Cost-Effective Eye Care: Avoid These 5 Tests and Treatments

Linda Roach

February 27, 2013

Whether the ophthalmic problem is pinkeye or cataract, physicians and patients should begin discussing which tests and treatments are most appropriate and which are not, according to new practice recommendations from the American Academy of Ophthalmology (AAO).

The AAO issued a list of 5 recommended practice changes on February 21 as part of the Choosing Wisely initiative of the American Board of Internal Medicine Foundation. The campaign aims to reduce waste in the American healthcare system by encouraging physicians to reconsider their medical routines and patients to adjust their expectations according to validated effectiveness research.

The recommendations, "Five Things Physicians and Patients Should Question," are based on well-established knowledge about how best to care for patients with eye problems, William L. Rich III, MD, the AAO's medical director of health policy, told Medscape Medical News.

Dr. Rich explained that the list addresses unnecessary tests and treatments that "are commonly done but without a lot of evidence base" in 5 areas:

  1. "Preoperative Medical Tests: Don't perform preoperative medical tests — such as an electrocardiogram or blood glucose test — prior to eye surgery unless there are specific signs indicating a need for them.

  2. Imaging Tests: Don't routinely order imaging tests when there are no symptoms or signs of significant eye disease.

  3. Antibiotics for Pink Eye: Don't prescribe antibiotics for pink eye that is caused by an adenovirus.

  4. Antibiotics for Eye Injections: Don't routinely provide antibiotics before or after injections into the vitreous cavity of the eye.

  5. Punctal Plugs for Dry Eye: Don't treat dry eye by inserting punctal plugs before attempting other options, such as medical treatments with artificial tears, lubricants and compresses."

The first recommendation, foregoing preoperative tests for most patients with cataract, was an important piece of "low-hanging fruit" to include on the Choosing Wisely list, Dr. Rich said. The National Eye Institute estimated a decade ago that the federal price tag for this common ophthalmic procedure in the elderly was $3.4 billion a year and rising.

Oregon retinal specialist David A. Wilson, MD, agreed with Dr. Rich's assessment. "In the past, there were just standard preoperative orders that everybody got an [electrocardiogram] and a chest X-ray. Changing that type of practice began many years ago, but there are still some vestiges of it," Dr. Wilson told Medscape Medical News. Dr. Wilson is a professor and Theile-Petti chair of ophthalmology at Oregon Health & Science University in Portland and director of the university's Casey Eye Institute.

About the third recommendation, regarding prescribing antibiotics for pinkeye, Dr. Rich said: "We get an awful lot of these [infectious conjunctivitis] cases, and most don't need antibiotics. So if a practitioner treats them with a $180 bottle of a fourth-generation fluoroquinolone, well, the payers are going to be able to measure that, and they will measure that."

Dr. Wilson praised the AAO's decision to join the Choosing Wisely effort. "These 5 measures were chosen as the ones that with careful research were felt to be very ironclad, and things that very few people would disagree with. I think they are going to be very popular with both physicians and patients," he said.

"The real take-home message is that patients, physicians, and everybody involved in healthcare needs to be taking a close look at where there are real savings that can be made," Dr. Wilson added. "This is a really good start to recognize the things that everybody agrees upon. It also will get everybody thinking about what other areas there are where we could find additional cost savings."

Dr. Rich also noted that there are pragmatic benefits for ophthalmologists who reduce their use of unnecessary tests.

"As a profession, all of medicine is now going to be judged and paid on the basis of...our quality and our efficiency. So if we're doing things that don't increase quality and that decrease efficiency, if you take a very pragmatic view, these measures also will be very beneficial for the individual practitioner to do," Dr. Rich concluded.

Dr. Rich receives a stipend from the AAO for serving as its medical director of health policy. Dr. Wilson has disclosed no relevant financial relationships.

"Five Things Physicians and Patients Should Question." American Academy of Ophthalmology. Published online February 21, 2013. Full text