Office-based surgery

From his Kaiser Permanente health plan office near Denver, Colorado, USA, Richard K Stiverson MD sees the future of cataract surgery – quite literally. “We have performed more than 36,000 cataract surgeries in our office suite,” he told the opening session of the 2017 American Society of Cataract and Refractive Surgery Symposium in Los Angeles, USA. Clinical results of Kaiser Permanente’s first 21,000 office-based cases published last year “were just as good if not better than in many hospitals and ambulatory surgery centres (ASC)” where the health plan logs most of its 100,000 annual cataract extractions, Dr Stiverson said. Visual outcomes and surgical complication rates were similar, while hospital admissions and falls after surgery were significantly lower (Ianchulev T et al. Ophthalmology 2016;123:1-6). So why bother? Moving cataract surgery from a highly regulated ASC to a similarly equipped, but more flexible, office suite saved Kaiser Permanente between $2 million and $3 million the first year, Dr Stiverson said. Office cataract surgery is more efficient because it allows delivery of high-quality, high-technology care without ASC rules that aren’t needed for cataract surgery, Dr Stiverson explained. “We don’t do surgery in a broom closet,” he said. But many ASC requirements that add cost without adding quality can be eliminated, such as excess operating room floor space, a separate surgical waiting room, extra timeouts before surgery, and even bouffant hair covers rather than surgical caps. With payers, both government and private, demanding better outcomes, lower costs and higher volume from ever-fewer ophthalmologists, change is needed, Dr Stiverson said. “We believe a cornerstone for future cataract surgery for some practices will be that it is office based. This will fulfil most of what payers and patients want: better access, lower cost, equivalent visual outcome and, at least in our practice, increased safety.” DROP-LESS, SAME-DAY SECOND-EYE SURGERY Cost and patient convenience pressures also will accelerate adoption of immediate sequential bilateral cataract surgery, Dr Stiverson said. Kaiser Permanente surgeons have already carried out more than 15,000 same-day bilateral procedures without a single case of endophthalmitis, and excellent visual outcomes. However, unlike most practices, Kaiser Permanente benefits financially from same-day bilateral surgery. It is paid a fixed amount per diagnosis rather than per procedure, so it banks any operating savings. “At some point payers will accept that same-day bilateral surgery will save hundreds of millions of dollars. We absolutely agree there must be fair reimbursement for both office procedures and for the second eye surgery.” Pioneers like Minnesota Eye Consultants co-founder Richard L Lindstrom MD follow the logic. “Reimbursement drives a lotof these decisions. If tomorrow a payer in Minnesota gave me $1 million to do 1,000 cataracts, I would go to same-day bilateral sequential surgery immediately, and put a sign that says ‘office’ over the A in ASC.” Better clinical and financial outcomes will also drive adoption of drop-less cataract surgery, in which a combined intravitreal injection of moxifloxacin-triamcinolone replaces topical antibiotics and steroids, Dr Stiverson said. “My colleagues in California have been drop-less for some time, with great success.” In Dr Stiverson’s brave new world of cataract surgery, subspecialists will separately handle phaco-MIGS, complex and routine cases. For routine surgery, the entire process, from biometry to counselling to bilateral surgery, will occur in half a day, with patients meeting the surgeon for the first time in the operating room. Excess sedation will disappear, and with it risks of falls and injury during recovery. Recovery room expenses also will disappear because recovery rooms will disappear, as they already have in Dr Stiverson’s office. “Patients have a light breakfast, and frequently go out to lunch with their families afterward.” Kaiser is already experimenting with one-day cataract surgery. Issues include scheduling, work-life balance and differences in compensation fairness perception across generations, Dr Stiverson said. Nonetheless, he believes the change is inevitable. He also sees new technologies, including cheaper femtosecond laser devices, eventually supplanting mature phacoemulsification technology. “This is going to be very, very exciting,” Dr Stiverson concluded. Richard K Stiverson: richard.stiverson@kp.org Richard L Lindstrom: rllindstrom@mneye.com