The Value of History and Physical Examination to Optimize Outcomes of Cataract Surgery: A Systematic Review

Author: Jackson CL, Rivers RJ, Conti ME, Freedman LS, Song M, Lehmann JD, Pandian V.

Geographical coverage: Not reported

Sector: Cataract surgery

Sub-sector: operative history and physical examination

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background

Cataract surgery is the most frequently performed operation in the United States and is largely funded by Medicare. In 2020, a federal policy change removed the requirement for a pre-operative history and physical (H&P) examination before ambulatory procedures, casting doubt on the examination’s contemporary relevance. Traditionally, the H&P has been used to assess peri-operative risk, particularly in older adults with multiple co-morbidities. Cataract surgery, however, is regarded as low risk, and annual expenditure on pre-operative H&Ps in the US is estimated at USD 450 million. Momentum towards high-value care encourages elimination of unnecessary interventions while safeguarding patient safety; therefore, clinicians must now balance cost, safety and patient experience when deciding whether an H&P is warranted.

Objective

To evaluate the value of pre-operative H&P examination and related pre-operative care in cataract surgery by assessing adverse events, patient experience and cost outcomes.

Main findings

Authors included a total of 12 non-randomised studies encompassing 28,489 participants. All studies exhibited moderate to serious risk of bias, and certainty of evidence was low.

• Adverse events: Stratifying patients into high-risk (with H&P) and low-risk (without H&P) cohorts increased minor adverse events in the low-risk group but did not increase major or surgical adverse events. Major events such as hospitalisation were rare (0–1.4 %). Minor events (notably hypertension-related) were marginally higher without an H&P (34.2 % versus 29.5 %). Surgery delays and hospital admissions remained uncommon in both groups.
• Cost: Three Canadian studies reported modest short-term savings when the H&P was omitted in low-risk populations (USD 56–81 per patient). The cost to avert a single adverse event was high (up to USD 27 508 for a major event).
• Patient experience: Two studies detected no significant differences in satisfaction or anxiety between patients who had an H&P and those who did not; both care pathways were considered convenient and well organised.

Overall, omitting the H&P in low-risk patients did not elevate major risk or diminish patient satisfaction, but it may modestly raise minor adverse events and forgo opportunities to optimise unrecognised or poorly controlled conditions in older individuals.

Methodology

Systematic searches of MEDLINE (via PubMed), Embase, Web of Science and CINAHL (2012–2022) identified observational, randomised and quality-improvement studies reporting at least one of the specified outcomes. Three reviewers independently screened records, extracted data and appraised quality (ROBINS-I for risk of bias; GRADE for certainty). Disagreements were resolved by discussion. Findings were synthesised narratively.

Applicability / external validity

All included studies were conducted outside the US, predominantly at single centres. Variations in anaesthetic practices, patient demographics and healthcare systems limit transferability to US settings. Evidence was skewed towards healthier, lower-risk patients; the complexity of peri-operative management in frail older adults may therefore be under-represented.

Geographic focus

No geographic restrictions were applied; studies were performed across several countries.

Summary of quality assessment

Confidence in the review’s conclusions is medium. Searches were comprehensive, eligibility criteria explicit, and data collection processes robust. Study characteristics were thoroughly reported and narrative synthesis was appropriate. Limitations include absence of an excluded-study list, no stratification of findings by risk-of-bias status, and no reference-list or expert querying to identify additional studies.