The Medical Money Machine — A Newly Published Study Takes Aim at Unnecessary Preoperative Tests before Cataract Surgery

© 2015 Peter Free

 

16 April 2015

 

 

Citation — to study

 

Catherine L. Chen, Grace A. Lin, Naomi S. Bardach, Theodore H. Clay, W. John Boscardin, Adrian W. Gelb, Mervyn Maze, Michael A. Gropper, and R. Adams Dudley, Preoperative Medical Testing in Medicare Patients Undergoing Cataract Surgery, New England Journal of Medicine 372(16): 1530-1538, DOI: 10.1056/NEJMsa1410846 (16 April 2015)

 

 

Another example of physicians ignoring evidence-based professional guidelines

 

From the abstract:

 

 

Routine preoperative testing is not recommended for patients undergoing cataract surgery, because testing neither decreases adverse events nor improves outcomes.

 

Using an observational cohort of Medicare beneficiaries undergoing cataract surgery in 2011, we determined the prevalence and cost of preoperative testing in the month before surgery.

 

Using multivariate hierarchical analyses, we examined the relationship between preoperative testing and characteristics of patients, health system characteristics, surgical setting, care team, and occurrence of a preoperative office visit.

 

Of 440,857 patients, 53% had at least one preoperative test in the month before surgery.

 

Preoperative testing before cataract surgery occurred frequently and was more strongly associated with provider practice patterns than with patient characteristics.

 

© 2015 Catherine L. Chen, Grace A. Lin, Naomi S. Bardach, Theodore H. Clay, W. John Boscardin, Adrian W. Gelb, Mervyn Maze, Michael A. Gropper, and R. Adams Dudley, Preoperative Medical Testing in Medicare Patients Undergoing Cataract Surgery, New England Journal of Medicine 372(16): 1530-1538, DOI: 10.1056/NEJMsa1410846 (16 April 2015) (at Abstract) (extracts)

 

From the University of California at San Francisco press release:

 

 

“Our study shows that routine preoperative testing still occurs in Medicare patients undergoing cataract surgery, even though it is one of the safest procedures out there,” said lead author Catherine Chen, MD, MPH, resident physician in the Department of Anesthesia and Perioperative Care at UCSF.

 

“The major professional societies have agreed for more than a decade that routine testing doesn’t improve outcomes from surgery.”

 

According to the study background, cataract surgery is the most common elective surgery among Medicare beneficiaries, with 1.7 million surgeries annually. The average surgery is just 18 minutes long, and virtually all are performed in an outpatient setting with eye drops for anesthesia.

 

“The ophthalmologist who operated on the patient was a stronger predictor of whether patients were tested than any other variable we looked at, which implies that it doesn't matter whether a patient is sick or healthy,” Chen said.

 

“There are certain doctors who will always order tests in their patients just because that patient is having surgery, even though studies have shown that these tests don't make a difference since cataract surgery itself is so low risk."

 

“[W]e found that the excess testing occurred primarily among a small number of physicians who are readily identifiable using claims data,” said senior author R. Adams Dudley . . . .

 

“[P]ayers like Medicare could use their own data to figure out which doctors they need to talk to about this.”

 

Chen is careful to point out it is not necessarily the ophthalmologist alone who is driving testing.

 

"We can't tell which doctor – the ophthalmologist, the anesthesiologist or the primary care provider – actually ordered the tests,” Chen said.

 

© 2015 Scott Maier, Unnecessary Preoperative Testing Still Done on Cataract Patients, University of California at San Francisco (15 April 2015) (extracts)

 

 

The moral? — Raking the money in is fun, and it is easy to fool patients into thinking that the tests are necessary

 

This combination probably explains why evidence-disproven clinical practices are so difficult to stamp out. When one keeps making money practicing lucrative but inefficient medicine, why quit?