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1.
Lancet ; 395(10219): 212-224, 2020 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-31954466

RESUMO

BACKGROUND: Cataract surgery is one of the most common operations in health care. Femtosecond laser-assisted cataract surgery (FLACS) enables more precise ocular incisions and lens fragmentation than does phacoemulsification cataract surgery (PCS). We hypothesised that FLACS might improve outcomes in cataract surgery compared with PCS despite having higher costs. METHODS: We did a participant-masked randomised superiority clinical trial comparing FLACS and PCS in two parallel groups (permuted block randomisation stratified on centres via a centralised web-based application, allocation ratio 1:1, block size of 2 or 4 for unilateral cases and 2 or 6 for bilateral cases). Five French University Hospitals enrolled consecutive patients aged 22 years or older who were eligible for unilateral or bilateral cataract surgery. Participants, outcome assessors, and technicians carrying out examinations were masked to the surgical treatment allocation until the last follow-up visit and a sham laser procedure was set up for participants randomly assigned to the PCS arm. The primary clinical endpoint was the success rate of surgery, defined as a composite of four outcomes at a 3-month postoperative visit: absence of severe perioperative complication, a best-corrected visual acuity (BCVA) of 0·0 LogMAR (logarithm of the minimum angle of resolution) or better, an absolute refractive error of 0·75 dioptres or less, and unchanged postoperative corneal astigmatism power (≤0·5 dioptres) and axis (≤20°). The primary economic endpoint was the incremental cost per additional patient who had treatment success at 3 months. Primary outcomes were assessed in all randomly assigned patients who met all eligibility criteria (missing data considered as failure). We used mixed logistic regression models or mixed linear regression models for statistical comparisons, adjusted on centres and whether cataract surgery was bilateral or unilateral. The study is registered with ClinicalTrials.gov, NCT01982006. FINDINGS: Of the 907 patients (1476 eyes) randomly assigned between Oct 9, 2013, and Oct 30, 2015, 870 (704 eyes in FLACS group and 685 eyes in the PCS group) were analysed. We identified no significant difference in the success rate of surgery between the FLACS and PCS groups (FLACS: 41·1% [289 eyes]; PCS: 43·6% [299 eyes]); adjusted odds ratio 0·85, 95% CI 0·64-1·12, p=0·250). The incremental cost-effectiveness ratio was €10 703 saved per additional patient who had treatment success with PCS compared with FLACS. We observed no severe adverse events during the femtosecond laser procedure, and most of the complications in the FLACS group related to the primary outcome measures occurred during the phacoemulsification phase or postoperatively. INTERPRETATION: Despite its advanced technology, femtosecond laser was not superior to phacoemulsification in cataract surgery and, with higher costs, did not provide an additional benefit over phacoemulsification for patients or health-care systems. FUNDING: French Ministry of Social Affairs and Health.


Assuntos
Extração de Catarata/economia , Extração de Catarata/métodos , Análise Custo-Benefício , Terapia a Laser/economia , Facoemulsificação/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Extração de Catarata/efeitos adversos , Estudos de Equivalência como Asunto , Feminino , Humanos , Terapia a Laser/efeitos adversos , Terapia a Laser/métodos , Masculino , Pessoa de Meia-Idade , Facoemulsificação/efeitos adversos , Facoemulsificação/métodos , Resultado do Tratamento
2.
Curr Opin Ophthalmol ; 31(1): 74-79, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31770166

RESUMO

PURPOSE OF REVIEW: To review various techniques of manual small incision cataract surgery (MSICS), updates on training residents and fellows, and cost-effectiveness of the surgery. RECENT FINDINGS: Recent population studies estimate that there are 53 million people blind worldwide from cataracts, up from previous figures. This is in part because of population growth and increased life expectancy worldwide. MSICS continues to play a significant role in addressing cataract burden and there is an increasing need to train surgeons in the technique. In response to this need, several modules and rubrics have been developed to assist in the training process. SUMMARY: MSICS has been refined over recent decades with overall outcomes comparable to phacoemulsification (phaco) in certain settings. MSICS cost and efficiency advantages support its ongoing essential role in addressing global cataract blindness.


Assuntos
Extração de Catarata/métodos , Microcirurgia/métodos , Extração de Catarata/economia , Extração de Catarata/educação , Análise Custo-Benefício , Educação de Pós-Graduação em Medicina , Humanos , Internato e Residência , Microcirurgia/economia , Microcirurgia/educação , Ferida Cirúrgica
3.
Inquiry ; 56: 46958019880740, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31617426

RESUMO

In medical services, charge according to the disease is an important way to promote the reform of pricing mechanism, control the unreasonable growth of medical expenses, as well as reduce the burden on patients. Single disease cost forecasting that both identify potential influencing or driving factors and enable better proactive estimation of costs can guide the management and control of medical costs. This study aimed to identify the factors that affect the medical costs of single disease cataract and compare 2 regression models for anticipating acceptable medical cost forecasts. For this purpose, 483 patients with cataract surgery completed in West China Hospital from May 1, 2015, to October 1, 2015, were selected from hospital information system. For cost forecasting, multivariable regression analysis (MRA) and backpropagation neural network (BPNN) were used. Analysis of data was performed with SPSS21.0 and MATLAB2014a software. Total medical costs of patients with cataract (n = 483) ranged from 2015.00 to 13 359.00 CNY, and the mean ± standard deviation is 6292.29 ± 2639.43 CNY. Factors influencing costs of cataract in the MRA include, in importance order, intraocular lens (IOL) implantation (|r|: 0.805, P < .01), doctor level (|r|: 0.644, P < .01), payment source (|r|: 0.554, P < .01), admission status (|r|: 0.326, P < .01), additional diagnosis (|r|: 0.260, P < .01), type of surgery (|r|: 0.127, P < .05), and type of anesthesia (|r|: 0.126, P < .05). In terms of forecasting performance, BPNN (average error: 2.81%) outperforms, yet is less interpretable than MRA (average error: 5.79%). Both MRA and BPNN are technically and economically feasible in generating medical costs of cataract. And some insights on using results of the forecasting model in controlling and reducing disease costs are obtained.


Assuntos
Extração de Catarata/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Oftalmologia/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , China , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Adulto Jovem
5.
JAMA Intern Med ; 179(5): 648-657, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30907922

RESUMO

Importance: Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. Objective: To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. Design, Setting, and Participants: This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n = 469) and Harbor-UCLA (University of California, Los Angeles) (control, n = 585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n = 1002; control, n = 511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. Interventions: Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. Main Outcomes and Measures: Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. Results: Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42 241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67 241 in savings. In a simulation of a FFS health system at 3 years, $88 151 in losses were estimated, and for societal 3-year perspectives, $217 322 in savings were estimated. Conclusions and Relevance: This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.


Assuntos
Extração de Catarata/métodos , Catarata , Testes Diagnósticos de Rotina/métodos , Custos de Cuidados de Saúde , Cuidados Pré-Operatórios/métodos , Melhoria de Qualidade , Idoso , California , Capitação , Extração de Catarata/economia , Redução de Custos , Testes Diagnósticos de Rotina/economia , Eletrocardiografia/economia , Eletrocardiografia/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/economia , Radiografia Torácica/economia , Radiografia Torácica/estatística & dados numéricos , Provedores de Redes de Segurança/economia
6.
Isr J Health Policy Res ; 8(1): 13, 2019 01 17.
Artigo em Inglês | MEDLINE | ID: mdl-30654847

RESUMO

The Israel Ministry of Health enacted regulations that aim to reduce private expenditure on healthcare services and mitigate social inequality. According to the modified rules, which went into effect in the second half of 2016, patients who undergo surgery in a private hospital and are covered by their healthcare provider's supplemental insurance (SI) make only a basic co-payment.The modified regulations limited the option of self-payment for advanced devices not covered by national health basket, meaning that patients for whom such devices are indicated had to pay privately for the entire procedure. These regulations applied to all medical and surgical devices not covered by national health insurance (NHI).Toric intraocular lenses (IOLs) are a case in point. These advanced lenses are implanted during cataract surgery to correct corneal astigmatism and, in indicated cases, obviate the need for complex eyeglasses postoperatively. Toric IOL implantation has been shown to be highly cost-effective in both economic and quality-of-life terms. Limitations of the use of these advanced IOLs threatened to increase social inequality.In 2017, further adjustments of the regulations were made which enabled supplemental charges for these advanced IOLs, performed through the SI programs of the healthcare medical organizations (HMOs). Allowing additional payment for these lenses at a fixed pre-set price made it possible to apply a supplemental part of the insurance package to the surgery itself. In mid 2018 these IOLs were included without budget in the national health basket, allowing for self-payment for the additional cost in addition to the basic coverage for all patients with NHI.This case study suggests that, in their efforts to enhance health care equity, policymakers may benefit if exercising due caution when limiting the extent to which SI programs can charge co-payments. This is because, when a service or product is not available via the basic NHI benefits package, limiting SI co-payments can sometimes result in a boomerang effect - leading to an increase in inequality rather than the sought-after decrease in inequality.


Assuntos
Equipamentos e Provisões , Política de Saúde , Oftalmologia/economia , Oftalmologia/legislação & jurisprudência , Astigmatismo/cirurgia , Catarata/terapia , Extração de Catarata/economia , Extração de Catarata/métodos , Humanos , Israel , Programas Nacionais de Saúde/legislação & jurisprudência , Programas Nacionais de Saúde/tendências , Oftalmologia/instrumentação , Facoemulsificação/economia , Facoemulsificação/métodos
8.
Cochrane Database Syst Rev ; 1: CD007293, 2019 01 08.
Artigo em Inglês | MEDLINE | ID: mdl-30616299

RESUMO

BACKGROUND: Cataract surgery is practiced widely, and substantial resources are committed to an increasing cataract surgical rate in low- and middle-income countries. With the current volume of cataract surgery and future increases, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management. OBJECTIVES: 1. To investigate the evidence for reductions in adverse events through preoperative medical testing2. To estimate the average cost of performing routine medical testing SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); Ovid MEDLINE; Embase.com; PubMed; LILACS BIREME, the metaRegister of Controlled Trials (mRCT) (last searched 5 January 2012); ClinicalTrials.gov and the WHO ICTRP. The date of the search was 29 June 2018, with the exception of mRCT which is no longer in service. We searched the references of reports from included studies for additional relevant studies without restrictions regarding language or date of publication. SELECTION CRITERIA: We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed risk of bias. MAIN RESULTS: We identified three randomized clinical trials that compared routine preoperative medical testing versus selective or no preoperative testing for 21,531 cataract surgeries. The largest trial, in which 19,557 surgeries were randomized, was conducted in Canada and the USA. Another study was conducted in Brazil and the third in Italy. Although the studies had some issues with respect to performance and detection bias due to lack of masking (high risk for one study, unclear for two studies), we assessed the studies as at overall low risk of bias.The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pre-testing group and 354 occurred in the no-testing group (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.86 to 1.16; high-certainty evidence). Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 0.99, 95% CI 0.71 to 1.38) or postoperative ocular adverse events (OR 1.11, 95% CI 0.74 to 1.67) when compared to selective or no testing (2 studies; 2281 cataract surgeries; moderate-certainty evidence). One study evaluated cost savings, estimating the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing (1 study; 1005 cataract surgeries; moderate-certainty evidence). There was no difference in cancellation of surgery between those with preoperative medical testing and those with selective or no preoperative testing, reported by two studies with 20,582 cataract surgeries (OR 0.97, 95% CI 0.78 to 1.21; high-certainty evidence). No study reported outcomes related to clinical management changes (other than cancellation) or quality of life scores. AUTHORS' CONCLUSIONS: This review has shown that routine preoperative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in low- and middle-income settings. Unfortunately, in these settings, medical history questionnaires may be useless to screen for risk because few people have ever been to a physician, let alone been diagnosed with any chronic disease.


Assuntos
Extração de Catarata/efeitos adversos , Extração de Catarata/economia , Testes Diagnósticos de Rotina/economia , Fatores Etários , Idoso , Extração de Catarata/estatística & dados numéricos , Redução de Custos , Hospitalização/estatística & dados numéricos , Humanos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto
9.
BMC Health Serv Res ; 18(1): 933, 2018 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-30514277

RESUMO

BACKGROUND: The number of people affected by cataract in the United Kingdom (UK) is growing rapidly due to ageing population. As the only way to treat cataract is through surgery, there is a high demand for this type of surgery and figures indicate that it is the most performed type of surgery in the UK. The National Health Service (NHS), which provides free of charge care in the UK, is under huge financial pressure due to budget austerity in the last decade. As the number of people affected by the disease is expected to grow significantly in coming years, the aim of this study is to evaluate whether the introduction of new processes and medical technologies will enable cataract services to cope with the demand within the NHS funding constraints. METHODS: We developed a Discrete Event Simulation model representing the cataract services pathways at Leicester Royal Infirmary Hospital. The model was inputted with data from national and local sources as well as from a surgery demand forecasting model developed in the study. The model was verified and validated with the participation of the cataract services clinical and management teams. RESULTS: Four scenarios involving increased number of surgeries per half-day surgery theatre slot were simulated. Results indicate that the total number of surgeries per year could be increased by 40% at no extra cost. However, the rate of improvement decreases for increased number of surgeries per half-day surgery theatre slot due to a higher number of cancelled surgeries. Productivity is expected to improve as the total number of doctors and nurses hours will increase by 5 and 12% respectively. However, non-human resources such as pre-surgery rooms and post-surgery recovery chairs are under-utilized across all scenarios. CONCLUSIONS: Using new processes and medical technologies for cataract surgery is a promising way to deal with the expected higher demand especially as this could be achieved with limited impact on costs. Non-human resources capacity need to be evenly levelled across the surgery pathway to improve their utilisation. The performance of cataract services could be improved by better communication with and proactive management of patients.


Assuntos
Extração de Catarata/estatística & dados numéricos , Catarata/economia , Idoso , Procedimentos Cirúrgicos Ambulatórios , Orçamentos , Extração de Catarata/economia , Custos e Análise de Custo , Procedimentos Clínicos/economia , Procedimentos Clínicos/estatística & dados numéricos , Previsões , Humanos , Masculino , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Reino Unido
10.
Bull World Health Organ ; 96(10): 695-704, 2018 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-30455517

RESUMO

Many low- and middle-income countries use national eye-care plans to guide efforts to strengthen eye-care services. The World Health Organization recognizes that evidence is essential to inform these plans. We assessed how evidence was incorporated in a sample of 28 national eye-care plans generated since the Universal eye health: a global action plan 2014-2019 was endorsed by the World Health Assembly in 2013. Most countries (26, 93%) cited estimates of the prevalence of blindness and 18 countries (64%) had set targets for the cataract surgical rate in their plan. Other evidence was rarely cited or used to set measurable targets. No country cited evidence from systematic reviews or solution-based research. This limited use of evidence reflects its low availability, but also highlights incomplete use of existing evidence. For example, despite sex-disaggregated data and cataract surgical coverage being available from surveys in 20 countries (71%), these data were reported in the eye health plans of only nine countries (32%). Only three countries established sex-disaggregated indicators and only one country had set a target for cataract surgical coverage for future monitoring. Countries almost universally recognized the need to strengthen health information systems and almost one-third planned to undertake operational or intervention research. Realistic strategies need to be identified and supported to translate these intentions into action. To gain insights into how a country can strengthen its evidence-informed approach to eye-care planning, we reflect on the process underway to develop Kenya's seventh national plan (2019-2023).


Assuntos
Extração de Catarata/estatística & dados numéricos , Catarata/diagnóstico , Países em Desenvolvimento , Planejamento em Saúde/organização & administração , Programas Nacionais de Saúde/organização & administração , Fatores Etários , Cegueira/prevenção & controle , Extração de Catarata/economia , Saúde Global , Planejamento em Saúde/normas , Prioridades em Saúde , Humanos , Sistemas de Informação/normas , Aplicativos Móveis , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/normas , Fatores Sexuais , Organização Mundial da Saúde
11.
J Health Econ ; 61: 111-133, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30114564

RESUMO

This paper examines how health care providers respond to a reference pricing insurance program that increases consumer cost sharing when consumers choose high-priced surgical providers. We use geographic variation in the population covered by the program to estimate supply-side responses. We find limited evidence of market segmentation and price reductions for providers with baseline prices above the reference price. Finally, approximately 75% of the reduction in provider prices is in the form of a positive externality that benefits a population not subject to the program.


Assuntos
Custo Compartilhado de Seguro , Mecanismo de Reembolso , Procedimentos Cirúrgicos Operatórios/economia , Artroscopia/economia , California , Extração de Catarata/economia , Colonoscopia/economia , Custo Compartilhado de Seguro/economia , Custo Compartilhado de Seguro/métodos , Competição Econômica , Honorários Médicos , Humanos , Mecanismo de Reembolso/economia , Mecanismo de Reembolso/organização & administração , Reembolso de Incentivo/economia , Reembolso de Incentivo/organização & administração
12.
Graefes Arch Clin Exp Ophthalmol ; 256(11): 2181-2189, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30132278

RESUMO

PURPOSE: To produce an economic comparison of the iStent ab interno trabecular microbypass implant accompanying cataract surgery and selective laser trabeculoplasty (SLT) as first-line treatment versus topical medications for open-angle glaucoma in New Zealand in 2016. METHODS: The current annual costs of 19 available fully subsidised topical glaucoma medications by Pharmaceutical Management Agency (Pharmac) in 2016 were identified. Adjustments for pharmacist prescribing charges and previously described wastage levels were applied. The costs to perform iStent implantation and the cost to perform SLT were obtained from the local distributors, with the latter taking into account staff and consumable cost. Procedure costs divided by eye drops' cost produced a break-even level in equivalent years of eye drops use. RESULTS: The range of annual eye drop cost was NZD$42.25 to NZD$485.11, with an average of NZD$144.81. Comparison of annual eye drop cost with iStent cost revealed 3 of 19 (15.8%) drops breaking even within 5 years, 9 of 19 (47.3%) within 10 years, and 12 of 19 (63.2%) within 15 years. The cost of bilateral SLT performed by a consultant was NZD$102.30 (breaking even in 0.71 years). The equivalent cost for a registrar was NZD$97.59 (breaking even in 0.67 years). CONCLUSION: Economically, the iStent would appear to be a reasonably cost-effective treatment for glaucoma patients undergoing cataract surgery in a public healthcare setting in New Zealand, particularly for those using more expensive topical glaucoma medications, whilst SLT appears to be a worthwhile consideration as a first-line treatment for glaucoma in New Zealand.


Assuntos
Anti-Hipertensivos/economia , Extração de Catarata/economia , Análise Custo-Benefício , Implantes para Drenagem de Glaucoma/economia , Glaucoma de Ângulo Aberto/economia , Custos de Cuidados de Saúde , Trabeculectomia/economia , Idoso , Custos de Medicamentos , Feminino , Glaucoma de Ângulo Aberto/tratamento farmacológico , Glaucoma de Ângulo Aberto/cirurgia , Pesquisa sobre Serviços de Saúde , Humanos , Pressão Intraocular , Terapia a Laser/economia , Lasers de Estado Sólido/uso terapêutico , Masculino , Nova Zelândia , Soluções Oftálmicas/economia , Saúde Pública
13.
Eye (Lond) ; 32(9): 1530-1536, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29875386

RESUMO

INTRODUCTION: Surgical adjuncts in cataract surgery are often perceived as sometimes necessary, always expensive, particularly in the "lean" cost-saving era. However, prevention of a surgical complication, rather than subsequent management, should always be the preferred strategy. We wished to model real-world costs associated with surgical adjuncts use and test the maxim for cataract surgery-"if you think of it, use it". METHODS: We compared UK list prices for equipment and related costs of preventing vitreous loss (VL) via use of surgical adjuncts vs its subsequent management in a hypothetical cataract surgery scenario of a white swollen cataract with a moderately dilated pupil. RESULTS: The original surgery costs for the "cautious with adjuncts, no complications" approach was £943.54, including adjuncts costing £137.47. In the "minimalist, no adjunct" scenario, management of VL using the Anterior Vitrectomy Kit cost £142.45, and additional management and follow-up costs resulted in total cost of £1178.20 (£234.66 (25%) more expensive). If left aphakic, an additional operation for secondary iris clip IOL insertion and further follow-up to address the impact of the complication ultimately cost £2124.67 overall. An additional initial spend on surgical adjuncts of £137.47 could potentially prevent £1293.60 (9× increase) in direct costs in this scenario. CONCLUSIONS: Through simple scenario modelling, we have demonstrated the cost benefits provided by the use of precautionary surgical adjuncts during cataract surgery. VL costs significantly more in terms of complication management and follow-up. This supports the cataract surgeon's maxim-"if you think of it, use it".


Assuntos
Extração de Catarata/economia , Redução de Custos , Complicações Intraoperatórias/prevenção & controle , Extração de Catarata/instrumentação , Extração de Catarata/métodos , Humanos , Complicações Intraoperatórias/economia , Modelos Econômicos , Equipamentos Cirúrgicos/economia , Reino Unido
14.
J Gen Intern Med ; 33(8): 1352-1358, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29869143

RESUMO

BACKGROUND: Wide variations exist in price and quality for health-care services, but the link between price and quality remains uncertain. OBJECTIVE: This paper used claims data from a large commercially insured population to assess the association between both procedure- and provider-level prices and complication rates for three common outpatient surgical services. DESIGN: This is a retrospective cohort study. SETTING: The study used medical claims data from commercial health plans between 2009 and 2013 for three outpatient surgical services-joint arthroscopy, cataract surgery, and colonoscopy. MAIN MEASURES: For each procedure, price was assessed as the sum of patient, employer, and insurer spending. Complications were identified using existing algorithms specific to each service. Multivariate regressions were used to risk-adjust prices and complication rates. Provider-level price and complication rates were compared by calculating standardized differences that compared provider risk-adjusted price and complication rates with other providers within the same geographic market. The association between provider-level risk-adjusted price and complication rates was estimated using a linear regression. KEY RESULTS: Across the three services, there was an inverse association between both procedure- and provider-level prices and complication rates. For joint arthroscopy, cataract surgery, and colonoscopy, a one standard deviation increase in procedure-level price was associated with 1.06 (95% CI 1.05-1.08), 1.14 (95% CI 1.11-1.16), and 1.07 (95% CI 1.06-1.07) odds increases in the rate of procedural complications, respectively. A one standard deviation increase in risk-adjusted provider price was associated with 0.09 (95% CI 0.07 to 0.11), 0.02 (95% CI 0.003 to 0.05), and 0.32 (95% CI 0.29 to 0.34) standard deviation increases in the rate of provider risk-adjusted complication rates, respectively. LIMITATIONS: Results may be due to unobserved factors. Only three surgical services were examined, and the results may not generalize to other services and procedures. Quality measurements did not include patient satisfaction or experience measures. CONCLUSIONS: For three common outpatient surgical services, procedure- and provider-level prices are associated with modest increased rates of complication rates.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Artroplastia/economia , Extração de Catarata/economia , Colonoscopia/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Procedimentos Cirúrgicos Ambulatórios/economia , Procedimentos Cirúrgicos Ambulatórios/normas , Artroplastia/estatística & dados numéricos , Extração de Catarata/estatística & dados numéricos , Criança , Pré-Escolar , Colonoscopia/estatística & dados numéricos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde , Estudos Retrospectivos , Risco Ajustado , Estados Unidos , Adulto Jovem
15.
JAMA Ophthalmol ; 136(7): 796-802, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29800002

RESUMO

Importance: Uptake of cataract surgery in developing countries is much lower than that in developed countries. Cataract unawareness and financial barriers have been cited as the main causes. Under the Universal Coverage Scheme (UCS), Thailand introduced a central reimbursement (CR) system for cataract surgery. It is unknown if this financial arrangement could incentivize service provision (private or public) in areas that are hard to reach. Objective: To examine the association between the CR policy and access to cataract surgery in Thailand. Design, Setting, and Participants: Using time series analysis, hospitalization data during 2005 to 2015 for UCS members were analyzed for time trends and subnational variations in the cataract surgery rate (CSR) before and after the CR implementation. Main Outcomes and Measures: The annual growth in access was estimated using segmented regression. The CSR gap across regions was determined by the slope index of inequality (SII). Unequal access across districts was represented by the gap between the top and bottom quintiles. Results: During 2005 to 2015, a total of 0.98 million UCS members (mean [SD] age, 67.4 [11.2] years; 58.7% female) received cataract surgery. The number of cases increased from 77 897 in 2005 to 192 290 in 2015. At the national level, the CSR per 100 000 population increased from 352.0 to 378.7 cases in 2005 to 2008, to 716.3 cases in 2013, and then to 765.3 cases in 2015. With the use of mobile services through an exclusive CR, 3 private hospitals took the lead in service growth, sharing 79.2% of cases in the private sector in 2009. From 2010, the number of cases in public hospitals grew yearly by 12.6% to 13.6% until 2012, rose 21.7% in 2013, and then the rate of increase declined to that of 8.2% to 8.3% in 2014-2015. During the periods of an increase in overall access, the CSR gap across regions widened as indicated by the SII of 755.4 cases per 100 000 population in 2010 because of rapid uptake in areas with mobile services. When the national CSR became adequately large and mobile services were discouraged in 2013, the gap in 2014-2015 narrowed. Conclusions and Relevance: This study found that the appropriate payment and service designs helped reduce the cataract surgery backlog. With an adequately high CSR, Thailand is on track to reach the VISION 2020 goal, aiming for blindness elimination by the year 2020, which has been achieved by most developed countries.


Assuntos
Extração de Catarata/estatística & dados numéricos , Tabela de Remuneração de Serviços/estatística & dados numéricos , Financiamento Governamental/estatística & dados numéricos , Política de Saúde/tendências , Acesso aos Serviços de Saúde/estatística & dados numéricos , Sistema de Pagamento Prospectivo/estatística & dados numéricos , Cobertura Universal do Seguro de Saúde/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Catarata/epidemiologia , Extração de Catarata/economia , Países em Desenvolvimento , Feminino , Financiamento Governamental/economia , Hospitais Públicos , Humanos , Masculino , Pessoa de Meia-Idade , Tailândia/epidemiologia , Cobertura Universal do Seguro de Saúde/economia
16.
JAMA Ophthalmol ; 136(3): 231-238, 2018 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-29346472

RESUMO

Importance: Routine preoperative medical testing is not recommended for patients undergoing low-risk surgery, but testing is common before surgery. A 30-day preoperative testing window is conventionally used for study purposes; however, the extent of routine testing that occurs prior to that point is unknown. Objective: To improve on existing cost estimates by identifying all routine preoperative testing that takes place after the decision is made to perform cataract surgery. Design, Setting, and Participants: This cross-sectional study assessed preoperative care in a 50% sample of Medicare beneficiaries older than 66 years who underwent ambulatory cataract surgery in 2011. Data analysis was completed from March 2016 to October 2017. Main Outcomes and Measures: Using ocular biometry as a procedure-specific indicator to mark the start of the routine preoperative testing window, we measured testing rates in the interval between ocular biometry and cataract surgery and compared this with testing rates in the 6 months preceding biometry. We estimated the total cost of testing that occurred between biometry and cataract surgery. Results: A total of 440 857 patients underwent cataract surgery. A total of 423 710 (96.1%) had an ocular biometry claim before index surgery, of whom 264 514 (60.0%) were female; the mean (SD) age of the cohort was 76.1 (6.2) years. A total of 111 998 (25.4%) underwent surgery more than 30 days after biometry. Among patients with a biometry claim, the mean number of tests/patient/month increased from 1.1 in the baseline period to 1.7 in the interval between biometry and cataract surgery. Although preoperative testing peaked in all patients in the 30 days preceding surgery (1.8 tests/patient/month), the subset of patients with no overlap between postbiometry and presurgery periods experienced increased testing rates to 1.8 tests per patient per month in the 30 days after biometry, regardless of the elapsed time between biometry and surgery. The total estimated cost of routine preoperative testing in the full cohort was $22.7 million; we estimate that routine preoperative testing costs Medicare up to $45.4 million annually. Conclusions and Relevance: In this study of Medicare beneficiaries, routine preoperative medical testing occurs more often and is costlier than has been reported previously. Extra costs are attributable to testing that occurs prior to the 30-day window preceding surgery. As a cost-cutting measure, routine preoperative medical testing should be avoided in patients with cataracts throughout the interval between ocular biometry and cataract surgery.


Assuntos
Extração de Catarata/economia , Testes Diagnósticos de Rotina/economia , Custos de Cuidados de Saúde , Medicare/economia , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Biometria , Redução de Custos , Estudos Transversais , Bases de Dados Factuais , Feminino , Humanos , Masculino , Padrões de Prática Médica/estatística & dados numéricos , Cuidados Pré-Operatórios/estatística & dados numéricos , Estados Unidos
17.
Ophthalmic Epidemiol ; 25(3): 227-233, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29182463

RESUMO

PURPOSE: Direct medical and non-medical costs incurred by those undergoing subsidised cataract surgery at Gusau eye clinic, Zamfara state, were recently determined. The aim of this study was to assess the willingness to pay for cataract surgery among adults with severe visual impairment or blindness from cataract in rural Zamfara and to compare this to actual costs. METHODS: In three rural villages served by Gusau eye clinic, key informants helped identify 80 adults with bilateral severe visual impairment or blindness (<6/60), with cataract being the cause in at least one eye. The median amount participants were willing to pay for cataract surgery was determined. The proportion willing to pay actual costs of the (i) subsidised surgical fee (US$18.5), (ii) average non-medical expenses (US$25.2), and (iii) average total expenses (US$51.2) at Gusau eye clinic were calculated. Where participants would seek funds for surgery was determined. RESULTS: Among 80 participants (38% women), most (n = 73, 91%) were willing to pay something, ranging from

Assuntos
Atitude Frente a Saúde , Extração de Catarata/economia , Catarata/economia , Financiamento Pessoal/economia , Custos de Cuidados de Saúde , População Rural , Adulto , Idoso , Catarata/epidemiologia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nigéria/epidemiologia , Prevalência , Inquéritos e Questionários
18.
Indian J Ophthalmol ; 65(12): 1477-1482, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29208839

RESUMO

PURPOSE: The aim of the study was to evaluate the safety and efficacy of consecutive bilateral cataract surgery (CBCS) on two successive days in a single hospital visit. METHODS: Prospective study was conducted on 565 patients of various tribes of hilly area of West Rajasthan who had come to our hospital through community outreach programmed (CORP) between January 2015 and March 2016. Patients with significant bilateral cataract without any other ocular morbidity were advised bilateral manual small incision cataract surgery on two consecutive days. Intraoperative and postoperative complications were evaluated, and follow-up was done at 1 week, 1 month, and 3 months. RESULTS: Out of 565 patients, 519 underwent both eye surgeries. Second eye surgery was deferred for a later date in 46 cases. Because of intraoperative and postoperative complications in the first eye, 31 had delayed surgeries while 15 patients refused to undergo another eye surgery either because of postoperative day 1 poor vision in the operated eye due to retinal pathologies (n = 8) or unwillingness (n = 7). The second eye surgery was performed for 519 patients, out of whom six had intra or postoperative complications. At 1 month follow-up, four patients had unilateral cystoid macular edema and three had prolonged postoperative inflammation. At 3 months, all patients were satisfied and had no complications. None of the patients had sight-threatening complications such as endophthalmitis, corneal decompensation, or vitreoretinal complications. CONCLUSION: CBCS may be considered safe and cost-effective for patients living in remote locations, dependent on CORP.


Assuntos
Extração de Catarata/métodos , Economia Hospitalar , Hospitais , Complicações Intraoperatórias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Extração de Catarata/economia , Relações Comunidade-Instituição , Análise Custo-Benefício , Feminino , Seguimentos , Humanos , Incidência , Índia/epidemiologia , Complicações Intraoperatórias/economia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/economia , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento
19.
J Fr Ophtalmol ; 40(10): 860-864, 2017 Dec.
Artigo em Francês | MEDLINE | ID: mdl-29129336

RESUMO

INTRODUCTION: The gold standard of cataract surgery, phacoemulsification is the most commonly performed surgical procedure in France. Surgical instruction often takes place in the operating room where residents and fellows perform real surgery, supervised by an experienced surgeon. The goals of this study were double: evaluate surgical times according to the person performing the surgery, in order to quantitate the cost incurred by teaching and compare complication rate between surgeons. METHODS: A retrospective single center study was performed at Simone-Veil Hospital, Eaubonne-Montmorency, France. Over a period of 13 consecutive weeks from January to March 2016, all patients who underwent phacoemulsification for cataract extraction were included. Patients were separated into three groups, according to the primary surgeon: group S for Senior was composed of two experienced surgeons who typically performed over 500 procedures per year; group A for assistant was composed of three residents who performed less than 500 procedures per year; 2 inexperienced interns constituted group I. Surgery duration was recorded by the OR nurse in minutes between the first incision and removal of the lid speculum. The cost of operating room time was estimated at seven euros per minute. The occurrence of complications was determined from the operative report. RESULTS: 408 cataract surgeries were performed during the study period, divided into 156 eyes in group S, 142 in group A and 110 surgeries in group I. The mean age at surgery was 74.1±9 years (39-95), comparable in the 3 groups. The operative time was significantly shorter in group S (11.7min) than in A (18.7min; P<0.001) and in I (18.8min; P<0.001). The complication rate was higher in group I than in group S (P=0.03). The average additional cost related to the lengthening of the teaching procedure was 49 euros for Group A and 49.7 euros for Group I. DISCUSSION: The hospital reimbursement for cataract surgery is higher in the public sector than in the private sector; it can absorb the cost of university training. CONCLUSION: Teaching cataract surgery entails an additional financial cost for the hospital. It is also responsible for a higher human cost due to a greater number of operative complications with interns.


Assuntos
Extração de Catarata/economia , Extração de Catarata/educação , Hospitais Públicos/economia , Internato e Residência/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Catarata/economia , Catarata/epidemiologia , Extração de Catarata/efeitos adversos , Extração de Catarata/estatística & dados numéricos , Custos e Análise de Custo , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Facoemulsificação/efeitos adversos , Facoemulsificação/economia , Facoemulsificação/educação , Facoemulsificação/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
20.
Healthc Q ; 20(3): 69-71, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29132454

RESUMO

Coding accuracy is an important factor in ensuring hospitals receive adequate reimbursement from the government for healthcare services rendered. A retrospective review of 100 charts, the purpose of this study was to determine the degree of coding accuracy from the surgeon perspective, for outpatient procedures performed for ophthalmic services at St. Joseph's Healthcare Hamilton from July to December 2016. Using ICD-10-CA, Canadian Classification of Health Interventions, Quality-Based Procedures criteria where applicable, and the 3M Coding and Reimbursement system, this paper reveals three primary sources of coding errors and presents recommendations to increase accuracy of reimbursement for the benefit of both the Ministry of Health and hospital organizations.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Controle de Formulários e Registros , Procedimentos Cirúrgicos Oftalmológicos/economia , Procedimentos Cirúrgicos Ambulatórios/normas , Extração de Catarata/economia , Extração de Catarata/normas , Humanos , Ontário , Procedimentos Cirúrgicos Oftalmológicos/normas , Mecanismo de Reembolso , Estudos Retrospectivos
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