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

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

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Shahzad I. Mian, MD, Kellogg Eye Center, University of Michigan, 1000 Wall St, Ann Arbor, MI 48105 (smian@med.umich.edu).

Accepted for Publication: September 12, 2021.

Published Online: October 28, 2021. doi:10.1001/jamaophthalmol.2021.4393

Author Contributions: Mr Cuttitta and Dr Henderson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cuttitta, Joseph, Henderson, Klarr, Shtein, Lee, Kerr, Mian.

Acquisition, analysis, or interpretation of data: Joseph, Henderson, Portney, Keedy, Benedict, Lahti, Shtein, Lee.

Drafting of the manuscript: Cuttitta, Joseph, Portney, Keedy, Mian.

Critical revision of the manuscript for important intellectual content: Joseph, Henderson, Portney, Benedict, Lahti, Klarr, Shtein, Lee, Kerr, Mian.

Statistical analysis: Joseph, Henderson, Portney.

Obtained funding: Kerr.

Administrative, technical, or material support: Cuttitta, Joseph, Portney, Lahti, Klarr, Lee, Kerr, Mian.

Supervision: Joseph, Mian.

Conflict of Interest Disclosures: Dr Portney reported equity in The Lens Newsletter, an ophthalmology research newsletter. No other disclosures were reported.

Meeting Presentations: Data from this article were presented at the American Academy of Ophthalmology 2021 Annual Meeting; November 12-15, 2021; New Orleans, LA, and the American Hospital Association High Value Health Care National Conference 2021; October 7-9, 2021; virtual meeting.

References
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