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Sponsored: Delivering a cost-effective ophthalmology service


18 December, 2020  

Support for the development of this article has been provided by Alcon

In recent years, there has been a shift towards what has been termed “value-based” medicine, which has been defined as the “practice of medicine incorporating the highest level of evidence-based data with the patient-perceived value conferred by healthcare interventions for the resources expended”.1 Value-based healthcare focuses on both patient outcomes and the cost of delivering those outcomes and is highly desirable given the evidence that in many developed healthcare markets, there is a significant variation in patient outcomes, even for the same procedures. For example, evidence from Sweden suggests that the complication rate from cataract surgery can be 36-times that of other patients and this arises because of variability in clinical practice rather than either demographics or any other complicating medical problems. Moreover, the combination of a high degree of variability in patient outcomes and ever increasing costs, places a considerable strain upon healthcare budgets. In short, value-based healthcare represents a major paradigm shift in healthcare procurement away from the established price-based model to one which considers total costs and outcomes. Nevertheless, a major barrier to more widespread adoption of value-based healthcare, is that current public procurement models generally focus on the upfront costs of medical equipment, devices etc and are largely driven by the need for cost savings, rather than on delivering the best possible outcomes for patients. In an effort to promote value-based healthcare, in 2014, the European Parliament passed directive 2014/24/EU which focused on public procurement.3 This directive sought to improve procurement through promoting quality and innovation while at the same time considering the longer-term costs. In effect, the directive enabled contracting authorities to utilise flexible procedures to examine the value for money provided by suppliers in the tendering process.

Efficiency gains in ophthalmology

A value-based approach to healthcare requires providers to consider the overall total costs of a procedure which includes not only equipment but also the costs associated with treating any subsequent complications for the patient. Furthermore, the current COVID-19 pandemic has led to longer waiting times for non-urgent surgery and emphasised the need for an efficient approach to the provision of healthcare services, for example, reducing the time spent by patients at clinics. While efficiency is important, it cannot come at the expense of the quality of the care delivered, hence the importance of ensuring that most recent technology and durable implantable intraocular lenses (IOLs) are used.

An important partner to help support ophthalmology departments deliver efficiencies in service delivery are product suppliers. For example, one supplier, Alcon, is the global leader in eye care dedicated to helping people see brilliantly and has invested heavily in the development of innovative products and services to enable ophthalmology providers to deliver better outcomes in efficient ways. For instance, during cataract surgery, surgeons need to dissolve the crystalline cataract lens, in a process termed phacoemulsification (phaco), prior to its removal. This can be achieved using a hand-held phaco device, the tip of which makes a small incision in the eye and literally sucks out the damaged lens. Furthermore, during surgery, it is desirable to maintain a constant intraocular pressure within the eye to prevent it from either over-inflating or collapsing. Another initiative likely to optimise time-management during surgery is a customisable pack containing all the sterile surgical equipment and instruments to meet the surgeon’s needs. Finally, the use of a delivery device reduces the IOL preparation time and risk of contamination with less human handling.

In addition to the use of the latest technologies, product supplies can also help ophthalmology services through the provision of educational resources for both staff and patients. For example, the use of specific patient education resources will ensure that patients have a better understanding of the different surgical options and IOLs available, e.g. monofocal or multi-focal. Staff too can benefit from educational resources, but their workload can also be reduced through the use of radio-frequency identification (RFID) technology to streamline inventory management systems. This technology enables electronic identification of current stock, short-dated stock and items that need to be re-stocked, streamlining the entire inventory process.

Finally, and to enable ophthalmology providers to make informed decisions, any value-based proposition should be supported by scientific evidence that examines the balance between the provision of excellent care and costs with patient outcomes. Here too, product suppliers can offer the necessary evidence to demonstrate the value of their products, especially in terms of a reduction in the rates of surgical complications.

Providing a value-based ophthalmology service: what needs to be done

Cataracts

Biological ageing is associated with a substantial increase of visual impairment.4 The best optical performance is obtained from a transparent lens but a common age-related cause of visual impairment is cataract, defined as the opacification (or clouding) of the crystalline lens, although the condition can result from trauma, metabolic disorders, medications or congenital problems.5 Cataracts are a frequent reason for blindness with one review finding that globally, of the estimated 36 million people who are blind, the leading cause, affecting 12.6 million, was a cataract.6 Additionally, in a recent study the age-standardised pooled prevalence estimate of having a cataract was 54.4% in those aged 60 years and older.7 Furthermore, in a report from the United Nations, the global population aged 60 years and over was thought to be around 962 million compared to 382 million in 1980.8 This increased life expectancy will undoubtedly lead to a higher incidence of cataracts and thus longer waiting times for surgery. From a UK perspective, a 2019 GIRFT (getting it right first time) report on ophthalmology services, estimated that around 2.5 million people aged 65 years and older (roughly 20–25% of that total demographic population) have some degree of visual impairment due to cataracts, leading to likely 50% increased demand for cataract surgery.9 Furthermore, in the UK, guidance from the National Institute for Health and Care Excellence (NICE) recommends that the decision for surgery should be made after a discussion of the benefits and risks of surgery with the patient rather than being based on their visual acuity.10 The impact of deteriorating vision due to cataracts has a major effect on patients with one recent survey of 207 patients revealing how 65% either agreed or strongly agreed that their eyesight was significantly interfering with their quality of life.11 With a potential greater demand for cataract procedures in the coming years, achieving efficiency gains in service provision becomes an important and vital first step. Alcon has taken the lead in the development of modern technology that is central to the provision of a value-based ophthalmology service that is capable of meeting the increasing demands of for cataract surgery while, most importantly, retaining a focus on improving patient outcomes.

Cataract surgery

Cataract surgery is an extremely common procedure and globally, there are estimated to be approximately 20 million operations every year.12 Cataract surgery is one of the most cost-effective surgeries with one study from 2007 finding that the procedure had a cost-utility (a measure of cost effectiveness) of between $245 to $2000/quality-adjusted life years which was comparable to a hip replacement.13 The surgical procedure is generally very safe and effective with at least 95% of patients expecting visual acuity outcomes better or the same as their pre-operative outcomes.14

Phaco technology

During surgery, a 2.2–2.4-mm incision is made in the eye and the cataract lens is removed using a phacoemulsifier aspirator. One of the most important aspects during phaco is ensuring a careful balance between aspiration and infusion pressures to maintain intraocular pressure (IOP) so that the eye remained inflated and stable during surgery. As the phaco aspirator sucks out the lens material, a potential problem is blockage of the tip; however, a more important concern is the transient increase in the aspiration rate and subsequent drop in IOP, termed an occlusion break surge, that occurs once the tip blockage is released. These break surges can cause the iris or posterior capsule to move towards the phaco aspirator tip, increasing the risk of posterior capsule rupture or iris trauma.15 Phaco systems therefore need to be able to react to pressure changes to minimise IOP fluctuations. Alcon’s Centurion® Vision System16 includes the Active sentry® handpiece17 with a built-in fluidics pressure sensor (Active fluidics™) that is able to detect pressure in real time. In a comparative study of aqueous volume losses associated with occlusion breaks, Alcon’s active fluidics® system was found to have the lowest surge volumes across all vacuum limits.18 Furthermore, the Centurion® System has been shown to have the highest surgical efficiency, the shortest surgery time and the lowest rate of post-operative complications.19 A further innovative feature of the Centurion® Vision System is the INTREPID® Hybrid tip, which is made of proprietary polymer rather than traditional metal and been proved to reduce the likelihood of posterior capsule rupture by almost 70%20 : this is particularly relevant for trainees where intra-op issues, such as PCR, are up to four-times more likely to occur.8,21

IOLs

Although there are a large number of different IOLs available, most commonly implanted IOLs are monofocal, which correct vision at one distance only, hence patients will require glasses for either near and intermediate vision. Nevertheless, the type of lens used should be discussed with the patient, as some individuals may prefer a lens that corrects more than only distance vision, a presbyopia correction lens that can offer more complete vision. It is therefore crucial that patients have some input into the decision-making process given that cataract surgery is a one-off procedure. Alcon has a wide range of IOLs to suit differing patient needs including the AcrySof® IQ Panoptix®22 trifocal IOL for near, intermediate and distant vision, the AcrySof®IQ Vivity®,23 a novel presbyopia correction IOL, the AcrySof® IQ toric IOL,24 which can be used to correct astigmatism and Clareon® AutononMe™,25 a new automated, disposable, pre-loaded delivery system with IOL bio material.

Although generally without problems, cataract surgery can lead to complications, of which the most common is posterior capsule opacification (PCO), which is sometimes referred to as a ‘secondary cataract’. The condition develops over the clear posterior capsule, a few months or years after the original surgery and is known to vary from as high as 50% to as low as 2% after uncomplicated cataract removal26 and is caused by residual lens epithelial cells forming an opaque membrane across the posterior capsule.27 Fortunately, PCO can be corrected through the use of neodymium-doped yttrium aluminium garnet (Nd:YAG) laser surgery. Though Nd:YAG surgery has become accepted as the standard treatment for PCO, the procedure is not without problems and reported complications have included damage to the IOL, increased IOP, retinal haemorrhage, iritis, vitreous prolapse, corneal injury, vitritis, pupil blockage, hyphaemia, cystoid macular oedema, retinal detachment, IOL dislocation and exacerbation of endophthalmitis.28

The majority of standard IOLs are composed of flexible materials, ideally a hydrophobic, acrylic material with small legs (haptics) which help keep the new lens in place once inserted into the capsule and there is considerable evidence demonstrating that the IOL characteristics can have a major impact on the subsequent risk of PCO. In fact, one suggested metric to assess IOL performance is the post-surgery rate of PCO9 as this reduces patient satisfaction after the original cataract surgery and often warrants further surgical intervention.

Available evidence

Many studies have revealed how the choice of IOL material and its design, affects the development of PCO. For instance, one review identified that the use of hydrophobic rather than hydrophilic IOLs led to a reduced incidence of PCO29 as does an IOL with a sharp optic edge.30 A pre-loaded device which delivers the IOL can improve the efficiency of cataract surgery through a reduction in preparation time and overall case time by avoiding the need for manual loading of the IOL.

Further evidence that the type of acrylic IOL material has an impact on the incidence of PCO and the need for Nd:YAG capsulotomy was examined in a recent UK-based, real-world study. Ursell et al31 compared AcrySof (Alcon) with other non-AcrySof hydrophobic and non-AcrySof hydrophilic acrylic IOLs in over 52,000 eyes, of which AcrySof was used in 13,329 eyes. After three years, the incidence of PCO was 4.7% in patients using the AcrySof IOL compared with 6.3% and 14.8% for the non-AcrySof hydrophobic IOL and the non-AcrySof hydrophilic IOLs respectively. Furthermore, the three-year Nd:YAG capsulotomy incidence for AcrySof was 2.4% compared with 4.4% for non-AcrySof hydrophobic IOLs and 10.9% for non-AcrySof hydrophilic IOLs.

The real-world results confirm those observed in clinical studies; in a systematic literature review and network meta-analysis, Thom et al32 compared the risk of Nd:YAG capsulotomy for AcrySof IOLs compared with a wider range of IOLs including non-AcrySof hydrophobic acrylic, hydrophilic acrylic, silicone and polymethylmethacrylate. A total of 59 randomised controlled trials were included in the analysis of between 40 and 2778 eyes and with a follow-up duration of 6 months to 12 years. The analysis revealed how AcrySof IOLs were associated with the lowest risk of subsequent Nd:YAG capsulotomy compared with other hydrophobic acrylic IOLs with a sharp edge design. It also appears that the characteristics of the AcrySof IOL material itself is an important factor in reducing the need for Nd:YAG capsulotomy, rather than the presence of a sharp edge profile. This was demonstrated in a three-year randomised trial by Leydolt et al,33 who recruited 100 patients with bilateral age-related cataracts and inserted an iMics1 IOL in one eye and an AcrySof IOL in the other eye. Patients had follow-up examinations after 1 week and 3 years. The authors used an objective PCO score ranging from 0 to 10, with higher scores indicating more severe PCO. After three years, the PCO score for iMics1 was 3.0 (± 2.0) and 1.9 (± 1.40) for AcrySof (p < 0.001). Subsequently, 35.6% of patients with iMics1 underwent Nd:YAG capsulotomy compared with only 13.7% with the AcrySof IOL. In a second real-world Finnish five-year study of the cumulative incidence of Nd:YAG capsulotomy, Lindholm et al,34 using multivariate regression, found that use of the SN60WF IOL (Alcon) resulted in a 38% reduced risk of PCO surgery.

Budgetary impact

In general terms, hydrophobic lenses are more expensive than the alternative hydrophilic lens. Nevertheless, when considering the totality of treatment costs, including the possible need for Nd:YAG capsulotomy and any subsequent complications, hydrophobic IOLs prove to be more cost-effective as illustrated in several budgetary analyses. For example, in a subsequent economic analysis of the data from the Lindholm study,34 Aaronson et al35 developed a cost-consequence model that compared the healthcare resource utilisation and costs associated with PCO. They estimated that use of the AcrySof SN60WF would, on a national level, result in 2969 fewer Nd:YAG capsulotomy procedures, potentially saving the Finnish health system €868,334 and a total of 464 working days. Kossack et al36 found similar results in their cost analysis of 3025 cataract patients. Post-operative treatment costs with hydrophilic IOLs was 75% higher during the four-year period vs cases where hydrophobic IOLs had been used. In a further cost-comparative analysis for the UK, Italy and Denmark, Dhariwal et al37 estimated the economic burden of Nd:YAG capsulotomy due to five different (AcrySof, AMO Tecnis, B&L Akreos, Lenstec Softec, Rayner C/Super-flex) monofocal IOLs, as well as the costs due to potential complications from Nd:YAG capsulotomy. Even though the model assumed that the five IOLs had the same price, the analysis still revealed how the AcrySof IOL was associated with a substantially lower number of Nd:YAG capsulotomy procedures and subsequent complications during the 3 years after cataract surgery. In fact, the total estimated cost savings, although dependent on the comparator IOL, ranged from €0.5 to €4.7 million. More recently, Raulinajtys-Grzybek et al38 modelled the impact of the more expensive hydrophobic IOL compared with hydrophilic IOLs in the Polish healthcare system. While not strictly generalisable to other nations because of differences in the cost of healthcare services, the model did find that total annual national health costs for a 3-year follow-up varied from €139.1 million to €143.1 million, depending on whether hydrophobic or hydrophilic IOLs were used.

Summary

The use of the last phaco technology and hydrophobic, sharp-edged, acrylic IOLs have been shown to be associated with a lower incidence of secondary interventions and despite being more expensive than hydrophilic IOLs, are ultimately more cost-effective as shown in budget impact modelling studies. These economic advantages translate into benefits for patients in terms of a reduced need for further treatments,31,34,35 and this is particularly relevant in the context of the current COVID-19 pandemic when we want to reduce the number of people visiting hospitals and also waiting times for non-urgent procedures are likely to be much longer.39,40 The current global rise in the elderly population with an accompanying increased need for cataract surgery is likely to result in longer waiting times and create a financial strain on healthcare systems. Partnering with Alcon and use of its growing innovative product portfolio and accompanying services and solutions offers an opportunity to deliver a value-based ophthalmology service that achieves the necessary efficiency gains to deal with the increased demands for cataract surgery.

Please refer to relevant product directions for use and operator manuals for complete list of indications, contraindications and warnings.

References

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5. Anon. Cataracts. BMJ Best Practice 2020. https://bestpractice.bmj.com/topics/en-gb/499.

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10. NICE. Cataracts in adults: management NG77. 2017. www.nice.org.uk/guidance/ng77/chapter/Recommendations#referral-for-cataract-surgery.

11. Naderi K et al. Attitudes to cataract surgery during the COVID-19 pandemic: a patient survey. Eye 2020;9–10.

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13. Lansingh VC, Carter MJ, Martens M. Global Cost-effectiveness of cataract surgery. Ophthalmology 2007;114(9):1670–8.

14. Anon. Sustainable ophthalmic pathways. R Coll Ophthalmol [Internet] 2018;(April). www.rcophth.ac.uk/wp-content/uploads/2018/06/Sustainable-Cataract-Pathways.pdf

15. Sharif-Kashani P, Fanney D, Injev V. Comparison of occlusion break responses and vacuum rise times of phacoemulsification systems. BMC Ophthalmol 2014;14(1):1–7.

16. Centurion® Vision System Operating Manual.

17. Active Sentry® pressure sensing handpiece. Directions for use.

18. Aravena C et al. Aqueous volume loss associated with occlusion break surge in phacoemulsifiers from 4 different manufacturers. J Cataract Refract Surg [Internet] 2018;44(7):884–8.

19. Huang J et al. Comparison of recently used phacoemulsification systems using a health technology assessment method. Int J Technol Assess Health Care 2017;33(2):232–8.

20. Shumway C. Utility of a novel hybrid phacoemulsification tip to prevent posterior capsule rupture. Presentation at ASCRS 2019, San Diego: 3–7 May.

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22. AcrySof® IQ PanOptix® Directions for Use.

23. AcrySof® IQ Vivity® Extended Vision IOL Directions for Use.

24. AcrySof® IQ Toric Directions for Use.

25. Clareon® AutonoMe™ Directions for Use.

26. Raj SM et al. Post-operative capsular opacification: a review. Int J Biomed Sci [Internet] 2007;3(4):237–50.

27. Morgan-Warren PJ, Smith JM. A. Intraocular lens-edge design and material factors contributing to posterior-capsulotomy rates: Comparing Hoya FY60AD, PY60AD, and AcrySof SN60WF. Clin Ophthalmol 2013;7:1661–7.

28. Karahan E, Er D, Kaynak S. An Overview of Nd:YAG Laser Capsulotomy. Med hypothesis, Discov Innov Ophthalmol J [Internet] 2014;3(2):45–50.

29. Zhao Y et al. Comparison of hydrophobic and hydrophilic intraocular lens in preventing posterior capsule opacification after cataract surgery. An updated meta-analysis. Medicine (United States) 2017;96(44):e8301.

30. Findl O, Buehl W, Bauer P, Sycha T. Interventions for preventing posterior capsule opacification. Cochrane Database Syst Rev 2010;issue 2:(Art No: CD003738).

31. Ursell PG et al. Three-year incidence of Nd:YAG capsulotomy and posterior capsule opacification and its relationship to monofocal acrylic IOL biomaterial: a UK Real World Evidence study. Eye 2018;32(10):1579–89.

32. Thom H et al. Effect of AcrySof versus other intraocular lens properties on the risk of Nd:YAG capsulotomy after cataract surgery: A systematic literature review and network meta-analysis. PLoS One 2019;14(8):1–15.

33. Leydolt C et al. Posterior capsule opacification with the iMics1 NY-60 and AcrySof SN60WF 1-piece hydrophobic acrylic intraocular lenses: 3-year results of a randomized trial. Am J Ophthalmol 2013;156(2):375-381.e2.

34. Lindholm JM, Laine I, Tuuminen R. Five-Year Cumulative Incidence and Risk Factors of Nd:YAG Capsulotomy in 10 044 Hydrophobic Acrylic 1-Piece and 3-Piece Intraocular Lenses. Am J Ophthalmol 2019;200:218–23.

35. Aaronson A, Grzybowski A, Tuuminen R. The health economic impact of posterior capsule opacification in Finland comparing the two single-piece intraocular lenses: a cost–consequence analysis. Acta Ophthalmol 2019;97(8):e1152–3.

36. Kossack N et al. German claims data analysis to assess impact of different intraocular lenses on posterior capsule opacification and related healthcare costs. J Public Health 2018;26(1):81–90.

37. Dhariwal M, Bouchet C, Jawla S. Comparing the long-term impact on health care resources utilization and costs due to various single-piece acrylic monofocal intraocular lens implantation during cataract surgery: A cost-consequence analysis for the United Kingdom, Italy, and Denmark. Clin Ophthalmol 2019;13:169–76.

38. Raulinajtys-Grzybek M et al. Budget impact analysis of lens material on the posterior capsule opacification (PCO) as a complication after the cataract surgery. Cost Eff Resour Alloc 2020;18(1):1–12.

39. www.theguardian.com/society/2020/apr/26/more-than-two-million-operations-cancelled-as-nhs-fights-covid-1940.

40. www.birmingham.ac.uk/news/latest/2020/05/covid-disruption-28-million-surgeries-cancelled.aspx