A Revised Estimate of Costs Associated With Routine Preoperative Testing in Medicare Cataract Patients With a Procedure-Specific Indicator

Abstract

IMPORTANCE Routine preoperative medical testing is not recommended for patients undergoing low-risk surgery, but testing is common before surgery. A 30-day preoperative testing window is conventionally used for study purposes; however, the extent of routine testing that occurs prior to that point is unknown. OBJECTIVE To improve on existing cost estimates by identifying all routine preoperative testing that takes place after the decision is made to perform cataract surgery. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study assessed preoperative care in a 50% sample of Medicare beneficiaries older than 66 years who underwent ambulatory cataract surgery in 2011. Data analysis was completed from March 2016 to October 2017. MAIN OUTCOMES AND MEASURES Using ocular biometry as a procedure-specific indicator to mark the start of the routine preoperative testing window, we measured testing rates in the interval between ocular biometry and cataract surgery and compared this with testing rates in the 6 months preceding biometry. We estimated the total cost of testing that occurred between biometry and cataract surgery. RESULTS A total of 440 857 patients underwent cataract surgery. A total of 423 710 (96.1%) had an ocular biometry claim before index surgery, of whom 264 514 (60.0%) were female; the mean (SD) age of the cohort was 76.1 (6.2) years. A total of 111 998 (25.4%) underwent surgery more than 30 days after biometry. Among patients with a biometry claim, the mean number of tests/patient/month increased from 1.1 in the baseline period to 1.7 in the interval between biometry and cataract surgery. Although preoperative testing peaked in all patients in the 30 days preceding surgery (1.8 tests/patient/month), the subset of patients with no overlap between postbiometry and presurgery periods experienced increased testing rates to 1.8 tests per patient per month in the 30 days after biometry, regardless of the elapsed time between biometry and surgery. The total estimated cost of routine preoperative testing in the full cohort was $22.7 million; we estimate that routine preoperative testing costs Medicare up to $45.4 million annually. CONCLUSIONS AND RELEVANCE In this study of Medicare beneficiaries, routine preoperative medical testing occurs more often and is costlier than has been reported previously. Extra costs are attributable to testing that occurs prior to the 30-day window preceding surgery. As a cost-cutting measure, routine preoperative medical testing should be avoided in patients with cataracts throughout the interval between ocular biometry and cataract surgery.

Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery

“…No administrative or billing data element in VHA CDW marks a particular test as “preoperative.” Therefore, we developed a method to identify screening tests that were ordered prior to CTR (Figure 1). A test was considered preoperative if it occurred within 30 days prior to CTR 21 , and within 30 days after an encounter in a specific VHA clinic where preoperative CTR screening tests are typically ordered, including those that are explicitly dedicated to preoperative care (i.e., 416 - Pre-Surgery Evaluation by Non-MD; 419 - Anesthesia Pre-Op/Post-Op Consult; 432 - Pre-Surgery Evaluation by MD; 433 - Pre-Surgery Evaluation by Nursing) or are likely preoperative (e.g., Hand Surgery, Neurosurgery, Plastic Surgery, Orthopedic clinic before CTR). A test was omitted if it also occurred within 30 days before a major non-CTR procedure (e.g., total knee arthroplasty) that justified the test being ordered.…”

Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System

“…verified whether the main measures were ordered and delivered using manual medical record review. Many options exist for attributing testing to preoperative care using administrative data, such as the novel use of biometry codes 33 ; however, because biometry was rarely coded at LAC-DHS, we used manual medical record review to determine whether the test was associated with the preoperative care. Secondary measures included serious 30-day postoperative adverse events (eg, myocardial infarction, stroke, or hypoglycemia) as defined by previous research.…”

<p>Assessing the value of preoperative medical clearance in patients with primary rhegmatogenous retinal detachment</p>

“…Large retrospective and prospective studies and Cochrane database reviews of randomized clinical trials have demonstrated that routine preoperative testing in patients undergoing cataract surgery does not significantly reduce the risk of intraoperative or postoperative medical adverse events 1–3. Furthermore, the continued reliance on routine preoperative testing in cataract surgery patients has been shown to be associated with significant costs, reaching a potential estimated $45.4 million annually for Medicare patients undergoing cataract surgery 4…”