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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 resources.

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 background.

 

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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.

About Cataracts

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.

A cataract is a clouding of the lens in your eye. It affects your vision. Cataracts are very common in older people. By age 80, more than half of all Americans either have a cataract or have had cataract surgery.

A cataract can occur in either or both eyes. It cannot spread from one eye to the other. Common symptoms are

  • Blurry vision

  • Colors that seem faded

  • Glare - headlights, lamps or sunlight may seem too bright. You may also see a halo around lights.

  • Not being able to see well at night

  • Double vision

  • Frequent prescription changes in your eye wear

Cataracts usually develop slowly. New glasses, brighter lighting, anti-glare sunglasses or magnifying lenses can help at first.

Surgery is also an option. It involves removing the cloudy lens and replacing it with an artificial lens. Wearing sunglasses and a hat with a brim to block ultraviolet sunlight may help to delay cataracts.

NIH: National Eye Institute

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 resources.”

The study was partially supported by funds from the department of Anesthesiology and Pain Medicine, University of Washington, Seattle.

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 concludes.

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