Patient-centric healthcare, combined surgeries and cost-effectiveness considered at ESCRS

Talk of lens selection and patient satisfaction dominated discussion during the Advanced IOLs Symposium; cost vs. benefit analysis emerges as a theme throughout the congress.

This year’s Congress of the European Society of Cataract and Refractive Surgeons that took place on 8th to 12th October at the RAI Centre in Amsterdam offered Sessions across such a wide range of subspecialities within ophthalmology that it was something of a challenge deciding which ones to attend. Thankfully, with the congress being on a smaller geographical scale this year, owing to its ‘hybrid’ (part virtual) format, the halls that hosted the talks were very close to one another, making manoeuvring between them a doddle.

Symposia in review: IOLs, MIGS and surgical innovation

The Main Symposium on the Saturday morning, entitled Selecting Advanced IOLs, certainly deserves a mention, attracting as it did an impressively large number of attendees, the largest, I noticed, of all Sessions throughout the conference. The popularity of these presentations demonstrates just how fast-moving advancements within the IOLs field are: everyone wanted in on the action.

Chaired by Drs Nic Reus of the Netherlands and Filomena Ribeiro, from Italy, the focus of the talks squared largely on the patient: the ultimate challenge in selecting premium IOLs, as Dr Reus pointed out, is “how to communicate … as to which lens is best”. This was echoed by several of the speakers, who also discussed the importance of informed consent and, above all, the demand for clear IOL terminology that is simple enough for all patients to understand.

“We should know our patient, listen and provide solutions where appropriate,” Dr Roberto Bellucci, in private practice in Saló, Italy, highlighted in his presentation on Management of the Unhappy Patient. He added that it is important to really understand patients’ personalities; the neurotic patient is likely going to be unhappy whatever lens they get.

There was clearly agreement that time is of the upmost importance, too. Time to help patients choose the right lens requires more than a quick 20-minute chat in the clinic, pointed out Dr Arthur Cummings, an ophthalmologist based in Dublin, Ireland, via video link.

He feels that observing patients in their home environment for, say, 36 hours, is ideal, something that is becoming showed feasibility during a clinical trial at the Wellington Eye Clinic in Dublin whereby patients considering multifocal IOLs wore a visual behaviour monitor that attached to their own spectacles. The device, worn over 3 days, could track a patient’s working distances, heat movements and even lighting conditions, before relaying data on their specific refractive requirements back to the clinic.

However, even with such comprehensive efforts at patient personalisation, with any IOL there will be some compromise involved when it comes to the visual acuity improvements achieved at given distances. The fact that choosing a lens is always going to be a compromise was a sentiment that cropped up a few times during the Symposium.

Dr Boris Malyugin, of the S. Fyodorov Eye Microsurgery Institution in Moscow, Russia, and pioneer of the Malyugin Ring pupil expansion device, chaired the MIGS Main symposium on the Saturday afternoon. Topics up for discussion included the opportunity of combining cataract surgery with glaucoma surgery and the need for more studies in this area; suprachoroidal shunts; and trabeculectomy.

Meanwhile, Dr Alex Huang travelled all the way from the United States (the David Geffen School of Medicine, UCLA, Los Angeles, California) to present his ground-breaking work on aqueous angiography, which is designed to optimise the efficacy of MIGS devices as well as improve understanding of aqueous outflow. This was a fascinating discussion on an imaging technique that is a relatively newer addition to the arsenal of imaging technologies within ophthalmology.

Cost versus benefits in ophthalmology

Has cost effectiveness and value-based healthcare entered ophthalmology? This was the subject of one of the Clinical Research Symposia I had earmarked as a must-attend on the Sunday, so I was pleased to find the presentations, chaired by none other than Ophthalmology Times Europe’s® Editorial Advisory Board members Dr Rudy Nuijts and Prof. Jorge L. Alio, were both informative and varied.

Prof. Gregory Katz of the University of Paris School of Medicine was one of the first presenters to stand at the podium: he spoke of how transparency and the reporting of patient outcome data acts to incentivise and encourage practitioners. Pointing to a series of graphs during his presentation, he explained that when clinicians can see their hospital or department is outperforming, their performance starts to pick up (and the line on the graph starts to creep up). Conversely, without this knowledge, they tend not to make the needed improvement. Fundamentally, this makes a lot of sense: if you don’t know what is broken, you can’t fix it.

Rather worryingly, there is a lot of variation in patient outcomes not just country to country but within different regions of the same country. Focusing on cataracts specifically, Prof. Katz said that in 2018 in Sweden, for example, there was a staggering 3,100% variation in capsular complications after cataract surgery. The problem, he emphasised, is that health systems don’t measure the outcomes of the healthcare they pay for.

He concluded his talk by stating the importance of standardising questionnaires on patient quality-of-life through scientific calibration, digitising outcomes data and comparing results through case-mix adjustments to prevent adverse selection of patients. The integrity of outcome data needs to be audited, he added, and outcomes should be shared with patients, practitioners, payers and industry.

Up next was Mr Alexander Day, cataract and laser vision correction surgeon, who posed the question during live video feed from Moorfields Eye Hospital NHS Foundation Trust: what can we learn from European randomised clinical trials about cost effectiveness outcomes? Mr Day stated that for any technique to be cost-effective it needs to be cheaper and/or increase productivity (to offset higher prices) and have better short and long-term outcomes.

Take the femtosecond laser-assisted cataract surgery (FLACS) versus phacoemulsification debate, for example. A thorough assessment of the costs and benefits profiles of these two technologies leads one to the conclusion that FLACS is not cost-effective overall, Mr Day pointed out.

Also weighing up the cost-effectiveness of two techniques was Dr Rob Simons, who discussed the expense associated with delayed versus immediate sequential bilateral cataract surgery, drawing on findings from the BICAT-NL study that took place in the Netherlands. This study found that ISBCS is cost-saving since it results in shorter times in operating rooms; one day of admission less; fewer post-operative visits; less homecare; and lower travel costs. The two procedures result in similar refractive outcomes, Dr Simons pointed out, with no increased bilateral complications and no bilateral endophthalmitis seen with ISBCS.

Dr Marie Joan Therese Balgos of Spain took to the podium next, to discuss findings comparing the cost-effectiveness of PRK, SMILE and FS-LASIK. “Cost is a significant consideration for patients who are contemplating laser vision correction,” she stated, arguing that laser refractive procedures are more cost-effective than a lifetime use of spectacles or contact lenses. “SMILE, PRK and FS-LASIK are all cost-effective from the payer’s perspective when done between the ages of 20 to 60 years,” Dr Balgos concluded, convincing the audience that the earlier a corneal refractive procedure is performed, the lower the incremental cost-effectiveness ratio.

The take-away message, I considered as this Symposium winded up, was that this is not a topic that will die out any time soon: cost versus benefit considerations have indeed entered the field of ophthalmology and will no doubt continue to drive debate in years to come, as well as likely feature on the agenda of future ESCRS congresses.

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