Preoperative Medical Testing and Falls in Medicare Beneficiaries Awaiting Cataract Surgery

More than 3.7 million cataract surgeries are performed annually in the United States, with approximately 80% covered by Medicare. Catherine Chen, MD, Mary Whooley, MD,  and Adams Dudley, MD, MBA along with their colleagues, detail the findings of the first study to evaluate the impact of routine preoperative testing on the risk of falling in cataract patients who are awaiting surgery in a recent Opthalmology article. Fall-related injuries in older adults are a major public health concern because of their prevalence, the associated morbidity and mortality, and their cost to the healthcare system.

The two key components of modern cataract surgery, the surgical extraction of the clouded lens and the simultaneous correction of any baseline refractive error, dramatically improves patients’ postoperative visual acuity as well as their ability to perform activities of daily living. More importantly, cataract surgery has been shown to reduce the incidence of significant harms in cataract patients who undergo the procedure. Examples of the harms avoided by undergoing timely cataract surgery include halving the rate of motor vehicle accidents during a multiyear follow-up period compared with patients with cataract disease who did not undergo surgery, a reduction in the risk of hip fracture during the first 12 months after surgery and a 34% decrease in the fall rate of patients who underwent cataract surgery within 6 weeks versus patients who waited at least 6 months for the procedure. In light of these data, the vast literature on the safety of cataract surgery, and its efficacy in correcting the vision loss associated with senile cataract, it generally is recommended that surgical delays be avoided.

According to clinical guidelines, routine preoperative medical testing is not necessary in advance of cataract surgery because it neither decreases the incidence of perioperative adverse events nor improves cataract surgery outcomes. However, testing still occurs frequently in anticipation of this low-risk procedure, with approximately half of Medicare cataract surgery patients undergoing at least one routine preoperative test. If a patient undergoes unnecessary testing, even if no abnormality is found, surgery is delayed because of the time it takes to undergo testing and await the results of those tests. Since cataract surgery is usually indicated at the point that the disease impacts vision enough to compromise activities of daily living, delays in surgical scheduling arising from unnecessary preoperative testing or for other reasons prolong the period during which these patients with poor vision are at an increased risk of falls and the serious injuries (such as hip fracture) that can result. 

Dr. Chen’s prior work showed that the strongest predictor of which patients undergo routine preoperative testing is the identity of the ophthalmologist, which was used as a proxy for the group of physicians managing the preoperative medical workup. In this innovative study the researchers found that patients of high-testing physicians waited longer for surgery and experienced more falls and fall-related injuries than patients of low-testing physicians.   Although the magnitude of effect of being treated by a high-testing physician was limited compared with some of the other risk factors for falling that the researchers accounted for in their analysis, their study still demonstrated that patients of high testing physicians experienced more falls and fall-related injuries during the brief but potentially avoidable surgical delay that accompanies the deployment of routine preoperative testing. 

Most notably, the researchers’ findings showed that a physician’s decision to order routine preoperative testing is associated with clinical harm. This study reinforces the importance of following longstanding guidelines that recommend that patients should not undergo routine preoperative testing before cataract surgery.

 

Catherine Chen, MD

 

 

 

 

 

Mary Whooley, MD

 

 

 

 

Preoperative Medical Testing and Falls in Medicare Beneficiaries Awaiting Cataract Surgery.

Chen CL, McLeod SD, Lietman TM, Shen H, Boscardin WJ, Chang HP, Whooley MA, Gelb AW, Lee SJ, Dudley RA.Ophthalmology. 2021 Feb;128(2):208-215. doi: 10.1016/j.ophtha.2020.09.013. Epub 2020 Sep 11.