ABSTRACT
PURPOSE: Examine the frequency and cost of procedural clearance tests and examinations in preparation for low-risk cataract surgery among members of a commercial healthcare organization in the United States. Determine what characteristics most strongly predict receipt of preoperative care and the probability that preoperative care impacts postsurgical adverse events. DESIGN: Retrospective healthcare claims analysis and medical records review from a large, blended-health organization headquartered in Western Pennsylvania. PARTICIPANTS: Members aged ≥ 65 years who were continuously enrolled 6 months before and after undergoing cataract surgery from 2018 to 2021 and had approved surgery claims. METHODS: Preoperative exams or tests occurring in the 30 days before surgery were identified via procedural and diagnosis codes on claims of eligible members (e.g., Current Procedural Terminology codes for blood panels and preprocedural International Classification of Diseases, 10th Revision, Clinical Modification codes). Prevalence and cost were directly estimated from claims; variables predictive of preoperative care receipt and adverse events were tested using mixed effects modeling. MAIN OUTCOME MEASURES: Total costs, prevalence, and strength of association as indicated by odds ratios. RESULTS: Up to 42% of members undergoing cataract surgery had a physician office visit for surgical clearance, and up to 23% of members had testing performed in isolation or along with clearance visits. The combined costs for the preoperative visits and tests were $4.3 million (approximately $107-$114 per impacted member). There was little difference in member characteristics between those receiving and not receiving preoperative testing or exams. Mixed effects models showed that the most impactful determinants of preoperative care were the surgical facility and member's care teams; for preoperative testing, facilities were a stronger predictor than care teams. Adverse events were rare and unassociated with receipt of preoperative testing, exams, or a combination of the two. CONCLUSIONS: Rates of routine preoperative testing before cataract surgery appear similar to those prior to the implementation of the Choosing Wisely campaign, which was meant to reduce this use. Additionally, preoperative evaluations, many likely unnecessary, were common. Further attention to and reconsideration of current policies and practice for preoperative care may be warranted, especially at the facility level. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
ABSTRACT
AIMS: Atherosclerosis accelerates with increasing age; however, young women presenting with acute coronary syndromes (ACS) have adverse outcomes compared to men despite less obstructive coronary artery disease. We sought to evaluate the in vivo plaque characteristics and composition of untreated non-culprit lesions (NCL) at two ages (<65 years old and ≥65 years old) in patients with ACS and examine the effect of sex in both groups. METHODS AND RESULTS: Untreated NCLs from 697 patients with ACS were imaged with greyscale and radiofrequency intravascular ultrasound. NCL plaque morphology, burden, composition, and major adverse cardiac events (MACE) were analysed in both age groups, and a posterior sex-based sub-analysis was performed. Plaques from patients ≥65 (n=974) vs. <65 (n=2,275) years old were longer (median 12.62 mm vs. 10.75 mm, p=0.008) and had greater plaque burden (48.2% vs. 47.5%, p=0.001), necrotic core (12.5% vs. 11.0%, p=0.001) and dense calcium (5.7% vs. 4.0%, p<0.0001). Men <65 years old also had a greater number of fibroatheromas (3.0 vs. 2.0, p=0.007) and NCLs per patient (5.0 vs. 4.0, p=0.004) with larger plaque volumes (47.7% vs. 46.8%, p=0.04), and fewer fibrotic plaques (2.2% vs. 4.4%, p=0.03) than women in the same age group. These sex differences were not observed in patients ≥65 years old. The incidence of MACE during median 3.4 year follow-up did not significantly differ according to age in this study. CONCLUSIONS: The current study confirms in vivo that, with aging, plaque burden, necrotic core and calcium content increase significantly. Moreover, gender-specific differences in the extent and composition of coronary plaque are present in patients <65 years (but not ≥65 years) of age, which suggest differential sex-related effects on atherosclerosis development and progression.
