Authors: Catherine L. Chen, MD, MPH et al
JAMA Ophthalmol. published January 18, 2018.
Question Can the full extent of routine preoperative testing in patients undergoing cataract surgery be ascertained to update previous studies’ use of 30-day preoperative testing windows?
Findings In this cross-sectional study of 440 857 Medicare beneficiaries undergoing cataract surgery, testing rates increased 41% during the interval between ocular biometry and cataract surgery, even after excluding tests occurring within 30 days before surgery. This expanded capture method estimates that Medicare expenditures for routine preoperative testing cost up to $45.4 million annually.
Meaning This study has the limitations associated with using administrative billing databases but suggests that routine preoperative testing can be identified earlier than 30 days before surgery and is costlier than previously described.
Importance Routine preoperative medical testing is not recommended for patients undergoing low-risk surgery, but testing is common before surgery. A 30-day preoperative testing window is conventionally used for study purposes; however, the extent of routine testing that occurs prior to that point is unknown.
Objective To improve on existing cost estimates by identifying all routine preoperative testing that takes place after the decision is made to perform cataract surgery.
Design, Setting, and Participants This cross-sectional study assessed preoperative care in a 50% sample of Medicare beneficiaries older than 66 years who underwent ambulatory cataract surgery in 2011. Data analysis was completed from March 2016 to October 2017.
Main Outcomes and Measures Using ocular biometry as a procedure-specific indicator to mark the start of the routine preoperative testing window, we measured testing rates in the interval between ocular biometry and cataract surgery and compared this with testing rates in the 6 months preceding biometry. We estimated the total cost of testing that occurred between biometry and cataract surgery.
Results A total of 440 857 patients underwent cataract surgery. A total of 423 710 (96.1%) had an ocular biometry claim before index surgery, of whom 264 514 (60.0%) were female; the mean (SD) age of the cohort was 76.1 (6.2) years. A total of 111 998 (25.4%) underwent surgery more than 30 days after biometry. Among patients with a biometry claim, the mean number of tests/patient/month increased from 1.1 in the baseline period to 1.7 in the interval between biometry and cataract surgery. Although preoperative testing peaked in all patients in the 30 days preceding surgery (1.8 tests/patient/month), the subset of patients with no overlap between postbiometry and presurgery periods experienced increased testing rates to 1.8 tests per patient per month in the 30 days after biometry, regardless of the elapsed time between biometry and surgery. The total estimated cost of routine preoperative testing in the full cohort was $22.7 million; we estimate that routine preoperative testing costs Medicare up to $45.4 million annually.
Conclusions and Relevance In this study of Medicare beneficiaries, routine preoperative medical testing occurs more often and is costlier than has been reported previously. Extra costs are attributable to testing that occurs prior to the 30-day window preceding surgery. As a cost-cutting measure, routine preoperative medical testing should be avoided in patients with cataracts throughout the interval between ocular biometry and cataract surgery.