Study: Cataract-surgery consultations on rise, but often not needed By CAROL M.OSTROM THE SEATTLE TIMES Extra preoperative consultations for Medicare patients about to have cat- aract surgery have increased rapidly, a University of Washington researcher has found, but the referrals, which incur additional charges, are often for healthy patients who don't need the evaluations. Dr. Stephan Thilen, a University of Washington assistant professor in the Department of Anesthesiology & Pain Medicine, focused on extra preoper- ative consultations for patients about to undergo cataract surgery, the most common elective surgical procedure for patients covered by Medicare. About 2 million Medicare benefi- ciaries each year undergo cataract surgery, a low-risk procedure for blurred vision caused by the lens of the eye becoming cloudy. A routine preoperative and preanesthesia evaluation by doctor and anesthesia provider is included in the set fees Medicare pays. Many patients also get another consultation a formal preoperative one with a third doctor, which is billed separately, Thilen found after analyzing a random sample of claims from 556,637 patients from 1995 to 2006. In some regions, as many as 69 percent of Medicare cataract-surgery patients get an extra consultation. Referrals for these consultations, Thilen and his colleagues wrote in the study published recently in JAMA Internal Medicine, "seems driven primarily by nonmedical factors including practice setting, type of anesthesia provider, and geographical region." Ideally, such consultations would only be done for high-risk patients who need extra assessment. But that's not what has been happening, Thilen said. If a patient who is generally healthy needs such a consultation for a "uniquely low-risk" procedure, he asked, should all patients coming for surgery get them as well? "We don't believe that all patients need to have a preoperative consulta- tion," Thilen said in an interview. "We have over 1,000 guidelines in med- icine today, for all sorts of things.... But we don't have a guideline for who needs a preoperative consultation." Extra consultations were relatively low in the South and West, but the rate was three times higher for patients living in the Northeast. When he analyzed the data by "hospital referral region," which designate regional health-care mar- kets for specialized consultative care ItAll) and include a major referral center, he found a huge variation. In several regions, no patients were sent for extra consultations, while in others, 69 percent were. "When you talk about a discre- tionary service like this, without a clear indication or guideline, there is a practice culture that developed - a culture that has taken hold in a certain geographical region," Thilen said. Although he looked to see if pa- tients had any high-risk diagnoses that might arguably qualify them for an extra consultation, he said the scope of this study didn't show whether doctors or patients initiated the request for a consultation. "I believe it is very unlikely that patients are driving this process," he said, but he and his colleagues hope to delve into that question in future research. Some doctors argue that higher rates of consultations reflect increasingly better levels of care. Dr. Daniel Albert, a founding director of the University of Wisconsin McPherson Eye Research Institute, told Reuters Health that the idea of doing "a more stringent examination" within 30 days of surgery became widespread over the period studied by Thilen. Albert, a professor in the de- partment of Ophthalmology and Visual Sciences at the University of Wisconsin who was not involved in Need help? Dial 211 to connect to more than 880 health and human service providers, representing local services available throughout Charlotte County. I, /Iod ... r 4k. 'o wlileI Evenv TIuIsda W We ^^>^1SUNA & 061 IWlIMIt0M414I the study, suggested that the data could be outdated, since the proce- dure has changed significantly since the beginning of the study period. "It's much safer, and the complication rate is far lower than it was in 1995," he told Reuters. In the last year of the study peri- od, 2006, more than 18 percent of Medicare cataract-surgery patients were referred to such consultations - up from 11 percent in 1995. At about $180 per consultation that adds up to a figure approaching $65 million -just for cataract surgeries, which are typically done in less than half an hour. Overall, a total of about 50 million surgical procedures are done in the U.S. annually, Thilen said. "The ques- tion is: How should these patients be managed properly, rationally, cost-ef- fectively?" he said. "We have limited resources and we need to devote them where they make a difference and we don't waste resources." Eliminating unnecessary or waste- ful tests and procedures is a focus of a recent campaign by the American Board of Internal Medicine called "Choosing Wisely," noted Dr. Lee Fleisher in a commentary accompa- nying the study. FILE P-i-.T-.. Such efforts to rein in "low-value or no-value care" could potentially save substantial amounts of mone\. said Fleisher, a professor and chaih of anesthesiology and critical care at the Leonard Davis Institute, Perelminaii School of Medicine at the Universiry of Pennsylvania in Philadelphia. Fleisher urged doctors to begin "choosing wisely" on consultation-, and tests "before external forces d-- it for us." He noted that there has been a sluift away from paying for each service separately the "fee for service" system. Insurers and government payers, such as Medicare, are among those most keenly interested in thi-, change. Thilen said that in his practice he sees patients who should have had a preoperative consultation but didift, and vice-versa. His research group. he said, wants to improve operatih e care across the board, and is in the first stages of what he hopes will be a long-running research project. "This is uncoordinated care, which we're famous for in the United State-., Thilen said. His effort, he added,' i-.ift all about finding waste and cutting that out it's about establishing rational models of care." Frantz Bladeless LASER Cataract Surgery Another FIRST in Cataract Surgery Technology Dr. Jonathan Frantz now offers the area's first LASER-guided technology with VerifEye to further customize your surgery and enhance your vision. Trust your eyes to our area's most experienced laser cataract surgeon. FRANTZ Cataract Center *Ifoe GO.- "" j-10 I :Page 16 The Sun /.urnclay .lariialy !':I, 4 www.sunnewspapers.net feelingfit.com P IP-] Toscheduleyorappo-i ntment : Call 505-2020 ^^^^1 or v