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Difficulty: MediumHealthcare Economics and Value-Based Care

A 68-year-old woman is evaluated in the outpatient clinic prior to a scheduled left eye cataract extraction (phacoemulsification). The surgery is planned to take place under local anesthesia in 2 weeks. Her medical history is notable for mild primary hypertension and osteoarthritis of the knees. Current medications include lisinopril and as-needed acetaminophen. The patient leads an active lifestyle and reports briskly walking 2 to 3 miles every morning without experiencing chest pain, dyspnea, palpitations, or lightheadedness. Vital signs today are within normal limits. Physical examination reveals clear lungs bilaterally, a regular heart rate and rhythm with no murmurs, and no peripheral edema. In the context of providing high-value, cost-conscious care, which of the following is the most appropriate next step in management?

  1. Proceed with the scheduled surgery without additional preoperative testingAnswer
  2. B
    Obtain a baseline posterior-anterior and lateral chest radiograph
  3. C
    Obtain a resting 12-lead electrocardiogram
  4. D
    Order a comprehensive metabolic panel and complete blood count
  5. E
    Refer the patient for formal cardiology preoperative clearance

Answer

Proceed with the scheduled surgery without additional preoperative testing
The correct action is to proceed with the scheduled surgery without further diagnostic testing. Cataract extraction is a low-risk surgical procedure (estimated cardiac event risk less than 1%). According to high-value care guidelines (such as the Choosing Wisely campaign), routine preoperative testing—including blood work, electrocardiograms, or chest radiographs—is not indicated for asymptomatic patients undergoing low-risk procedures. This patient has excellent functional capacity (>4 metabolic equivalents) and no active cardiac or pulmonary symptoms. Ordering additional tests will not change perioperative management but will increase healthcare costs and potentially lead to false-positive results that require further invasive, high-risk workups.

Step-by-Step Solution

1
Assess the surgical risk of the planned procedure.
Cataract extraction under local anesthesia is considered a low-risk procedure, carrying a cardiac risk of less than 1%.
Surgical risk categorizations dictate the necessity and extent of further preoperative cardiovascular evaluation.
2
Evaluate the patient's functional capacity and current symptoms.
The patient walks 2 to 3 miles daily without cardiopulmonary symptoms, indicating excellent functional capacity (greater than 4 metabolic equivalents).
Patients with adequate functional capacity and an absence of unstable cardiac symptoms do not require additional cardiovascular testing before low-risk surgeries.
3
Apply high-value care guidelines regarding preoperative testing.
Routine preoperative testing, including laboratories, electrocardiograms, and imaging, is omitted.
In asymptomatic patients undergoing low-risk procedures, routine testing provides no clinical benefit, increases healthcare costs, and carries the risk of false-positive results leading to potentially harmful invasive workups.

Key Concept

Routine preoperative testing (such as laboratory tests, electrocardiograms, or chest radiographs) represents low-value care and is not indicated for asymptomatic patients with good functional capacity undergoing low-risk surgical procedures.
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Topics

Healthcare Economics and Value-Based Care

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