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Outcomes/Effectiveness Research

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Studies focus on anesthesia management in cataract surgery

More than 1 million cataract surgeries are performed in the United States each year at a cost of about $3.4 billion to the Medicare program. Most of these operations are done on an outpatient basis using a variety of local anesthesia techniques, which seem to be determined mostly by surgeon preference and practice setting.

Use of additional intravenous anesthetic agents to decrease pain and alleviate anxiety is associated with increased complications, but cataract surgery nevertheless remains a safe, low-risk procedure, concludes a study supported in part by the Agency for Healthcare Research and Quality (HS08331). A second AHRQ-supported study (contract 290-97-0006) finds that cost and preferences are important considerations when choosing an anesthesia management strategy. For some surgeries, substantial cost savings may be had for a small change in preference. Both studies are described here.

Katz, J., Feldman, M.A., Bass, E.B., and others. (2001, October). "Adverse intraoperative medical events and their association with anesthesia management strategies in cataract surgery." Ophthalmology 108, pp. 1721-1726.

These investigators compared medical complications due to different anesthesia strategies for cataract surgery among patients mostly in their 70s, who underwent 19,250 cataract surgeries at nine centers in the United States and Canada between 1995 and 1997. They looked at local anesthesia applied topically or by injection, with or without oral and intravenous sedatives, opioid analgesia, hypnotics, and diphenhydramine (Benadryl). Twenty-six percent of surgeries were performed with topical anesthesia and the remainder with injection anesthesia. Results revealed no increase in deaths or hospitalizations associated with any specific anesthesia strategy. Although the findings suggested that the current common practice of administering multiple intravenous agents for cataract surgery may not be optimal, the surgery nevertheless remains a low-risk, safe procedure.

Overall, there was no significant difference observed in the prevalence of intraoperative problems between topical and injection anesthesia without intravenous sedatives (0.13 vs. 0.78 percent). The use of intravenous sedatives was associated with a significant increase in adverse events for topical (1.20 percent) and injection anesthesia (1.18 percent) relative to topical anesthesia without intravenous sedation. The use of short-acting hypnotic agents with injection anesthesia also was associated with a significant increase in adverse events when used alone (1.40 percent) or in combination with opiates (1.75 percent), sedatives (2.65 percent), and a combination of opiates and sedatives (4.04 percent), even after adjustment for age, sex, duration of surgery, and anesthesiology risk class.

Nevertheless, the total percent of medical problems was 1.95 percent and 1.23 percent intraoperatively and postoperatively, respectively, and there were no deaths on the day of surgery and very few hospitalizations. Most of the problems were associated with arrhythmias (particularly bradycardia), hypertension, hypotension, and angina. The researchers conclude that the choice of anesthesia strategy is complex and should include a careful weighing of patient preferences and clinician assessment of the medical risks associated with different strategies to achieve optimal results.

Reeves, S.W., Friedman, D.S., Fleisher, L.A., and others. (2001). "A decision analysis of anesthesia management for cataract surgery." American Journal of Ophthalmology 132(4), pp. 528-536.

Cost and preferences are important considerations when choosing an anesthesia management strategy for cataract surgery. The investigators compared the trade-offs in cost and preference for six strategies differing in sedation, local anesthetic, and monitoring approach.

A panel of physicians and anesthetists assigned preference values to the strategies and potential outcomes on a 0 to 1 scale. Outcome probability estimates were obtained from a study of 19,557 cataract surgeries and from the panel, and cost estimates were derived from several sources. Anesthesiologists were calculated to cost $1,000 per 10-hour day (about 10 cases per day at $100 a case).

The researchers found that strategy 1 (intravenous sedation with block anesthesia with an anesthesiologist present throughout the surgery) had the highest expected net preference value. It was 19 percent greater (0.875 vs. 0.738) than the net preference for the next most preferred strategy 2 (oral sedation with block anesthesia and an anesthesiologist on call), but the expected anesthesia costs per case were much greater for strategy 1 ($324) than for strategy 2 ($42).

Strategy 2 was superior to strategies 3 (oral sedation plus block anesthesia and no anesthesiologist available), 5 (oral sedation plus topical anesthesia plus anesthesiologist on call) and 6, which had the lowest net preference value (oral sedation plus topical anesthesia with no anesthesiologist available). A substantially higher expected net preference value was obtained for strategy 2 for about the same expected cost per case. Strategy 2 was dominant over strategy 4 (intravenous sedation plus topical anesthesia and an anesthesiologist present) because it had a higher expected preference value (0.738 vs. 0.644) at a significantly lower expected net cost ($41.47 vs. $324.72).

In this study, the researchers evaluated both traditional approaches to care, as well as models not commonly employed in the United States at this time (i.e., no anesthesiologist involved). They conclude that substantial cost savings may be available in the management of anesthesia in some cataract surgeries for a small change in preference.

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