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Study: Femtosecond laser-assisted cataract surgery not as cost-effective as traditional phaco
For femtosecond lasers to become financially attractive, a significant reduction in click fees and/or consumables is needed.
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Despite potential improvements in visual acuity outcomes and complication rates, femtosecond laser-assisted cataract surgery is not as cost-effective as conventional phacoemulsification cataract surgery, according to a study.
“Thus far, promotion of femtosecond laser-assisted cataract surgery has been directed toward its efficacy and safety,” study co-author Brendan J. Vote, FRANZCO, a cataract and vitreoretinal specialist at Launceston Eye Institute, Australia, told Ocular Surgery News. “A greater cost from the addition of new technology can be acceptable if it is more efficacious than current practices. At the same time, safety profiles should be comparable. Theoretically, a safer and more efficacious procedure may be more efficient, resulting in increased patient turnover and fewer complications, which will reduce subsequent costs.”
The prospective cost-effectiveness analysis published in Ophthalmology used computer-based econometric modeling to evaluate a hypothetical cohort of patients derived from current literature and direct experience. The complication rates from surgery were gleaned from a review of the current literature, whereas improvements in best corrected visual acuity from the literature were used to calculate the increase in quality-adjusted life years (QALYs) in the cohort between 6 months and 1 year after surgery.
Because femtosecond laser-assisted cataract surgery is in its early stages, there has been limited research on efficacy and minimal evidence of superiority over conventional phacoemulsification, Vote said.
“As such, many surgeons are asking the question of how cost-effective the technology is at its current level. We wanted to illustrate to the ophthalmic community the costs involved in the technology and the effectiveness in regard to current and potential benefits of the technology, whether theoretical or realized,” Vote said.
Costs of the procedures
The study calculated the direct and indirect costs of the two procedures, including subsequent treatments and interventions as a result of complications or less desirable outcomes, as well as visual acuity measured as a utility of QALYs.
Brendan J. Vote
The authors found that at its current costs, and predicated on evidence of only limited improvements over phaco, femtosecond laser-assisted cataract surgery was not cost-effective when compared with current established cost-effectiveness thresholds. Calculations were based on simulated complication rates for both procedures and visual acuity improvement of 5% in uncomplicated cases of laser-assisted cataract surgery, using weighted cost of $3,500 for phaco and $4,500 for laser-assisted cataract surgery.
One of the main proposed and marketed benefits of laser-assisted cataract surgery is reduced corneal stress and hence potentially reduced corneal decompensation.
“However, already with [phaco], the risk of corneal decompensation is only about one in 2,000 cataract operations,” Vote said. “Interestingly, we found it would cost in excess of $5 million health dollars (cumulative patient costs) to save one cornea per 1,000 cataract surgeries from decompensation that would require corneal transplantation. This highlights that, on safety grounds alone, [laser-assisted cataract surgery] is hardly cost-effective.”
Cost-effectiveness
Until laser-assisted cataract surgery is able to demonstrate dramatic benefits over phaco, it is unlikely that many surgeons will be able to justify the extra expense associated with it, Vote said, especially when phaco is a procedure that is already performed very well.
Nonetheless, improved manufacturing processes and a greater market share should decrease the costs of the technology and consumables, and consequently the cost-effectiveness of the laser procedure.
Vote said that an overall reduction in patient cost to around $300 would make laser-assisted cataract surgery much more cost-effective, particularly by reducing the expense of the click fees and/or consumables.
“Even if the technology evolves as expected, such as the realization of improved visual outcomes and a reduction in complication rates, [laser-assisted cataract surgery] will not be cost-effective unless the cost to the patient is reduced significantly,” he said.
A best-case scenario for laser-assisted cataract surgery with 100% excellent visual outcomes, no complications and a reduced cost to the patient of $300 would result in an incremental cost-effectiveness ratio of $20,000, compared with $3,500 for phaco.
Meanwhile, a volume-based economic model for laser-assisted cataract surgery would allow broader uptake, with the increased volume bringing greater profit, even though the actual cost is reduced.
“For example, reducing the cost by half would likely increase uptake by more than fourfold,” Vote said. “This would enhance not only the cost- effectiveness of [laser-assisted cataract surgery], which benefits the patient, but also would not compromise the market viability of the laser procedure and may actually improve it.”
But even if laser-assisted cataract surgery proves to be more cost-effective than it is currently, price should not be the only criterion for performing one procedure over the other, Vote said.
“Surgeons need to be confident of safety and improved surgical outcomes,” Vote said. “There is also a learning curve associated with [laser-assisted cataract surgery], and an adopting surgeon/practice needs to determine how much benefit they will see from the surgery if they are already achieving superior outcomes with [conventional phaco].”– by Bob Kronemyer