Perceived Barriers to the De-implementation of Routine Preoperative History & Physicals Preceding Low-Risk Ambulatory Procedures: A Qualitative Study of Surgeon Perspectives.

BACKGROUND: For patients undergoing surgery at an Ambulatory Surgical Center, recent changes to Centers for Medicare and Medicaid Services policy allow for the omission of a 30-day preoperative History and Physical (H&P). Preoperative H&Ps for low-risk surgery may contribute to health care waste and lead to unnecessary preoperative testing and treatment cascades. METHODS: In this qualitative study, we conducted 30 semi-structured interviews with surgeons who frequently perform low-risk surgeries. We aimed to evaluate surgeon perspectives on the continued use of the 30-day preoperative H&P and specifically the potential risks and benefits associated with the elimination of a preoperative H&P requirement from institutional practice. We used an interpretive description approach to generate a thematic description. RESULTS: Most participants felt that the 30-day preoperative H&P was low value and frequently described it as "unnecessary," "redundant," or "just checking a box." Many viewed the 30-day requirement as arbitrary and felt that new H&P findings were rare and unlikely to influence surgical care. The participants who favored the preoperative H&P felt it was a safeguard to ensure "nothing was missed" and were less likely to be burdened by the requirement than participants who felt it was low value. CONCLUSIONS: Surgeons performing low-risk procedures question the utility and value of conducting a preoperative H&P within 30 days of surgery. De-implementation of the 30-day preoperative H&P for low-risk patients may increase convenience for patients and providers. Furthermore, it may improve value in surgery by increasing access to services for patients with greater need for preoperative assessment.

Feasibility of a Risk-Based Approach to Cataract Surgery Preoperative Medical Evaluation.

IMPORTANCE: In 2019, the US Centers for Medicare & Medicaid Services implemented the Patients Over Paperwork initiative, allowing hospitals and ambulatory surgery centers to establish their own policies on preoperative history and physical requirements. A risk-based approach to preoperative medical evaluation may allow surgeons to provide high-value patient care. OBJECTIVE: To assess the feasibility of a risk-based approach to cataract surgery preoperative medical evaluation through a lens of safety and throughput. DESIGN, SETTING, AND PARTICIPANTS: A pilot study was performed to evaluate the implementation of a risk-based approach to preoperative medical evaluation for cataract surgery using a virtual medical history questionnaire. The intervention group, seen from June to September 2020, received the risk assessment and those who were low risk proceeded to surgery without further preoperative evaluation prior to the day of surgery. The preintervention control group included patients who received standard care from January to December 2019. MAIN OUTCOMES AND MEASURES: Primary outcomes included rates of intraoperative complications, noneye-related emergency department visits within 7 days, inpatient admissions within 7 days of surgery, case delays, and rates of case cancellation. The secondary outcome included patient perception regarding preoperative care. RESULTS: A total of 1095 patients undergoing cataract surgery were included in the intervention group (1813 [58.2%] female) and 3114 were in the control group (621/1095 [56.7%] female). The mean (SD) age was 68.6 (11.0) in the control group and 68.4 (10.5) in the intervention group. The intervention group included 126 low-risk individuals (11.5%) and 969 individuals who received standard care (88.5%). There were no differences between the control and intervention groups in terms of rates of intraoperative complications (control group vs intervention group: 21 [0.7%] vs 3 [0.3%]; difference, -0.4% [95% CI, -0.82 to 0.02]), 7-day noneye-related ED visits (5 [0.2%] vs 3 [0.3%]; difference, 0.1% [95% CI, -0.23 to 0.45]), 7-day inpatient admissions (6 [0.2%] vs 2 [0.2%]; difference, -0.01% [95% CI, -0.31 to 0.29]), or same-day cancellations (31 [0.8%] vs 10 [0.6%]; difference, -0.15% [95% CI, -0.63 to 0.34]). The control group had more case delays (59 [1.9%] vs 7 [0.6%]; difference, -1.3% [95% CI, -1.93 to -0.58]). CONCLUSIONS AND RELEVANCE: This study suggests that a virtual, risk-based approach to preoperative medical evaluations for cataract surgery is associated with safe and efficient outcomes. These findings may encourage health care systems and ambulatory surgery centers to tailor preoperative requirements for low-risk surgery patients.