FEMTOSECOND LASERS HERE TO STAY?

Femtosecond (Fs) lasers are widely touted as the next big thing in cataract surgery. Early studies suggest that the technology has the potential to improve precision and predictability while making some of the most difficult steps, such as capsulorhexis, much easier. it could also lead to a revolution in related fields such as lens design as the ability to manipulate the capsule to achieve reliable placement evolves. Recognising this potential, half of surgeons polled at the opening session of the XXiX Congress of the EsCRs said they would use the technology if cost were no object. But in the real world, the costs are high – just how high no one really knows, said EsCRs past-president and Board member Paul Rosen FRCS, FRCOphth, MBA, London. Complicating the issue further, the clinical benefits of Fs laserassisted cataract surgery have not yet been conclusively proven. 'Whenever we have a new technology we have to do a health technology assessment,' Dr Rosen said. Questions include: Does the technology work? Which patients benefit? What is the benefit? What is the cost? And, importantly, how does it compare to current practice? The review progresses in two stages. First is a review of published and unpublished literature. Then comes an economic evaluation – is the intervention cost effective compared to the current technology? Often, reality overtakes this formal process. Looking at the re-introduction of phaco in Europe in 1990, Dr Rosen noted that questions about cost and outcomes also were asked. he began a study in 1993 to examine the issues, and found that phaco produced better outcomes and improved throughput, and was therefore more costeffective – but in the eight years it took to publish. 'Within that eight years everyone had adopted phaco. so i can see certain parallels between what happened then and what is likely to happen now.'

Perceived value Cost-effectiveness analysis depends on the benefit achieved, and that benefit is different for different people. Providers may consider profit to be a benefit, while patients seek better individual outcomes that also benefit society. individuals may choose to spend more for a procedure that produces better outcomes, but the ideal is to come up with procedures that cost less but deliver the same or better outcomes. For policy purposes, cost effectiveness is typically judged in terms of cost per qualityadjusted life years (QALY). Currently the cost per QALY in the Us for standard cataract surgery is roughly $2,700. however, the abstract value set for this exercise may have little to do with the value individuals place on an outcome such as spectacle independence. As a result, some will be willing to pay more at the outset for the perceived benefit of a new technology. As costs come down and the benefits become clearer, others will try it. This phenomenon drives the product life cycle, in which risk-oriented innovators go first followed by early adopters. The lifecycle reaches maturity as the majority adopts it, Dr Rosen noted.

Dr Rosen believes there are two value propositions. For private practice, value is primarily related to quality while for public practice it is closely related to quantity and cost. These disparate concerns will likely drive how and when femto technology enters practice, Dr Rosen said. On the quality side, Fs technology allows better wound construction, better rhexis and better astigmatism management for a potentially safer and accurate outcome. But whether it actually reduces infection risk, results in a more predictable lens position, reduces capsule complications and vitreous loss or reduces ultrasound-related endothelial cell loss remains unknown. On the cost side, early estimates are that femto cataract systems will cost about €400,000 with maintenance running about €45,000 annually and per procedure fees and consumables in the €300 to €400 range. Also, how Fs technology will affect surgical process maps, staffing and procedure time is unknown. Extra time spent on surgery adds costs through other procedures forgone, Dr Rosen noted.

Adoption scenarios Factors influencing introduction of Fs cataract surgery vary by country, Dr Rosen said. They include demographics, wealth and disposable income, awareness and patient education, policies of government and private insurers, the ability to charge co-payments, and the drive for quality and lower costs. in the private sector, surgeons who get in early would be at an advantage. Dr Rosen estimates that breaking even over five years would require charging an extra €500 per procedure for 128 eyes per month up to €900 for 25 per month. While this is substantial, it could work. he cited an estimate by marketer sharif Mahdavi in the Us that about 30 per cent of patients would opt for femto cataract surgery at a price of an extra $1,000. The inelasticity of private demand suggests that lowering the price would not increase volume, Dr Rosen said. in the public sector, Fs cataract surgery could be adopted if it ends up saving money, including reduced costs for complications, or can demonstrate clearly superior outcomes, Dr Rosen said. he estimates the additional cost ranging from about €700 per eye for 25 cases a month down to €342 for 100-plus cases in the UK. 'it comes down to whether people are willing to pay that difference in a publicly funded system.' Dr Rosen noted that it is too soon to judge the costs or the benefits of Fs cataract surgery. But it is developing rapidly and purchasers should try to protect themselves with contracts that include upgrades. 'its initial presence will be in the private pay market, but i expect there will be gradual introduction in to the publicly funded healthcare market over the next five to 10 years. i believe it is a powerful technology that is here to stay.'