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Invited Commentary |

Preoperative Consultation Before Cataract Surgery:  Are We Choosing Wisely or Is This Simply Low-Value Care?

Lee A. Fleisher, MD1
[+] Author Affiliations
1Department of Anesthesiology and Critical Care, Leonard Davis Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Intern Med. 2014;174(3):389-390. doi:10.1001/jamainternmed.2013.12298.
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A major focus in fixing the health care crisis has been a shift from volume-based to value-based care.1 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 Foundation.2 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% of them undergo a procedure on an ambulatory basis, the elimination of extensive preoperative tests and consultations represents an area of potentially large health care savings. In this issue of JAMA Internal Medicine, Thilen and colleagues3 demonstrate not only that this is not occurring but that the incidence of preoperative consultations is actually increasing in the Medicare population for patients undergoing cataract surgery.

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Cataract pre-ops are driven by the ophthalmologists
Posted on December 24, 2013
David L. Keller, M.D.
none
Conflict of Interest: None Declared
The American College of Cardiology and the American Society of Anesthesiologists are in agreement that the routine pre-operative examination is not necessary for stable patients. That is good, but you will not see a decrease in the number of these exams until the ophthalmologists sign on to that agreement. Here is how it works in private practice: an elderly patient shows up in their internist's office one day, after skipping their routine follow-up appointments for way too long, perhaps to the point where their internist has been mailing them reminder letters and enlisting the patient's pharmacist to remind the patient to follow up soon. Finally, the patient shows up with a note from their ophthalmologist requesting certain specific blood tests, an EKG and "clearance" for the cataract procedure. If these instructions are not followed by the internist, the patient's cataract extraction will be postponed, and the internist may lose the patient to a more user-friendly PCP. To improve its impact, this article should be co-published in JAMA - Ophthalmology.
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