More than half of all Medicare patients who have cataract surgery undergo unnecessary routine preoperative testing, despite strong evidence that these tests usually are not beneficial and increase national healthcare costs, report investigators in a study that was published on April 16 in The New England Journal of Medicine.
“For more than a decade, published guidelines from multiple national medical societies have recommended against ordering routine preoperative tests in cataract surgery patients, since there is already strong evidence that these tests do not decrease complications or improve outcomes,” said Catherine L. Chen, MD, lead study author. “Although Medicare spending on preoperative testing in cataract patients is an area in which we can safely cut healthcare costs without compromising quality of care, our research shows that physicians continue to order these tests at the same frequency as before the evidence-based guidelines were introduced.”
J.P. Abenstein, MSEE, MD, president of the American Society of Anesthesiologists, said, “We know that over-testing is expensive, but it can also be harmful if it leads to overtreatment or causes complications.”
However, in response to a question from Same-Day Surgery, Chen said there was a study by Phillips et al published in Anesthesiology in 2011 which showed that 100 (19%) of 530 ophthalmic surgery patients (including cataract) had an abnormal condition found on the preoperative office visit that required further evaluation, and of these, 12 patients (12%) had surgery postponed so the patient could undergo additional testing.
Cataract surgery is the most common elective surgery among Medicare patients, with 1.7 million surgeries annually. This number is expected to grow to 4.4 million surgeries by 2030.
In the most recent study, researchers analyzed 441,000 Medicare patients undergoing cataract surgery in 2011 to determine the frequency and cost of routine preoperative testing, as well as the number of office visits to physicians (other than ophthalmologists) one month before surgery. Preoperative tests included in the study were complete blood count, basic and comprehensive metabolic panel, urinalysis, electrocardiogram, cardiac stress tests, and other tests and procedures that are commonly ordered in older patients in anticipation of scheduled surgery.
Fifty-three percent of patients had a least one routine preoperative test, and 52% had a preoperative office visit in the month before surgery. More than 798,000 tests were performed in the month before surgery, at a cost of approximately $16.1 million, while patients went to more than 308,000 office visits at a cost of $28.3 million.
In one of the more interesting findings, researchers said that preoperative testing varied widely among physicians and was more strongly associated with an individual physician’s practice patterns rather than patient characteristics such as old age or having multiple concurrent illnesses. In fact, 36% of ophthalmologists had ordered that preoperative tests be performed in more than 75% of their patients, and 8% of ophthalmologists had all of their patients tested.
However, the authors note that the specific physician within the perioperative care team who actually ordered the tests (for example, ophthalmologist, primary care physician, or physician anesthesiologist) could not be reliably determined from the Medicare claims.
“The reasons physicians might still be ordering routine preoperative tests for cataract patients are varied and may be out of habit or because there is a perception that other physicians expect this testing,” said Chen. She says she hopes “this study will actually encourage physicians to examine their practice and align their preoperative testing practices for cataract surgery to the current evidence-based guidelines on their own accord, rather than in response to any outside intervention.”