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Prevalence and Cost of Care Cascades Following Low-Value Preoperative Electrocardiogram and Chest Radiograph Within
Aimee N Pickering1,2, Xinhua Zhao3, Florentina E Sileanu3
1Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. pickeringan@upmc.edu.
Insights
Low-value preoperative electrocardiograms (EKG) and chest radiographs (CXR) in Veterans lead to more downstream services and higher healthcare costs. These findings highlight the need for de-implementation strategies to reduce unnecessary care and spending.
Area of Science:
- Health Services Research
- Health Economics
- Clinical Quality Improvement
Background:
- Low-value care cascades, involving downstream services from low-value initial care, contribute to patient harm and healthcare waste.
- These cascades have not been previously characterized within the Veterans Health Administration (VHA).
Purpose of the Study:
- To investigate the association between low-value preoperative testing (electrocardiogram [EKG] and chest radiograph [CXR]) and subsequent utilization and costs of related downstream health services.
- To characterize low-value care cascades in Veterans undergoing low or intermediate-risk surgery within the VHA.
Main Methods:
- Retrospective cohort study utilizing VHA administrative data from fiscal years 2017-2018.
- Comparison of Veterans who received low-value preoperative EKG or CXR versus those who did not, focusing on low- or intermediate-risk surgeries.
- Analysis of the rate and cost of potential cascade services.
Main Results:
- Among 635,824 Veterans, 7.8% had preoperative EKGs, leading to an average of 52.4 additional cascade services and $138.28 excess cost per Veteran.
- Among 739,005 Veterans, 3.9% had preoperative CXRs, resulting in 61.9 additional cascade services and $152.08 excess cost per Veteran.
- Cascade services primarily included repeat tests, follow-up imaging, and visits, with few invasive procedures.
Conclusions:
- Low-value care cascades following routine preoperative EKG and CXR are common in the VHA.
- These cascades result in increased utilization of unnecessary care and elevated healthcare costs.
- Findings support de-implementation policies targeting prevalent and costly downstream effects of low-value services in integrated healthcare systems.
Background:
Low-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).
Objective:
To 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.
Design:
Retrospective 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.
Participants:
National cohort of Veterans at low risk of cardiopulmonary disease undergoing low- or intermediate-risk surgery.
Main Measures:
Difference 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.
Conclusions:
Among 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.
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