Clinicians at Los Angeles County (LAC)+USC Medical Center, part of the second largest safety-net health system in the nation, were used to ordering several tests for patients prior to surgery, including cataract procedures.
Many of these pre-operative visits and tests (e.g., EKGs, X-rays, lab tests) were identified as potentially unnecessary through guidelines distributed by the Los Angeles County Department of Health Services (DHS), a grantee partner in the Choosing Wisely campaign. They highlighted the American Academy of Ophthalmology Choosing Wisely recommendation against preoperative medical tests for eye surgery unless there are specific medical indications.
Despite the availability of these evidence-based guidelines, Eric K. Wei, MD, Associate Medical Director, Quality, Safety and Risk, at LAC+USC Medical Center, said he heard anecdotes that clinicians were reluctant to stop unneeded pre-operative tests based on fears of surgical cases being cancelled due to missing pre-operative workups.
“Testing is not a benign thing,” Dr. Wei said. “There are risks from radiation from chest X-rays and there is a risk of ‘incidentalomas’ — variations in results that can lead to even more unneeded testing and a delay in addressing the actual health problem.”
He said that LAC+USC Medical Center focused on reducing unneeded tests prior to cataract surgery because it was low-risk and, after chart reviews, the team found that the preoperative workup had no impact on care.
Patricia Godoy-Travieso, Quality Improvement Advisor, conducted an initial chart review of 12 cases to obtain baseline data in 2015 including the length of time that elapsed between diagnosis and surgery, comorbidities, and what kind of pre-operative tests were done.
She found most patients scheduled for cataract surgery received unnecessary pre-operative tests and that the results did not change the course of care and, instead, delayed the procedure for several weeks. After a second review of an additional 10 cases to confirm the findings, she and her team presented the information to the Departments of Ophthalmology and Anesthesia to see if they would adopt the Choosing Wisely guidelines to reduce unneeded preoperative testing.
“The doctors were very enthusiastic about implementing the new guidelines but questioned the safety of their patient population,” she said. “The baseline data was key to get buy-in from the team. How you put the team together is also important, including securing leadership approval, finding a physician champion and connecting with the right clinic stakeholders to move forward.”
A quality improvement initiative at LAC+USC Medical Center was devised with senior leadership in Ophthalmology, Anesthesiology and Quality Improvement to implement the guidelines. The team recruited an ophthalmology resident champion, who, along with department chairs, emailed all ophthalmology and anesthesiology physicians guidelines based on AAO’s Choosing Wisely recommendations articulating when pre-operative testing for cataract surgery is—and is not—appropriate.
An initial three-month chart review demonstrated that 85 percent of patients had preoperative testing prior to guideline implementations and only 9 percent of patients had preoperative test after the intervention.
One challenge faced during this process was data gathering for pre- and post-project analysis. LAC+USC Medical Center was moving from paper records to an electronic health record (EHR) close to the time the new guidelines were adopted. While working to set up an automatic report, the team manually reviewed data. Detailed results continued to show that the intervention was successful:
- 76 percent of pre-intervention patients had unnecessary pre-operative medical visits; compared to 12 percent post.
- 90 percent of pre-intervention patients had unnecessary pre-operative laboratory testing; compared to 31 percent post.
- Patients waited a median of 239 days until surgery pre-intervention; compared to a median of 68 days post.
- Pre-operative testing is estimated to be $1,200 dollars per case, leading LAC+USC Medical Center to anticipate significant cost savings with no adverse impact on patient care.
“We were very excited to see that there was a dramatic decrease,” Dr. Wei said. “Though cataracts are a slow progressive disease, there were many reasons to cut down the time between diagnosis and surgery. For patient satisfaction and experience it does make a huge difference, and you can avoid losing contact with patients during delays in care.”
Godoy-Travieso said that it is still important to do random chart reviews as well, to see if guidelines are continually followed. Other steps the team agreed were important: Celebrate the success and share it with stakeholders.
“We try to take every opportunity to keep it at the forefront and keep people excited,” Dr. Wei said. “Our hope is to first work locally to reduce unneeded testing before other surgeries. We also hope to publish our results to spark more conversations nationally and internationally. We found that you can really use the structure of performance improvement to get engagement in Choosing Wisely from frontline clinicians up to leadership.”