背景:医疗保险和医疗补助服务中心(CMS)最近取消了门诊手术前对术前病史和体检(H&P)的要求。我们试图评估低风险非卧床手术前单独开单的术前H&P利用率的变化,描述与术前测试的任何关系,并在此政策变更之前确定这些会诊的独立预测因素,以帮助描述这些会诊的潜在不必要利用和低风险手术前的潜在不必要术前检查的特征.
方法:一项回顾性队列研究使用2015年1月至2019年6月密歇根州医院价值合作组织的索赔数据进行,包括接受以下三种门诊手术之一的患者:乳房肿块切除术,腹腔镜胆囊切除术,和腹腔镜腹股沟疝修补术。确定手术后30天内的术前H&P访视率。H&P和术前测试的关联进行了探讨,和患者水平,实践层面,使用回归模型评估医院水平的利用率决定因素。生成了经风险和可靠性调整的毛毛虫图,以证明医院水平的利用率差异。
结果:包括50,775例患者,其中50.5%进行了术前H&P访视,这些就诊在合并症增加的患者中更为常见(1.9±2.2vs1.4±1.9;P<0.0001)。术前测试与H&P访视相关(57.2%vs41.4%;P<0.0001)。在调整了H&P就诊的患者病例混合和院际和院际差异后,在合并症增加的患者中,利用率仍然存在显著关联.
结论:在密歇根州进行三次低风险门诊外科手术之前,术前H&P访视是常见的,并且与较高的低价值术前检测率相关。提示术前H&P访视可能产生临床动力,导致不必要的检测.这些发现将为低风险外科手术前调整术前护理的策略提供信息,并可能导致低价值术前检查的利用率降低。
BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery.
METHODS: A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization.
RESULTS: 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities.
CONCLUSIONS: Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.