Carbon footprint and cost effectiveness of cataract surgery

Transcription

1 REVIEW C URRENT OPINION Carbon footprint and cost effectiveness of cataract surgery Rengaraj Venkatesh a,, Suzanne W. van Landingham b, Ashish M. Khodifad a, Aravind Haripriya c,, Cassandra L. Thiel d, Pradeep Ramulu b, and Alan L. Robin b,e,f,g Purpose of review This article raises awareness about the cost effectiveness and carbon footprint of various cataract surgery techniques, comparing their relative carbon emissions and expenses: manual small-incision cataract surgery (MSICS), phacoemulsification, and femtosecond laser-assisted cataract surgery. Recent findings As the most commonly performed surgical procedure worldwide, cataract surgery contributes significantly to global climate change. The carbon footprint of a single phacoemulsification cataract surgery is estimated to be comparable to that of a typical person s life for 1 week. Phacoemulsification has been estimated to be between 1.4 and 4.7 times more expensive than MSICS; however, given the lower degree of postoperative astigmatism and other potential complications, phacoemulsification may still be preferable to MSICS in relatively resource-rich settings requiring high levels of visual function. Limited data are currently available regarding the environmental and financial impact of femtosecond laser-assisted cataract surgery; however, in its current form, it appears to be the least cost-effective option. Summary Cataract surgery has a high value to patients. The relative environmental impact and cost of different types of cataract surgery should be considered as this treatment becomes even more broadly available globally and as new technologies are developed and implemented. Keywords carbon footprint, cataract surgery, cost effectiveness, manual small-incision cataract surgery, value-based medicine INTRODUCTION Cataract is the most common global cause of blindness, causing an estimated 51% of blindness in 2010 [1]. Cataract surgery is a cure to this disabling condition, and as such is in high demand worldwide. It is a one-time procedure, has an extremely high success rate, and requires minimal follow-up with resumption of prior levels of health related quality of life. Over the last 100 years and more so over the last 40, it has evolved remarkably from couching through intracapsular cataract extraction, conventional extracapsular cataract extraction, manual small-incision cataract surgery (MSICS), and phacoemulsification to femtosecond laser-assisted cataract surgery (FLACS), with each of the techniques having its own advantages and drawbacks. The main driving forces for these innovations have been improved visual outcomes, patient comfort, and increased reimbursement for the surgeon. Cost effectiveness and environmental impact of these techniques are also important, however, and are often under-addressed. The authors discuss a Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Pondicherry, Tamil Nadu, India, b Wilmer Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, c Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Madurai, Tamil Nadu, India, d Department of Civil and Environmental Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, e Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, f Department of Ophthalmology, University of Maryland and g Department of International Health, Bloomberg School of Public Health, Johns Hopkins, University, Baltimore, Maryland, USA Correspondence to Alan L. Robin, Department of Ophthalmology, University of Maryland, 6115 Falls Road, Baltimore, MD 21209, USA. Tel: ; fax: ; arobin@glaucomaexpert.com Rengaraj Venkatesh and Aravind Haripriya contributed equally to the writing of this article. Curr Opin Ophthalmol 2016, 27:82 88 DOI: /ICU Volume 27 Number 1 January 2016

2 Cost--effectiveness of cataract surgery Venkatesh et al. KEY POINTS Cataract surgery leaves a substantial carbon footprint. Innovations in cataract surgery should be studied and implemented with their environmental impact in mind. Cataract surgery is a very cost-effective procedure that has high value to the patient. MSICS is more cost-effective than phacoemulsification with comparable outcomes, arguing for its use in relatively resource-poor settings. herein these traditionally under-valued aspects, including the carbon footprint of cataract surgery and value-based cataract surgery, and compare the relative cost and environmental impact of three types of cataract surgery techniques in use today. CARBON FOOTPRINT OF CATARACT SURGERY Climate change is predicted to be one of the largest global health threats of the 21st century [2]. Human activities are the major driving force of these changes [3], with healthcare being a large contributor [4 &&,5]. For example, the carbon emissions of the National Health Service in England is estimated to be 20 million tons of greenhouse gases per annum and accounts for 25% of all public sector emissions in the UK [5]. Cataract surgery is one of the most commonly performed surgical procedures worldwide. In the UK, for instance, according to National Health Service data, over cataract extractions are performed annually [6]. The number of cataract surgeries performed in India in year is estimated to be more than 6.6 million [7]. Although similar data are not available for all countries, these findings from the UK and India illustrate the high volumes of cataract surgery performed worldwide, making it an ideal target for limiting the healthcare-related carbon footprint. product are expressed in the units of CO 2 equivalents (CO 2 eq). How does cataract surgery leave its carbon footprint? The environmental impact of cataract surgery arises out of the consumption of energy by machines and buildings, travel of patients and staff, transportation and manufacture of surgical products, and the use of drugs and stationery, among other things. All these activities can be classified into three main categories: (1) Direct emissions from building energy use. (2) Direct emissions from the travel of patients and staff. (3) Indirect procurement emissions defined as the emissions associated with the production, consumption, and disposal of all goods and services either consumed within the cataract pathway or arising in the industrial supply and disposal chains [4 && ]. Figure 1 illustrates an example of one cataract surgery workflow, highlighting the steps that contribute carbon emissions at either an eye camp or vision center where patients next proceed to have cataract surgery. Several studies have examined the carbon footprints of entire healthcare systems or various components thereof, although this represents a relatively new field of study [4 &&,5,9 13]. This sort of analysis involves many assumptions and estimations on the part of the investigators. For example, a calculation of how much carbon is emitted for a patient to travel to the eye clinic involves assuming the patient s mode of transportation, the fuel efficiency of the vehicle, and the distance from their home to the clinic. Furthermore, the generalizability of these studies is limited by the fact that these parameters may vary dramatically depending on setting and the workflow used. What is a carbon footprint? The effect of human activities on the environment is often expressed in the form of the carbon footprint of an activity. This refers to an assessment of the gaseous emissions resulting from the full life cycle of a product or process, with particular attention given to those emissions considered to be of relevance to climate change. The Kyoto Protocol identifies six main gases important to climate change out of which CO 2, the most commonly used, is the reference gas [8]. The total emissions of the activity/ Magnitude of carbon emissions Two studies by the same group represent the only published attempts thus far to quantify the carbon emissions associated with cataract surgery [4 &&,14]. In Somner and colleagues 2009 study, they compared the carbon footprint of phacoemulsification versus modified MSICS at two Scottish centers using two different stop strategies (number of patient visits per surgery). Their outcomes were the weight of the plastic and paper waste generated, the electricity used by the phacoemulsification machine, Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. 83

3 Cataract surgery and lens implantation Travel Referral from VC/Camp/GP Travel, building energy Hospital visit for consultation, preoperative work-up Travel, building energy Hospital visit for surgery Sterilization Surgery Instruments Waste disposal Building energy consumption Stationery Postoperative - Medications - Visits Drugs Linen IOL FIGURE 1. Flow chart showing the major steps of cataract consultation and surgery (central boxes) with component steps resulting in carbon admissions (side boxes). GP, general practitioner; IOL, intraocular lens; VC, vision center. and the emissions associated with patient travel. They calculated a 3.4-fold difference in plastic waste and a 1.7-fold difference in paper waste when comparing phacoemulsification with MSICS, and highlighted the difference in travel-related emissions associated with a one versus five-stop strategy. Morris and colleague s [4 && ] 2013 study represents a more sophisticated component analysis study estimating the carbon footprint of one patient s first eye cataract surgery at the University Hospital of Wales, Cardiff. They calculate the carbon footprint for one cataract operation as kg CO 2 eq [4 && ]. They do not specify what type of cataract surgery was performed, however, we have assumed that they are referring to phacoemulsification-type cataract surgery given the location and time of the study (UK, 2013). The authors put this finding into perspective by noting that the average carbon footprint of a UK resident is estimated at about 10 tons CO 2 eq/year [15 && ], meaning that cataract surgery in one eye will produce the same amount of CO 2 produced by the individual in 1 week of his life. In this study, building and energy use were estimated to account for 36.1% of overall emissions, travel 10.1% and procurement 53.8% [4 && ]. This finding is similar to the results of the few other published carbon footprinting studies in the medical literature [5,9 11]. In the procurement subsection, medical equipment accounted for the most emissions at 32.6% with pharmaceuticals being the second highest [4 && ]. This implies that production, transportation, maintenance, and disposal of the medical equipment and drugs account for a large portion of cataract surgery s environmental impact. The emissions accounting for waste management contribute only 1.88% [4 && ]. There are no published data regarding the carbon footprint of FLACS; however, it is logical to think that the emissions associated with FLACS would be higher than that of phacoemulsification because of the additional costly machine and its maintenance. Practical implications There is little literature published regarding the environmental impact of cataract surgery. The two studies described above represent an excellent start, and indicate that cataract surgery as currently practiced has an impressively large carbon footprint. Here, we will discuss some ways that this footprint is being decreased, or may be further decreased in the future. As discussed earlier, the production, transportation, and maintenance of medical equipment and pharmaceuticals account for the highest emissions. Advances in technology to make these procedures more eco-friendly will have a great impact. Telemedicine has the potential to reduce the number of preoperative and postoperative visits, which, as demonstrated by Somner and colleagues [14], can greatly decrease the environmental impact of this as well as any surgical procedure. Paper use can be reduced via electronic medical records and the use 84 Volume 27 Number 1 January 2016

4 Cost--effectiveness of cataract surgery Venkatesh et al. of electronic gadgets for patient education, vision charts, and visual acuity measurements. Making system-wide changes to use resources as efficiently as possible can further reduce the cataract surgery s carbon footprint. For instance, increasing volume while simultaneously maintaining the highest quality maximizes use of costly operating rooms. One can standardize instrument trays to contain all commonly needed instruments, whereas unusual or seldom-used items can be individually packaged, limiting the need for cleaning and repackaging. At Aravind Eye Care System, some of these measures are commonly employed like telemedicine, electronic medical records, electronic gadgets for visual acuity, standardized instrument sets, and maintaining high volume with high quality to maximize operating room utility. Although no published data are available, the authors have found these measures to be eco-friendly, efficient, and effective. The emissions accounting for waste management contribute only 1.88% [4 && ]. The introduction of strategies to recycle components of the waste is therefore likely to have a limited impact upon the overall carbon footprint. Such strategies should still be promoted, however, as they will lead both to staff awareness of the importance of sustainability within healthcare and at the same time be cost effective. To summarize, the innovation in cataract surgery should not only be driven by improved visual outcomes but in addition, technology should also be used to make the procedure more environmentally friendly. What we need is not just a 6/6 (20/20) outcome but also a sustainable, eco-friendly, cost-effective cataract surgery. COST EFFECTIVENESS OF CATARACT SURGERY An untreated cataract, with 20/80 vision in the better-seeing eye, is associated with a quality of life similar to that of renal dialysis and poorer than that associated with systemic arterial hypertension, diabetes mellitus, and human immunodeficiency virus infection [15 && ]. As such, it is obvious that cataract surgery, which offers a cure for this disabling condition, has great value to the individual patient. Because of the enormous prevalence of cataracts [1], however, treatment is very costly at a population level. Healthcare cost is an especially important consideration in developing countries. A method of cataract surgery that is cost effective, quick, low technology, and has an extremely low complication rate is needed. Cost effectiveness analysis of different cataract surgery techniques may be the best tool for helping healthcare providers and policy makers determine the best balance of quality and cost, particularly in resource-poor settings. This section will introduce the concepts of value-based medicine and cost effectiveness research, and then review the literature on this topic relevant to cataract surgery, with a focus on comparing the cost effectiveness of different types of cataract surgery. Value-based medicine and cost effectiveness analysis Value-based medicine is a field of study devoted to calculating the value of medical interventions. The cost consideration of any medical intervention takes two main aspects into account: human (patient) value and financial value [16]. The human value is defined as the improvement in quality of life, length of life gained, or both from an intervention. In cataract surgery, it is defined as the improvement in quality of life after surgery. The financial value considers the expenditures for each technique and the expenditures obviated by the intervention. Measures of financial value with regard to cataract surgery include reducing spectacle dependence (through improved refractive outcomes), reducing indirect healthcare costs related to comorbidities in the elderly as a result of poor vision, and reducing costly complications such as corneal decompensation, cystoid macular edema, and postoperative endophthalmitis. Cost effectiveness analysis is a form of valuebased medicine that calculates the resources spent per outcome achieved by an intervention. The dollar per quality-adjusted life year ($/QALY) is a popular unit used in cost effectiveness analysis. The QALY is a function of the utility value conferred by an intervention and the length of time that effect lasts (often the patient s life expectancy). The utility can be calculated in many ways, one common method being the time-tradeoff (example: a patient is asked to say how much they would be willing to shorten their life span in order to avoid and obtain better than 20/100 vision) [16]. Cost effectiveness of cataract surgery (any type) The first major, formal cost utility study of cataract surgery was published in 2002 by Busbee and colleagues [17]. This study used data from the 772 patients undergoing cataract extraction in the United States as part of the US National Cataract Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. 85

5 Cataract surgery and lens implantation Table 1. Cost in US dollars of phacoemulsification and manual small-incision cataract surgery Study Location Phacoemulsification (US$) MSICS (US$) Muralikrishnan et al. [19] India Gogate et al. [20] India Ruit et al. [21] Nepal Khan et al. [22 & ] India MSICS, manual small-incision cataract surgery. Patient Outcomes Research Team. Patients underwent surgery in 1991 and were followed for 4 months to determine short-term complications and visual outcomes. Nearly 67.3% of these patients underwent phacoemulsification and 32.7% had extracapsular cataract extraction; results were not separated by surgery type. Life expectancy and longterm visual outcomes were estimated using data from other investigations. The authors used previously published utility values based on time-tradeoff questions. The cost of cataract surgery was determined using published Medicare fee schedules for provider services and publically available pricing data for perioperative medications. The cost and likelihood of various complications of cataract surgery were also taken into account. The authors found that first-eye cataract surgery confers a 20.8% quality of life gain, and second-eye cataract surgery conveys an additional 12.7% increase in quality of life [17]. They calculated that the cost of first-eye cataract surgery in 1991 in the United States was $2525. The cost effectiveness was calculated as $2020/QALY. In the United States, interventions valued at less than $20 000/QALY are considered very cost-effective and those valued at more than $ /QALY are not cost-effective [18]. Thus, cataract surgery would be considered very cost-effective. Thesedatawereupdatedbythesamegroupin 2012 [15 && ]. They found that the direct cost of unilateral cataract surgery was then $2653. They calculated that the cost effectiveness from the standpoint of the payer was $1636/QALY for unilateral cataract surgery. In an additional analysis, however, they also used calculated medical (depression, injury, and nursing facility admission) and nonmedical (lost wages) costs incurred by having visually significant cataracts and estimated that cataract surgery actually had a net negative $74 759/QALY cost, indicating that once the indirect cost of vision loss is taken into account, cataract surgery may actually save society money. It should be noted that the cost of cataract surgery varies dramatically by setting, and the cost of cataract surgery calculated here is much greater than those from studies performed in some other countries (Table 1). Standards of cost effectiveness also vary depending on the resources available to the health system. Indeed, the WHO offers a formula for deciding whether or not an intervention is cost-effective in a particular country based on how the cost to avert one lost QALY for an intervention compares with the gross domestic product per capita [23]. Cost effectiveness of manual small-incision cataract surgery and phacoemulsification MSICS and phacoemulsification are often compared, as two methods of cataract surgery that have good outcomes and that may both be appropriate in different settings. Here, we will compare the two techniques and review the literature comparing their relative cost and cost effectiveness. MSICS is a commonly performed cataract surgery technique that is comparable with phacoemulsification in almost all aspects except postoperative astigmatism [24]. It is particularly useful in intumescent white cataracts, hard nuclei, black and brown cataracts, and lens-induced glaucoma cases [24 26]. It can also be performed under topical or sub-tenon s anesthesia, and temporal incisions may help to lessen the burden of postoperative astigmatism [24]. Furthermore, MSICS requires less expensive equipment, can be performed more quickly, and entails a smaller learning curve for the new surgeon. Phacoemulsification scores excellently with patient value analysis with a small incision, early rehabilitation, and less astigmatism providing reduced dependence on glasses. Modern phacoemulsification machines are expensive to purchase and maintain, have relatively high disposable costs, and require extensive surgical training [24]. Furthermore, for more advanced and mature cataracts, performing phacoemulsification becomes more difficult. Both MSICS and phacoemulsification give similar best-corrected visual acuity but unaided vision has been shown to be slightly better in 86 Volume 27 Number 1 January 2016

6 Cost--effectiveness of cataract surgery Venkatesh et al. phacoemulsification because of less astigmatism [24]. Several studies have compared the cost and cost effectiveness of phacoemulsification and MSICS. Muralikrishnan et al. [19], Gogate et al. [20], Ruit et al. [21], and Khan et al. [22 & ] found that phacoemulsification was between 1.4- and 4.7-fold more expensive than MSICS at their respective institutions in India [19,20,22 & ] and Nepal [21] (Table 1). Of these four studies, Khan et al. [22 & ] is the only one that conducted a formal cost effectiveness analysis of the two techniques. They randomized fifty-two patients presenting with a need for cataract surgery to receive either MSICS or phacoemulsification and found the two procedures to be similar in terms of vision outcomes, visual function, and QALYs gained. They calculated a value of $20.1/QALY for MSICS and $30.9/QALY for phacoemulsification. Because of its good patient value and cost effectiveness, MSICS may be the most appropriate technique in some high volume, low resource, and high backlog settings such as developing countries. The high cost of machine and longer learning curve [24,27] are potential drawbacks of phacoemulsification when compared with MSICS and these aspects make it less appropriate for limited resource settings. The excellent patient value profile (smaller incision, less astigmatism, earlier rehabilitation, reduced dependence on spectacles) of phacoemulsification makes it the preferred technique for affluent healthcare systems where cataract surgery is performed before the lenses are mature. Cost effectiveness of femtosecond laser-assisted cataract surgery FLACS is a new technology that some argue is improving cataract surgery. The reported benefits of FLACS include increased precision and reproducibility of anterior capsulotomy and subsequently improved effective lens positioning [28 30], reduced ultrasound power requirement during phacoemulsification [28,31 33] leading to a reduction in postoperative corneal endothelial cell loss [34], decreased collateral tissue damage [35], and better corneal wound architecture [33,36]. These reported advantages need to be validated by large-scale studies. One study by Abel et al. [37] demonstrated similar visual outcomes for FLACS and phacoemulsification, though some postulate that FLACS may reduce spectacle dependence compared with phacoemulsification cataract surgery. To our knowledge, there has been only one formal cost effectiveness analysis comparing FLACS with phacoemulsification to date [38 & ]. Abel and Vote modeled the $/QALY of FLACS and phacoemulsification in Australia, using the literature to estimate the risks of complications and the bestcorrected visual acuity following each procedure. They included the cost of purchasing and using the femtosecond laser in their analysis. They calculated a 0.06 gain in QALY over the life expectancy of the typical Australian cataract patient for FLACS compared with phacoemulsification, a difference driven mostly by the marginally decreased complication rate offered by FLACS. They calculated a $4378/QALY for phacoemulsification and a $ /QALY for FLACS (Australian dollars). This work would suggest that FLACS, irrespective of potential improvements in visual acuity outcomes and complication rates, is not currently cost effective when compared with MSICS or phacoemulsification. A significant reduction in the cost to patient (via reduced consumable/click cost) would increase the cost effectiveness of FLACS. CONCLUSION Overall, phacoemulsification remains the surgery of choice in affluent healthcare systems because of its high patient value profile and relatively good costeffectiveness. MSICS is preferred both in settings with significantly more difficult cases or in settings of high volume, low resources, and high case backlogs, often found in developing countries. FLACS surgery as currently performed is the least costeffective of the three techniques examined here, however, innovations to reduce its cost along with the studies to validate its reported advantages may make FLACS more cost-effective in the future. Limited data are available regarding the relative carbon footprint of different types of cataract surgery; however, it does seem proportional to the direct cost of the operation. Carbon footprint and cost effectiveness analysis are relatively new concepts in the field of ophthalmology. Although patient value remains the most important outcome in cataract surgery, both environmental impact and cost effectiveness should be considered in the development of new technologies and can help to inform healthcare policy makers. Given the differences in healthcare delivery environmental impact and costs throughout the world, the generalizability of the calculated carbon footprint, cost, and cost efficiency of cataract surgery in the studies outlined above is limited. The data do highlight important trends, however, and suggest the need for further study in this area Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. 87

7 Cataract surgery and lens implantation Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest. REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Pascolini D, Mariotti SP. Global estimates of visual impairment: Br J Ophthalmol 2012; 96: Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009; 373: Intergovernmental Panel on Climate Change 2007: summary for policymakers. Solomon S, Qin D, Manning M, et al., editors. Climate change 2007: the physical science basis. Contribution of working group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge: Cambridge University Press; && Morris DS, Wright T, Somner JEA, Connor A. 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Cost-effectiveness of femtosecond laser-assisted cataract & surgery versus phacoemulsification cataract surgery. Ophthalmology 2014; 121: The study is the only published formal cost effectiveness analysis of FLACS Volume 27 Number 1 January 2016