Increase in consultations for Medicare patients before cataract surgery

December 23, 2013

Preoperative consultations before cataract surgery became more common for Medicare patients despite no clear guidelines about when to require such a service, hinting at unnecessary use of health care resources, according to a study published by JAMA Internal Medicine.

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 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.

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.

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.

"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 ."

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 ," 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.

Explore further: Pre-op depression linked to narcotic use before spinal Sx

More information: JAMA Intern Med. Published online December 23, 2013. DOI: 10.1001/jamainternmed.2013.13426
JAMA Intern Med. Published online December 23, 2013. DOI: 10.1001/jamainternmed.2013.12298

Related Stories

Pre-op depression linked to narcotic use before spinal Sx

December 19, 2013
(HealthDay)—For patients undergoing spinal surgery for a structural lesion, preoperative depression and anxiety are associated with increased preoperative narcotic use, according to a study published in the Dec. 1 issue ...

Antibiotics before heart surgery protect against infection

December 23, 2013
A new study found preoperative antibiotic therapy administered within two hours of cardiac surgery decreased the risk of developing surgical site infections (SSIs) significantly. The study was published in the January issue ...

Pre-op physiatry consultation reduces spinal surgery rates

February 5, 2013
(HealthDay)—Requiring patients interested in spinal surgery to first see a rehabilitation physician reduces the number of spinal surgeries, reduces costs, and leaves patients largely satisfied, according to a study published ...

Early emergency department palliative care consultations resulted in significantly shorter hospital stays

December 11, 2013
New York University College of Nursing researcher and Assistant Professor Abraham A. Brody, RN, PhD, GNP-BC and colleagues reporting in Journal of Palliative Medicine found that initiating a palliative care consult in the ...

History of falls linked to post-surgery complications in seniors

October 10, 2013
(HealthDay)—Seniors who've had one or more falls in the six months prior to surgery are at increased risk for poorer outcomes after their operation, according to a new study.

Pre-surgery exam rates vary widely among hospitals

December 21, 2011
Hospitals vary greatly in the number of patients who see an internal medicine specialist before major non-cardiac surgery, with rates ranging from five per cent of patients to 90 per cent, new research has found.

Recommended for you

World's first child hand transplant a 'success'

July 19, 2017
The first child in the world to undergo a double hand transplant is now able to write, feed and dress himself, doctors said Tuesday, declaring the ground-breaking operation a success after 18 months.

Knee surgery—have we been doing it wrong?

July 18, 2017
A team of University at Buffalo medical doctors have published a study that challenges a surgical practice used for decades during arthroscopic knee surgery.

New tools help surgeons find liver tumors, not nick blood vessels

July 17, 2017
The liver is a particularly squishy, slippery organ, prone to shifting both deadly tumors and life-preserving blood vessels by inches between the time they're discovered on a CT scan and when the patient is lying on an operating ...

Researchers discover indicator of lung transplant rejection

July 13, 2017
Research by scientists at Dignity Health St. Joseph's Hospital and Medical Center's Norton Thoracic Institute was published in the July 12, 2017 issue of Science Translational Medicine titled "Zbtb7a induction in alveolar ...

New device could make closing surgical incisions a cinch

July 7, 2017
Like many surgeons, Dr. Jason Spector is often faced with the challenge of securely closing the abdominal wall without injuring the intestines. If the process goes awry, there can be serious consequences for patients, including ...

Success with first 20 patients undergoing minimally invasive pancreatic transplant surgery

June 29, 2017
Surgeons at Johns Hopkins Medicine report that their first series of a minimally invasive procedure to treat chronic pancreas disease, known as severe pancreatitis, resulted in shorter hospital stays, less need for opioids ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.