No matter how ingrained, health care providers should challenge practices that confer no measurable benefit.
Consider cataract extraction as an example. It is the most commonly performed surgery in the United States and one of the safest. About 3 million cataract surgical procedures are performed annually,1 and the associated risk of a major adverse event is far less than 1%.2 At a cost of approximately $160 per preoperative evaluation visit,3 the evaluation alone carries a financial burden of almost $500 million annually, with an additional cost of about $150 million4 for tests (eg, blood counts, serum chemistries, electrocardiography) ordered at the preoperative visit. Such testing has been definitively shown to offer no benefit to patient safety when compared with no testing.5 In addition, we have estimated that an additional $40 per patient is spent when medical staff collect and review a patient's history and physical (H&P), increasing the total annual costs associated with the preoperative evaluation to more than $700 million nationwide just for cataract surgery (Table). However, there is no evidence that a preoperative H&P plus the same-day evaluation conducted by an anesthesiologist or Certified Registered Nurse Anesthetist increases the safety of cataract surgery for most patients.6
IN LIGHT OF THESE FACTS, WHY IS A PREOPERATIVE EVALUATION DONE?
Currently, the Department of Health & Human Services and the Centers for Medicare & Medicaid Services mandate that patients undergo a comprehensive medical H&P evaluation within 30 days before surgery. And this evaluation is in addition to undergoing an examination immediately before surgery "to evaluate the risk of anesthesia and of the procedure being performed."7 There are no exceptions for cataract surgery. Yet, it could be reasonably argued that cataract surgery poses the same level of medical risk as colonoscopy and dental surgery. These latter 2 procedures are performed on similar populations, and routine preoperative medical history and physical examinations are neither routine nor required. Despite contrary evidence regarding the utility of such mandates, providers must continue to order and perform an H&P before cataract surgery to meet the regulatory requirement.
A WAY TO MOVE FORWARD
To constitute a benefit, the preoperative H&P should detect findings that would require medical intervention that might, in turn, reduce the perioperative medical risk for a patient. Certainly, there are cataract surgical patients for whom a preoperative medical evaluation might well confer value, such as those with advanced cardiopulmonary disease, brittle insulin-dependent diabetes, or other unstable conditions. However, based on the low medical risk of cataract surgery and the ambulatory population undergoing this procedure, the proportion of patients likely to benefit from a preoperative evaluation is almost certainly very low. However, the ability to reliably identify those patients who might benefit is the fundamental requirement of any rational change in policy and practice.
We are finalizing a perioperative risk assessment questionnaire with input from colleagues in the departments of anesthesiology and critical care and internal medicine. The questionnaire is an 8-item checklist. It is brief enough to reasonably be completed at the time of surgical scheduling but sensitive enough, we believe, to identify those who should undergo the standard or even an enhanced preoperative H&P.
We conducted a pilot evaluation of the questionnaire at The Johns Hopkins Wilmer Eye Institute.6 It took less than 2 minutes to administer the questionnaire to each patient, and results demonstrated that less than 20% of patients would likely benefit from the standard, comprehensive preoperative H&P. Therefore, for the vast majority of patients, a focused anesthesia risk assessment on the morning of surgery would be safe, sufficient, and rational care.
We propose to explore ways to institute more value-oriented care in this arena and make the case to the Centers for Medicare & Medicaid Services to consider individualized patient care. The best medical practice and cost-responsible care should match the level of preoperative evaluation for cataract surgery to the specific medical needs of each patient. This approach could also be used for other low-risk medical procedures.
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