More than half of Medicare beneficiaries undergoing cataract surgery have at least one preoperative test, despite published guidelines against this testing, according to a study published April 16 in the New England Journal of Medicine. The authors say clinicians’ lack of adherence to guidelines results in substantial, unnecessary Medicare expenses. To assess current prevalence and cost of preoperative testing, the researchers used claims from 440,857 Medicare beneficiaries (66 years of age and older) undergoing cataract surgery in 2011. Tests were classified as preoperative if ordered within 30 days of surgery and included: complete blood count, chemical analysis, coagulation studies, urinalysis, electrocardiography, echocardiography, cardiac stress tests, chest radiography, and pulmonary-function tests, as well as components of standard laboratory panels. The researchers found that roughly half of all beneficiaries underwent at least one preoperative test (53 percent). Patient characteristics were similar between those having and not having a preoperative test. Compared to the 11-month baseline period, the mean number of tests per beneficiary during the preoperative month increased by 66 percent. While 13 percent of patients underwent one test during the preoperative month, 11 percent underwent two, 10 percent underwent three, 7 percent underwent four, and 13 percent underwent five or more. […]
More than half of Medicare beneficiaries undergoing cataract surgery have at least one preoperative test, despite published guidelines against this testing, according to a study published April 16 in the New England Journal of Medicine. The authors say clinicians’ lack of adherence to guidelines results in substantial, unnecessary Medicare expenses.
To assess current prevalence and cost of preoperative testing, the researchers used claims from 440,857 Medicare beneficiaries (66 years of age and older) undergoing cataract surgery in 2011. Tests were classified as preoperative if ordered within 30 days of surgery and included: complete blood count, chemical analysis, coagulation studies, urinalysis, electrocardiography, echocardiography, cardiac stress tests, chest radiography, and pulmonary-function tests, as well as components of standard laboratory panels.
The researchers found that roughly half of all beneficiaries underwent at least one preoperative test (53 percent). Patient characteristics were similar between those having and not having a preoperative test. Compared to the 11-month baseline period, the mean number of tests per beneficiary during the preoperative month increased by 66 percent. While 13 percent of patients underwent one test during the preoperative month, 11 percent underwent two, 10 percent underwent three, 7 percent underwent four, and 13 percent underwent five or more. The 798,150 tests performed during the preoperative month cost approximately $16.1 million. The Medicare expenditures on testing in the month prior to surgery were $4.8 million higher than the mean monthly expenditures during the preceding 11 months, which “strongly suggests,” the authors say, that most of the additional tests classified as preoperative tests were in fact being ordered in anticipation of surgery.
There was substantial variation among ophthalmologists in the use of preoperative testing. More than one third (36 percent) of ophthalmologists ordered preoperative testing for 75 percent or more of their patients, while 8 percent ordered testing for every patient. The researchers note a limitation of the data precludes identification of the actual physician (ophthalmologist or other member of the care team) responsible for the excess testing performed. Compared with patients undergoing surgery in ambulatory surgery centers, patients undergoing surgery in hospital outpatient departments had higher odds of testing. Yet, the authors say the ophthalmologist performing the surgery appeared to be a more powerful driver of testing than patient characteristics.
“Our results showed no difference in the prevalence of testing as compared with 20 years ago, before the introduction of guidelines,” write the authors, led by Catherine Chen, M.D., from University of California, San Francisco. “This is an important problem, considering that the number of annual cataract surgeries is projected to increase to 4.4 million by 2030, with Medicare paying for more than 80 percent of cataract surgical procedures in the United States.”
