Defunding the pre-operative history and physical exam: Putting the cart before the evidence?

Abstract Body:

Purpose: Several health authorities within Canada have recently decided to defund the routine pre-operative history and physical exam traditionally performed prior to cataract surgery. While these authorities suggest that their decisions are evidence based, the authors are not aware of any comprehensive review of the literature addressing this topic, nor have the relevant health authorities been forthcoming with the evidence used in their decision processes. Accordingly, the objective of the instant study is to fill this evidentiary deficiency and perform a comprehensive review of the literature as it pertains to the value of the pre-operative history and physical examination in the context of cataract surgery.

Study Design: Systematic review.

Methods: The following databases were searched with search strings prepared in consultation with a staff librarian at the local university health sciences library: PubMed, MEDLINE, Cochrane Library, Google Scholar, Web of Science, EMBASE, CINAHL, BIOSIS Previews. Only higher-level forms of evidence were assessed, including randomized controlled trials, cohort, and case-control studies. Two reviewers independently assessed title and abstracts per inclusion criteria. Disagreements between the authors were resolved by discussion.

Results: We identified three articles that met our inclusion criteria: two prospective cohort studies and one retrospective cohort study. These articles suggest that traditional pre-operative histories and physical examinations could be replaced by a health questionnaire (Jastrzebski et al. and Reeves et al.) or eliminated altogether (Alboim et al.). However, various methodological weaknesses, and the very data derived from these studies, appear to undercut these conclusions. Examples of these weaknesses include: (1) the insensitivity of questionnaires for medical conditions predisposing patients to perioperative morbidity and mortality; (2) cohort populations that were strongly biased for “un-assessed” patients to be relatively healthier than “assessed” patients; and (3) lower quality methodologies such as cohort studies rather than randomized controlled trials.

Conclusions: The scientific literature presently contains three studies suggesting that the pre-operative history and physical exam could be modified, restricted, or eliminated altogether. However, the evidence supporting these suggestions remains tenuous due to methodological weaknesses and poor supporting data. While finding efficiencies in providing medical care is an admirable goal, physicians should be cautious in accepting recommendations that reduce the checks and balances that ensure  perioperative safety. Further studies of better methodological quality should be completed to clarify the present evidence regarding pre-operative assessments prior to cataract surgery.