Preoperative Tests Still Too Frequent for Cataract Surgery

Pam Harrison

April 15, 2015

More than half of Medicare beneficiaries undergoing cataract surgery undergo at least one preoperative test, despite strong evidence showing that preoperative tests are not associated with any improvement in outcomes, new research shows.

Moreover, the prevalence of preoperative testing before cataract surgery is not different than it was 20 years ago, before the introduction of guidelines stating that routine preoperative testing for cataract surgery is not necessary.

The study was published online April 15 in the New England Journal of Medicine.

"I think people are probably aware of these guidelines, but that awareness doesn't filter down to: 'Oh, I should change what I do,' and a big part of that is inertia," Adams Dudley, MD, professor of medicine and health policy and director, University of California, San Francisco, Center for Healthcare Value, told Medscape Medical News. Dr. Dudley was not involved in the study.

"But cataract surgery has just gotten so much easier than it was, and once it's been decided that you can do this procedure on a patient, there is no need for blood testing or heart testing or pulmonary tests because we know that all of these people actually got their procedure and they had to be rock solid stable."

Catherine Chen, MD, from the University of California, San Francisco, and colleagues identified patients undergoing cataract surgery in 2011 on the basis of the Current Procedural Terminology codes for cataract surgery.

The researchers included patients 66 years of age and older with at least 12 months of Medicare eligibility before surgery in the study.

Investigators compared the prevalence of preoperative testing and office visits with the mean percentage of beneficiaries who underwent tests and who had office visits during the preceding 11 months.

Possible preoperative tests included complete blood counts, chemical analysis, coagulation studies, urinalysis, electrocardiography, echocardiography, cardiac stress tests, chests radiography, and pulmonary function tests.

Of 440,857 beneficiaries, 232,889, or 53% of the cohort, underwent at least one preoperative test, and 229,832 patients, or 52% of the cohort, had a preoperative office visit.

The mean number of tests per beneficiary rose by 66% during the month before surgery, relative to the baseline period, and the mean number of office visits rose by 63%.

During that preoperative month, 13% of beneficiaries underwent one test, 11% underwent two, 10% underwent three, 7% underwent four, and 13% of the cohort underwent five or more tests.

All of the percentages of tests were higher than the mean of the monthly percentages during the baseline period, the investigators add.

Among some 222,741 beneficiaries with 6 months of postoperative follow-up, the team also found a similar increase in testing and office visits per beneficiary before surgery, followed by a return to baseline levels after the surgery had been completed.

A total of 798,150 tests were performed during the preoperative month, at a cost of approximately $16.1 million, and another $28.3 million was spent on 308,397 office visits, the researchers write.

This means that expenditures on testing in the month before surgery were $4.8 million higher and expenditures on office visits were $12.4 million higher (42% and 78% higher, respectively) than the mean monthly expenditures during the preceding 11 months, the researchers add.

"Of the 9253 ophthalmologists who operated on five or more patients in 2011, more than one third (36%) ordered preoperative testing for 75% or more of their patients, and 8% ordered testing for every patient," the authors note.

Indeed, this select group of ophthalmologists collectively treated only about one quarter of all patients who received cataract surgery under Medicare, but their patients accounted for 84% of all testing above the baseline mean, the authors observe.

"Most ophthalmologists have gotten the message, and they don't change their practice because of an upcoming cataract surgery," Dr Dudley observed.

"But if you are a doctor, being a laggard can be very harmful: You can cost tax payers a lot of money, you can cause patients a lot of inconvenience, and they if they have to pay for the tests, you can cost them a lot of money, too," he said.

"So I think given the waste and the harm, it's time for systems leaders to say: 'We're tracking you, and if you keep doing this, we're docking your ophthalmology payments for all of these extra things that you're doing.' "

Surgery Cancelled Unnecessarily

Asked to comment on the study, Neel Shah, MD, executive director of Costs of Care, told Medscape Medical News that it is not just the tests themselves that are costly, it is the fact that when physicians order tests in general that are not indicated, "they can give you information that you don't know how to interpret," he said.

"I'm a surgeon myself," Dr Shah added, "and I've seen patients get their surgery cancelled unnecessarily because they have a lab value that we think might require some follow-up."

However, changing physician behavior is not as easy as giving them the evidence.

"There are a lot of things in medicine where we've known the evidence for a very long time and it hasn't really changed our behavior," Dr Shah said.

"For example, we know we should wash our hands, that's been clear for 150 years now, but given the recent Ebola outbreak in Texas, we're still working on it," he said, adding: "With minimally invasive surgery like cataract surgery, we're not adapting our preoperative testing appropriately, we're still applying standards from other surgeries to cataract surgery.

"So I think when trying to change physician behavior in general, and in particular, when we are trying to get people to do less, we have to try to think about why the unnecessary tests are happening in the first place, and then a cultural paradigm shift has to happen."

The study was supported by grants from the Foundation for Anesthesia Education and Research and the Grove Foundation. Dr Dudley has reported receiving grant support from the Grove Foundation during the conduct of the study. Two coauthors report receiving grant support from the Foundation for Anesthesia Education and Research. The other authors and Dr Shah have disclosed no relevant financial relationships.

N Engl J Med. Published online April 15, 2015.


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