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 "The preoperative medical consultation is an understudied
area. It's an intervention that we spend several billion dollars
on each year in this country. We know surprisingly little about
the process," Dr. Stephen Thilen told Reuters Health.
"What we're studying here is how often do we bring a third
provider in — a service that is in addition to the others and
it's separately billed. It adds an expense," said Thilen, an
assistant professor of anesthesiology and pain medicine at the
University of Washington in Seattle who led the study.
A cataract is a medical condition in which the lens of the eye
becomes opaque and causes blurred vision.
Surgery to remove the cataract is generally low-risk, and is the
most common elective surgery performed on beneficiaries of
Medicare, the U.S. health insurance program for people over 65.
Patients awaiting cataract surgery generally see the
ophthalmologist who performs the surgery and the
anesthesiologist or anesthetist if one is needed. Both
consultations are covered by the flat price Medicare pays those
providers for the surgery.
Thilen's team looked at trends in additional preoperative
consultations with the patient's family doctor, cardiologist,
pulmonologist, endocrinologist or other physician not directly
involved in the surgery.
So far, little is known about the value of these extra
consultations when patients are involved in lower-risk
procedures, such as most cataract surgeries, Thilen said.
"There has been more published on high-risk patients. Generally
we would expect patients coming for heart surgery, liver
transplants, vascular surgery — those high risk procedures — we
would expect them to often have preoperative medical
consultations because they're high risk patients and they have
many issues that need to be addressed," Thilen said.
No national guidelines indicate whether and when cataract
surgery patients need an additional preoperative consultation,
Thilen and his colleagues write in JAMA Internal Medicine.
So they looked at Medicare billing data for 556,637 patients who
had their first cataract surgeries between 1995 and 2006 and
found that the proportion of patients getting preoperative
medical consultations rose from 11 percent in 1995 to 18 percent
in 2006.
When they analyzed claims for the last two years of that period,
they found the patients most likely to have the extra
consultations tended to be older and also had anesthesiologists
involved in their care. The number of consultations was also
higher in urban areas and they were about three times more
common in the northeastern U.S. compared to the South.
The researchers did not have access to clinical records so they
don't know why any of the consultations were ordered or if they
added any value to patient care.
"We're only in the beginning of this. We hope to contribute to
more cost effective care and peri-operative management. We will
study other procedures, we will look at other types of data
beyond Medicare data," Thilen said.
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"Ideally we should have more information on whether these
consultations improve outcomes in one way or another," Thilen
said.
More than two million Medicare beneficiaries have cataract
surgery every year, Thilen and his colleagues note in their report.
"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," Dr. Lee Fleisher writes in a commentary
accompanying the study.
Fleisher is professor and chair of anesthesiology and critical care
at the Leonard Davis Institute, Perelman School of Medicine of the
University of Pennsylvania in Philadelphia.
"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 percent of them undergo a procedure on an
ambulatory basis, the elimination of extensive preoperative tests
and consultations represents an area of potentially large healthcare
savings," he writes.
But Dr. Daniel Albert thinks preoperative consultations are more
common because the standard of care is higher now than in 1995.
The surgeon's reimbursements for cataract surgery are lower now than
in 1995," said Albert, who is founding director of the University of
Wisconsin McPherson Eye Research Institute and a professor in the
Department of Ophthalmology and Visual Sciences at the University of
Wisconsin. He was not involved in the study.
"The idea that you had to have a more stringent examination and it
had to be done within 30 days of the surgery became more widespread
over the period they're looking at," Albert said.
The type of anesthesia may also have something to do with when
preoperative consultations or done, he told Reuters Health.
Albert said most cataract surgeries performed at his institution are
done with local (or topical) anesthetics with a 'regular' nurse
assisting, but some places require monitored anesthesia — the type
that requires the presence of an anesthesiologist or nurse
anesthetist.
He also points out that the data might be outdated, since the study
ended in 2006 and even the surgical procedure has changed
considerably since then.
"It's much quicker now and more technologically driven. It's much
safer and the complication rate is far lower than it was in 1995,"
he said.
Albert also said that co-management in cataract surgery usually is
between an optometrist and ophthalmologist, and usually the family
practitioners or internal medicine physicians are not involved.
___
Source: http://bit.ly/1e8PEU6 and
http://bit.ly/1cvIJHk
JAMA Internal Medicine, online Dec. 23
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