Feasibility of a Risk-Based Approach to Cataract Surgery Preoperative Medical Evaluation

This study seeks to assess the feasibility of a tailored approach to preoperative medical evaluations before cataract surgery through a lens of safety and throughput.

Key Points

Question

Is it feasible to perform preoperative medical evaluation for cataract surgery in a tailored, risk-based approach without compromising patient safety?

Findings

In this pilot study of 4209 patients, the intervention group was not superior to the preintervention control group in terms of intraoperative complications, noneye-related emergency department visits or inpatient admissions within 7 days of surgery, and case cancellation rates, However, there were fewer case delays in the intervention group.

Meaning

These findings suggest that a risk-based approach to preoperative medical evaluations before cataract surgery may be feasible and may not compromise patient safety.

Abstract

Importance

In 2019, the US Centers for Medicare & Medicaid Services implemented the Patients Over Paperwork initiative, allowing hospitals and ambulatory surgery centers to establish their own policies on preoperative history and physical requirements. A risk-based approach to preoperative medical evaluation may allow surgeons to provide high-value patient care.

Objective

To assess the feasibility of a risk-based approach to cataract surgery preoperative medical evaluation through a lens of safety and throughput.

Design, Setting, and Participants

A pilot study was performed to evaluate the implementation of a risk-based approach to preoperative medical evaluation for cataract surgery using a virtual medical history questionnaire. The intervention group, seen from June to September 2020, received the risk assessment and those who were low risk proceeded to surgery without further preoperative evaluation prior to the day of surgery. The preintervention control group included patients who received standard care from January to December 2019.

Main Outcomes and Measures

Primary outcomes included rates of intraoperative complications, noneye-related emergency department visits within 7 days, inpatient admissions within 7 days of surgery, case delays, and rates of case cancellation. The secondary outcome included patient perception regarding preoperative care.

Results

A total of 1095 patients undergoing cataract surgery were included in the intervention group (1813 [58.2%] female) and 3114 were in the control group (621/1095 [56.7%] female). The mean (SD) age was 68.6 (11.0) in the control group and 68.4 (10.5) in the intervention group. The intervention group included 126 low-risk individuals (11.5%) and 969 individuals who received standard care (88.5%). There were no differences between the control and intervention groups in terms of rates of intraoperative complications (control group vs intervention group: 21 [0.7%] vs 3 [0.3%]; difference, −0.4% [95% CI, −0.82 to 0.02]), 7-day noneye-related ED visits (5 [0.2%] vs 3 [0.3%]; difference, 0.1% [95% CI, −0.23 to 0.45]), 7-day inpatient admissions (6 [0.2%] vs 2 [0.2%]; difference, −0.01% [95% CI, −0.31 to 0.29]), or same-day cancellations (31 [0.8%] vs 10 [0.6%]; difference, −0.15% [95% CI, −0.63 to 0.34]). The control group had more case delays (59 [1.9%] vs 7 [0.6%]; difference, −1.3% [95% CI, −1.93 to −0.58]).

Conclusions and Relevance

This study suggests that a virtual, risk-based approach to preoperative medical evaluations for cataract surgery is associated with safe and efficient outcomes. These findings may encourage health care systems and ambulatory surgery centers to tailor preoperative requirements for low-risk surgery patients.

Introduction

In the United States, the completion of a full preoperative history and physical examination by the surgeon within 30 days of all surgeries has traditionally been required regardless of surgical risk. However, previous studies have suggested that universal preoperative evaluation requirements may hold limited value for low-risk cataract surgery patients.^1,2 In 2019, the US Centers for Medicare & Medicaid Services removed the history and physical examination requirement with its Patients Over Paperwork initiative, allowing surgery centers to establish their own policies based on procedure and patient risk.³

Eliminating preoperative physical examinations for cataract surgery has been proposed to reduce health care costs while continuing to provide high-value care to patients.^4,5,6 Reducing low-value in-person patient visits has the potential to increase efficiency and throughput as well as patient safety in the setting of the COVID-19 pandemic. Despite these benefits, there is a paucity of literature detailing how to safely and efficiently implement such changes. In this pilot study, we sought to assess the feasibility of a tailored approach to preoperative medical evaluations before cataract surgery through a lens of safety and throughput.

Methods

The pilot took place from June through September 2020. In the intervention group, all cataract surgery patients received a virtual preoperative appointment (in lieu of an in-person visit) where a risk assessment was performed using a questionnaire (eTable in the Supplement). The risk assessment questionnaire was developed by a multidisciplinary team including surgeons, anesthesiologists, preoperative physician assistants, and triage nurses. Low-risk patients did not receive an in-person physical examination by the surgeon. Moderate- and high-risk patients underwent a physical examination by the surgeon on the day of surgery, which included vital signs and cardiopulmonary examinations. All patients received at least 2 physical examinations by anesthesia on the day of surgery. All patients who underwent cataract surgery in 2019 were included as a preintervention control group (Figure). This project was determined by the University of Michigan institutional review board to be not regulated as a quality improvement project. As the study used retrospective data review, consent was not required by the institutional review board.

Figure. Clinical Flow Diagram of Control and Intervention Groups.

A total of 3114 patients from 2019 were included as control group patients who underwent in-person history and physical examinations prior to surgery. In the intervention group, 1095 patients first underwent a virtual history (coinciding with the COVID-19 pandemic) to stratify into risk groups. Low-risk patients (n = 126) did not receive an in-person physical examination by the surgeon. Moderate- and high-risk patients (n = 969) underwent a physical examination by the surgeon on the day of surgery. All patients received at least 1 physical examination by anesthesia on the day of surgery. OR indicates operating room.

Safety and efficiency outcomes were compared between the intervention and control groups. Primary outcome measures included rates of intraoperative complications, noneye-related emergency department (ED) visits within 7 days, inpatient admissions within 7 days, case delays, and case cancellations. Secondary measures included patient satisfaction, measured through a 4-question telephone survey with a 5-point Likert-type scale administered to intervention group patients only. Safety and efficiency outcomes were compared using 2-sample z tests for a difference in proportions and reported with 95% CIs. Patient satisfaction measures were compared using 2-sample t tests. P values were 2-sided and were not adjusted for multiple analyses. A threshold of P < .05 was used to classify an outcome as changed. Statistical analyses were performed in R version 4.0.4 (R Foundation).

Results

A total of 1095 patients undergoing cataract surgery were included in the intervention group and 3114 were in the control group. There were no differences in self-reported sex (female: 1813 of 3114 [58.2%] in the control group vs 621 of 1095 [56.7%] in the intervention group; difference, −1.5%; 95% CI, −4.9 to 1.9; P = .38) or age (mean [SD] age: 68.6 [11.0] years in the control group vs 68.4 [10.5] years in the intervention group; difference, 0.2; 95% CI, −0.6 to 0.9; P = .68). Among 1095 patients screened as part of the pilot, 126 (11.5%) were identified as being low risk using the risk assessment questionnaire. The remaining 969 individuals (88.5%) received usual care and underwent an in-person preoperative physical examination by the surgeon.

There were no differences between the control group and intervention group in terms of rates of intraoperative complications (21 [0.7%] vs 3 [0.3%]; difference, −0.4% [95% CI, −0.82 to 0.02]), 7-day noneye-related ED visits (5 [0.2%] vs 3 [0.3%]; difference, 0.1% [95% CI, −0.23 to 0.45]), or 7-day inpatient admissions (6 [0.2%] vs 2 [0.2%]; difference, −0.01% [95% CI, −0.31 to 0.29]) (Table). There were more individuals with eye-related ED visits in the intervention group (2 of 3114 [0.1%] vs 12 of 1095 [1.1%]; difference, 1.0% [95% CI, 0.41-1.66]). Medical record review was performed on all 12 patients to confirm that the ED visits were not for any nonophthalmologic medical reasons related to surgery. For efficiency outcomes, there were fewer case delays in the intervention group (59 [1.9%] vs 7 [0.6%]; difference, −1.3% [95% CI, −1.93 to −0.58]); however, rates of same-day changes or cancellations were not different (31 [0.8%] vs 10 [0.6%]; difference, −0.2% [95% CI, −0.63 to 0.34]).

Table. Safety and Efficiency Outcomes for the Control and Intervention Groups.

Outcome	No. (%)		Difference, % (95% CI)a	P value
	Control group (n = 3114)	Intervention group (n = 1095)
Safety outcome
Intraoperative complications	21 (0.7)	3 (0.3)	−0.4 (−0.82 to 0.02)	.13
7-d Noneye-related emergency department visits	5 (0.2)	3 (0.3)	0.1 (−0.23 to 0.45)	.46
7-d admissions	6 (0.2)	2 (0.2)	0.0 (−0.31 to 0.29)	.95
Efficiency outcome
Case delays	59 (1.9)	7 (0.6)	−1.3 (−1.93 to −0.58)	.004
Same-day cancellationsb	31 (0.8)	10 (0.6)	−0.2 (−0.63 to 0.34)	.57

^a Intervention group minus control group.

^b For cancellations, denominators (control group n = 3913; intervention group n = 1548) representing scheduled rather than completed surgeries were used.

A total of 144 intervention group patients (21 in the low-risk group and 123 in the usual care group) responded to the 5-point satisfaction survey. Perceptions of the preoperative process as helpful to patients (mean [SD] score for low risk vs usual care: 4.76 [0.44] vs 4.70 [0.59]; difference, 0.05; 95% CI, −0.22 to 0.31; P = .59), convenient for patients (mean [SD] score for low risk vs usual care: 4.81 [0.40] vs 4.63 [0.63]; difference, 0.18; 95% CI, −0.11 to 0.46; P = .10), and well organized (mean [SD] score for low risk vs usual care: 4.81 [0.51] vs 4.70 [0.57]; difference, 0.11; 95% CI, −0.15 to 0.37; P = .38), in addition to patient preparedness for surgery (mean [SD] score for low risk vs usual care: 4.62 [0.92] vs 4.71 [0.59]; difference, −0.10; 95% CI, −0.40 to 0.21; P = .67) were positive in both groups and showed no significant differences.

Discussion

Our findings suggest that a risk-based approach to cataract surgery preoperative medical evaluation is associated with safe and efficient outcomes. Specifically, we identified no increase in the rates of intraoperative complications, noneye-related ED visits, or inpatient readmissions after the intervention. These results are in line with several previous cataract surgery studies: Benoit et al⁷ found no increase in adverse medical events with the omission of a preoperative history and physical examination for low-risk patients screened with a preoperative questionnaire; Alboim et al⁸ and Jastrzebski et al⁹ found no increase in adverse perioperative or postoperative outcomes and concluded that a comprehensive preoperative evaluation was minimally beneficial and not cost effective. The findings of our study strengthen the evidence for a tailored approach to cataract surgery preoperative evaluation to eliminate low-value interventions without compromising patient safety.

Cataract surgery is the most common incisional ophthalmologic surgery in Medicare patients.^4,10 Schein et al^4,5 and others⁶ have suggested that eliminating universal preoperative evaluation for cataract surgery has the potential to reduce health care costs and improve operational efficiency. Jastrzebski et al⁹ highlighted the economic benefit of limiting preoperative physical examinations for the health care system broadly. In our intervention where the in-person preoperative medical history evaluation was replaced with a virtual visit for all patients and the surgeon preoperative physical examination was eliminated for low-risk patients, there were fewer case delays and no change in cancellations. Therefore, our findings suggest that a tailored approach to preoperative evaluation for cataract surgery could indeed improve operational efficiency.

Limitations

Our study has the following limitations. First, adverse outcomes associated with cataract surgery are rare, limiting the power of the study. Nevertheless, our data shed light on the minimal impact of in-person preoperative assessments on safety outcomes. Second, the lack of randomization in our pilot study limits the ability to precisely understand the effect of surgeon physical examinations. Third, the intervention took place at a single academic medical center, limiting the generalizability of our findings. Finally, our risk assessment questionnaire and our definition of low risk was highly conservative due to the pilot nature of our study (eTable in the Supplement). Therefore, future studies should investigate the effect of expanding this tailored approach of preoperative evaluation to patients with varying levels of medical complexity.

Conclusions

Our pilot study suggests that a risk-based approach to preoperative evaluation where cataract surgery patients received a virtual evaluation for medical risk assessment, and low-risk patients received no further surgical preoperative evaluation, is associated with safe and efficient outcomes. Future studies should aim to quantify the time and costs saved with a more efficient preoperative process, in addition to understanding the effect and allocation of these savings. Our findings support further efforts to streamline the preoperative process for low-risk surgeries such as cataract surgery to reduce health care cost, increase efficiency, and throughput, while continuing to offer safe, high-value care.

Supplement.

eTable. Risk Assessment Questionnaire