Cataract Surgery: QI Initiative Markedly Reduced Low-Value Preoperative Care Interview with:

John N. Mafi MPH Assistant Professor of Medicine David Geffen School of Medicine University of California, Los Angeles Natural scientist in Health Policy RAND Corporation Santa Monica, California

Dr. Mafi

John N. Mafi, MD, MPH
Division of General Internal Medicine and Health Services Research
Department of Medicine
David Geffen School of Medicine at UCLA
RAND Health, RAND Corporation What is the background for this study? What types of services are low-value in this setting? 

Response: For decades we have known that offering routine preoperative testing for patients undergoing cataract surgery provides limited value, yet low-value preoperative testing persists at very high rates, even at Los Angeles County Department of Health Services, one of the largest safety net health systems in the United States. What are the main findings? 

Response: Motivated and supported by the American Board of Internal Medicine Foundation Choosing Wisely campaign, a Los Angeles County University of Southern California (LAC+USC) Medical Center quality improvement nurse reviewed the medical records of patients undergoing cataract surgery and presented overuse data to the chiefs of anesthesiology and ophthalmology, obtaining their support. All three then educated faculty, trainees, and staff on reducing routine preoperative care, and they eliminated the institutional protocol of requiring routine preoperative testing and medical visits for patients undergoing cataract surgery. After the intervention, preoperative medical visits, chest x-rays, EKGs, and labs all declined absolutely by 71%, 75%, 74%, and 55% respectively among intervention patients (469 patients) when compared with control patients (585 patients).

The intervention reduced a licensed vocation nurse’s workload by 70% and 3-year projections estimated modest cost savings associated with the initiative (~$67K). But cost-savings depend entirely on who’s perspective you are taking. When we hypothetically changed the financial perspective to society’s perspective we estimated bigger savings (~$217K) but when we hypothetically changed the financial perspective to a fee-for-service health system we estimated losses (~$88K). What should readers take away from your report?

Response: We found that a clinician-led quality improvement initiative was associated with markedly reduced low-value preoperative care and modest cost savings for the safety net health care system. Ultimately, these findings suggest that fee-for-service payment may represent a barrier to reducing low-value care. What recommendations do you have for future research as a result of this work?

Response: This was a clinician-led non-randomized intervention in a safety net health system with a local culture probably amenable to change, and so the intervention may not necessarily work everywhere. These and other approaches will require more rigorous evaluation in prospective randomized controlled trials. I am very lucky to be involved in two such ongoing randomized controlled trials with Dr. Catherine Sarkisian of UCLA Health and Ms. Beth Bortz of Virginia Health Innovation in Virginia. Please follow me on twitter for more studies on this important topic! Is there anything else you would like to add?

Response: This work was supported by an American Board of Internal Medicine Foundation Choosing Wisely grant to reduce low-value care. Dr Mafi was supported by a National Institutes of Health/National Center for Advanced Translational Science Institute KL2TR001882 award (PI: Mitchell Wong). Dr Sarkisian was supported by a National Institute on Aging 1K24AG047899-01 award. Dr Damberg was supported by the RAND Center of Excellence on Health System Performance funded by grant 1U19HS024067-01 from the Agency for Healthcare Research and Quality.


Mafi JN, Godoy-Travieso P, Wei E, et al. Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System. JAMA Intern Med. Published online March 25, 2019. doi:10.1001/jamainternmed.2018.8358 

Mar 27, 2019 @ 1:02 am 

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