A study of U.S. Medicare claims finds a jump in extra doctor consultations before cataract surgery, but no clear medical reason for the added costs.

“The preoperative medical consultation is an understudied area. It’s an intervention that we spend several billion dollars on each year in this country. We know surprisingly little about the process,” Dr. Stephen Thilen told Reuters Health.

“What we’re studying here is how often do we bring a third provider in - a service that is in addition to the others and it’s separately billed. It adds an expense,” said Thilen, an assistant professor of anesthesiology and pain medicine at the University of Washington in Seattle who led the study.

A cataract is a medical condition in which the lens of the eye becomes opaque and causes blurred vision.

Surgery to remove the cataract is generally low-risk, and is the most common elective surgery performed on beneficiaries of Medicare, the U.S. health insurance program for people over 65.

Patients awaiting cataract surgery generally see the ophthalmologist who performs the surgery and the anesthesiologist or anesthetist if one is needed. Both consultations are covered by the flat price Medicare pays those providers for the surgery.

Thilen’s team looked at trends in additional preoperative consultations with the patient’s family doctor, cardiologist, pulmonologist, endocrinologist or other physician not directly involved in the surgery.

So far, little is known about the value of these extra consultations when patients are involved in lower-risk procedures, such as most cataract surgeries, Thilen said.

“There has been more published on high risk patients. Generally we would expect patients coming for heart surgery, liver transplants, vascular surgery - those high risk procedures - we would expect them to often have preoperative medical consultations because they’re high risk patients and they have many issues that need to be addressed,” Thilen said.

No national guidelines indicate whether and when cataract surgery patients need an additional preoperative consultation, Thilen and his colleagues write in JAMA Internal Medicine.

So they looked at Medicare billing data for 556,637 patients who had their first cataract surgeries between 1995 and 2006 and found that the proportion of patients getting preoperative medical consultations rose from 11 percent in 1995 to 18 percent in 2006.

When they analyzed claims for the last two years of that period, they found the patients most likely to have the extra consultations tended to be older and also had anesthesiologists involved in their care. The number of consultations was also higher in urban areas and they were about three times more common in the northeastern U.S. compared to the South.

The researchers did not have access to clinical records so they don’t know why any of the consultations were ordered or if they added any value to patient care.

“We’re only in the beginning of this. We hope to contribute to more cost effective care and peri-operative management. We will study other procedures, we will look at other types of data beyond Medicare data,” Thilen said.

“Ideally we should have more information on whether these consultations improve outcomes in one way or another,” Thilen said.

More than two million Medicare beneficiaries have cataract surgery every year, Thilen and his colleagues note in their report.

“One approach to improving the value equation is the elimination of unnecessary or wasteful tests and procedures. This forms part of the basis of the Choosing Wisely campaign from the American Board of Internal Medicine,” Dr. Lee Fleisher writes in a commentary accompanying the study.

Fleisher is professor and chair of anesthesiology and critical care at the Leonard Davis Institute, Perelman School of Medicine of the University of Pennsylvania in Philadelphia.

“A major theme within the Choosing Wisely campaign has been the elimination of routine preoperative evaluation in low-risk patients. Given that 30 million Americans undergo surgery annually and approximately 60 percent of them undergo a procedure on an ambulatory basis, the elimination of extensive preoperative tests and consultations represents an area of potentially large healthcare savings,” he writes.

But Dr. Daniel Albert thinks preoperative consultations are more common because the standard of care is higher now than in 1995.

The surgeon’s reimbursements for cataract surgery are lower now than in 1995,” said Albert, who is founding director of the University of Wisconsin McPherson Eye Research Institute and a professor in the Department of Ophthalmology and Visual Sciences at the University of Wisconsin. He was not involved in the study.

“The idea that you had to have a more stringent examination and it had to be done within 30 days of the surgery became more widespread over the period they’re looking at,” Albert said.

The type of anesthesia may also have something to do with when preoperative consultations or done, he told Reuters Health.

Albert said most cataract surgeries performed at his institution are done with local (or topical) anesthetics with a ‘regular’ nurse assisting, but some places require monitored anesthesia - the type that requires the presence of an anesthesiologist or nurse anesthetist.

He also points out that the data might be outdated, since the study ended in 2006 and even the surgical procedure has changed considerably since then.

“It’s much quicker now and more technologically driven. It’s much safer and the complication rate is far lower than it was in 1995,” he said.

Albert also said that co-management in cataract surgery usually is between an optometrist and ophthalmologist and usually the family practitioners or internal medicine physicians are not involved.

SOURCE: JAMA Internal Medicine, online December 23, 2013.

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Preoperative Consultations for Medicare Patients Undergoing Cataract Surgery

Design, Setting, and Participants Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556 637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89 817 individuals who underwent surgery from 2005 to 2006.

Main Outcomes and Measures  Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery.

Results  The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75-84 years vs 66-74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04-1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65-0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49-1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05-1.15]), anesthesia provider (anesthesiologist vs non–medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10-1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI, 2.33-4.10]). The burden of comorbidity was associated with consultation, but the effect size was small (

<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0–69%]), even after accounting for differences in patient-level, anesthesia provider–level, and facility-level characteristics.

Conclusions and Relevance  Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.

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