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Jennifer T. Anger - One of the best experts on this subject based on the ideXlab platform.
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Preoperative Testing for Urethral Sling Surgery for Stress Urinary Incontinence: Overuse, Underuse and Cost Implications
The Journal of urology, 2015Co-Authors: Tom Feng, Colby E. Perkins, Lauren N. Wood, Karyn S. Eilber, Jerome K. Wang, Catherine Bresee, Jennifer T. AngerAbstract:Purpose We identify areas of overuse and underuse in the Preoperative evaluation of patients undergoing mid urethral sling surgery. We also estimate the effect of overuse of Preoperative Testing on health care costs. Materials and Methods We conducted a retrospective review of women who underwent sling surgery with or without concomitant prolapse repair between 2012 and 2013. Physician orders for Preoperative electrocardiogram, chest x-ray, basic metabolic panel, complete blood count, coagulation studies and urinalysis were classified as appropriate or inappropriate based on summary guidelines from the American Academy of Family Physicians. The additional costs of inappropriate tests were estimated using the 2014 Medicare clinical laboratory and physician fee schedules. Results A total of 101 women who underwent mid urethral sling surgery were identified and 346 Preoperative tests were ordered. Overall 76% of coagulation profiles, 73% of complete blood counts, 47% of basic metabolic panels, 39% of chest x-rays and 21% of electrocardiograms ordered did not have an appropriate clinical indication. In addition, 6% of electrocardiograms, 22% of chest x-rays and 10% of urinalyses were not ordered despite an appropriate indication. The estimated charges of overused tests were $1,844.15 for the cohort, or $18 per patient. Conclusions Preoperative Testing is overused as well as underused in patients undergoing sling surgery. The greatest variation occurred with the use of electrocardiograms, chest x-rays and urinalysis. Poor adherence to national guidelines leads to increased health care costs and warrants increased awareness in following evidence-based guidelines.
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the role of Preoperative Testing on outcomes after sling surgery for stress urinary incontinence
The Journal of Urology, 2007Co-Authors: Jennifer T. Anger, Larissa V Rodríguez, Qin Wang, Chris L Pashos, Mark S LitwinAbstract:Purpose: In this study we analyzed Medicare claims data to measure the effect of Preoperative urodynamics and cystoscopy on outcomes after sling surgery.Materials and Methods: We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of beneficiaries. Women who underwent sling procedures between July 1, 1999 and December 31, 2000 were identified on the basis of the presence of CPT-4 code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify type of Preoperative studies performed (urodynamics and cystoscopy) and for 12 months after surgery to assess short-term complications.Results: Of 1,356 subjects 24.8% underwent Preoperative cystoscopy and 27.4% underwent Preoperative urodynamic Testing. In postoperative year 1, 32.4% of subjects underwent cystoscopy and 30.5% underwent urodynamics. Patients who underwent Preoperative urodynamics were more likely to be newly diagnosed with urge incontinence after surgery (21.9% vs 12.7%, p <0.0...
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The role of Preoperative Testing on outcomes after sling surgery for stress urinary incontinence.
The Journal of urology, 2007Co-Authors: Jennifer T. Anger, Larissa V Rodríguez, Qin Wang, Chris L Pashos, Mark S LitwinAbstract:In this study we analyzed Medicare claims data to measure the effect of Preoperative urodynamics and cystoscopy on outcomes after sling surgery. We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of beneficiaries. Women who underwent sling procedures between July 1, 1999 and December 31, 2000 were identified on the basis of the presence of CPT-4 code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify type of Preoperative studies performed (urodynamics and cystoscopy) and for 12 months after surgery to assess short-term complications. Of 1,356 subjects 24.8% underwent Preoperative cystoscopy and 27.4% underwent Preoperative urodynamic Testing. In postoperative year 1, 32.4% of subjects underwent cystoscopy and 30.5% underwent urodynamics. Patients who underwent Preoperative urodynamics were more likely to be newly diagnosed with urge incontinence after surgery (21.9% vs 12.7%, p <0.0001). Those who underwent Preoperative cystoscopy were significantly more likely to be diagnosed with (9.4% vs 6.1%, p <0.043) or treated for (10.6% vs 7.2%, p <0.047) outlet obstruction postoperatively than those who did not. Multivariate analysis revealed that subjects who underwent Preoperative urodynamics were significantly less likely to undergo postoperative urodynamics than those who did not (OR 0.34, 95% CI 0.24-0.48). Our findings of worse outcomes among women who underwent Preoperative Testing may be due in part to case selection. Our finding that women who underwent Preoperative urodynamics were only a third as likely to undergo postoperative urodynamics as those who did not supports the use of urodynamics in the Preoperative setting. However, the true effect of urodynamics on sling outcomes remains controversial.
Mark S Litwin - One of the best experts on this subject based on the ideXlab platform.
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the role of Preoperative Testing on outcomes after sling surgery for stress urinary incontinence
The Journal of Urology, 2007Co-Authors: Jennifer T. Anger, Larissa V Rodríguez, Qin Wang, Chris L Pashos, Mark S LitwinAbstract:Purpose: In this study we analyzed Medicare claims data to measure the effect of Preoperative urodynamics and cystoscopy on outcomes after sling surgery.Materials and Methods: We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of beneficiaries. Women who underwent sling procedures between July 1, 1999 and December 31, 2000 were identified on the basis of the presence of CPT-4 code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify type of Preoperative studies performed (urodynamics and cystoscopy) and for 12 months after surgery to assess short-term complications.Results: Of 1,356 subjects 24.8% underwent Preoperative cystoscopy and 27.4% underwent Preoperative urodynamic Testing. In postoperative year 1, 32.4% of subjects underwent cystoscopy and 30.5% underwent urodynamics. Patients who underwent Preoperative urodynamics were more likely to be newly diagnosed with urge incontinence after surgery (21.9% vs 12.7%, p <0.0...
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The role of Preoperative Testing on outcomes after sling surgery for stress urinary incontinence.
The Journal of urology, 2007Co-Authors: Jennifer T. Anger, Larissa V Rodríguez, Qin Wang, Chris L Pashos, Mark S LitwinAbstract:In this study we analyzed Medicare claims data to measure the effect of Preoperative urodynamics and cystoscopy on outcomes after sling surgery. We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of beneficiaries. Women who underwent sling procedures between July 1, 1999 and December 31, 2000 were identified on the basis of the presence of CPT-4 code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify type of Preoperative studies performed (urodynamics and cystoscopy) and for 12 months after surgery to assess short-term complications. Of 1,356 subjects 24.8% underwent Preoperative cystoscopy and 27.4% underwent Preoperative urodynamic Testing. In postoperative year 1, 32.4% of subjects underwent cystoscopy and 30.5% underwent urodynamics. Patients who underwent Preoperative urodynamics were more likely to be newly diagnosed with urge incontinence after surgery (21.9% vs 12.7%, p <0.0001). Those who underwent Preoperative cystoscopy were significantly more likely to be diagnosed with (9.4% vs 6.1%, p <0.043) or treated for (10.6% vs 7.2%, p <0.047) outlet obstruction postoperatively than those who did not. Multivariate analysis revealed that subjects who underwent Preoperative urodynamics were significantly less likely to undergo postoperative urodynamics than those who did not (OR 0.34, 95% CI 0.24-0.48). Our findings of worse outcomes among women who underwent Preoperative Testing may be due in part to case selection. Our finding that women who underwent Preoperative urodynamics were only a third as likely to undergo postoperative urodynamics as those who did not supports the use of urodynamics in the Preoperative setting. However, the true effect of urodynamics on sling outcomes remains controversial.
Andreas Sönnichsen - One of the best experts on this subject based on the ideXlab platform.
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the impact of Preoperative Testing for blood glucose concentration and haemoglobin a1c on mortality changes in management and complications in noncardiac elective surgery a systematic review
European Journal of Anaesthesiology, 2015Co-Authors: Matthias Bock, Tim Johansson, Gerhard Fritsch, Maria Flamm, Bernhard Hansbauer, Eva Mann, Andreas SönnichsenAbstract:BACKGROUNDThe risks associated with surgery are elevated in patients with diabetes mellitus. For this reason, Preoperative diagnostics frequently include the measurement of blood glucose and haemoglobin A1c (HbA1c), but it is unclear whether these tests contribute to improved perioperative or postop
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Effectiveness of non-cardiac Preoperative Testing in non-cardiac elective surgery: a systematic review
British journal of anaesthesia, 2013Co-Authors: Tim Johansson, Gerhard Fritsch, Maria Flamm, Bernhard Hansbauer, N. Bachofner, Eva Mann, Matthias Bock, Andreas SönnichsenAbstract:Elective surgery is usually preceded by Preoperative diagnostics to minimize risk. The results are assumed to elicit preventive measures or even cancellation of surgery. Moreover, physicians perform Preoperative tests as a baseline to detect subsequent changes. This systematic review aims to explore whether Preoperative Testing leads to changes in management or reduces perioperative mortality or morbidity in unselected patients undergoing elective, non-cardiac surgery. We systematically searched all relevant databases from January 2001 to February 2011 for studies investigating the relationship between Preoperative diagnostics and perioperative outcome. Our methodology was based on the manual of the Ludwig Boltzmann Institute for Health Technology Assessment, the Scottish Intercollegiate Guidelines Network (SIGN) handbook, and the PRISMA statement for reporting systematic reviews. One hundred and one of the 25 281 publications retrieved met our inclusion criteria. Three test grid studies used a randomized controlled design and 98 studies used an observational design. The test grid studies show that in cataract surgery and ambulatory surgery, there are no significant differences between patients with indicated Preoperative Testing and no Testing regarding perioperative outcome. The observational studies do not provide valid evidence that Preoperative Testing is beneficial in healthy adults undergoing non-cardiac surgery. There is no evidence derived from high-quality studies that supports routine Preoperative Testing in healthy adults undergoing non-cardiac surgery. Testing according to pathological findings in a patient's medical history or physical examination seems justified, although the evidence is scarce. High-quality studies, especially large randomized controlled trials, are needed to explore the effectiveness of indicated Preoperative Testing.
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non adherence to guidelines for Preoperative Testing in a secondary care hospital in austria the economic impact of unnecessary and double Testing
European Journal of Anaesthesiology, 2011Co-Authors: Maria Flamm, Gerhard Fritsch, Josef Seer, Sigrid Panisch, Andreas SönnichsenAbstract:ContextPreoperative evaluation is aimed at prevention of complications and risk stratification. Routine Testing should be abandoned in favour of selective ordering according to contemporary guidelines. This study was conducted to calculate the possible economic impact of a Web-based Preoperative dia
Kim A. Eagle - One of the best experts on this subject based on the ideXlab platform.
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ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery--Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996
Anesthesia & Analgesia, 2008Co-Authors: Kim A. Eagle, Hugh Calkins, Richard J Gusberg, Kirsten E. Fleischmann, Peter B Berger, Bernard R Chaitman, James B Froehlich, Lee A Fleisher, Jeffrey A LeppoAbstract:Table of ContentsI. IntroductionA. Development of GuidelinesB. General ApproachC. Preoperative Clinical EvaluationII. Further Preoperative Testing to Assess Coronary RiskA. Clinical MarkersB. Functional CapacityC. Surgery-Specific RiskIII. Management of Specific Preoperative Cardiovascular Condition
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acc aha guideline update for perioperative cardiovascular evaluation for noncardiac surgery executive summary a report of the american college of cardiology american heart association task force on practice guidelines committee to update the 1996 gui
Anesthesia & Analgesia, 2002Co-Authors: Kim A. Eagle, Hugh Calkins, Richard J Gusberg, Jeffrey A Leppo, Kirsten E. Fleischmann, Peter B Berger, Bernard R Chaitman, James B Froehlich, Lee A Fleisher, Thomas J. RyanAbstract:Table of ContentsI. IntroductionA. Development of GuidelinesB. General ApproachC. Preoperative Clinical EvaluationII. Further Preoperative Testing to Assess Coronary RiskA. Clinical MarkersB. Functional CapacityC. Surgery-Specific RiskIII. Management of Specific Preoperative Cardiovascular Condition
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Perioperative- and long-term mortality rates after major vascular surgery: the relationship to Preoperative Testing in the medicare population.
Anesthesia and analgesia, 1999Co-Authors: Lee A Fleisher, Kim A. Eagle, Thomas J. Shaffer, Gerard F. AndersonAbstract:UNLABELLED Debate continues regarding the value of cardiovascular Testing and coronary revascularization before major vascular surgery. Whereas recent guidelines have advocated selective Preoperative Testing, several authors have suggested that it is no longer necessary in an era of low perioperative cardiac morbidity and mortality. We used data from a random sample of Medicare beneficiaries to determine the mortality rate after vascular surgery, based on the use of Preoperative cardiac Testing. A 5% nationally random sample of the aged Medicare population for the final 6 mo of 1991 and first 11 mo of 1992 was used to identify a cohort of patients who underwent elective infrainguinal or abdominal aortic reconstructive surgery. Use within the first 6 mo of 1991 was reviewed to determine if Preoperative noninvasive cardiovascular imaging or coronary revascularization was performed. Thirty-day (perioperative) and 1-yr mortalities were assessed. Perioperative mortality was significantly increased for aortic surgery (209 of 2865 or 7.3%), compared with infrainguinal surgery (232 of 4030 or 5.8%); however, 1-yr mortality was significantly increased for infrainguinal surgery (16.3% vs 11.3%, P < 0.05). Stress Testing, with or without coronary revascularization, was associated with improved short-and long-term survival in aortic surgery. The use of stress Testing with coronary revascularization was not associated with reduced perioperative mortality after infrainguinal surgery. Stress Testing alone was associated with reduced long-term mortality in patients undergoing infrainguinal revascularization. IMPLICATIONS Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality. The reduced long-term mortality in patients who had previously undergone Preoperative Testing and coronary revascularization reinforces the need for a prospective evaluation of these practices.
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Dobutamine stress echocardiography. Stressing the indications for Preoperative Testing.
Circulation, 1997Co-Authors: David S. Bach, Kim A. EagleAbstract:In the current issue of Circulation, Poldermans et al1 report on the long-term prognostic value of dobutamine stress echocardiography in patients undergoing major vascular surgery. Their findings add to the growing literature on the use of exercise and dobutamine stress echocardiography as adjuncts in the assessment of prognosis among patients with known or suspected coronary artery disease. To date, the published experience with dobutamine stress echocardiography for assessment of prognosis and perioperative risk is relatively small compared with that using nuclear perfusion imaging techniques. Stress echocardiography is a more recently developed technique to detect coronary artery disease and myocardial ischemia, and all studies related to prognosis have been published since 1991. However, stress echocardiography is of increasing importance because of the increasing availability these techniques and because ofseveral advantages it offers over nuclear perfusion imaging. In addition to providing apparently equivalent data with respect to the presence and extent of coronary artery disease and myocardium at risk, dobutamine stress echocardiography allows assessment of valvular anatomy and function as well as resting and stress ventricular systolic function. This allows a more complete assessment of overall cardiac function, pertinent especially among patients with a history of congestive heart failure or cardiac murmur. Finally, stress echocardiographic techniques appear to have lower associated costs than the equivalent nuclear perfusion imaging counterparts, which may become increasingly important as the healthcare environment requires the delivery of cost-effective medical care. Poldermans et al2 and others3 4 have previously published reports on the utility of dobutamine stress echocardiography in the assessment of prognosis in a general population4 and for the identification of patients at increased perioperative risk during major vascular surgery.2 3 The report in the current issue of Circulation is important in that it describes the long-term prognostic data afforded by Preoperative …
Catherine L. Chen - One of the best experts on this subject based on the ideXlab platform.
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Preoperative medical Testing and falls in medicare beneficiaries awaiting cataract surgery
Ophthalmology, 2020Co-Authors: Catherine L. Chen, Stephen D. Mcleod, Han-ying Peggy Chang, Adrian W. Gelb, John W Boscardin, Thomas M Lietman, Hui Shen, Mary A Whooley, Sei J LeeAbstract:ABSTRACT Objective Delaying cataract surgery is associated with an increased risk of falls, but it is unknown whether routine Preoperative Testing delays cataract surgery long enough to cause clinical harm. We sought to determine whether the use of routine Preoperative Testing leads to harm in the form of delayed surgery and falls in Medicare beneficiaries awaiting cataract surgery. Design Retrospective observational cohort study using 2006-2014 Medicare claims Participants Medicare beneficiaries age 66+ with a CPT claim for ocular biometry Methods We measured the mean and median number of days between ocular biometry and cataract surgery, calculated the proportion of patients waiting >30 days or >90 days for surgery, and determined the odds of having a fall within 90 days of biometry among patients of high-Testing physicians (Testing performed in ≥75% of their patients) compared to patients of low-Testing physicians. We estimated the number of days of delay attributable to high-Testing physicians relative to other factors that may determine surgical scheduling. Main Outcome Measures Incidence of falls occurring between biometry and surgery, odds of falling within 90 days of biometry, and estimated delay in days associated with physician Testing behavior . Results Of 248,345 beneficiaries, 16.4% were patients of high-Testing physicians. More patients of high-Testing physicians waited >30 days and >90 days to have cataract surgery (31.4% and 8.2% versus 25.0% and 5.5%, respectively, p Conclusions Overuse of routine Preoperative medical Testing by high-Testing physicians is associated with delayed surgery and increased falls in cataract patients awaiting surgery.
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A Revised Estimate of Costs Associated With Routine Preoperative Testing in Medicare Cataract Patients With a Procedure-Specific Indicator.
JAMA ophthalmology, 2018Co-Authors: Catherine L. Chen, Theodore H. Clay, Stephen D. Mcleod, Han-ying Peggy Chang, Adrian W. Gelb, R. Adams DudleyAbstract:Importance Routine Preoperative medical Testing is not recommended for patients undergoing low-risk surgery, but Testing is common before surgery. A 30-day Preoperative Testing window is conventionally used for study purposes; however, the extent of routine Testing that occurs prior to that point is unknown. Objective To improve on existing cost estimates by identifying all routine Preoperative Testing that takes place after the decision is made to perform cataract surgery. Design, Setting, and Participants This cross-sectional study assessed Preoperative care in a 50% sample of Medicare beneficiaries older than 66 years who underwent ambulatory cataract surgery in 2011. Data analysis was completed from March 2016 to October 2017. Main Outcomes and Measures Using ocular biometry as a procedure-specific indicator to mark the start of the routine Preoperative Testing window, we measured Testing rates in the interval between ocular biometry and cataract surgery and compared this with Testing rates in the 6 months preceding biometry. We estimated the total cost of Testing that occurred between biometry and cataract surgery. Results A total of 440 857 patients underwent cataract surgery. A total of 423 710 (96.1%) had an ocular biometry claim before index surgery, of whom 264 514 (60.0%) were female; the mean (SD) age of the cohort was 76.1 (6.2) years. A total of 111 998 (25.4%) underwent surgery more than 30 days after biometry. Among patients with a biometry claim, the mean number of tests/patient/month increased from 1.1 in the baseline period to 1.7 in the interval between biometry and cataract surgery. Although Preoperative Testing peaked in all patients in the 30 days preceding surgery (1.8 tests/patient/month), the subset of patients with no overlap between postbiometry and presurgery periods experienced increased Testing rates to 1.8 tests per patient per month in the 30 days after biometry, regardless of the elapsed time between biometry and surgery. The total estimated cost of routine Preoperative Testing in the full cohort was $22.7 million; we estimate that routine Preoperative Testing costs Medicare up to $45.4 million annually. Conclusions and Relevance In this study of Medicare beneficiaries, routine Preoperative medical Testing occurs more often and is costlier than has been reported previously. Extra costs are attributable to Testing that occurs prior to the 30-day window preceding surgery. As a cost-cutting measure, routine Preoperative medical Testing should be avoided in patients with cataracts throughout the interval between ocular biometry and cataract surgery.
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Preoperative medical Testing in medicare patients undergoing cataract surgery
The New England Journal of Medicine, 2015Co-Authors: Catherine L. Chen, Theodore H. Clay, Adrian W. Gelb, Naomi S Bardach, John W Boscardin, Mervyn Maze, Michael A Gropper, Adams R DudleyAbstract:BackgroundRoutine Preoperative Testing is not recommended for patients undergoing cataract surgery, because Testing neither decreases adverse events nor improves outcomes. We sought to assess adherence to this guideline, estimate expenditures from potentially unnecessary Testing, and identify patient and health care system characteristics associated with potentially unnecessary Testing. MethodsUsing an observational cohort of Medicare beneficiaries undergoing cataract surgery in 2011, we determined the prevalence and cost of Preoperative Testing in the month before surgery. We compared the prevalence of Preoperative Testing and office visits with the mean percentage of beneficiaries who underwent tests and had office visits during the preceding 11 months. Using multivariate hierarchical analyses, we examined the relationship between Preoperative Testing and characteristics of patients, health system characteristics, surgical setting, care team, and occurrence of a Preoperative office visit. ResultsOf 440,...