Second-Eye Cataract Surgery is a Keeper!
Second-Eye Cataract Surgery is a Keeper!
By Melissa M. Brown, MD, MN, MBA
In this column, we have looked at various interventions and their relative comparative- and cost-effectiveness. We have yet, however, to wade very far into the world of “what if's” about which many ophthalmologists have queried: what if Medicare and other insurers begin denying care based on cost?
We hear about the possible denial of healthcare interventions in Canada and the United Kingdom as health-care funds become tighter. But what about in the United States? Our policymakers, after all, are actively calling for a reduction in healthcare costs.
As a reader of this column, you already know that our ophthalmic interventions save our country considerable dollars by enhancing vision and, thus, decreasing caregiver costs, improving employment opportunities, pay and productivity!
Second-eye Surgery Stats
To play the devil's advocate, however, what about those cataracts in the second eye? Might cataract surgery in the second eye be a surgery itself on the chopping block in an era of strict cost-cutting? “No,” is the right answer, but let's look at the data that supports the case for second-eye surgery. The relevant questions are:
(1) How much human value gain does cataract surgery in the second eye confer to a patient?
(2) How does this human value compare to that from other interventions?
(3) How much are we paying for that value?
(4) How does what we pay compare to that for other medical interventions?
First, how much value, from a quality-of-life standpoint, does cataract surgery confer? When we look at patient-derived utilities, we find that those who have undergone cataract surgery in the first eye experience a 20.8% gain in patient quality of life for the remainder of life. Nonetheless, cataract surgery in the second eye, again using the opinions of patient, accrues a 12.7% gain in quality of life for the average person.
Secondly, these numbers begin to stand out when compared with another common medical issue: systemic arterial hypertension. Depending upon which pharmacologic agent used, the treatment for hypertension confers a total gain in value in the range of 6% to 9%.
And while the human value of hypertension treatment in cludes not only quality-of-life improvement, it also reflects the lengthening of life due to treatment as well. Gain in value from cataract surgery generally does not include the latter component.
Now, let's look again at what we pay for cataract surgery in the second eye. The cost-utility ratio associated with cataract surgery in the first eye is $2,020/QALY (quality-adjusted life-year), while that in the second eye is $2,727/QALY.1 In nominal dollars (unadjusted for inflation) both are virtually the same as in year 2003, since the associated fees have not risen appreciably. In real dollars (adjusted for inflation) the fees associated with secondary cataract are less than in year 2003.
How does what we pay compare to that for other medical interventions? Returning to systemic arterial hypertension, the cost-utility ratio varies greatly depending upon which medical agent is used. The median cost-utility ratio for hypertension treatment ranges from $5,000/QALY-$7,000/QALY. However the cost-utility ratio range including most treatments lines up to vary between -$1,700/QALY and >$300,000/QALY. The negative utility ratio indicates a very inexpensive treatment that returns more direct medical costs to society than its initial cost of treatment.
In the Final Analysis
Thus, cataract surgery in the second eye is a very cost-effective procedure—considerably more so than the average anti-hypertensive therapy. And when one considers the most typical US upper limit of cost-effectiveness to be $100,000/QALY, second-eye cataract surgery is highly cost-effective. In fact, utilizing the World Health Organization criterion of approximately 1x GDP per capita (US $47,000/QALY) as very cost-effective and 3x GDP per capita (US $141,000/QALY) as cost-effective, cataract surgery in the second eye ranks as one of the most cost-effective interventions in our entire healthcare system.
This comes as no surprise to those of us who strive to maintain and return vision to our patients; it is important to understand, as well, that the gain the surgery delivers for our society goes far beyond even the gain in quality of life for our patients. OM
1. Busbee B, Brown M, et at. Cost Utility Analysis of Cataract Surgery in the Second Eye. Ophthalmology 2003;110:2310-2317.
Value-Based Medicine is a registered trademark of the Center for Value-Based Medicine.
||Melissa M. Brown, MD, MN, MBA, is president and CEO of the Center for Value-Based Medicine in Philadelphia. She can be reached via e-mail at email@example.com.|
Ophthamology Management, Issue: April 2011