKGROUND

Routine preoperative testing is not recommended for patients undergoing cataract surgery, because testing neither decreases adverse events nor improves outcomes. We sought to assess adherence to this guideline, estimate expenditures from potentially unnecessary testing, and identify patient and health care system characteristics associated with potentially unnecessary testing.

METHODS

Using an observational cohort of Medicare beneficiaries undergoing cataract surgery in 2011, we determined the prevalence and cost of preoperative testing in the month before surgery. We compared the prevalence of preoperative testing and office visits with the mean percentage of beneficiaries who underwent tests and had office visits during the preceding 11 months. Using multivariate hierarchical analyses, we examined the relationship between preoperative testing and characteristics of patients, health system characteristics, surgical setting, care team, and occurrence of a preoperative office visit.

RESULTS

Of 440,857 patients, 53% had at least one preoperative test in the month before surgery. Expenditures on testing during that month were $4.8 million higher and expenditures on office visits $12.4 million higher (42% and 78% higher, respectively) than the mean monthly expenditures during the preceding 11 months. Testing varied widely among ophthalmologists; 36% of ophthalmologists ordered preoperative tests for more than 75% of their patients. A patient's probability of undergoing testing was associated mainly with the ophthalmologist who managed the preoperative evaluation.

CONCLUSIONS

Preoperative testing before cataract surgery occurred frequently and was more strongly associated with provider practice patterns than with patient characteristics. (Funded by the Foundation for Anesthesia Education and Research and the Grove Foundation.).

Mortality Risk and Prospective Medicare Expenditures for Persons with Dementia

OBJECTIVES

To determine whether an index that stratifies dementia patients into high- and low-mortality-risk groups can be effective in prospectively identifying persons with high and low expenditures.

DESIGN

A mortality risk index developed for persons with dementia was used to stratify persons into groups at high and low risk of 12-month mortality. Expenditures were compiled from Medicare claims for 12 months after the predicted mortality classification.

SETTING

The Medicare Alzheimer's Disease Demonstration Evaluation (MADDE) operated in eight sites across the United States. Subjects were living in a community setting at time of their mortality risk classification.

PARTICIPANTS

Participants (N=2,255) were volunteer enrollees in MADDE; all had a diagnosis of irreversible dementia and two or more limitations in activities of daily living (ADLs).

MEASUREMENTS

Outcomes were Medicare Part A expenditures. Risk factors included age, sex, ADL limitations, selected chronic conditions, prior year hospital stays, and relationship to caregiver.

RESULTS

Patients predicted as at high risk of death had higher average monthly Medicare expenditures than those predicted to be at low risk of death. At the 50th sensitivity percentile for mortality, differences in average expenditures exceeded 700 dollars per month.

CONCLUSION

It is not known whether it is possible to achieve reductions in expenditures for patients with advanced dementia at high risk of mortality, but study findings support consideration of an advanced illness model that would attempt to generate acute services savings and use these savings for palliative services that might improve patients' and caregivers' quality of life.

Excretion of urinary N-telopeptides reflects changes in bone turnover during ovarian suppression and indicates individually variable estradiol threshold for bone loss

OBJECTIVE

To evaluate the effectiveness of N-telopeptides and E2 in monitoring bone turnover during GnRH agonist- (GnRH-a) or danazol-induced hypoestrogenism.

DESIGN

Comparative, nonrandomized prospective study.

SETTING

Institute for the Study and Treatment of Endometriosis.

PATIENT(S)

Premenopausal women undergoing ovarian suppression with GnRH-a (n = 16) or danazol (n = 9).

INTERVENTION(S)

Serum and urine samples were collected and bone mineral density was measured before, during, and after treatment.

MAIN OUTCOME MEASURE(S)

N-telopeptide excretion, serum E2, and bone mineral density at L1 to L4 and femoral neck.

RESULT(S)

During treatment in the GnRH-a group, mean E2 levels were 53% below and N-telopeptides were 38% above the mean baseline. At 1 month post-treatment, L1 to L4 bone mineral density decreased by 3.85%. In the danazol group, E2, N-telopeptides and L1 to L4 bone mineral density changed nonsignificantly in the opposite direction with the mean 1.25% increase in L1 to L4 at 1 month post-treatment. In combined groups, L1 to L4 bone mineral density better correlated with other measures than femoral neck bone mineral density. N-telopeptide excretion was more predictive of L1 to L4 change, with correlation the highest between N-telopeptides at month 4 and bone mineral density at month 1 afterward, while E2 appeared more predictive of the less reliable femoral neck bone mineral density. Individual exceptions to the model of an E2 threshold for bone loss were observed. Also noted were high correlation between on-therapy levels of E2 and N-telopeptides, as well as the presence of a 1-month time lag between E2 and N-telopeptide changes.

CONCLUSION(S)

Bone density decreases during GnRH-a and may slightly increase during danazol treatment. However, E2 threshold for bone loss varies individually. N-telopeptides predict changes in bone mineral density at L1 to L4 better than E2.