At Press Time

Report Assesses Cataract Surgery Efficiency

Patient Satisfaction Is Also Evaluated.

■ A recent survey focusing on cataract surgery efficiency and quality encompassing 16 practices and 286 patients in the ASC setting indicates that the vast majority of patients report a high level of satisfaction with their overall experience.

The survey was conducted as a benchmarking exercise by the Institute for Quality Improvement of the Accreditation Association for Ambulatory health Care.

The 16 practices that participated in the survey reported a median annual volume of 1,380 cataract cases. The median cost for supplies was $273.50 per case, with the practice reporting the lowest cost emphasizing that it had policies in place to standardize supplies, negotiate prices with vendors and use a buying group to keep supply prices down.

In terms of staffing costs, the practice reporting the lowest cost said it normally used two operating rooms with eight beds and two surgeons. It also relies on cross training, obtaining patient information in advance and having one RN who admits and one who discharges.

Overall facility time required per case ranged from 50 to 283 minutes, with a median of 115 minutes. The practice with the lowest facility time uses two ORs, gives a compounded drop for dilation so that only one drop is given, employs eight trays of instruments with no waiting for sterilization and primarily uses topical anesthesia.

All patients were surveyed to determine their overall satisfaction levels. More than 90% rated their experience as a “5,” the highest possible rating. Patient satisfaction ratings were based on such criteria as ease of scheduling, having surgery at the time scheduled, facility cleanliness, concern for patient comfort and time to return to normal activities. Almost all of the patients surveyed said they would recommend the facility in which they had their procedure to a relative or best friend.

Medicare Ends “Consult” Coding

A Major Fee Adjustment for Subspecialists.

■ Beginning with the start of 2010, Medicare has changed its coding procedures so that ophthalmologists will no longer be permitted to code for inpatient and outpatient consultations. Non-Medicare insurance carriers may still permit such coding under existing CPT codes but practices should check with individual carriers.

“There could be a significant loss of income for retinal physicians and other subspecialists, particularly those who practice in an ophthalmology group as an ophthalmic subspecialist,” says coding expert Riva Lee Asbell.

Ms. Asbell advises that all practices should quickly get up to speed on how to request reimbursement for patients who previously fell under the “consultation” category. She says these patients will now have to be categorized as “new patients” or “established patients,” depending on which criteria they meet. She notes that the criteria for a “new patient” changed several years ago and the more recent criteria must be used.

“For example, if nursing home patients were having meds renewed for a few years but not examined for more than three years, they would now be new patients if examined in the office, whereas before they would be established patients,” says Ms. Asbell.

A new patient is now defined by CPT and Medicare as a patient who has not received any face-to-face services from the practice (not the specific physician in the practice) for the past three years.

“Subspecialists in a group practice with other ophthalmologists (especially those who are retina specialists) will most acutely feel the loss of income caused by the inability to code for intraoffice consultations,” asserts Ms. Asbell. “Those encounters, formerly coded as consultations, now have to be coded as established patients.”

Ms. Asbell says practices must brush up on E/M coding and carefully select the code that best suits the circumstances, is in compliance with Medicare's rules (especially medical necessity) and optimizes reimbursement. Since these intraoffice referrals now must be coded as established patients, the basic choices will be between certain E/M codes and certain Eye codes.

Ms. Asbell cautions that not understanding the new rules could result in both loss of income and an audit. She says that now may be the time to obtain the services of a coding expert if the practice does not already have access to such expertise.

Alcon to Acquire Optonol, Ltd.

Ex-Press Glaucoma Shunt is Key Product.

■ Alcon has entered into a definitive agreement to acquire Optonol, Ltd., a medical device company that develops, manufactures and markets miniature surgical implants used to lower IOP in patients with glaucoma.

With this acquisition, Alcon will acquire Optonol's key commercialized product, the Ex-Press Mini Glaucoma Shunt.

In an article on glaucoma shunts in a recent issue of Ophthalmology Management, glaucoma specialist Andrew Rabinowitz described the Ex-Press and its implantation procedure:

“This device is a relative hybrid of an aqueous shunt and a trabeculectomy,” said Dr. Rabinowitz. “Unlike a trabeculectomy, which involves the removal of a block of trabecular tissue followed by an iridectomy, the Ex-Press is placed into the eye once a standard scleral flap has been fashioned. The device does not require removing any trabecular or scleral tissue. Additionally, it does not require, in most instances, the creation of a surgical iridectomy. This simplifies the surgery by removing these two steps.”

Dr. Rabinowitz notes that the ExPress may provide “an excellent platform” for less-experienced surgeons to transition from trabeculectomy to the addition of aqueous shunts to their surgical arsenal.

The Ex-Press mini-shunt.

Alcon believes that the acquisition of Optonol will complement the company's pharmaceutical products that lower IOP in patients with glaucoma and ocular hypertension, and will be additive to the company's growth opportunities.

“This transaction demonstrates Alcon's strong commitment to providing physicians with comprehensive treatment options for patients with glaucoma,” said Robert Warner, Alcon's vice president of US pharmaceutical products. “This surgical procedure provides incremental surgeon and patient benefits over trabeculectomy, which is currently considered the standard of care in glaucoma surgical therapy.”

The American Medical Association assigned the Ex-Press Mini Glaucoma Shunt to CPT 0192T effective July 1, 2008 and it is currently reimbursed by Medicare and other payers. The device is also approved and currently marketed in Europe, Canada, Australia and several other countries.

“The acquisition of Optonol is part of our strategy to bolster organic growth with targeted investments in key therapeutic areas that have the potential to contribute in both the near and long term,” said Kevin Buehler, Alcon's president and CEO. “Because the product is already approved in the United States and other major markets, it will begin contributing commercially in 2010.”

Research Digest

New & Noteworthy Journal Articles

Compiled by Andrew E. Mathis, PhD, Medical Editor

► No link found between phaco and AMD progression. A frequent concern of surgeons performing phacoemulsification on patients with dry AMD is that the underlying disease will progress to its more damaging wet form. These surgeons may have less reason to worry, according to a study in the November 2009 issue of Archives of Ophthalmology.

Physicians at SUNY-Stony Brook and Johns Hopkins enrolled 108 patients with dry AMD, all of whom were awaiting phaco, into their study. The team conducted fluorescein angiography preoperatively and postoperatively at week 1, month 3, and month 12 visits.

After disqualifying six of 71 eyes with gradable images because they had progressed less than one week following phaco or were missing images, the identified incidence of progression in the group was three of 65 eyes, or 4.6%.

The authors conclude, in part, that one reason a correlation may previously have been seen between AMD progression and phaco is lens opacity, with cataracts inhibiting the ability to completely image the retina. While they concede that larger studies are needed, the authors believe the relationship between phaco and AMD progression may ultimately be disproved.

► Bad news for repeat trabeculectomy. Two articles in the November 2009 issue of the American Journal of Ophthalmology on the topic of trabeculectomy for patients with glaucoma find that repeat surgeries are less effective.

Three-year data from the 312-patient Tube Versus Trabeculectomy (TVT) study comparing the safety and efficacy of trabeculectomy with mitomycin C (MMC) vs. nonvalved tube shunt surgery, concluded that tube shunt surgery is more successful than trabeculectomy with MMC with comparable efficacy. Postop complications were also higher with trabeculectomy, though none were serious.

A second study, conducted at the Jules Stein Eye Institute at UCLA, looked at 75 eyes in 67 patients who had undergone repeat trabeculectomy for open-angle glaucoma. The study team found that, in the case of eyes that underwent initial trabeculectomy with MMC, the success rate in lowering IOP was 20% higher than in patients who underwent repeat procedures. They further found that the younger age of repeat trabeculectomy patients and the need to use laser sutures were complicating factors in the repeat surgery group. The number of required medications was also lower in the initial trabeculectomy group.

The studies suggest a future trend for surgical glaucoma treatment, with newer procedures pushing out trabeculectomy and fewer repeat procedures.

► Higher corneal thickness in type 1 diabetes. Turkish ophthalmologists have published a study determining a correlation between type 1 diabetes in children and central corneal thickness (CCT).

The paper, which appears in the November 2009 issue of the Journal of Refractive Surgery reports data from examinations of 97 patients (59 with diabetes and 38 control subjects), who were compared in CCT measured by pachymetry. The thicknesses were then correlated with data concerning age, gender, duration of disease, mean and current hemoglobin a1c measurements and fasting blood-sugar levels.

The team found that patients with type 1 diabetes had significantly increased CCT, with a mean difference of −55 μm compared to the control group. While multivariate analysis was statistically significant for all variables, the only significant predictor was current hemoglobin a1c level.

The authors recommend that, because of the identified relationship between current hemoglobin level and corneal thickness, any refractive surgery on patients with type 1 diabetes require hemoglobin a1c levels checked preoperatively

► Does money cause vision loss? Seeking to determine whether the inverse correlation between socioeconomic status and rates of eye disease extended to retinal detachment, retinal physicians in Scotland conducted a multicenter analysis of 572 patients who presented with retinal detachments over a one-year period. Data including income, employment, health, education, housing, geographic accessibility and crime were applied to the patient group, which was divided into socioeconomic quartiles.

The ophthalmologists were surprised to find that, generally speaking, the more affluent a patient was, the more likely to develop a retinal detachment. The most affluent quartile had an incidence of retinal detachment 15.4 per 100,000, compared to 13.6, 9.3, and 6.9 in the second, third and fourth quartiles, respectively.

The Scottish team cannot explain this reverse correlation.

► Hope for dry eye in diabetic patients. Ophthalmologists at the Hershey Medical Center at Penn State University have found that topical application of naltrexone hydrochloride (NTX) may have a beneficial effect in treating dry eye in patients with diabetes.

In a paper appearing in the November 2009 Archives of Ophthalmology NTX, an opioid receptor antagonist used in the treatment of alcoholism and as an additive to painkillers to block euphoric side effects, was administered to rats with chemically induced type 1 diabetes. NTX was also found to restore corneal sensitivity when compared to eyedrops of insulin.

While the authors concede that no firm conclusions can be made, they nevertheless urge that more research be conducted on using opioid antagonists in cases of dry eye and reduced corneal sensitivity, both of which are common anterior-segment complications of diabetes.

Direct-to-Consumer Stirs Interest in IOL

B&L Takes Crystalens Message to the Public in Key Markets.

■ Bausch & Lomb's recent strategy of a direct-to-consumer advertising campaign for its Crystalens IOL in US test markets was a success in generating patient interest in the lens, according to some surgeons in those markets. Aimed at educating baby boomers and seniors, the ads appeared on television, radio and in print last year. Markets included St. Louis, Dallas and Raleigh-Durham, NC.

While B&L had notified local practices when the campaign was about to begin for their areas, Dawn Cavanaugh, chief operating officer at Pepose Vision Institute located in Chesterfield, Mo., says the increase in phone inquiries about the Crystalens was what alerted her that the campaign had begun.

“We definitely saw it on our phones. They were insisting on being seen by the surgeon right away and mentioning the Crystalens by name.”

Dean Dornic, MD, of Eye Specialists of Carolina, in Cary NC, reports that a number of patients mentioned seeing the Crystalens commercial. “And for the most part, they were new patients,” he says.

The average Crystalens-ad respondent tended to be well informed about what the IOL could do for vision. What they tended not to be informed about, however, was the additional out-of-pocket cost for the Crystalens. That part of the education process was left to the eyecare practices. Dr. Dornic reports that some patients did experience sticker shock.

“Patients would at first respond, ‘Oh, yeah, I've got Medicare, I've got this really good coinsurance, and they cover everything. And I have to say, ‘Nope, they don't cover that.’

When some patients who had come in asking for the Crystalens by name turned out to be unsuitable candidates for the IOL, Dr. Dornic and Ms. Cavanaugh report that they were amenable to whatever IOL the surgeon recommended for them.

“The baby boom generation are very informed consumers and they are quite adaptable to understanding why they would not be a candidate,” says Ms. Cavanaugh.

In some markets, however, the direct-to-consumer campaign simply could not trump the effects of the current economic downturn.

“We have not seen a major influx of inquiry,” as a result of the campaign, says Dan Chambers, practice administrator of Key-Whitman Eye Center, Dallas. “It's hard to adjust for it because the economy has continued to sour.” He noted fewer patients have asked about other premium IOLs in recent months either, which he also attributed to the recession.

Still, Mr. Chambers believes, direct-to-consumer advertising campaigns don't hurt. “It helps the brand image to create activity.”

Dr. Dornic agrees. “It helped to at least introduce the idea of premium IOLs to patients.”

Apologies Help Defuse Medical Errors

A Way to Maintain Patients' Trust.

■ Doctors who make full and heartfelt apologies for medical errors have a better chance of retaining patients' trust than doctors who provide general explanations of what went wrong, according to a study published in the September issue of the Journal of General Internal Medicine.

However, an apology, no matter how heartfelt, may not help to stave off a lawsuit.

Researchers at Johns Hopkins Bloomberg School of Public Health and the University of Florida showed videos of actors portraying physicians apologizing after medical mistakes; some of scenarios portrayed a full apology where the “doctors” took full responsibility, while others offered a non-specific or non-apology with no real acceptance of responsibility for the error.

“When viewers thought that the doctor had apologized and taken responsibility, they gave the doctors much higher ratings,” says author Albert Wu, MD, MPH, a professor at Johns Hopkins. About 81% of viewers said they still trusted the physician and 56% said they would still refer the physician after the apology, says Dr. Wu. “However, despite the positive reaction to perceived apology or responsibility, viewers were only slightly less inclined to want to sue.”