Assessing the feasibility and impact of a risk-based approach to cataract surgery pre-operative medical evaluation

From the 2021 HVPAA National Conference

Tony Cuttitta (University of Michigan), Shahzad Mian, James Henderson, David Portney, Jenna Keedy, Wendy Benedict, Hannah Lahti, Pattricia Klarr, Roni Shtein, Paul Lee, Shannon Joseph, Eve Kerr

Background

In 2019, the Centers for Medicare & Medicaid Services (CMS) implemented the Patients Over Paperwork initiative allowing hospitals and ambulatory surgery centers (ASCs) to establish their own policies on pre-operative history and physical requirements. This allows ASCs to eliminate low value preoperative evaluation by implementing a risk-based approach to pre-operative medical examination before low-risk procedures such as cataract surgery.

Objective

To assess the feasibility of a risk-based approach to cataract surgery pre-operative medical evaluation, which eliminated pre-operative examination for patients considered to be at low risk for complications, and its impact on safety and throughput.

Methods

The intervention took place at an academic center between June to September 2020. The intervention group (IG) consisted of cataract surgery patients who underwent pre-operative screening using a risk assessment questionnaire during a virtual visit. Low-risk patients proceeded to surgery without further pre-operative evaluation. Non-low-risk patients underwent usual care. Primary outcomes compared the IG to a pre-intervention control group (CG) for key measures which included intraoperative complications, 7-day inpatient admissions, case delays, and same-day changes or cancellations. These data were collected from anesthesia records and through chart review of the medical records system. Secondary outcomes assessed these same measures, but also compared patient groups within the IG to each other (low-risk versus non-low-risk). Patient perceptions of care were also measured among IG patients only through a four-question survey with a 5-point Likert scale.

Results

There were 1,095 patients included in the IG and 3,114 in the CG. In the IG, 126 patients (11.5%) were low-risk cases and proceeded to surgery without further physical examination; the remaining 969 (88.5%) cases received standard care (underwent an in-person physical exam prior to surgery). There were no significant differences between CG and IG (CG vs IG; diff [95% CI]) when comparing rates of intraoperative complications (0.7% vs 0.4%; -0.3% [-0.82, 0.02]), 7-day inpatient admissions (0.2% vs 0.2%; -0.01% [-0.31, 0.29]), or same day cancelations (0.8% vs 0.6%; -0.15% [-0.63, 0.34]). The CG had more case delays (1.9% vs 0.6%, -1.3% [-1.93, -0.58]). When comparing patient groups within the IG (low-risk to non-low-risk) there were no significant differences in intraoperative complications, 7-day inpatient admissions, 7-day ED visits for non-eye related reasons, case delays, same day cancelations, or patient perceptions of care.

Conclusions

A risk-based approach using a detailed medical screening at a virtual visit to determine need for pre-operative physical exams is associated with safe and efficient outcomes for cataract surgery.

Clinical Implications

This cohort study examined the feasibility and impact of a risk-based approach to preoperative medical evaluations for cataract surgery and found that patients identified as low-risk for complications may safely proceed to cataract surgery without a separate pre-operative physical exam. These findings support prior evidence that a limited pre-operative evaluation does not compromise safety for low-risk patients. These findings should encourage health systems and ASCs to tailor their pre-operative requirements for low-risk surgery cases, particularly cataract surgery, and eliminate low value preoperative services.