Customized ablation can lower practice’s re-treatment rate, improving bottom line

What’s good for patients is also good for practice profit and growth.

Issue: September 1, 2004

ByDaniel S. Durrie, MD

Most refractive surgeons provide LASIK enhancements when needed at little or no cost to the patient. But how many surgeons know the actual direct, indirect and opportunity costs associated with re-treatments?

The truth is that an enhancement costs much more than the $75 key card or click fee, which is why reducing that enhancement rate should be an important goal for every surgeon. The hope is always that new technology can help us achieve such goals.

Over the years, I have tracked my enhancement rate closely because I feel it reflects both the advancement of technology and my clinical skill and is also an important financial benchmark. Even though I am a relatively aggressive enhancer, I find that my enhancement rate has dropped significantly with the introduction of customized wavefront-driven ablation.

In 2002, when I was performing conventional LASIK surgery commercially with the Alcon LADARVision and Bausch & Lomb Technolas lasers, my enhancement rate was 6%. After converting to LADARVision CustomCornea in late 2002, my enhancement rate dropped to 3%. In the past year, I incorporated the IntraLase femtosecond laser into my standard procedure and my enhancement rate is now below 2% (Figure). In fact, my most recent 6-month evaluation of 200 eyes revealed only one enhancement.

This enhancement rate is far lower than I have ever seen in the past with any combination of technologies and it has tremendous benefits for my patients’ satisfaction with their outcomes, as well as for my bottom line.

The cost of re-treatment

Let’s look more closely at the costs associated with re-treatments (Table 1).

First, there are the direct costs, such as the key card fee and disposable products, as well as a facility fee for surgeons who don’t own their own laser center.

Next, we have to consider the indirect costs, such as staff time and, in my case, surgery center usage. I calculated how much I spend on staff salaries for a comprehensive preoperative exam and for postoperative exams. These figures do not include my own time.

Satisfied LASIK patients typically have three postop exams at our center: 1 day, 1 month, and 3 months, after which they are generally discharged. When an enhancement is needed, however, the patient comes in for a comprehensive dilated exam after the 3-month mark to confirm stability and obtain wavefront images for the second procedure. Following the enhancement, there will be the typical three postop exams and probably one additional. I think we all take greater caution and provide extra handholding for re-treatment patients.

The other indirect cost of re-treatments, which is harder to put a price tag on, is the potential damage to one’s reputation and referral rate. Patients who have an outstanding outcome the first time are much more likely to feel positively about the experience and refer their friends and family to our practice. Higher patient satisfaction correlates with practice growth through word-of-mouth referrals. Over time, this kind of referral base means you don’t have to market and advertise as much – another cost savings, although one that is harder to quantify.

Finally, one has to take into account the opportunity cost of performing enhancements. Every additional follow-up exam in an enhancement case takes the place of office visits that could generate new, revenue-building LASIK procedures.

Table 2 compares the financial implications of converting to custom surgery for a relatively high-volume practice performing 700 LASIK procedures per year. Using my costs per procedure as outlined in Table 1, we can see that this practice could save more than $33,000 per year by converting to custom ablation and reducing their re-treatment rate. When the lost time in the clinic and the opportunity costs of not seeing new patients are factored in, the net benefit of reducing the re-treatment rate increases dramatically to more than $488,000 per year.

Reducing the number of enhancements you perform makes sense, from both a clinical and financial perspective. It requires careful tracking of your current and future re-treatment rates, use of the latest technology, such as CustomCornea and IntraLase, and close attention to detail.

Achieving lower enhancement rates

In my opinion, the Alcon CustomCornea system does the best job helping surgeons improve their re-treatment rates for several reasons.

First, the custom ablation algorithm of CustomCornea has gone through more refinement than any other laser on the market, which allows for extreme accuracy of the treatment pattern. Along the way to wavefront ablation, all three laser companies have been refining these complex algorithms, resulting in lasers that are now able to more accurately correct the lower-order aberrations. Because of this, 20/20 uncorrected visual acuity rates have gone up dramatically from 60% to 70% a few years ago to around 90% today.

With CustomCornea, not only are lower-order aberrations being treated, but higher-order aberrations (HOAs) are being addressed as well.

CustomCornea is now showing low postop HOAs – the key to real customized ablations. We still aren’t completely eliminating aberrations, but the CustomCornea HOA induction rate is lower than that of conventional ablation and, in many cases, we are able to achieve a net reduction in HOAs, particularly coma and spherical aberration.

Most importantly, however, is that CustomCornea offers the best means of registering the wavefront to the eye’s position. The surgeon marks the eye and registers each of the wavefront readings and the laser treatment to those marks. This allows the surgeon to maintain alignment during surgery and compensate for cyclotorsion so that the treatment is applied more accurately.

We know that patients who have fewer HOAs have better contrast sensitivity and greater satisfaction with the procedure. As surgeons have converted to customized ablation, we have seen subjective satisfaction and the objective numbers on our tests improve compared to conventional ablations. More telling, though, are some of our cases of postop conventional LASIK patients with 20/20 Snellen acuity but poor quality of vision. These patients, after customized enhancement, are experiencing reduced aberrations and symptoms. Such cases solidify for me that wavefront-guided treatments are doing something besides just correcting sphere and cylinder. We are really correcting HOAs with CustomCornea.

The combination of a good aberrometer, good registration, a maximized laser algorithm and a laser-created flap that does not induce new aberrations has been essential to improving my outcomes.

I also have a highly skilled individual performing the aberrometry readings, which I personally review for accuracy. The importance of doing this cannot be overstated since the aberrometry readings drive the laser treatment. If the surgeon does not maintain careful oversight of the wavefront imaging process, it is akin to delegating refractive surgery planning to a technician.

All of these factors combined have led to a two-thirds reduction in our enhancement rate in recent years, which has lead to happier patients, more word-of-mouth referrals and a better bottom line.

For Your Information:

Daniel S. Durrie, MD, can be reached at Durrie Vision, 5520 College Blvd., Suite 201, Overland Park, KS 66211; 913-491-3737; fax: 913-469-6686. Dr. Durrie is a paid consultant for Alcon and IntraLase.