Eyeworld

EW CATARACT 28 May 2014 by Maxine Lipner EyeWorld Senior Contributing Writer Cataract care: Getting wise to extraneous testing A n asymptomatic patient who appears reasonably healthy is scheduled for phacoemulsification the next day. Should he or she be sent for further testing? Not necessarily, thinks Lee A. Fleisher, MD, Robert D. Dripps professor and chair of anesthesiology, University of Pennsylvania, Philadelphia. This is an area where a dent may actually be made in healthcare spending, he said. In a commentary published in the March issue of JAMA Internal Medicine, Dr. Fleisher pointed out that this has been a major theme of the "Choosing Wisely" campaign currently being undertaken by the American Board of Internal Medicine Foundation. "The interesting thing about cataract surgery is that we've done research and others have done re- search showing that even within eye surgery, cataract surgery is very low risk," Dr. Fleisher said. "Particularly now almost no one is done under general—it's done under either a block or topical anesthesia." As a result, when presence of co-morbidities is considered, these do not add risk, he said. "The pres- ence of other medical conditions in a stable patient rarely influences outcome," Dr. Fleisher said. Given that years ago the existence of medical conditions was found to slightly influence vitreo- retinal surgery, Dr. Fleisher believes that the type of anesthesia used for cataract surgery may well play a role here. "It may be related to the fact that a lot of these (cataract proce- dures) are done under topical (anesthesia)," he said. "That's the uniqueness of cataract surgery." Rise in consultations Still, for patients poised to undergo cataract surgery, testing such as an EKG is frequently done as well as blood work for hemoglobin and electrolytes, Dr. Fleisher said. He cited findings from a study also published in the March issue of JAMA, led by Stephan R. Thilen, MD, which indicated that the number of consultations among Medicare patients before cataract surgery had risen substantially. "When you do studies like this in- volving the Medicare population, they found that the rate of consulta- tions increased dramatically from about 11% to 18%," Dr. Fleisher said. Meanwhile, current American Heart Association guidelines advise that in the absence of unstable symptoms, practitioners could pro- ceed to the OR without further diag- nostic testing, he went on. Then the question becomes: Is the patient being sent for testing because he happened to see the doctor who felt that it was important to do it any- way, or is this being done because someone wants him to be "cleared" for cataract surgery? That's some- thing that can't be extrapolated from this latest study data, Dr. Fleisher said. The study also indicated that the increase in consultations tended to be linked to certain factors. "Urban residents went a little more frequently than those in rural towns," Dr. Fleisher said. "Also, hospitals did consultations a little more frequently than ambulatory surgery centers." Cases involving an anesthesiologist tended to involve consultations more than those when a nurse anesthetist was used. The ge- ographic region where the cataract surgery was being performed played a role, with those in the Northeast seeking consultations 3 times as frequently as others, he pointed out. Dr. Fleisher views this last factor as most concerning. While it does not prove that it is worse in the Northeast or that they use it more inappropriately, it does suggest geographic variation, he said. The question is: Is this variation in consultations sought linked to the fact that there are more providers around for referrals or to the fact that this is more appropriate for the patient? Choosing wisely This all harks back to whether wise choices are being made. "We don't know the answer, but we should start to question when we're getting these type of tests if they're really necessary," Dr. Fleisher said. "One of the key things that we in anesthesia have seen when we created our 'Choosing Wisely' list is that testing is done frequently because there are anesthesiologists who say you need it and there are surgeons who are afraid that if they don't get it, some- one will cancel their case," he said. Others worry about what may occur if something bad happens in a case where no testing was done. Dr. Fleisher pointed out that akin to recent findings in mammography where lives are saved but there are also a huge number of false posi- tives, testing here may be inadver- tently problematic. "You find something, you intervene, and the patient gets a stent and has a com- plication," all when the patient may have been asymptomatic and not undergone the procedure and remained without symptoms. "It's not just that we're worried that more tests will drive up healthcare," he said. "Once you start doing test- ing, you can find things and do workups in asymptomatic patients that can cause harm that you wouldn't have done if you had seen them in your office for a routine examination." Dr. Fleisher advises ophthalmic practitioners to keep this in mind. "I think that for patients who are stable and asymptomatic, partic- ularly if they have seen their physi- cian in the last 6 to 12 months, then they don't need anything further," he said. He pointed out that the "Choosing Wisely" campaign is about having frank discussions with patients. "If patients are worried that they have heart disease and haven't gotten a recent EKG, part of it is explaining to patients why more is not always better," Dr. Fleisher said. "For people with heart disease, you may want to get an EKG, but if they're stable and they got one 6 months ago and you wouldn't have gotten an EKG anyway, do they need another? Probably not," Dr. Fleisher said. Overall, he encourages a team approach. "It would be great to say, 'Have you seen your internist in the last 6 months? If you have and everything is stable, great. If not, we'll send you there,'" Dr. Fleisher said. "No testing unless it's indi- cated, regardless of the surgery— that is the message that we need to send." EW Reference Stephan R. Thilen, MD, MS, Miriam M. Treggiari, MD, MPH, PhD, Jane M. Lange, MS, Elliott Lowy, PhD, Edward M. Weaver, MD, MPH, Duminda N. Wijeysundera, MD, PhD. Preoperative Consultations for Medicare Pa- tients Undergoing Cataract Surgery. JAMA In- ternal Medicine. 2014 March. 174(3):380-388. Editors' note: Dr. Fleisher has no finan- cial interests related to his comments. Contact information Fleisher: lee.fleisher@uphs.upenn.edu Study results indicate that consultations for cataract surgery have risen dramatically. The question is whether these are really needed. Source: National Eye Institute

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