Referrals for medical workups prior to low-risk surgeries such as cataract removal needlessly raise costs for Medicare and other payers, researchers find.
Despite guidelines in 2002 that advised against precautionary testing of patients before cataract surgery, which is considered to be a safe, quick procedure, 53% were referred for low-benefit and costly tests days before their operations researchers have found.
A research team led by Catherine Chen, MD, and R. Adams Dudley, MD, of the University of California San Francisco Medical Center, conducted an analysis of more than 440,000 randomly sampled Medicare fee-for-service beneficiaries who had a cataract removed in 2011. The team’s findings were published in the New England Journal of Medicine Thursday.
“We know that routine preoperative testing doesn’t change outcomes in cataract surgery,” Chen says. “And we definitely think these physicians should not be ordering these tests unless their patients have some underlying medical condition, and even then they would have been worked up anyway, regardless of whether they are getting cataract surgery.”
“I think ophthalmologists might feel a little bit of heat after this paper comes out,” says Chen, a resident physician and anesthesiologist.
The pre-operative tests included blood, urine, chest, lung, or cardiac function exams. Dudley and Chen say that such testing can produce false alarms, which can lead to further testing and interventions.
For example, CT scans “might be ordered after a finding of an abnormal blood test, which might lead to an X-ray for no good reason to see if there’s an infection, and then there’s a possible spot, and now they’re worried they have lung cancer,” and go on to have [another] CT, without real indication, says Dudley, a pulmonologist who also directs UCSF’s Center for Healthcare Value.
Guidelines from multiple specialty societies, such as those representing cardiology, echocardiography, anesthesiology, and ophthalmology have recommended against pre-operative testing prior to cataract surgery, which lasts about 18 minutes and is routinely done using a topical anesthetic.
Large Practice Variation
Dudley and Chen say their data shows that about 36% of ophthalmologists ordered one preoperative test before cataract surgery for 75% of their patients and 8% ordered at least one test for every one of their patients. “When 100% of your patients are getting pre-op testing, it’s almost certainly because doctors are asking them to get these tests prior to their surgery,” Dudley says.
The researchers say that the lesson is an important one for policymakers going forward, because with the aging population, cataract surgeries will more than double from about two million today to 4.4 million in 2030, with Medicare paying 80% of those costs.
Chen and Dudley emphasize that they are not suggesting that doctors are referring their patients for pre-procedure testing to make money or help their referral networks, although that might be happening in some settings.
Rather, Dudley says, the reason for all this testing is likely just a matter of habit, with old practice patterns proving tough for physicians to break.
When cataract surgeries became commonplace decades ago, they were perceived as much riskier, requiring general anesthesia, which can be problematic for people with heart problems or other comorbidities. There was also concern that ophthalmologic surgeons would nick the eye, so they wanted patients to be completely immobilized, Chen says.
Now, she says, the technology and surgeons’ skill has improved to the extent that “they can now perform the procedure with a topical anesthetic” such as lidocaine.
Another possible reason for the amount of preoperative blood and cardiac function testing is that some of it might be unrelated to cataract surgery. For example, a Medicare beneficiary might be scheduling routine medical procedures, such as blood draws or urine tests, in close time proximity to her eye surgery.
That, however, is unlikely because according to the data, the number of beneficiaries receiving tests in a given month remains steady for all other beneficiaries. But for those undergoing cataract surgery, the rate of these tests bumps up dramatically in the 30 days prior to their procedures.
The chair of the Academy’s cataract preferred practice patterns panel, Randall Olson, MD, responding to questions by e-mail, said that the UCSF study “is limited because it cannot identify who ordered the (pre-surgical testing) services. …This could have been anyone on the care team—anesthesiologists, internists, primary care physicians, nurse practitioners or physician assistants.”
And tests may have been required because of the patient’s health status. The study does not distinguish whether tests performed 30 days prior to cataract surgery “were directly related to the surgery itself, or another health condition.” Gaps in clinical data, according to Olson, also limit the study’s usefulness by failing to show that in some cases, patients should have had preoperative testing.
But overall, the academy “continues to support the position that pre-operative medical testing is not routinely recommended for cataract surgery,” he concluded.
Another finding from the study is a sharp bump in office visits to primary care or other non-ophthalmology or optometry doctors 30 days prior to surgery, another possible waste of time and spending, Dudley and Chen say.
That’s complicated by the fact that the Centers for Medicare & Medicaid Services and The Joint Commission both require that doctors take a medical history and do a physical exam within 30 days of any surgery. But that can be accomplished by the ophthalmologist just before cataract surgery, Dudley contends.
The study found that 52% of beneficiaries in 2011 had an office visit with another practitioner in the 30 days before their cataract procedure. Ophthalmologists might perform such exams prior to surgery, but many ophthalmologists “don’t feel comfortable assessing the patient’s other comorbidities,” Chen says.
High Costs, Low Mortality
The message for ophthalmologists, professional societies, and policy makers alike is that an unnecessary referral for a medical workup just to assess risk for a low-risk surgery such as cataract removal creates a setting for primary care and other doctors to order more tests, and generate more false positives, Dudley says.
And unnecessary testing raises costs. According to the report, for the 440,587 patients in the study, 798,150 tests were performed during the preoperative month at a cost of approximately $16.1 million. Another $28.3 million was spent on 308,397 office visits.
Those testing expenditures were $4.8 million higher, and costs of office visits $12.4 million higher (42% and 78% respectively) than the mean monthly expenditure during the preceding 11 months.
The cost estimates do not include beneficiary costs, costs paid by other insurers, or “downstream costs accruing because of follow-up of abnormal results from unnecessary tests.”
Chen stresses that cataract surgery today is extraordinarily safe. In the researchers’ analysis and in other studies, the mortality rate within the seven days after cataract surgery for Medicare beneficiaries was only one per 100,000 surgeries.
“These pre-op tests have not been shown to prevent any adverse events or death in this patient population,” she says. “This type of routine testing is not indicated for patients if it’s being performed for the sole reason [that] they are scheduled for cataract surgery.”