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Publication Briefs

Study Shows Low-Value Preoperative Testing for Cataract Surgery is Common Across VA

In 2013, the Choosing Wisely campaign was initiated to advance a national dialogue on avoiding unnecessary medical tests, treatments, and procedures. Cataract surgery is the most common elective surgery among Medicare beneficiaries and older populations, with 1.7 million procedures performed annually, further, the number of these surgeries in VA is expected to increase over the next decade. This retrospective cohort study sought to determine the extent, variability, and costs of low-value pre-operative tests (LVTs) before cataract surgery within the VA healthcare system (135 facilities). A test was considered pre-operative if it occurred within 30 days prior to cataract surgery AND within 30 days after an encounter in a specific VA clinic where pre-operative screening tests are typically ordered. Using VA data from FY2017, investigators identified Veterans (n=50,106) who underwent cataract surgery in VA. In addition to pre-operative testing, investigators assessed patient sociodemographics, body mass index, and comorbidities. They also examined facility characteristics (i.e., surgical complexity, annual cataract surgery volume).


  • Frequent low-value testing persists approximately four years after the Choosing Wisely campaign. About 49% (n=33,424) of cataract surgeries performed on VA patients were preceded by one or more LVT with an overall cost of $2,597,623.
  • While the most common low-value preoperative test was an EKG (30%), investigators noted the frequent use of lower-cost blood tests as well as more expensive tests (13%), such as chest X-rays and pulmonary function tests.
  • The strongest variables associated with the receipt of any test included being Black, an increasing number of comorbidities, and receipt of general anesthesia.
  • About 33% of LVTs were in facilities that typically do not have a designated preoperative clinic.


  • Results suggest that publishing evidence-based guidelines alone—such as the Choosing Wisely campaign—does not sufficiently influence individual physician behavior, even within a healthcare system without financial incentives for ordering tests. System-level efforts to directly de-implement LVT are, therefore, necessary to effect sustained change.


  • It is uncertain whether all tests were ordered as a result of the planned surgery.

This study was funded by HSR&D (IIR 16-216 and CDA 13-279). Dr. Sox-Harris also was supported by an HSR&D Research Career Scientist Award. Drs. Pershing, Hawn, Eisenberg, Finlay, and Sox-Harris, and Mr. Bowe are part of HSR&D’s Center for Innovation to Implementation (Ci2i), Palo Alto, CA. Dr. Sears is part of HSR&D’s Center for Clinical Management Research (CCMR), Ann Arbor, MI.

Mudumbai S, Pershing S, Bowe T, Kamal R, Sears E, Hawn M, Eisenberg D, Finlay A, Hagedorn H, and HS Harris A. Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery within the Veterans Health Administration. JAMA Network Open. May 6, 2021;4(5): e217470.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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