BACKGROUND: There is strong consensus – based on robust randomized trial data - that routine pre-operative (pre-op) testing for cataract surgery is inappropriate. Despite the widely endorsed evidence-based recommendations, most seniors undergoing cataract surgery still receive unnecessary blood testing, EKGs, and chest X-rays (CXRs). With cataract surgery being the most common medical procedure among Medicare beneficiaries (predicted 4.4 million per year by the year 2030), reducing pre-op testing for low-risk cataract surgery would save billions of dollars in financial costs to patients and hospitals, reduce exposure to unnecessary and potentially harmful tests, and allow millions of seniors to spend more time enjoying personally meaningful activities instead of receiving unnecessary health screening.
RESEARCH DESIGN AND METHODS: A team of Ophthalmologist, Anesthesiologist and Hospitalists at UCLA have been leading a dedicated pre-op clinic with a workflow redesign since January 2017, utilizing current evidence and collaboratively creating guidelines for pre-operative testing of patients undergoing cataract surgeries. Patients undergoing cataract surgery at the Stein Eye Institute (SEI) with one of two surgeons – surgeon A and B – were offered a pre-op visit in the UCLA Hospitalist pre-op clinic. The segregation was not randomized. Our intervention group included patients seen by UCLA Hospitalists at the new designated pre-op clinic, while our control group included all other patients undergoing the identical procedure who were seen by numerous other primary care providers who were not part of the designated UCLA Hospitalist group. Pre-intervention data included all patients who underwent cataract surgery at the SEI during the 42 months leading up to the intervention date and post-intervention data included all patients who underwent cataract surgery at the SEI during the 18 months following the intervention date. The results obtained from the patients in our intervention group were compared to that in the control group. Our primary outcome was the percentage of patients receiving pre-op testing (labs, EKGs, CXRs, echocardiogram, stress test, sleep studies) within 30 days of surgery. Our secondary outcome was the percentage of patients with same-day surgery cancellations. Evaluation of the outcomes was performed using segmented regression analysis of interrupted time series. Intervention effects was summarized using percentage of patients who received testing in each group and p-value for the change in the trend of testing between intervention and control group.
RESULTS: Of the patients seen by Surgeons A and B, 65 were seen at the new dedicated pre-op clinic (intervention group), while the rest of 1108 patients were seen by any of the other UCLA primary care providers (control group). Before the intervention, Hospitalists were less likely to order pre-op testing for their patients compared to UCLA primary care providers (62% vs. 86%). Following the intervention, there was an even greater decrease in pre-op testing in the intervention group (62% vs. 51%) with a profound decrease in the two most commonly ordered tests: labs (41% vs 12%) and EKGs (49% vs 34%). Segmented regression analysis of interrupted time series revealed significant change in the rate of average testing in intervention group compared to control group post intervention (p=0.015). The rate of change for EKGs and Any Test also decreased significantly (p=0.004, p=0.006 respectively). There was no detectable change in the percentage of day of surgery cancellation post intervention.
CONCLUSION: This interdisciplinary workflow re-design was associated with substantial reductions in the percentage of patient who received pre-op testing for cataract surgery. Although there was not detectable change in the percentage of day of surgery cancellation, a larger sample size could determine true effect of intervention on the day of surgery cancellation. The new model moved from the traditional physician centered care model – in which the decision to order tests and procedures is influenced by provider’s personal past experiences, preferences, and interpretation of the guidelines – to a patient centered model – in which a shared mental model drives patient care. We demonstrated that a collaboration between Ophthalmologists, Anesthesiologists and Hospitalists is associated with reductions in low-value care in the pre-op assessment and preparation for cataract surgery. Additional surgeon and patient recruitment in the study can better demonstrate the statistical and clinical significance of the above findings. Further studies need to be conducted to measure patients experience through surveys and additional outcomes including costs, readmission rates, and associated adverse events.