By Susan Wolf, PA-C

Over the years, there has been much discussion and debate regarding the need for preoperative testing for patients undergoing ophthalmic surgery. The rationales for performing preoperative testing have been varied. Arguments have been made that these tests help predict patient risk for postoperative complications, help screen for unknown abnormalities, establish baseline values and provide the ordering practitioner, medico-legal protection. Numerous studies now involving well over one million patients have been performed. The results of these studies have overwhelmingly reached the same conclusion: the surgical and medical outcome of patients are statistically negligible, regardless of whether or not patients receive preoperative labs, ECGs, or in many cases, even echocardiograms or stress tests. 

The shift now is to focus on Clinical Practice Guidelines (CPGs) to identify high-risk patients, use Risk Assessment Tools to asses the patient's current health status and comorbidities, optimize these high-risk patients and to choose wisely when ordering tests. To achieve this, Perioperative Optimization has become an emerging specialty. 

Centers for Perioperative Optimization (CPOs) staffed by anesthesiologists, PAs and NPs familiar with CPGs and familiar with Risk Assessment Tools have been proven to decrease cost of testing, decrease cancellations/delays and decrease adverse perioperative events. Factors considered, in addition to the patient's health, are: type of surgery, type of anesthesia; patient comorbidities such as CHF and PAH; and, OR setting (freestanding clinic versus tertiary center). Based on a patient's Risk Assessment score, the COP practitioners can decide if a patient needs further evaluation by a specialist or any further testing such as echo, stress test, PFTs, etc. 

Commonly used Risk Assessment Tools: 

• American Society of Anesthesiologist ASA Physical Status Classification: assesses patient physical status based on their health and co-morbidities 
• The Revised Cardiac Risk Index (RCRI): uses six independent predictors and assigns a complications' risk percentage
• Pulmonary Arterial Hypertension (PAH) Classification: assesses patient risk based on degree and cause of pulmonary hypertension 
• Functional Capacity Assessment Tools: uses METS; metaboloic equivalent; a measure of exercisse intensity based on oxygen consumption or energy expended
• New York Heart Association (NYHA) Classes: assesses patient's functional capacity and assigns a risk classification
• CHAD2DS2 Vascular Score: uses eight risk factors to assess patient risk for stroke

One last thought -- it is predicted in 2020 that 3.3 million Medicare patients will undergo cataract surgery and 4.4 million patients in 2030. Using today's average cost of $175.00 for preoperative evaluation (H&P/CBC/BMP, ECG) by 2030, testing will cost approximately $770,000,000. And this is only for one type of ophthalmic surgery!). Using clinical practice guidelines and Risk Assessment Tools, it is estimated that only one out of five patients undergoing ophthalmic surgery benefit from preoperative testing. This would save over $616,000,000 in unnecessary testing in addition to saving patients from increased pain, inconvenience and anxiety.