SMART SHOPPER Cataract surgery's thin profit margin demands investing in products that provide significant clinical benefit or that attract patients and surgeons to your ORs.

The nearly 200 facility leaders who took our 5th annual Cataract Surgery Technology Survey provided a glimpse into what's driving purchasing decisions and which technological advances are catching on at eye centers across the country. Femtosecond lasers still haven't deeply penetrated the market — and facilities won't be adding a laser anytime soon if they haven't already done so. Facility leaders will gladly invest in ergonomic solutions such as heads-up video displays to protect their surgeons from repetitive stress injuries, but tighten up the purse strings when it comes to adding dropless cataract surgery, pupillary maintenance solutions or surgical microscope imaging upgrades.

The bottom line appears to be the bottom line: We get the sense that eye center administrators want to buy into the future of cataract surgery, as long as the price is right. Deciding where to spend your facility's hard-earned money demands considering not only the technology you'll add, but also the patients and surgeons who might go elsewhere if you don't pull the trigger on new purchases. "Your cataract service line must remain profitable and current," says Carol Cappella, RN, MSN, CNOR, clinical director of the Delray Beach (Fla.) Surgery Center. "You also have to look at what you can't afford to lose."

Lasers level off
Half of our survey's respondents currently offer femtosecond laser cataract surgery at their facilities and 45% own their platforms outright. A majority of respondents say the technology is used in fewer than half of all cataract cases performed at their facilities. When we asked those without lasers how likely they were to add the technology within the next 2 years, 75% said they're "unlikely" or "very unlikely" to do so.

The physician-owners of the 3-OR Eye Surgery Center at the Biltmore in Phoenix, Ariz., invested in a femtosecond platform in late 2012. About 45% of the center's 7,600 cataract patients choose to undergo laser surgery. The center has increased profits by charging patients for the use of the laser in pass-through fees that cover premium IOLs and improved refractive outcomes, says administrator Sharon Dillon, RN, CNOR, CASC, adding that aligning laser technology with pre-op diagnostic platforms — which feed patient data directly to the laser unit — maps out a surgical plan designed to improve the accuracy of lens implant placement and refractive outcomes, particularly in patients with astigmatism.

Ms. Dillon says the Eye Surgery Center made a substantial initial investment in the platform and faces ongoing per-case click fees and annual maintenance costs. The surgeons knew they'd need to perform 11 cases a month to break even over the 5-year finance term. They've blown that projection away by more than 250 cases per month.

The Delray Beach Surgery Center began leasing a femtosecond laser nearly 3 years ago and has plans to buy it outright when the lease ends in a couple of months. "We added the technology because we were afraid we'd lose patients if we didn't offer it," says Ms. Cappella. She can't pad facility fees for procedures involving the laser, so her center doesn't make money off the technology. In fact, she charges surgeons $700 each time they use the laser to recoup associated expenses.

Ms. Cappella opted to lease, but outsourcing laser technology or standard cataract equipment is a viable option for facilities without the case volume to fully support a cataract service line. About 1 in 10 (9.7%) of our survey's respondents work with an outsourcing firm, which isn't that surprising considering we targeted facilities with established cataract programs. Half of the facilities that do outsource are very satisfied with the arrangement, according to the survey.

Dorothy Zimdahl, RN, BS, CNOR, CASC, administrator of the eye-only ASC of Niagara in Niagara Falls, N.Y., looked into outsourcing cataract equipment when she worked at an acute care hospital. Although the hospital couldn't meet the minimum amount of cases the outsourcing firm required to bring equipment in, Ms. Zimdahl sees the potential benefit of using an outside service. She recently spoke with leaders at an orthopedic-focused center who were considering adding cataracts to their case mix. "It'd be an ideal fit for them," she says. "They could try out procedures with no commitment and see if they have the staff and surgeons to turn cases fast enough to eventually buy their own equipment."

SEEING IS BELIEVING Facility leaders pointed to premium IOLs as the primary technology that lets surgeons deliver on promises of excellent refractive outcomes.

Digging deeper
Here's what we found when we asked about dilation, going dropless, IV-free drugs and doctor discomfort.

Doing away with drops. Slightly more than one-third (35.2%) of our respondents say their surgeons use dropless cataract surgery, which involves injecting the eye with an antibiotic-steroid combination before closing, so patients don't have to self-administer eye drops post-operatively. Ms. Dillon's surgeons used to perform dropless surgery, but decided against the practice, because, she says, there was no way for the center to recoup the costs.

While dropless surgery adds about $23 to her case costs, Ms. Zimdahl believes the additional expense is well worth it to patients. "You spend money on technology that makes surgeons more efficient and improves clinical outcomes, but investing in dropless surgery provides direct benefit to patients who can't comply with post-op drop regimen or would have a hard time doing so," says Ms. Zimdahl. "It simplifies things for them."

No IVs needed. Only one-third (34%) of respondents support the use of "IV-free" anesthesia, which involves sedating patients by giving them 1 to 2 sublingual tablets containing midazolam, ketamine and an antiemetic. Ms. Dillon's staff and surgeons trialed the tablets, but decided against using them. "Sometimes 1 tablet wasn't enough, and 2 were too many," says Ms. Dillon. "We found that it took patients longer than the typical 10 to 15 minutes to recover after surgery."

The bigger issue is that the tablets are controlled substances that need to be refrigerated. "We had to figure out a way to double-lock the medications in a refrigerator," says Ms. Dillon, who ended up storing the tablets in a small safe placed in a refrigerator, which had French handles she could secure with a bike lock. "Those are things you don't think about."

Pupil maintenance. Roughly two-thirds (63%) of respondents say their surgeons use mechanical devices — Malyugin rings and iris hooks, for example — in less than 5% of cataract cases to maintain pupil size in patients who are difficult to dilate. The survey also shows that 45% of respondents say their surgeons use pharmaceutical pupillary dilations methods in less than 5% of cataract cases. However, one-third say their surgeons use the drugs in more than 20% of cases.

Ms. Dillon's surgeons trialed a pupillary dilation medication, but found it wasn't overly helpful and was also cost-prohibitive, even though her facility could apply for reimbursement. "If I'm paying $460 per case and waiting to be reimbursed, surgeons will see their dividends dwindle until that reimbursement comes back," says Ms. Dillon.

Pharmaceutical options for keeping pupils dilated were too expensive for the ASC of Niagara, says Ms. Zimdahl, so surgeons there now choose between epi-Shugarcaine ($26 per case), Malyugin rings and iris retractors ($100-plus per case).

Improved refractive outcomes. Promising patients that their vision will improve dramatically after surgery — and delivering on that promise — remains cataract surgery's foundation for success. Nearly all of our survey's respondents say multifocal IOLs (87%) and toric IOLs (94%) let surgeons achieve precise post-op visual results.

Ms. Cappella says a new IOL that promises excellent distance and intermediate vision and functional near vision has caught the eye of her surgeons, so she's had to adjust the lenses she keeps on consignment to ensure they have access to their preferred implants. Managing her lens inventory is no easy task. She tries to get surgeons to agree on a single lens, but often ends up with a closet packed with options.

Lens loading. Preloaded IOL-injection systems are used in only 38% of facilities, our survey found. That's somewhat surprising, considering the reported benefits they provide. Ms. Cappella says her surgical techs have to learn how to load various IOLs into various injectors. It's a difficult process that can result in torn lenses, wasted time and frustrated surgeons. "It's a skill you have to develop and practice," says Ms. Cappella. "Preloaded IOL-injector systems eliminate a lot of stress from the techs' perspective."

Surgeon satisfiers. The bad news: Ophthalmic surgeons who sit awkwardly for hours on end performing the same procedure over and over again are susceptible to debilitating neck and back strains. The good news: 80% of our respondents say they've invested in surgical microscopes with oculars that allow for a more natural posture and surgeon chairs or stools designed with ergonomics in mind. However, fewer than half (45%) of respondents say they've added heads-up surgical displays, which let surgeons operate by looking at a flat screen monitor instead of peering into a microscope.

One of Ms. Zimdahl's surgeons wanted to buy a heads-up display to improve his posture during surgery. "We're a new facility and the reality is that we can't invest in that technology right now," she says. "We need to take care of the basic stuff first, and determine where we'll get the most bang for our buck."

Do you want to be known as the center that always has shiny new equipment? Do you want to run a cost-effective facility that produces excellent outcomes? The 2 goals aren't mutually exclusive, but the secret to running a successful center often demands finding the sweet spot in between. OSM