The Hill’s need for ‘medical reasoning’

I’ve never understood the value of getting pre-op lab work for cataract surgery patients, even when I started practicing in the late 1980s. If the urine contained blood cells — a false positive — that meant repeating labs and delaying surgery. That happened a lot. If results were abnormal, there were more delays: find the patient, discuss the results. As time passed and labs proved to be of little or no value, I cut back on them. When a landmark 2000 study¹ confirmed the obvious — routine pre-ops labs for cataract surgery were unnecessary — I quit testing for good.

So when I read the JAMA paper² showing many patients still get routine lab work before cataract surgery, I was dumbstruck, realizing who was at fault for this. Doesn’t the government read?

A little walk-back in time. In the days of general anesthesia, patients experienced significantly higher morbidity, especially because they were bed-bound in the hospital, sandbags on either side of their head. DVTs anybody? We took full histories and physicals on all cataract surgery patients, and it became standard of care to order a full component of blood work and chest X-rays.

Today, most patients have surgery in ASCs, frequently receive only oral sedation and go home in less than two hours. From a patient’s perspective, it’s arguably less traumatic than dental cleaning. However, the government now requires an H&P, nebulously defined, on every patient — even YAG laser capsulotomies!

Nebulous meaning, a general test, one not specific to ocular concerns. Consulted primary-care docs are ordering many or most of these unnecessary tests — costing at an estimated $.5 billion a year. And if 30 or more days pass between eyes, you’ll run labs all over again. As an accompanying JAMA editorial³ states, “Such requirements reflect only bureaucratic logic, not medical reasoning.”

At our center a nurse practitioner or physician’s assistant does a basic H&P before surgery admission. No labs are ordered, no patients are charged exorbitant fees. Maybe one day smarter minds will allow treating physicians, not regulators, to make this decision. I welcome your thoughts and comments. OM

REFERENCES

1. Schein OD, Katz J, Bass EB et al. The Value of Routine Preoperative Medical Testing before Cataract Surgery. NEJM. 2000:342(3):168-175.
2. Chen CL, Clay TJ, McLeod S, et al. A revised estimate of costs associated with routine preoperative testing in Medicare cataract patients with a procedure-specific indicator. JAMA. 2018: Jan. 18; https://tinyurl.com/yd8y7ggq
3. Merali FI, Schein OD. Preoperative evaluations for cataract surgery are routine but anachronistic. JAMA. 2018: Jan. 18. https://tinyurl.com/y8y9c3sq