Routine preoperative medical testing for cataract surgery

Abstract

Background Cataract surgery is practiced widely, and substantial resources are committed to an increasing cataract surgical rate in low- and middle-income countries. With the current volume of cataract surgery and future increases, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management. Objectives To investigate the evidence for reductions in adverse events through preoperative medical testing To estimate the average cost of performing routine medical testing Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); Ovid MEDLINE; Embase.com; PubMed; LILACS BIREME, the metaRegister of Controlled Trials (mRCT) (last searched 5 January 2012); ClinicalTrials.gov and the WHO ICTRP. The date of the search was 29 June 2018, with the exception of mRCT which is no longer in service. We searched the references of reports from included studies for additional relevant studies without restrictions regarding language or date of publication. Selection criteria We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery. Data collection and analysis Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed risk of bias. Main results We identified three randomized clinical trials that compared routine preoperative medical testing versus selective or no preoperative testing for 21,531 cataract surgeries. The largest trial, in which 19,557 surgeries were randomized, was conducted in Canada and the USA. Another study was conducted in Brazil and the third in Italy. Although the studies had some issues with respect to performance and detection bias due to lack of masking (high risk for one study, unclear for two studies), we assessed the studies as at overall low risk of bias. The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pre-testing group and 354 occurred in the no-testing group (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.86 to 1.16; high-certainty evidence). Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 0.99, 95% CI...

Multicomponent Deimplementation Strategy to Reduce Low-Value Preoperative Testing

“…31 Prior investigations have effectively reduced testing in select populations and operations, primarily within Veterans Health Administration hospitals and in older adults undergoing cataract surgery. 5 These results support the ability to deimplement low-value testing in 3 of the top 10 most common general surgery procedures. Reducing low-value testing in these high-volume cases has the potential for significant impact.…”

Multicomponent Deimplementation Strategy to Reduce Low-Value Preoperative Testing

“…31 Prior investigations have effectively reduced testing in select populations and operations, primarily within Veterans Health Administration hospitals and in older adults undergoing cataract surgery. 5 These results support the ability to deimplement low-value testing in 3 of the top 10 most common general surgery procedures. Reducing low-value testing in these high-volume cases has the potential for significant impact.…”

Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration

“…Our findings are pertinent to clinical practice given the well-established guidelines by the Choosing Wisely Campaign for limiting preoperative testing before low-risk surgical procedures . Systemic complications following cataract surgery are extremely rare, with 30-day mortality being below 0.1% .…”

Comorbidities in Age-Related Cataract: Epidemiological Burden and Public Health Implications

“…Despite the need to investigate and assess the multiple comorbidities that can interfere with the outcomes of cataract surgery in older adult patients, since the early 2000s, substantial evidence has shown that performing routine preoperative testing for every patient does not improve surgical outcomes. This is supported by Keay et al, who included more than 21,000 cataract surgeries in their meta-analysis and found no significant difference in intraoperative or postoperative medical adverse events between patients undergoing routine preoperative testing and those receiving selective or no testing (odds ratio 1.00, 95% confidence interval 0.86–1.16) [ 151 ]. Nevertheless, older adult patients still frequently undergo redundant medical assessments, often driven by institutional practices rather than patient-specific clinical indications.…”

Multicomponent Deimplementation Strategy to Reduce Low-Value Preoperative Testing

“…31 Prior investigations have effectively reduced testing in select populations and operations, primarily within Veterans Health Administration hospitals and in older adults undergoing cataract surgery. 5 These results support the ability to deimplement low-value testing in 3 of the top 10 most common general surgery procedures. Reducing low-value testing in these high-volume cases has the potential for significant impact.…”

Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration

“…Our findings are pertinent to clinical practice given the well-established guidelines by the Choosing Wisely Campaign for limiting preoperative testing before low-risk surgical procedures . Systemic complications following cataract surgery are extremely rare, with 30-day mortality being below 0.1% .…”

Comorbidities in Age-Related Cataract: Epidemiological Burden and Public Health Implications

“…Despite the need to investigate and assess the multiple comorbidities that can interfere with the outcomes of cataract surgery in older adult patients, since the early 2000s, substantial evidence has shown that performing routine preoperative testing for every patient does not improve surgical outcomes. This is supported by Keay et al, who included more than 21,000 cataract surgeries in their meta-analysis and found no significant difference in intraoperative or postoperative medical adverse events between patients undergoing routine preoperative testing and those receiving selective or no testing (odds ratio 1.00, 95% confidence interval 0.86–1.16) [ 151 ]. Nevertheless, older adult patients still frequently undergo redundant medical assessments, often driven by institutional practices rather than patient-specific clinical indications.…”

Multicomponent Deimplementation Strategy to Reduce Low-Value Preoperative Testing

“…31 Prior investigations have effectively reduced testing in select populations and operations, primarily within Veterans Health Administration hospitals and in older adults undergoing cataract surgery. 5 These results support the ability to deimplement low-value testing in 3 of the top 10 most common general surgery procedures. Reducing low-value testing in these high-volume cases has the potential for significant impact.…”

Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration

“…Our findings are pertinent to clinical practice given the well-established guidelines by the Choosing Wisely Campaign for limiting preoperative testing before low-risk surgical procedures . Systemic complications following cataract surgery are extremely rare, with 30-day mortality being below 0.1% .…”

Comorbidities in Age-Related Cataract: Epidemiological Burden and Public Health Implications

“…Despite the need to investigate and assess the multiple comorbidities that can interfere with the outcomes of cataract surgery in older adult patients, since the early 2000s, substantial evidence has shown that performing routine preoperative testing for every patient does not improve surgical outcomes. This is supported by Keay et al, who included more than 21,000 cataract surgeries in their meta-analysis and found no significant difference in intraoperative or postoperative medical adverse events between patients undergoing routine preoperative testing and those receiving selective or no testing (odds ratio 1.00, 95% confidence interval 0.86–1.16) [ 151 ]. Nevertheless, older adult patients still frequently undergo redundant medical assessments, often driven by institutional practices rather than patient-specific clinical indications.…”