NEW YORK (Reuters Health) – Routine preoperative testing should be avoided in patients undergoing cataract surgery, particularly when surgery is performed more than 30 days after biometry, to reduce costs as well as inconvenience for patients and clinicians, researchers say.
“In the case of cataract surgery, it is very clear that routine preoperative medical testing (i.e., testing that is ordered simply because a patient is scheduled to undergo cataract surgery) does not benefit patients, is not recommended by any of the specialty societies, and should be avoided,” Dr. Catherine Chen of the University of California, San Francisco, said in an email to Reuters Health.
“We are not saying that there should not be any medical testing in the lead up to cataract surgery, she stressed. “Some patients may have true clinical indications for testing while awaiting surgery, but there generally should not be a sudden spike of excess testing associated with cataract surgery over the baseline rate of testing in this patient population.”
To update cost estimates for routine preoperative testing for cataract surgery, Dr. Chen and colleagues performed a cross-sectional study in a 50% sample of Medicare beneficiaries (mean age, 76; 60% women) who had undergone cataract surgery in 2011.
Ocular biometry marked the start of the routine preoperative testing window, and testing rates and costs in the interval between that test and cataract surgery were compared with testing rates in the six months before biometry.
As reported in JAMA Ophthalmology, online January 18, a total of 440,857 patients underwent cataract surgery, of whom 96% had an ocular biometry claim before the index surgery.
Among patients who had biometry, 6% had a biometry claim the day of surgery, 25% had surgery more than 30 days after biometry, and 5% had surgery more than 90 days after biometry. Overall, the interval between biometry and surgery ranged from zero days to 24 months.
More than a million tests were performed in that interval. Routine preoperative testing rates were higher during the interval between biometry and surgery (1.7 tests/patient/month) compared with the baseline rate (1.1 tests/patient/month) and with the rate during the months following cataract surgery (1.1 tests/patient/month).
Preoperative testing peaked whether measured in relation to the 30 days after biometry (1.7 tests/patient/month) or the 30 days before surgery (1.8 tests/patient/month).
After excluding tests performed in the preoperative month, there was still an increase of approximately 41% in the rate of testing over baseline during the interval between biometry and surgery.
In the subset of patients with no overlap between the post-biometry and pre-surgery periods, preoperative testing spiked in both the post-biometry and pre-surgery months (1.8 and 2.2 tests/patient/month, respectively).
The total estimated cost of routine preoperative testing in the full cohort was $22.7 million. The authors estimate that routine preoperative testing costs Medicare up to $45.4 million annually, including $7.3 million on testing during the extended preoperative testing period (47% higher than the total spent in the 30 days before surgery).
“Many physicians are already following practice guidelines and avoiding routine preoperative testing in these patients, but we can certainly do better,” Dr. Chen said.
“Further improvements can be achieved as individual physicians change their approach to testing,” she added, “and in parallel, change the culture at the places we work to incorporate this knowledge into our daily practice.”
“These additional tests should ordered be based on findings from the individual patient’s history and physical exam,” she concluded, “and not simply to check a box.”
Dr. Oliver Schein of Johns Hopkins University School of Medicine in Baltimore, coauthor of a related editorial, agreed that “a ‘complete history and physical’ provides no clinical benefit – reduction in risk/harm – for the majority of patients undergoing cataract surgery.”
“The medical risk of that procedure is extremely low, (and) the small proportion of patients who might benefit can be identified preoperatively,” he told Reuters Health by email.
“The regulatory requirement for the preoperative history and physical is not evidence-based, imposes tremendous costs, and is not an effective use of patient or health care provider time and resources,” he added.
“I have some optimism and expectation that the Centers for Medicare and Medicaid Services will reduce such regulatory burden and allow healthcare professionals – in this instance, ophthalmologists, anesthesiologists and internists/general practitioners – to match the level of preoperative evaluation to the procedure, planned anesthesia care, and patient medical history,” he said.
“For the majority of cataract patients, this would mean a screening questionnaire confirming low risk and the usual day of surgery evaluation by the surgeon and anesthesia staff,” he concluded.
SOURCES: http://bit.ly/2DR5WFf and http://bit.ly/2DpfZUW
JAMA Ophthalmol 2018.
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