How much money is wasted on tests prior to cataract surgery? And why?
Reviewed by Jonathan C P Roos

For routine cataract surgery, numerous studies have found that preoperative testing does not contribute usefully to safety or surgical success. Despite such guidelines, tests ordered for patients prior to phacoemulsification in the US remains high. To quantify the associated costs, Chen and colleagues studied patients on Medicare – the US federal health insurance system which pays for 80% of cataract surgery in the United States. The authors studied a cohort of patients who had such surgery in 2011, comparing the tests performed in the month prior to surgery with those ordered for the same patient in the preceding 11 months. Patients were identified using billing codes used by Medicare which allowed identification of the practice setting, geographical area and surgeon. There were 500,000 such patients selected randomly. The following tests were considered when ordered a month before surgery: full blood count (FBC), urea & electrolytes (U&Es), Coag screen, urinalysis, ECG, cardiac echo, stress test, chest x-ray and pulmonary function tests. Fifty-three percent of patients had at least one such preoperative test and the excess spend in the month prior to surgery (compared to the 11 month baseline) totalled $17.2million. The main predictive factor for ordering such tests was unrelated to the patient or region: 8% of cataract surgeons ordered preoperative tests on all their patients; 36% ordered preoperative tests for more than 75% of patients. Thirteen percent of patients had one of the tests listed above, 11% had two, 10% three, 7% four and 13% had five or more – and all for routine cataract surgery! Surprisingly the rate had not changed after the introduction of clinical guidelines aimed at curtailing such testing. The authors concluded that preoperative testing represents a significant expense; publishing guidelines does not necessarily alter surgeon behaviour and physicians vary greatly in their practice. Is this relevant to UK ophthalmologists? This study reminds us to be careful guardians of the health budget, to be aware of guidelines’ effects on budgets and illustrates how colleagues abroad approach practice – particularly when transatlantic treaties currently being negotiated at the EU level could possibly put UK practitioners in direct competition with other such providers.

Preoperative medical testing in medicare patients undergoing cataract surgery.
Chen C, Lin G, Bardach NS, et al.
THE NEW ENGLAND JOURNAL OF MEDICINE
2015;372:1530-8.