More than half of all Medicare patients who have cataract surgery undergo unnecessary routine preoperative testing, despite strong evidence that these tests are usually not beneficial and increase national health care costs, reports a study 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, M.D., ASA member and lead study author. "Although Medicare spending on preoperative testing in cataract patients is an area in which we can safely cut health care 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."
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. Medicare pays for more than 80 percent of cataract surgeries in the United States.
Cataract surgery is considered to be one of the lowest risk surgeries. The majority of cataract surgeries are performed by an ophthalmologist in the outpatient setting with topical anesthesia that is administered through eye drops. Furthermore, these patients are usually monitored by an anesthesia provider such as a physician anesthesiologist.
In the 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 percent 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. Expenditures on testing were 42 percent and office visits were 78 percent higher ($4.8 million and $12.4 million, respectively) in the month before surgery than the average of the mean monthly expenses during the preceding 11 months.
Interestingly, researchers found 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 percent of ophthalmologists had preoperative tests performed in more than 75 percent of their patients and 8 percent 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 (e.g. ophthalmologist, primary care physician, physician anesthesiologist) could not be reliably determined from 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 Dr. Chen. "We have shown that we can use Medicare claims to identify the physician care teams whose patients tend to have more testing than average. Payers like Medicare could use this study to potentially target interventions to the groups of physicians who are ordering more tests, rather than all physicians across the board. However, I hope 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."
Dr. Chen's research was supported by a career development grant from the Foundation for Anesthesia Education and Research (an ASA related organization), and a grant from The Grove Foundation.
"This research sheds light on preoperative testing and how we might improve care in the future," said ASA President J.P. Abenstein, M.S.E.E., M.D. "We know that over-testing is expensive, but it can also be harmful if it leads to overtreatment or causes complications. FAER and Dr. Chen should be commended for their important work on this topic."
Last year ASA introduced the Perioperative Surgical Home (PSH) model of care, which would reduce unnecessary testing by creating a patient-centered, multidisciplinary, team-based setting for patient care. The PSH model emphasizes the cost-efficient use of resources as well as lead physician, multi-specialty team and patient-shared decision-making.
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