Background 

Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use.

Questions/purposes 

(1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not?

Methods 

In this retrospective, comparative study using a large national database, we queried a large health insurance provider’s administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use.

Results 

When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually.

Conclusion 

Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test–associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies.

Level of Evidence 

Level III, therapeutic study.

中文翻译：

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低风险手部手术前的低价值检测是否与下游医疗保健使用和报销的增加有关？国家索赔数据库分析

 背景

小型手工手术通常可以在办公室完成，无需任何实验室测试。小型手部手术前的术前筛查测试是不必要的，并且被认为价值较低，因为它们可能导致可预防的侵入性确认测试和/或手术。先前的研究表明，低风险手部手术前的低价值测试仍然很常见，但对其下游影响和相关成本知之甚少。评估这些下游事件可以阐明获得低价值测试的后果，并为特定情况的干预措施提供信息以减少其使用。

 问题/目的

(1) 在接受低风险手部手术的健康成年人中，接受术前低值测试的患者是否比未接受低值测试的患者更有可能进行后续诊断测试和手术？ (2) 与未接受低值检测的患者相比，接受低值检测的患者与后续诊断检测和手术相关的 90 天报销增加了多少？

 方法

在这项使用大型国家数据库的回顾性比较研究中，我们查询了一家大型健康保险公司的行政索赔数据，以确定接受低风险手部手术（腕管松解术、扳机指松解术、掌腱膜腱膜切除术、de Quervain松解术、拇指腕掌骨松解术）的成年患者。 2011 年至 2017 年间的关节成形术、腕部神经节囊肿或肿块切除术）。选择​​该数据库是因为它能够纵向跟踪患者索赔，并直接提供大量、地域不同的患者群体的报销数据。术前 30 天内至少接受过一项低值测试（包括全血细胞计数、基础代谢检测、心电图、胸片、肺功能测试和尿液分析）的患者与未接受过低值测试的患者进行倾向评分匹配。在符合我们纳入标准的 73,112 名患者中（平均年龄 57 ± 14 岁；68% [49,847] 为女性），27% (19,453) 接受了至少一项术前低值测试，并且与接受此项测试的患者进行了倾向评分匹配不是。进行多变量回归分析以评估术后 90 天内后续诊断测试和程序的频率和报销，同时控制潜在的混杂变量，例如年龄、性别、合并症和基线医疗保健使用。

 结果

当控制年龄、性别、合并症和基线医疗保健使用等协变量时，低值测试队列中的患者的调整后比值比为 1.57（95% 置信区间 [CI] 1.50 至 1.64；p < 0.001）与那些没有进行低值测试的人相比，术后使用事件（下游诊断测试或程序）。接受低值测试的患者与下游利用事件相关的每位患者报销中位数 (IQR) 为 231.97 美元（64.37 至 1138.84），未接受低值测试的患者报销中位数为 191.52 美元（ 57.1 至 899.42）（控制协变量时调整后的差异：每位患者 217.27 美元 [95% CI 59.51 至 375.03]；p = 0.007）。调整通货膨胀后，低价值测试队列中患者的额外报销总额逐年增加。

 结论

低价值测试产生的下游测试和程序已知对健康患者的益处微乎其微，并且可能使患者面临与针对误报的后续不必要的侵入性测试和程序相关的潜在危害。尽管如此，低价值检测仍然很常见，并且低价值检测相关支出的上升趋势表明需要采取多方面的干预措施来针对付款人和卫生系统层面的变化。此类干预措施应该会抑制最初的低价值测试以及随后可能发生的级联测试。未来确定减少手外科低价值检测的障碍和促进因素的工作可以为取消实施策略的制定和修订提供信息。

 证据水平

III级，治疗研究。