title: Preoperative consultations for medicare patients undergoing cataract surgery.
abstract: OBJECTIVE
  Low-risk elective surgical procedures are common, but there are no clear guidelines for when preoperative consultations are required. Such consultations may therefore represent a substantial discretionary service.
  
  
  OBJECTIVE
  To assess temporal trends, explanatory factors, and geographic variation for preoperative consultation in Medicare beneficiaries undergoing cataract surgery, a common low-risk elective procedure.
  
  
  METHODS
  Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556,637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89,817 individuals who underwent surgery from 2005 to 2006.
  
  
  METHODS
  Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery.
  
  
  RESULTS
  The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75-84 years vs 66-74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04-1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65-0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49-1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05-1.15]), anesthesia provider (anesthesiologist vs non-medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10-1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI, 2.33-4.10]). The burden of comorbidity was associated with consultation, but the effect size was small (<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0-69%]), even after accounting for differences in patient-level, anesthesia provider-level, and facility-level characteristics.
  
  
  CONCLUSIONS
  Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Washington, Seattle.
authors.forename: Stephan R
authors.initials: SR
authors.lastname: Thilen
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Washington, Seattle2Department of Epidemiology, University of Washington, Seattle.
authors.forename: Miriam M
authors.initials: MM
authors.lastname: Treggiari
authors.affiliation: Department of Biostatistics, University of Washington, Seattle.
authors.forename: Jane M
authors.initials: JM
authors.lastname: Lange
authors.affiliation: Veterans Affairs Puget Sound Health Care System, Seattle, Washington5Department of Health Services, University of Washington, Seattle.
authors.forename: Elliott
authors.initials: E
authors.lastname: Lowy
authors.affiliation: Veterans Affairs Puget Sound Health Care System, Seattle, Washington6Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle.
authors.forename: Edward M
authors.initials: EM
authors.lastname: Weaver
authors.affiliation: Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada8Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada9Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada10.
authors.forename: Duminda N
authors.initials: DN
authors.lastname: Wijeysundera
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002387:Cataract Extraction; D005260:Female; D006801:Humans; D008297:Male; D006278:Medicare; D011300:Preoperative Care; D012017:Referral and Consultation; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States