Preoperative Medical Testing and Falls in Medicare Beneficiaries Awaiting Cataract Surgery

Abstract

Purpose: Delaying cataract surgery is associated with an increased risk of falls, but whether routine preoperative testing delays cataract surgery long enough to cause clinical harm is unknown. We sought to determine whether the use of routine preoperative testing leads to harm in the form of delayed surgery and falls in Medicare beneficiaries awaiting cataract surgery.

Design: Retrospective, observational cohort study using 2006-2014 Medicare claims.

Participants: Medicare beneficiaries 66+ years of age with a Current Procedural Terminology claim for ocular biometry.

Methods: We measured the mean and median number of days between biometry and cataract surgery, calculated the proportion of patients waiting ≥ 30 days or ≥ 90 days for surgery, and determined the odds of sustaining a fall within 90 days of biometry among patients of high-testing physicians (testing performed in ≥ 75% of their patients) compared with patients of low-testing physicians. We also estimated the number of days of delay attributable to high-testing physicians.

Main outcome measures: Incidence of falls occurring between biometry and surgery, odds of falling within 90 days of biometry, and estimated delay associated with physician testing behavior.

Results: Of 248 345 beneficiaries, 16.4% were patients of high-testing physicians. More patients of high-testing physicians waited ≥ 30 days and ≥ 90 days to undergo surgery (31.4% and 8.2% vs. 25.0% and 5.5%, respectively; P < 0.0001 for both). Falls before surgery in patients of high-testing physicians increased by 43% within the 90 days after ocular biometry (1.0% vs. 0.7%; P < 0.0001). The adjusted odds ratio of falling within 90 days of biometry in patients of high-testing physicians versus low-testing physicians was 1.10 (95% confidence interval [CI], 1.03-1.19; P = 0.008). After adjusting for surgical wait time, the odds ratio decreased to 1.07 (95% CI, 1.00-1.15; P = 0.06). The delay associated with having a high-testing physician was approximately 8 days (estimate, 7.97 days; 95% CI, 6.40-9.55 days; P < 0.0001). Other factors associated with delayed surgery included patient race (non-White), Northeast region, ophthalmologist ≤ 40 years of age, and low surgical volume.

Conclusions: Overuse of routine preoperative medical testing by high-testing physicians is associated with delayed surgery and increased falls in cataract patients awaiting surgery.

Keywords: Cataract; Cataract surgery; Delayed surgery; Fall; Fall-related injury; Medicare beneficiaries; Ocular biometry; Physician preoperative testing behavior; Routine preoperative medical testing; Surgical timing.

Figure 1:

Percent of patients waiting for surgery, stratified by physician testing behavior

Figure 2a.. Falls and fall-related injuries within 90 days of biometry, stratified by physician testing behavior^1,2

1) Falls in Figure 2a occurred before or after surgery, within 90 days of biometry. 2) n=40,829 and 207,516 for patients of high-testing physicians and low-testing physicians, respectively.

Figure 2b.. Falls and fall-related injuries within 90 days of biometry that occurred prior to cataract surgery, stratified by physician testing behavior^1,2

1) All Falls in Figure 2b occurred before surgery, within 90 days of biometry. 2) n=40,829 and 207,516 for patients of high-testing physicians and low-testing physicians, respectively.