Premium IOLs: What Do Your Patients Really Think?

Post-surgical questionnaires help evaluate the technology and your practice.

BY MICHAEL P. VRABEC, M.D., F.A.C.S.

When your practice incorporates premium IOLs, there is an increasing need to ensure that the patient experiences in the office, at the time of surgery and postoperatively, are the best you can make them. You also want to know whether the refractive solution you provided (in the case here, a presbyopia-correcting IOL) has met their expectations. The most direct way to measure both the patient's experience and satisfaction with the outcome is to ask them. We have created a survey to do exactly that (see below).

Survey Review

We typically mail out surveys to all premium IOL patients a month after the second eye has undergone surgery. Our estimate is that 30% to 40% of patients return the surveys to us.

There are 13 questions to the survey that have been chosen to help us evaluate patient visual results (Q1-Q3), their spectacle independence (Q4), visual disturbances (Q5-Q6), presbyopic IOL value (Q7-Q9) and their overall rating of their clinical experience (Q10). Questions 11 and 12 provide us with some chance to correlate their answers with their visual needs, while question 13 is open-ended. We also track what lens implant was used to correct each patient, which again gives us a chance to correlate answers to specific technologies.

Reading the surveys is, of course, only the start. To be truly effective, you and your staff should be ready to review the questionnaires in detail, learn from them and implement necessary changes where they are indicated.

I would suggest several approaches:

The first thing we do is to look at the questionnaires individually. Of particular interest are patients who are very happy or very unhappy. We evaluate specific comments regarding the preoperative, surgical and postoperative experience in the office. For those who are very satisfied, we want to look for ways to recreate their positive experience for our other patients. If a survey includes comments that highlight the work of a specific individual, I use the feedback for staff reinforcement and to credit those involved. Reading positive survey comments in our standing refractive surgery staff meetings is both satisfying and motivating. With patients whose experience was less satisfactory, we also look for specifics to determine if changes should or could be made to our procedures.

We also review the chart. Sometimes a single procedure, such as a YAG capsulotomy or LASIK to correct residual astigmatism, can make all the difference in a patient's outcome. When there are negative comments they are also read aloud, but without identifying the patient or staff member involved. This provides a chance to discuss how we might have improved the situation for that patient.

When we look at the questionnaires individually, one of the other things we do is determine the overall satisfaction of the patient. This is generally self-evident if responses are at the extreme ends of a survey question and when any comments are included. We categorize the patients as "happy," "neutral" or "unhappy." We can then look at the aggregate question responses for each of these three groups to tell us where we are exceeding expectations, or to try to determine the source of any apparent dissatisfaction.

There is no hard and fast rule as to how to review aggregate statistics. Averages can be used but they can sometimes mask what is going on. For instance, on a scale of one to 10 in a question there is a big difference if the average of eight patient scores is 5.0 but four scores of 10 and four scores of 0 were recorded, compared with eight scores of 5.0. We often look at the percentage of patients with a particular score or range of scores to determine where the majority of the patients fall. And, just as there are no hard and fast rules regarding analysis, how you implement changes suggested by the results of a survey will vary.

The other thing to keep in mind is that responses are also a reflection of expectations. As with any premium product, out-of-pocket expenses for premium IOLs raise patients' expectations. Properly setting those expectations preoperatively will have an effect on subjective satisfaction ratings in any postoperative questionnaire.

Finally, some patients will be extremely happy (or extremely unhappy) no matter what their experience. So, while the "extreme" responses may help you identify areas of particular strength or weakness, looking for the response of the majority of patients is also critical.

Recent Results

In one recent 4-month period, we had a total of 81 questionnaires returned. Of these, 29 were bilateral ReZoom (AMO, Santa Ana, Calif.) patients and 34 were bilateral ReSTOR (Alcon, Fort Worth, Texas) (non-aspheric) patients with another 10 patients having a mixed ReSTOR/ReZoom combination; the final eight patients were unilateral corrections. While not exhaustive, some of the findings of interest are listed here as an example of what analysis of patient questionnaires can tell you about your practice and your choice of lenses.

An item of considerable interest to patients is, of course, their degree of spectacle independence, as this is their primary measure of success. Table 1 shows the percentages of spectacle independence achieved by the various patient groups. Of interest here is the mix/match group. While mixing and matching is suggested to decrease patients' dependence on spectacles, we found that spectacle independence was lowest in this group and the likelihood of wearing glasses most of the time was highest. This was one of the reasons we moved away from mixing and matching to using the same implant in both eyes.

An interesting but not surprising finding is that spectacle independence appears correlated with patient happiness. Table 2 shows the percentage of happy patients using the spectacle independence ratings from Table 1. The likelihood of a happy patient when spectacle independence is achieved is 75%, but the likelihood of a happy patient when they are wearing spectacles most of the time is only 14%.

A critical question is, of course, how patients rate their care at the clinic. A total of 87% rated care as 7 or higher on our 10-point scale, with fewer than one in ten rating it below 5. All of the latter patients are categorized in the "unhappy" category. Looking in more detail at this subgroup, there was no clear trend. However, the majority of them were wearing spectacles more than 50% of the time and one patient, who wore spectacles only 10% of the time, was experiencing significant halos. The comments on these surveys are of particular importance to us so that we can better understand the source of the dissatisfaction, whether it was setting expectations or communicating the likelihood of spectacle independence.

Conclusions

I feel that the information we have gained in surveying our patients has been very valuable in terms of fine-tuning our clinic experience and determining our use of the various presbyopic lens options. However, to be effective requires a major commitment from you and your staff. Surveys take time to administer and evaluate. If you are conducting the surveys in-house, it is important to provide a location where patients can feel free to fill out the questionnaire in privacy and without being rushed. Some staff training will also be required to ensure that the questionnaire is presented appropriately to patients and to ensure that patients understand that their opinions are valued. These requirements add up to additional work for your staff, so it is important to demonstrate to them that the data collected are being used to positively affect the practice.

In closing, it is worth reiterating that patients can be your biggest advocates and word-of-mouth referral can be a powerful practice growth tool, particularly in the area of presbyopia-correcting IOLs. Using a questionnaire to evaluate both the patient experience in your practice and patient satisfaction with their implant choice allows you to maximize the patient experience and increase the likelihood of continued referrals. OM

Dr. Vrabec is in private practice at Valley Eye Associates in Appleton, Wisc. The practice includes LASIK, premium IOL cataract surgery and corneal transplantation.