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N Engl J Med. 2015 Apr 16;372(16):1530-8. doi: 10.1056/NEJMsa1410846.

Preoperative medical testing in Medicare patients undergoing cataract surgery.

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  • 1From the Departments of Anesthesia and Perioperative Care (C.L.C., A.W.G., M.M., M.A.G.), Pediatrics (N.S.B.), and Medicine and Epidemiology and Biostatistics (W.J.B., R.A.D.), Center for Healthcare Value (C.L.C., G.A.L., N.S.B., R.A.D.), Division of General Internal Medicine (G.A.L.), and Philip R. Lee Institute for Health Policy Studies (G.A.L., R.A.D.), University of California, San Francisco, San Francisco; and Clay Software and Statistics, Ashland, OR (T.H.C.).



Routine preoperative testing is not recommended for patients undergoing cataract surgery, because testing neither decreases adverse events nor improves outcomes. We sought to assess adherence to this guideline, estimate expenditures from potentially unnecessary testing, and identify patient and health care system characteristics associated with potentially unnecessary testing.


Using an observational cohort of Medicare beneficiaries undergoing cataract surgery in 2011, we determined the prevalence and cost of preoperative testing in the month before surgery. We compared the prevalence of preoperative testing and office visits with the mean percentage of beneficiaries who underwent tests and had office visits during the preceding 11 months. Using multivariate hierarchical analyses, we examined the relationship between preoperative testing and characteristics of patients, health system characteristics, surgical setting, care team, and occurrence of a preoperative office visit.


Of 440,857 patients, 53% had at least one preoperative test in the month before surgery. Expenditures on testing during that month were $4.8 million higher and expenditures on office visits $12.4 million higher (42% and 78% higher, respectively) than the mean monthly expenditures during the preceding 11 months. Testing varied widely among ophthalmologists; 36% of ophthalmologists ordered preoperative tests for more than 75% of their patients. A patient's probability of undergoing testing was associated mainly with the ophthalmologist who managed the preoperative evaluation.


Preoperative testing before cataract surgery occurred frequently and was more strongly associated with provider practice patterns than with patient characteristics. (Funded by the Foundation for Anesthesia Education and Research and the Grove Foundation.).

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