Bypassing preoperative evaluation for cataract extraction is impractical for many centres: Our response to IE Gabbay et al.

Dear Editor,

We applaud IE Gabbay et al. for their recent study ¹ whose logic could reduce costs across many healthcare systems. Nonetheless, we wish to question the degree to which their approach should be generalised and adopted. We are concerned that it might raise rates of cancellation of the patients while adding to the logistical challenges that many face, especially those who need to travel longer distances and coordinate convalescent care with the families, and it will increase substantial amount of dissatisfaction among the patients and may invite legal lawsuits as well.

The study recommendations appear optimally suited to tertiary centres with established protocols, often with the patient attending on the day of operation carrying a good-quality referral letter. Patients without such a document, or with one of poor quality, were referred to the preoperative clinic for evaluation. Thus, patients who were not well evaluated for their surgery were referred back for preoperative evaluation in the same study centre, even if healthy or lacking significant comorbidity as judged by the secondary-level hospitals. While preoperative evaluation by those referral centres may not have been conducted according to ideal standards, this may reflect the lack of a protocolized guideline, or failure by the tertiary study centre to circulate one. By developing such an approach, and circulating it to relevant referring hospitals a more streamlined, efficient patient management strategy may be created. We feel this is important because even small numbers of cancellations with regressive steps along the patient pathway – such as cancelling surgery, and going back to preoperative assessment – can generate major inconvenience to families and relatives who have planned their lives around a defined timeline. The social cost of cancellations may outweigh some of the financial savings that the approach realised.

Second, the authors have counted hypertension, bradycardia and atrial fibrillation as unavoidable causes of cancellation on the day. These comorbidities are commonly chronic, and as such amenable to identification and optimisation in good referral centres. Thus, rescheduling of surgery can be largely avoided. ² There is also evidence to support the idea of telephone-based preoperative assessment in reducing cancellations on the day of surgery. ³ Indeed, quite simple forms of preoperative assessment have been shown to reduce morbidity and mortality. ⁴ Ultimately then, we should acknowledge the high value of very basic forms of preoperative assessment. Thirteen of the 45 postponement events cited were due to health-related issues, perhaps illustrating the need for preoperative assessment and optimisation.

The present study shows that many who present for cataract surgery do not require a comprehensive preoperative evaluation at the tertiary hospital level, if the physician in the referring hospital has evaluated and declared them fit by the standards of the operative centre. However, some form of a preoperative screening, even if telephonic, will be of value not only to reduce the workload of the tertiary hospital, but also to minimise unnecessary cancellation with associated suffering and inconvenience. One can indeed reduce healthcare costs by curtailing these services, but the trade-off in terms of patient suffering, delays in accessing care and family inconvenience is not easy measured in any comparable way. The amount of harassments and dissatisfaction resulting from that may lead to legal lawsuit as well which should also be kept in mind.