Friday, May 08, 2015

Snapping defeat from the jaws of victory

What is it about opthalmologists and cataract surgery?  If there were ever a success story in the world of medicine it is this:  Better and more consistent quality than years ago delivered at a remarkably lower cost.  But it seems like the profession insists on ways to make it more expensive.

I have discussed one such "innovation," the femtosecond laser, and the thousands of dollars in direct consumer cost that it entails and that has been authorized by CMS, the Medicare agency.

Now Michelle Andrews at Kaiser Health News summarizes a recent NEJM article.  Excerpts:

Requiring patients to get blood work and other tests before undergoing cataract surgery hasn’t been recommended for more than a dozen years. There’s good reason for that: The eye surgery generally takes less time than watching a rerun of “Marcus Welby, MD” — just 18 minutes, on average. It’s also incredibly safe, with a less than 1 percent risk of major cardiac problems or death.

Yet more than half of Medicare patients received at least one pre-operative test in the month before undergoing surgery to remove cataracts in 2011, a recent study found.

“Their patients [tested] were no sicker or older,” says Catherine Chen, an anesthesiologist at the University of California, San Francisco, and the lead author of the study. “It suggests that it’s habit or practice patterns.”

Cataract surgery used to take a few hours and require general anesthesia. In those days, preoperative testing made more sense, says Chen. Now people often receive only a topical anesthetic eye drop to numb the eye or sometimes a local anesthetic that may include a sedative for relaxation.

But research shows that today, pre-operative testing for cataract surgery doesn’t result in fewer adverse events or better surgical outcomes, regardless of a patient’s health, says Chen.

Where is the American Academy of Opthalmology on such issues?  Who stands for the patients?  Where is CMS, and why do they allow this pattern of testing?  Who stands for the costs incurred by the American public?


Barry Carol said...

It wouldn’t surprise me if this is yet another example of increasing defensive medicine in a litigious society. If it is, I don’t know if the specialty society is leading the way or the ophthalmologists are clamoring for maximum protection from potential lawsuits. I would be willing to bet that the extra testing is more likely to be driven by fear of lawsuits as opposed to an attempt to drive revenue. Even if outcomes are no better with testing, it looks better in court when doctors do more testing rather than less.

Jordan said...

In my experience this process (pre-op testing prior to cataract surgery) is completely driven by anesthesiology.

At my institution we have fought to change this process to no avail so recently we started having topical days without any anesthesia staff present. We give the patient a mild oral anti-anxiety medication (if needed) and do the short case under topical conditions. Without anesthesia monitoring the cost is even lower.

Let's also not forget about the added cost of cardiology and pulmonary "clearances" required for some of the sicker patients undergoing eye surgery or the cost/time wasted for the patient and family when their scheduled surgery is cancelled on the day of because the patient does not have these clearances completed.

Anonymous said...

Part of the problem might also be is that how someone has done something and refuses to listen to new guidelines. I see that a lot: this is how I do it and a refusal to change.