Does Cataract Surgery Need Preoperative
Consultation? It is Increasing for Medicare Patients
Older patients (75 to 84) were more likely to have a
consultation than patients age 66 to 74
Dec. 23, 2013 Cataract surgery a low-risk
surgery that has almost become routine for senior citizens has
increasingly involved a preoperative consultation for Medicare patients,
despite no clear guidelines about when to require such a service. A new
study suggests in may be unnecessary use of Medicare health care
Preoperative medical consultation is a common
health care service that can be billed separately to Medicare. There is
little information about how often preoperative consultation is
performed among the large numbers of patients in the United States who
undergo elective, low-risk surgical procedures that may not require
routine consultation, and how the referral for such consultation varies
by patient, facility and geographic region, according to the study
The study findings indicate preoperative
consultations became more common, increasing from 11.3 percent in 1998
to 18.4 percent in 2006.
Older patients (age 75 to 84 years) were more
likely to have a consultation than patients between age 66 to 74 years,
while patients who were black or lived in a rural area were less likely
to receive a consultation.
Those patients who had their cataract surgery in an
inpatient or outpatient hospital had higher odds of having a
consultation than those whose surgery was performed in an office.
Patients who had an anesthesiologist involved with
their care (either personally administering it or medically directing or
supervising certified registered nurse anesthesists) also had higher
odds of having a preoperative consultation. Living in the northeast also
meant higher odds that a patient would have a consultation compared with
patients living in the South or West.
Who is at risk for cataract?
The risk of cataract increases as you get older. Other risk factors for cataract include:
Certain diseases such as diabetes.
Personal behavior such as smoking and alcohol use.
The environment such as prolonged exposure to sunlight.
the lens in
your eye. It
age 80, more
than half of
or have had
can occur in
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is also an
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The study is published by JAMA Internal Medicine,
a JAMA Network publication.
Stephan R. Thilen, M.D., M.S., of the University of
Washington, Seattle, and colleagues measured consultations performed by
family practitioners, general internists, pulmonologists,
endocrinologists, nurse practitioners or anesthesiologists as early as
42 days before cataract surgery.
Researchers analyzed a 5 percent sample
of Medicare part B claims, which included 556,637 patients 66 years or
older who had cataract surgery from 1995 to 2006.
This large retrospective study suggests that there
was substantial use of preoperative medical consultation for cataract
surgery and that referrals for consultation had increased during the
study period. With the exception of age, referral for preoperative
consultation seems driven primarily by nonmedical factors including
practice setting, type of anesthesia provider and geographical region,
the authors conclude.
These data highlight an area of opportunity for
interventions aimed at reducing unwanted practice variability in a
process that has the potential to consume vast amounts of health care
The study was partially supported by funds
from the department of Anesthesiology and Pain Medicine, University of
Commentary: Are We Choosing Wisely or is This
Simply Low-Value Care?
In a related commentary, Lee A. Fleisher, M.D., of
the University of Pennsylvania, Philadelphia, writes: A major theme
within the Choosing Wisely campaign has been the elimination of routine
preoperative evaluation in low-risk patients. In this issue of JAMA
Internal Medicine, Thilen and colleagues demonstrate not only that
this is not occurring but that the incidence of preoperative
consultations is actually increasing in the Medicare population for
patients undergoing cataract surgery.
The results of this study suggest that a great
deal of low-value care is occurring among patients who undergo cataract
surgery, Fleisher continues.
So how do we ensure that provision of low-value
or no-value care is reduced or eliminated? Payment reform in which
either the entire surgical episode is bundled or the patient is enrolled
in an accountable care organization may itself lead to more appropriate
use of consultation and testing. It will be important for physicians,
armed with this information about current practice patterns, to take the
lead in choosing wisely with respect to which patients require a
consultation and test before external forces do it for us, Fleisher
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