Safety and comparative costs of preoperative assessments for cataract surgery: traditional mandatory assessment versus a novel graded assessment system

Economic evaluations in cataract surgery: a narrative review

Economic evaluations are tools for assessing emerging technologies and a complement for decision-making in healthcare systems. However, this topic may not be familiar for doctors and academics, who may be confused when interpreting the results of studies using these tools. Cataract is a disease which has received special attention in healthcare systems due to its high incidence, the great impact that it could have on patients' quality of life, and the fact that it can be definitively solved in almost all cases through cataract surgery. Historically, economic evaluations in cataract surgery have been conducted for many purposes by simply assessing whether the surgery is cost-effective for specific questions related to the implantation of multifocal intraocular lenses, surgical techniques, optimizing assessments, preventing diseases or complications, etc. Moreover, although there are systematic reviews about cataract surgery and narrative reviews introducing the concept of economic evaluations, as far as we know, no previous study has been conducted that synthesizes and integrates evidence coming from both fields. Thus, the purpose of this narrative review is to introduce doctors and academics to economic evaluation tools, to describe how these have been historically applied to cataract surgery, and to provide special considerations for the correct interpretation of economic studies.

Pre-anaesthesia assessment in cataract surgery: Recommendations from the SEDAR Working Group

INTRODUCTION AND OBJECTIVES

Cataract surgery is one of the most common procedures in outpatient surgery units. The use of information and communication technologies (ICT) in clinical practice and the advent of new health scenarios, such as the Covid pandemic, have driven the development of pre-anaesthesia assessment models that free up resources to improve access to cataract surgery without sacrificing patient safety. The approach to cataract surgery varies considerably among public, subsidised and private hospitals. This raises the need for guidelines to standardise patient assessment, pre-operative tests, management of background medication, patient information and informed consent.

RESULTS

In this document, the SEDAR Clinical Management Division together with the Major Outpatient Surgery Division SEDAR Working Group put forward a series of consensus recommendations on pre-anaesthesia testing based on the use of ITCs, health questionnaires, patient information and informed consent supervised and evaluated by an anaesthesiologist.

CONCLUSIONS

This consensus document will effectivise pre-anaesthesia assessment in cataract surgery while maintaining the highest standards of quality, safety and legality.

Economic Evaluation of Cataract: A Systematic Mapping Review

INTRODUCTION

The purpose of this article was to ascertain the existing literature and find the gaps in economic evaluations of cataracts.

METHODS

Systematic methods were used to search and collect the published literature on economic evaluations of cataracts. A mapping review of studies published in the following bibliographical databases was performed: the National Library of Medicine (PubMed), EMBASE, Web of Science (WOS), and the Central of Reviews and Dissemination (CRD) database. A descriptive analysis was conducted and relevant studies were classified into different groups.

RESULTS

Among 984 studies screened, 56 studies were included in the mapping review. Four research questions were answered. There has been a progressive increase of publications during the last decade. The majority of the included studies were published by authors from institutions in the USA and UK. The most commonly investigated area was cataract surgery followed by intraocular lenses (IOLs). The studies were classified into different categories according to the main outcome evaluated, such as comparisons between different surgical techniques, costs of the cataract surgery, second eye cataract surgery costs, quality of life gain after cataract surgery, waiting time of cataract surgery and costs, and cataract evaluation, follow-up, and costs. In the IOL classification, the most frequently studied area was the comparison between monofocal and multifocal IOLs, followed by the comparison between toric and monofocal IOLs.

CONCLUSIONS

Cataract surgery is a cost-effective procedure compared with other non-ophthalmic and ophthalmic interventions and surgery waiting time is an important factor to consider because vision loss has a huge and broad-ranging impact on society. Numerous gaps and inconsistencies are found among the studies included. For this reason, there is a need for further studies according to the classification described in the mapping review.

Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse

INTRODUCTION

The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery.

MATERIALS AND METHODS

A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization.

RESULTS

50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities.

CONCLUSIONS

Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.

Preoperative evaluations for ophthalmic surgery: A systematic review of 48,869 eyes

Eliminating low-yield testing can reduce the burden on modern health care systems. Our purpose is to determine whether routine preoperative assessment impacts the incidence of perioperative complications in ophthalmic surgery. We conducted a comprehensive search of Ovid MEDLINE, EMBASE, and Cochrane Library databases to identify studies investigating the incidence of perioperative complications following any preoperative assessment for patients undergoing ophthalmic surgery (PROSPERO ID#164008). Four randomized controlled trials (RCTs) and 5 observational studies were selected for inclusion. Risk of bias assessment revealed a lack of masking and insufficient statistical power in RCTs, and confounding in observational studies. Routine preoperative testing-including laboratory tests, electrocardiogram, and imaging studiesdid not decrease the incidence of adverse events or risk of perioperative ocular and systemic complications in most studies. Two cohort studies (1 retrospective, 1 prospective) suggestd that patients with certain preexisting health conditions were at increased risk for adverse events perioperatively. Another retrospective study found a lower risk of complications in high-risk patients who underwent evaluation. While patients with comorbidities may be at increased risk of adverse events, the role of preoperative assessment is not well delineated in this population. Further study is required to determine the comparative safety, effectiveness, and implementation of alternative assessment tools.

Perceived Barriers to the De-implementation of Routine Preoperative History & Physicals Preceding Low-risk Ambulatory Procedures: A Qualitative Study of Surgeon Perspectives

BACKGROUND

For patients undergoing surgery at an Ambulatory Surgical Center, recent changes to Centers for Medicare and Medicaid Services policy allow for the omission of a 30-day preoperative History and Physical (H&P). Preoperative H&Ps for low-risk surgery may contribute to health care waste and lead to unnecessary preoperative testing and treatment cascades.

METHODS

In this qualitative study, we conducted 30 semi-structured interviews with surgeons who frequently perform low-risk surgeries. We aimed to evaluate surgeon perspectives on the continued use of the 30-day preoperative H&P and specifically the potential risks and benefits associated with the elimination of a preoperative H&P requirement from institutional practice. We used an interpretive description approach to generate a thematic description.

RESULTS

Most participants felt that the 30-day preoperative H&P was low value and frequently described it as "unnecessary," "redundant," or "just checking a box." Many viewed the 30-day requirement as arbitrary and felt that new H&P findings were rare and unlikely to influence surgical care. The participants who favored the preoperative H&P felt it was a safeguard to ensure "nothing was missed" and were less likely to be burdened by the requirement than participants who felt it was low value.

CONCLUSIONS

Surgeons performing low-risk procedures question the utility and value of conducting a preoperative H&P within 30 days of surgery. De-implementation of the 30-day preoperative H&P for low-risk patients may increase convenience for patients and providers. Furthermore, it may improve value in surgery by increasing access to services for patients with greater need for preoperative assessment.

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

Importance

In 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 Participants

A 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 Relevance

This 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.

Does eliminating the preoperative history and physical make a difference in low-risk cataract surgery patients? A before and after study of 30-day morbidity and mortality

OBJECTIVE

To evaluate the safety of omitting the conventional preoperative history and physical examination (H&P) for low-risk cataract surgery patients.

DESIGN

Comparison of outcomes before and after the January 1, 2015 system wide implementation of a program that eliminated the conventional preoperative H&P for low-risk patients as identified by a 12-item risk stratification questionnaire.

PARTICIPANTS

Two separate groups of Winnipeg residents who had cataract surgery at the city's sole ophthalmological referral centre between July 1 and December 31, 2014 (preimplementation reference group) or between October 1, 2015 and March 31, 2016 (postimplementation intervention group).

METHODS

A detailed chart review was completed for cataract surgery patients who experienced a postoperative medical event (a composite of death or hospital admission or emergency department visit, identified within administrative databases) within 30 days of surgery. Nonfatal events were captured for all 7 hospitals and urgent care centres in the city, including the ophthalmological referral centre.

RESULTS

Postoperative medical events occurred in 114 of 2981 (3.82%) intervention group surgeries and 125 of 3037 (4.12%) reference group surgeries (Relative risk 0.92, 95% confidence interval 0.72 to 1.19, p = 0.6 Fisher exact test). Subgroup analyses of major medical events and medical events by affected organ system yielded no significant differences between the 2 groups. In the opinion of the physician chart reviewers, none of the events among low-risk patients in the intervention group were related to the omission of a conventional preoperative H&P.

CONCLUSIONS

The risk of adverse medical events within 30 days of cataract surgery was not higher after the omission of the conventional preoperative H&P in patients screened to be low risk by a validated preoperative questionnaire.

Evaluating patient preparedness for cataract surgery and satisfaction with preoperative care

OBJECTIVE

To evaluate preoperative preparedness and patient satisfaction after implementation of the Cataract Screening Preprocedural Questionnaire (CSPQ) at Hamilton Regional Eye Institute.

DESIGN

Single-centred, prospective, cross-sectional study.

PARTICIPANTS/METHODS

One-hundred fifty-one adult patients undergoing elective cataract surgery completed the CSPQ questionnaire. Based on the responses, patients were triaged to the preoperative anaesthesia clinic or booked directly for surgery. Outcome measures included anxiety level, delays or cancellations in surgery, preoperative blood pressure, glucose levels, and satisfaction with the quality of preoperative instructions provided. Results were compared between patients who attended and those who bypassed the preoperative anaesthesia clinic.

RESULTS

Of the study population, 87 patients were female (57.6%) and the mean age was 72.0 ± 10.5 years. Only 11 patients (7.43%) were referred for preoperative consultation. Patients reported receiving preoperative instructions via handouts (94%) and verbally in combination with handouts (59.33%). Patients felt that adequate information was provided regarding preoperative medications (96.69%), eye drops (99.34%), fasting guidelines (98.68%), arrival time (99.34%), and instructions for accompaniment/drivers postoperatively (100%). All patients were compliant with the fasting guidelines. Patient satisfaction with the information received regarding cataract surgery and anaesthesia were 4.39 ± 0.88 and 3.80 ± 0.95, respectively. There was no difference in the anxiety level between patients who attended and those who bypassed the preoperative clinic (4.09 ± 2.92 and 5.18 ± 2.57, p = 0.14). There were no cancellations, delays, or immediate postoperative systemic complications.

CONCLUSIONS

The CSPQ model can be effectively used to streamline the preoperative preparation of patients for cataract surgery while maintaining a high degree of patient satisfaction with the perioperative experience.

Healthcare delivery cost and anesthesiologists: Time to have a greater role and responsibility

With the advancement of technology and health sciences, health care delivery costs are steadily increasing. This affects both households and governments. Unfortunately, the present truth is that health has become an essential but unaffordable commodity. This is very concerning. Quality, up-to-date, cost-effective health care delivery is one of the prime objectives, and focuses on administration and health care authority. As the per capita spent on health from public/government funds is very poor in developing countries, the responsibility of cost-effective health care delivery falls primarily on the shoulder of the treating physicians. Anesthesiologists are becoming an indispensable part of health care delivery, having a diverse role in the emergency, critical care, pain, and perioperative care of patients. As the population ages, the need for surgical care is also increasing. Therefore, the anesthesiologist can also play a more significant role in delivering cost-effective health care, and minimize the cost without affecting the quality. This brief narrative review analyzes the current practice of anesthesiologists in two prime areas in the context of cost-savings: Preoperative investigation and low/minimal flow anesthesia.

Defunding preoperative histories and physical exams: putting the cart before the evidence?

OBJECTIVE

Several Canadian health authorities have defunded preoperative cataract history and physical examinations performed by general practitioners. While these authorities suggest that such decisions are evidence-based, we are unaware of reviews addressing this topic, nor have health authorities been forthcoming with evidence used in their decision-making processes. The objective of this study is to perform a comprehensive review of the literature regarding the value of preoperative histories and physical examinations in cataract surgery.

DESIGN

Systematic review.

METHODS

The following databases were searched: PubMed, MEDLINE, Cochrane Library, Google Scholar, Web of Science, EMBASE, CINAHL, and BIOSIS Previews. Only higher-level forms of evidence were assessed, including randomized controlled trials, cohort, and case-control studies. Two reviewers independently assessed titles and abstracts for concordance with inclusion criteria. Disagreements between authors were resolved by discussion.

RESULTS

We identified 3 articles that met our inclusion criteria: two prospective and one retrospective cohort studies. These articles suggest traditional preoperative histories and physical examinations could be replaced by a health questionnaire (Jastrzebski et al. and Reeves et al.) or eliminated altogether (Alboim et al.).

DISCUSSION

Scientific literature presently contains 3 studies suggesting that preoperative histories and physical examinations could be modified or eliminated. However, methodological weaknesses and data analysis derived from these studies suggests defunding preoperative medical examination may be premature.

CONCLUSIONS

While finding efficiencies in medical care is admirable, physicians should be cautious in accepting recommendations that reduce checks ensuring perioperative safety. Further studies of better methodological quality should be completed to clarify the present evidence.

"Do not do" recommendations of the Spanish Society of Anaesthesiology, Critical Care and Pain Therapy. "Commitment to Quality by Scientific Societies" Project

In April 2013 the Ministry of Health (MSSSI) adopted the project called "Commitment to Quality by Scientific Societies in Spain", in response to social and professional demands for sustainability of the health system. The initiative is part of the activities of the Spanish Network of Agencies for Health Technology Assessment and Services of the National Health System, and is coordinated jointly by the Quality and Cohesion Department, the Aragon Institute of Health Sciences (IACS), and the Spanish Society of Internal Medicine (SEMI). All the scientific societies in Spain have been included in this project, and its main objective is to reduce the unnecessary use of health interventions in order to agree "do not do" recommendations, based on scientific evidence. The primary objective was to identify interventions that have not proven effective, have limited or doubtful effectiveness, are not cost-effective, or do not have priority. Secondary objectives were: reducing variability in clinical practice, to spread information between doctors and patients to guide decision-making, the appropriate use of health resources and, the promotion of clinical safety and reducing iatrogenesis. The selection process of the 5 "do not do" recommendations was made by Delphi methodology. A total of 25 panellists (all anaesthesiologists) chose between 15 proposals based on: evidence that supports quality, relevance, or clinical impact, and the people they affect. The 5 recommendations proposed were: Do not maintain deep levels of sedation in critically ill patients without a specific indication; Do not perform preoperative chest radiography in patients under 40 years-old with ASA physical status I or II; Do not systematically perform preoperative tests in cataract surgery unless otherwise indicated based on clinical history and physical examination; Do not perform elective surgery in patients with anaemia at risk of bleeding until a diagnostic workup is performed and treatment is given; and not perform laboratory tests (blood count, biochemistry and coagulation) prior to surgery in healthy or low risk patients (ASA I and II) with minimal estimated blood loss.