Preoperative Consultation Before Cataract Surgery: Are We Choosing Wisely or Is This Simply Low-Value Care?

Amajor focus in fixing the health care crisis has been a shift fromvolume-based tovalue-based care.1One approach to improving the value equation is the elimination of unnecessary or wasteful tests and procedures. This forms part of the basis of theChoosingWisely campaign from theAmericanBoardof Internal Medicine Foundation.2 A major theme within the Choosing Wisely campaign has been the elimination of routine preoperative evaluation in low-risk patients. Given that 30million Americans undergo surgery annually and approximately 60% of them undergo a procedure on an ambulatory basis, the eliminationof extensivepreoperative tests and consultations represents an area of potentially large health care savings. In this issue of JAMA Internal Medicine, Thilen and colleagues3demonstratenotonly that this is not occurringbut that the incidenceof preoperative consultations is actually increasing in the Medicare population for patients undergoing cataract surgery. Cataract surgery is unique among the surgical procedures in having a very large randomized clinical trial with sufficient power todemonstrate that routinepreoperative laboratory testing is not associatedwith improvement in outcome compared with those who did not receive routine testing.4 In fact, perioperativemorbidity andmortality after cataract surgery is extremely low, and even a history of myocardial infarction doesnot adversely affect outcome. The American College of Cardiology Foundation/American Heart Association guidelines propose proceeding to the operating room without further cardiovascular testing unless unstable symptoms are present in this low-risk cohort of patients.5 The list of 5 things proposed by theAmerican Society of Anesthesiologists for the ChoosingWisely campaign includes a statement to avoiddiagnostic testing in thiscohortofpatients.6Giventheevidenceand clearguidelines,whydoestherecontinuetobeasubstantialand increasing incidence of preoperative consultations in patients undergoing cataract surgery? Toanswer thisquestion, it is important tounderstandwhat theauthorsdidandthe limitationsof theirapproach.Theyused a 5% national random sample of Medicare part B files for the years 1995 to 2006.They identified consultation codes that occurred within 42 days of surgery and reported that the frequency of consultation increased from 11.0% in 1995 to 18.4% in2006.When internalmedicinephysiciansarecombinedwith family practitioners, this group provided 85% of all consultations,whereasspecialists suchascardiologistsandpulmonologists together representedonly 11%of the consultations. Such ahigh incidence of consultations byprimary caregivers could represent routine follow-up by the patient's primary physicianasopposed toanadditional evaluationobtained solely for thepurposes of the surgical procedure. If the formerwas true, then the incremental costswouldbenegligible comparedwith those of routine care unless the consultation led to additional laboratory tests beingobtained solely for thepurposeof clearing the patient for the surgical procedure. If no tests were obtained, then clearly the consultation could be consideredpart of routine care. However, if the consultation was performed solely for the purpose of an evaluation for the surgical procedure, then such additional medical services could be consideredunnecessaryandof lowvalue.Thekeyquestion iswhether thepatienthasbeen in stable condition since theprevious routine examination. It is hoped that the surgeon or anesthesiologist can assess the patient and, if the patient’s condition is stable, obtaina simplehistoryandmedication list fromtheprimary care provider. Given this framework, the authors attempt to address the question of appropriateness of the preoperative consultations by assessing geographic variations. They report increased utilization in the Northeast sector of the country and whenanesthesiologists are involved. They also observed substantial variation in frequency of consultation across hospital referral regions, again suggesting that this practice may reflect local utilizationpatterns rather thanunderlyingmedical necessity. Aswith all analyses of administrative claims, the goals are clearly togenerateahypothesis rather than toanswer thequestion ofwhether these consultations are truly indicated. However, the results of this study suggest that a great deal of lowvalue care is occurring among patients who undergo cataract surgery. Because much of this care occurs more frequently when patients undergo the procedure with an anesthesiologist present, better communication between the anesthesiologist, surgeon, and internists or other primary care providers is required inorder todefine thepopulationwhoneedssuch evaluation testing, which could lead to reduced testing. The resultsofThilenet al3 alsoparallel thoseof another recentpublication concerningpotentially low-value care,whichdemonstrated increased use of stress testing in noncardiac surgical patients without risk factors.7 This is the motivation behind thePerioperativeSurgicalHomeconcept recentlyproposedby the American Society of Anesthesiologists.8 So how do we ensure that provision of low-value or novalue care is reducedor eliminated? Payment reform inwhich either the entire surgical episode is bundled or the patient is enrolled in anaccountable care organizationmay itself lead to moreappropriateuseof consultationand testing. Itwill be important forphysicians, armedwith this informationabout current practice patterns, to take the lead in choosingwiselywith respect to which patients require a consultation and test before external forces do it for us. Related article page 380 Medicare Patients Undergoing Cataract Surgery Original Investigation Research