Medicare Patients Undergoing Cataract Surgery
Original Investigation Research
Invited Commentary
Preoperative Consultation Before Cataract Surgery Are We Choosing Wisely or Is This Simply Low-Value Care? Lee A. Fleisher, MD
A major focus in fixing the health care crisis has been a shift from volume-based to value-based care.1 One approach to improving the value equation is the elimination of unnecessary or wasteful tests and procedures. This forms part of the basis of the Choosing Wisely campaign from the American Board of 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 30 million Americans undergo surgery annually and approximately 60% of them undergo a procedure on an ambulatory basis, the elimination of extensive preoperative tests and consultations represents an area of potentially large health care savings. In this issue of JAMA Internal Medicine, Thilen and colleagues3 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. Cataract surgery is unique among the surgical procedures in having a very large randomized clinical trial with sufficient power to demonstrate that routine preoperative laboratory testing is not associated with improvement in outcome compared with those who did not receive routine testing.4 In fact, perioperative morbidity and mortality after cataract surgery is extremely low, and even a history of myocardial infarction Related article page 380 does not 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 the American Society of Anesthesiologists for the Choosing Wisely campaign includes a statement to avoid diagnostic testing in this cohort of patients.6 Given the evidence and clear guidelines, why does there continue to be a substantial and increasing incidence of preoperative consultations in patients undergoing cataract surgery? To answer this question, it is important to understand what the authors did and the limitations of their approach. They used 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% in 2006. When internal medicine physicians are combined with family practitioners, this group provided 85% of all consultations, whereas specialists such as cardiologists and pulmonologists together represented only 11% of the consultations. Such a high incidence of consultations by primary caregivers could represent routine follow-up by the patient's primary physician as opposed to an additional evaluation obtained solely for jamainternalmedicine.com
the purposes of the surgical procedure. If the former was true, then the incremental costs would be negligible compared with those of routine care unless the consultation led to additional laboratory tests being obtained solely for the purpose of clearing the patient for the surgical procedure. If no tests were obtained, then clearly the consultation could be considered part 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 considered unnecessary and of low value. The key question is whether the patient has been in stable condition since the previous routine examination. It is hoped that the surgeon or anesthesiologist can assess the patient and, if the patient’s condition is stable, obtain a simple history and medication list from the primary 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 when anesthesiologists are involved. They also observed substantial variation in frequency of consultation across hospital referral regions, again suggesting that this practice may reflect local utilization patterns rather than underlying medical necessity. As with all analyses of administrative claims, the goals are clearly to generate a hypothesis rather than to answer the question of whether 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 in order to define the population who needs such evaluation testing, which could lead to reduced testing. The results of Thilen et al3 also parallel those of another recent publication concerning potentially low-value care, which demonstrated increased use of stress testing in noncardiac surgical patients without risk factors.7 This is the motivation behind the Perioperative Surgical Home concept recently proposed by the American Society of Anesthesiologists.8 So how do we ensure that provision of low-value or novalue 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. JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: by a Kaohsiung Med Univ User on 03/07/2018
389
Research Original Investigation
Medicare Patients Undergoing Cataract Surgery
ARTICLE INFORMATION Author Affiliation: Department of Anesthesiology and Critical Care, Leonard Davis Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Corresponding Author: Lee A. Fleisher, MD, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Dulles 680, Philadelphia, PA 19104 ([email protected] .edu). Published Online: December 23, 2013. doi:10.1001/jamainternmed.2013.12298. Conflict of Interest Disclosures: None reported. Correction: This article was corrected on January 8, 2014, to fix an error in the first paragraph. REFERENCES 1. Porter ME, Lee TH. The strategy that will fix health care. Harv Bus Rev. 2013;91(10):50-70.
390
2. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802. 3. Thilen SR, Treggiari MM, Lange JM, Lowy E, Weaver EM, Wijeysundera DN. Preoperative consultations for Medicare patients undergoing cataract surgery [published online December 23, 2013]. JAMA Intern Med. doi:10.1001 /jamainternmed.2013.13426. 4. Schein OD, Katz J, Bass EB, et al; Study of Medical Testing for Cataract Surgery. The value of routine preoperative medical testing before cataract surgery. N Engl J Med. 2000;342(3): 168-175. 5. Fleisher LA, Beckman JA, Brown KA, et al; American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular
Medicine; Society for Vascular Surgery. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2009;54(22):e13-e118. 6. American Society of Anesthesiologists. Five Things Physicians and Patients Should Question. Choosing Wisely website. http://www .choosingwisely.org/doctor-patient-lists/american -society-of-anesthesiologists/. Accessed October 25, 2013. 7. Sheffield KM, McAdams PS, Benarroch-Gampel J, et al. Overuse of preoperative cardiac stress testing in Medicare patients undergoing elective noncardiac surgery. Ann Surg. 2013;257(1):73-80. 8. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol. 2013;13:6.
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: by a Kaohsiung Med Univ User on 03/07/2018
jamainternalmedicine.com
Original Investigation Research
Invited Commentary
Preoperative Consultation Before Cataract Surgery Are We Choosing Wisely or Is This Simply Low-Value Care? Lee A. Fleisher, MD
A major focus in fixing the health care crisis has been a shift from volume-based to value-based care.1 One approach to improving the value equation is the elimination of unnecessary or wasteful tests and procedures. This forms part of the basis of the Choosing Wisely campaign from the American Board of 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 30 million Americans undergo surgery annually and approximately 60% of them undergo a procedure on an ambulatory basis, the elimination of extensive preoperative tests and consultations represents an area of potentially large health care savings. In this issue of JAMA Internal Medicine, Thilen and colleagues3 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. Cataract surgery is unique among the surgical procedures in having a very large randomized clinical trial with sufficient power to demonstrate that routine preoperative laboratory testing is not associated with improvement in outcome compared with those who did not receive routine testing.4 In fact, perioperative morbidity and mortality after cataract surgery is extremely low, and even a history of myocardial infarction Related article page 380 does not 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 the American Society of Anesthesiologists for the Choosing Wisely campaign includes a statement to avoid diagnostic testing in this cohort of patients.6 Given the evidence and clear guidelines, why does there continue to be a substantial and increasing incidence of preoperative consultations in patients undergoing cataract surgery? To answer this question, it is important to understand what the authors did and the limitations of their approach. They used 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% in 2006. When internal medicine physicians are combined with family practitioners, this group provided 85% of all consultations, whereas specialists such as cardiologists and pulmonologists together represented only 11% of the consultations. Such a high incidence of consultations by primary caregivers could represent routine follow-up by the patient's primary physician as opposed to an additional evaluation obtained solely for jamainternalmedicine.com
the purposes of the surgical procedure. If the former was true, then the incremental costs would be negligible compared with those of routine care unless the consultation led to additional laboratory tests being obtained solely for the purpose of clearing the patient for the surgical procedure. If no tests were obtained, then clearly the consultation could be considered part 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 considered unnecessary and of low value. The key question is whether the patient has been in stable condition since the previous routine examination. It is hoped that the surgeon or anesthesiologist can assess the patient and, if the patient’s condition is stable, obtain a simple history and medication list from the primary 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 when anesthesiologists are involved. They also observed substantial variation in frequency of consultation across hospital referral regions, again suggesting that this practice may reflect local utilization patterns rather than underlying medical necessity. As with all analyses of administrative claims, the goals are clearly to generate a hypothesis rather than to answer the question of whether 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 in order to define the population who needs such evaluation testing, which could lead to reduced testing. The results of Thilen et al3 also parallel those of another recent publication concerning potentially low-value care, which demonstrated increased use of stress testing in noncardiac surgical patients without risk factors.7 This is the motivation behind the Perioperative Surgical Home concept recently proposed by the American Society of Anesthesiologists.8 So how do we ensure that provision of low-value or novalue 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. JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: by a Kaohsiung Med Univ User on 03/07/2018
389
Research Original Investigation
Medicare Patients Undergoing Cataract Surgery
ARTICLE INFORMATION Author Affiliation: Department of Anesthesiology and Critical Care, Leonard Davis Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Corresponding Author: Lee A. Fleisher, MD, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Dulles 680, Philadelphia, PA 19104 ([email protected] .edu). Published Online: December 23, 2013. doi:10.1001/jamainternmed.2013.12298. Conflict of Interest Disclosures: None reported. Correction: This article was corrected on January 8, 2014, to fix an error in the first paragraph. REFERENCES 1. Porter ME, Lee TH. The strategy that will fix health care. Harv Bus Rev. 2013;91(10):50-70.
390
2. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802. 3. Thilen SR, Treggiari MM, Lange JM, Lowy E, Weaver EM, Wijeysundera DN. Preoperative consultations for Medicare patients undergoing cataract surgery [published online December 23, 2013]. JAMA Intern Med. doi:10.1001 /jamainternmed.2013.13426. 4. Schein OD, Katz J, Bass EB, et al; Study of Medical Testing for Cataract Surgery. The value of routine preoperative medical testing before cataract surgery. N Engl J Med. 2000;342(3): 168-175. 5. Fleisher LA, Beckman JA, Brown KA, et al; American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular
Medicine; Society for Vascular Surgery. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2009;54(22):e13-e118. 6. American Society of Anesthesiologists. Five Things Physicians and Patients Should Question. Choosing Wisely website. http://www .choosingwisely.org/doctor-patient-lists/american -society-of-anesthesiologists/. Accessed October 25, 2013. 7. Sheffield KM, McAdams PS, Benarroch-Gampel J, et al. Overuse of preoperative cardiac stress testing in Medicare patients undergoing elective noncardiac surgery. Ann Surg. 2013;257(1):73-80. 8. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol. 2013;13:6.
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: by a Kaohsiung Med Univ User on 03/07/2018
jamainternalmedicine.com
