MAY 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 27 of 86

May 2013 EW International 25 ISBCS: The elephant in the (U.S. cataract) room by Charles ClaouŽ, MD Yes, there is a society of bilateral cataract surgeons. And yes, they advocate for immediate sequential bilateral cataract surgery (ISBCS). As a profession, ophthalmologists have always been heretics, proposing radical ideas that shake up the status quo. Each crazy idea has caused us to reconsider what is comfortably familiar. The deep controversy over intraocular lenses gave birth to a splinter group that became ASCRS. And what about the other crazy ideas like outpatient surgery, sutureless incisions, and topical anesthetic? Each in turn has evolved into what we now accept to be routine. Now we consider bilateral cataract surgery. Charles Claoué, MD, presents a well-researched argument that ISBCS is not only safe but cost effective. Read on and see if you find his logic compelling. Personally, I am not a member of this society, yet. John Vukich, MD, international editor "A wise man changes his mind; a Fool never does!" –Spanish proverb I n preparing this article I have taken some small liberties with assumptions and in rounding figures to make the arithmetic easier to follow. While I acknowledge that this also makes criticism easier, the critics should perhaps look at the message, which is that to your surprise, the pressure to adopt immediate sequential bilateral cataract surgery (ISBCS) will come not from your international peers but from Medicare and Medicaid. The debate about ISBCS is as old as cataract extraction and is regularly re-rehearsed.1,2 Although the antagonists have no new arguments (simultaneous bilateral endophthalmitis; refractive surprises) the new scientific standards of data collection and analysis have not favored their positions.3,4,5,6,7,8 As an example, the falling incidence of endophthalmitis to approximately one in 2,000 makes the risk of simultaneous bilateral endophthalmitis (SBE) approximately 1 in 4 million, or one case every 24 months if all cases of cataract surgery (assumed to be 2 million/year) in the U.S. were undertaken as ISBCS. If the figures for the International Society of Bilateral Cataract Surgeons (ISBCS) members are used,9 the rate is 1 in 14,352 cases, meaning that SBE incidence would be 1 in 206 million, or one case every 100 years in the U.S. if all cases were done as ISBCS. I accept that not all patients have bilateral cataract surgery, but probably the majority do within two years.10 The International Society of Bilateral Cataract Surgeons was set up in 2008 to collate data on ISBCS and to provide a forum for discussion. The Society holds its annual meeting as a satellite to ESCRS, but is rarely successful in organizing courses at ASCRS in marked contrast to ESCRS. Why is this? Certainly, there are countries in Europe such as Finland or areas such as the Canary Islands where ISBCS is extremely common and may be the most common mode of delivering cataract surgery. The Society has worldwide membership with some 23 countries represented. However, whenever the subject is broached with surgeons from the U.S., the discussion usually ends with "but we only get reimbursed 50% for the second eye." Interestingly, where this argument does not apply (refractive lensectomy), the practice of ISBCS in the U.S. is not insignificant at 7% of respondents (ASCRS 2008 survey). The reduced remuneration for second eye cataract surgery in ISBCS is not a purely American phenomenon. Private healthcare insurers in the U.K. attempted to mandate a 25% fee for the second eye as their surgeon remuneration. However, many surgeons in the U.K. were prepared to spend the chair time educating their patients about the absurdity of this, and as a result most patients prefer to pay their insurance company shortfall rather than have delayed sequential bilateral cataract surgery (DSBCS). This is comparable to the ABN (advanced beneficiary notice) used in some circumstances in the U.S. There are many other countries where the second eye procedure in ISBCS is severely financially penalized and where the surgeon is not permitted to recoup the shortfall from the patient (e.g., Japan, Israel), and therefore ISBCS is not frequent in these countries. According to Prof. ClaouŽ the falling incidence of endophthalmitis to approximately 1 in 2,000 makes the risk of simultaneous bilateral endophthalmitis approximately 1 in 4 million, or 1 case every 24 months if all cases of cataract surgery (assumed to be 2 million a year) in the U.S. were undertaken as ISBCS. Source: Nick Mamalis, MD Let us try to look at the financial side of ISBCS in the U.S. in a different way. Leivo et al. have credibly shown that ISBCS is cheaper by €1,670.00 per patient.11 This has been independently verified by Lundstrom12 and O'Brien.13 The figures are remarkably similar at around €1,500 per patient, or around $2,0000.00 If we play with the numbers, 2,000,000 cataract surgeries per year in the U.S. and say this is 1 million patients, the potential savings is 2x10^9 dollars, which is a lot of money. If the total U.S. healthcare budget is 2.3 trillion dollars (2.3x10^12), it represents a potential savings of less than 1%, but given the size in real terms, and the fact that the number of cataract operations is predictably certain to grow, I believe that healthcare economists are likely to jump at the opportunity when they become aware of it. So let me pretend to be the U.S. healthcare administrator (nice office!) who decides what U.S. ophthalmologist are to be paid and needs to save money. I suddenly become aware that 1. Cataract surgery is probably the most common surgical procedure in the U.S.; 2. It can predictably be seen to be increasing in frequency and likely to continue; 3. Many if not most patients will want/benefit from second eye surgery; 4. There are 2 billion dollars of potential savings; 5. Surgeons seem happy to do ISBCS for refractive lens exchanges, but are deterred from doing this for cataract surgery as they are financially penalized; 6. If even 1% of patients had ISBCS the savings to the nation's economy would be 20 million dollars a year; and 7. It's a no brainer. I need to encourage U.S. ophthalmologists to do ISBCS, and I can start by taking the financial disincentive away. Should I try to actively encourage it by offering a surgeon revenue premium? No, that's a step too far for today. What is needed is bold action in the U.S. Those who represent the speciality should consider having meetings with healthcare administrators who need education about ISBCS. Faced with the potential savings of up to 2 billion dollars a year, the pressure on U.S. cataract surgeons to adopt ISBCS will not come from your European, Canadian, and other overseas colleagues, but from what you think is the most unlikely source: your national healthcare system. And finally, I do appreciate that it is unlikely that all patients in any country will opt for ISBCS, but each one that does offers a "saving" for the state. I understand that endophthalmitis may not occur at random as assumed, but that the risk can be minimized by following the "iSBCS General Principles for Excellence in continued on page 26

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