COMMENTARY

Getting Ready for Cataract Surgery: Are All Those Tests Really Necessary?

Brianne N. Hobbs, OD

Disclosures

September 29, 2015

Preoperative Medical Testing in Medicare Patients Undergoing Cataract Surgery

Chen CL, Lin GA, Bardach NS, et al
N Engl J Med. 2015;372:1530-1538

      $597 billion - Total Medicare payments in 2014[1]      
      $1 trillion - Projected total Medicare payments for 2024[1]      
      80% - Percentage of cataract extractions covered by Medicare[2]      
      30 million - Estimated number of Americans who will have cataracts by 2020      

These numbers indicate the increasing strain on the healthcare system as a larger percentage of the population become Medicare beneficiaries in the coming years. Cataract surgery is the most common reason for referral to ophthalmologists by optometrists and the most popular elective surgery in elderly patients. It comprises a substantial portion of Medicare payments. Although cataract surgery is considered low-risk, boasting a < 1% risk for adverse events, the population that requires this surgery often has multiple comorbidities.[3]

Routine preoperative testing for patients undergoing cataract surgery is common despite a paucity of evidence to support routine testing. The Royal College of Ophthalmologists, the American Academy of Ophthalmology, and the American Society of Anesthesiologists have published position statements recommending against routine preoperative testing for cataract surgery.[4,5,6] Despite these evidence-based guidelines, widespread preoperative testing persists, escalating healthcare costs. What are the factors that determine which patients receive preoperative testing? What are the motivating factors for the physicians who order these tests? The answers to these questions can help optometrists make better referrals and reduce unnecessary testing.

Study Summary

The New England Journal of Medicine published a study by Chen and colleagues that assessed the prevalence of preoperative testing and the factors driving the requests for testing. The study included 440,857 randomly selected Medicare beneficiaries who opted for elective cataract extraction. Preoperative tests and visits were assessed via a chart review. The following preoperative tests were considered routine if performed within 30 days of surgery: complete blood count, chemical analysis, coagulation studies, urinalysis, electrocardiography, cardiac stress test, chest radiography, and pulmonary function tests. Preoperative visits were conducted by members of the care team other than the ophthalmologist.

At least one routine preoperative test was undergone by 53% of beneficiaries, and 52% attended at least one preoperative visit. The number of preoperative tests varied widely among the beneficiaries: 13% of patients had only one test, but another 13% received five or more tests. The preoperative tests cost an estimated $16.1 million and the preoperative visits totaled $28.3 million in costs—not an insignificant number considering the questionable benefit.

Practice patterns for preoperative testing and visits varied greatly among the care teams. Of note, approximately one third of ophthalmologists (36%) ordered preoperative tests for more than 75% of their patients. This 36% of ophthalmologists treated only 26% of the patients but accounted for 86% of the testing. A small percentage of care teams (8%) ordered routine preoperative testing for every patient.

The factor that was most strongly predictive of preoperative testing was not related to patient factors, such as age, race, or comorbidities. Rather, it was the habits of the ophthalmologist performing the surgery. This finding indicates that the practice pattern of the ophthalmologist trumped patient factors. Patient factors, such as the comorbidity index, did influence the number of tests ordered but not as strongly as the prescribing ophthalmologist.

Viewpoint

This study highlights an unfortunate truth in medicine. Often, evidence-based guidelines are trumped by the individual preferences of clinicians. Fear of legal repercussions, resistance to change, and a desire to maintain the status quo are all potential reasons that routine preoperative testing persists despite a conclusive lack of evidence to support this practice. It is also possible that routine preoperative testing lingers because it was more beneficial in the past, when cataract extractions were performed under general anesthesia.

Regardless of the individual motivations behind routine preoperative testing, it is inflating costs without providing benefit. As optometrists, we should be aware of the prescribing habits of the ophthalmologists we refer to so that we can best serve our patients and stem rising costs. We also should examine our own practice preferences, determine which are in line with evidence-based guidelines, and do our part to eliminate low-yield testing.

Abstract

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