Work

Examining patient perspectives on low‐value care: Findings from a survey on preoperative testing for cataract surgery

Year: 2023

Type: article

Abstract: Despite national recommendations against routine preoperative (pre-op) testing before cataract surgery, over 80% of Medicare patients still receive this low-value care.1, 2 Although theories have been proposed to explain drivers such as institutional requirements and legal concerns, the impact of patient influence has not been previously reported.3, 4 The patient-provider interaction has been identified as a significant driver of excessive testing in other healthcare settings.5 As part of a large health system quality improvement initiative to reduce unnecessary pre-op testing, we sought to measure patient perspectives. We hypothesized that patient preference and expectation might contribute to high rates of pre-op testing before cataract surgery; however, we also anticipated that patients would report negative experiences resulting from over-testing. We developed a 10-question survey to measure cataract surgery patients' attitudes and expectations surrounding pre-op testing. The survey aimed to measure the patient's perspective on various aspects of pre-op evaluation, including the time taken away from meaningful activities, anxiety level, preferences, expectations, and provider communication. We tested the survey items by conducting cognitive interviews with groups of older adults and made iterative revisions until the participants demonstrated a thorough understanding of the questions. We distributed paper versions of the questionnaires along with a stamped envelope to patients seen by a single ophthalmologist at a large urban health center during the postoperative visit between September 2021 and May 2022. Participants who returned a completed survey and a signed consent form were sent a gift card afterwards. Descriptive statistics were calculated to analyze the survey responses. The study protocol received approval from the institutional review board of the University of California, Los Angeles. Of the approximately 150 surveys distributed, we received 58 completed surveys from patients who consented to participate in the study, resulting in a response rate of 39%. Most participants were older than 65 years (83%) and female (70%) (Table 1). Internal consistency reliability analysis revealed a Cronbach's Alpha value of 0.693, indicating satisfactory reliability. Ninety-three percent of patients reported undergoing at least one pre-op test, such as an EKG or blood test. Fifty-seven percent of respondents somewhat or strongly disagreed that pre-op tests took time away from other meaningful activities, while 66% somewhat or strongly disagreed that the tests increased their anxiety. In terms of expectations toward pre-op testing, 76% of respondents somewhat or strongly agreed that they were glad they had pre-op testing, and 47% somewhat or strongly agreed that they expected their doctor to order tests. Regarding doctor communication, 55% of respondents strongly or somewhat agreed that their doctor communicated the reasons they may or may not need pre-op testing (Figure 1). Additionally, we solicited free-response comments from respondents. Some of the comments included: “The pre-operative tests gave me confidence in the surgery,” “making sure that there is no underlying condition or issue prior to surgery is a good thing,” and “having pre-op is totally necessary for successful surgeries.” We found that in this sample of 58 patients surveyed at a single academic medical center, the perception of pre-op testing for cataract surgery was largely positive and desirable. This finding supports the hypothesis that patient factors may contribute to physicians ordering tests, even when professional societies discourage such testing.5 Contrary to our initial hypothesis that patients would express concerns about pre-op testing taking time away from other meaningful activities and increasing anxiety, most respondents reported the opposite. There was a strong preference and expectation among patients to undergo testing. The survey responses, particularly the open-ended comments, indicate that patients may overestimate the benefit of testing and underestimate the potential harm. These findings were observed despite most patients reporting good communication from their doctor during their pre-op visit. A limitation of the study is the inclusion of patients from a single ophthalmologist and the relatively low response rate, which may introduce selection and nonresponse biases. Additionally, the racial and ethnic distribution of patients in our sample may not reflect the demographics of the patients in this healthcare setting or across the United States. Given that patients often equate more care with better care,6 transitioning to high-value care and reducing unnecessary testing while maintaining patient satisfaction remains a challenge. Further investigations should explore how patient expectations can be adjusted to reduce unnecessary testing. To effectively stop inappropriate pre-op testing for cataract surgery, quality improvement interventions should prioritize the development of direct messaging aimed at educating and informing patients. All authors had substantial contributions to conception and design of the study, acquisition, analysis, and interpretation of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be published. This work was supported by the National Institute on Aging (NIA) grant numbers 3R01AG05981501S1, 1R01AG05981501, 1K24AG047899-02, and UCLA Clinical and Translational Science Institute (CTSI) grant number UL1TR001881. The authors declare no conflicts of interest. The study funder has no role in the study design, data collection, management, analysis, and interpretation of data, writing of the report, and the decision to submit the report for publication.

Source: Journal of the American Geriatrics Society

DOI: 10.1111/jgs.18494