Feasibility of a Risk-Based Approach to Cataract Surgery Preoperative Medical Evaluation

Abstract

IMPORTANCEIn 2019, the US Centers for Medicare & Medicaid Services implemented the Patients Over Paperwork initiative, allowing hospitals and ambulatory surgery centers to establish their own policies on preoperative history and physical requirements. A risk-based approach to preoperative medical evaluation may allow surgeons to provide high-value patient care.OBJECTIVE To assess the feasibility of a risk-based approach to cataract surgery preoperative medical evaluation through a lens of safety and throughput. DESIGN, SETTING, AND PARTICIPANTSA pilot study was performed to evaluate the implementation of a risk-based approach to preoperative medical evaluation for cataract surgery using a virtual medical history questionnaire. The intervention group, seen from June to September 2020, received the risk assessment and those who were low risk proceeded to surgery without further preoperative evaluation prior to the day of surgery. The preintervention control group included patients who received standard care from January to December 2019.MAIN OUTCOMES AND MEASURES Primary outcomes included rates of intraoperative complications, noneye-related emergency department visits within 7 days, inpatient admissions within 7 days of surgery, case delays, and rates of case cancellation. The secondary outcome included patient perception regarding preoperative care.RESULTS A total of 1095 patients undergoing cataract surgery were included in the intervention group (1813 [58.2%] female) and 3114 were in the control group (621/1095 [56.7%] female). The mean (SD) age was 68.6 (11.0) in the control group and 68.4 (10.5) in the intervention group. The intervention group included 126 low-risk individuals (11.5%) and 969 individuals who received standard care (88.5%). There were no differences between the control and intervention groups in terms of rates of intraoperative complications (control group vs intervention group: 21 [0.7%] vs 3 [0.3%]; difference, −0.4% [95% CI, −0.82 to 0.02]), 7-day noneye-related ED visits (5 [0.2%] vs 3 [0.3%]; difference, 0.1% [95% CI, −0.23 to 0.45]), 7-day inpatient admissions (6 [0.2%] vs 2 [0.2%]; difference, −0.01% [95% CI, −0.31 to 0.29]), or same-day cancellations (31 [0.8%] vs 10 [0.6%]; difference, −0.15% [95% CI, −0.63 to 0.34]). The control group had more case delays (59 [1.9%] vs 7 [0.6%]; difference, −1.3% [95% CI, −1.93 to −0.58]). CONCLUSIONS AND RELEVANCEThis study suggests that a virtual, risk-based approach to preoperative medical evaluations for cataract surgery is associated with safe and efficient outcomes. These findings may encourage health care systems and ambulatory surgery centers to tailor preoperative requirements for low-risk surgery patients.