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    Insider secrets to improve value-based medicine

    Drs. Gary and Melissa Brown share lifelong vision for improved patient quality of life

     

    We looked at the value of cataract surgery as it impacts the lives of thousands of patients. A very detailed questionnaire is used to measure a patient’s perception of function, work, hobbies, and independence. These responses are correlated with ophthalmic findings, such as best-corrected vision, age, density of cataract, whether it is unilateral or bilateral, and presence of other conditions, such as age-related macular degeneration. We found that cataract surgery on the first eye provided a huge increase in value for the patient’s life and an enormous return to society.

    Blog: In defense of OD-performed surgeries

    MELISSA: QALY also allows us to compare and contrast different treatments. For example, we found that cataract surgery on patients’ first eye led to a 20.8% improvement in their quality of life. Cataract surgery on both eyes led to an increase of more than 36%, a huge improvement.

    This contrasts with the treatment of systemic hypertension with beta-blockers with improvement of around 8.0%. Today, cataract surgery’s fees have decreased 89.9% since 1985.

    Gary and I found that cataract surgery on the first eye yields an extraordinary 4,567% financial return on investment to society over the 13 years that we have studied it. This return factors in gains to society, such as a return to work, independent and safer living, and allowing caretakers to pursue other productive activities. Although surgery on the second eye didn’t provide the same increase, it did provide a very positive return.

    Gary Brown, MD, MBAGARY: And it draws a bright line between cost and value. We found that focal laser therapy for a subretinal neovascular membrane is effective compared with anti-VEGF therapy when only considering cost. But, when applying QALY standards to each, anti-VEGF has a much higher benefit correlation and provides greater value to the patient as well as society. Cost and value are very different things although payers don’t often differentiate the two.

    DR. NOREIKA: Melissa, you’ve had some first-hand experience in the political arena. What have you learned? How has it helped?

    MELISSA: I ran twice for the House of Representatives from my district in Montgomery county and Northeast Philadelphia. Although unsuccessful, it provided me an intimate understnading of the inner workings of Washington, DC.

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    • STEPHENHSINCLAIR
      Re: focal points presentation of the editorial advisory board appearing in Ophthalmology Times May 2015 “At the Center of Pursuit for Value –-Based Medicine" Dear Dr. Noreika, I read your Sight Lines article about the timeless work and lifelong vision of Gary and Melissa Brown toward improving the evaluation of patient quality of life that we provide our patients by our medical care. I am well aware of their work and of the dedication of these two timely physicians as well as the increased concern voiced in the medical literature and by CMS demanding our attention in this regard. The problem I have is with the chronic dependency of ophthalmology and optometry upon utilizing chart visual acuity in the measurement of our outcomes, and, as you are aware it is the basis of the Brown's research in evaluating ocular procedures against others in defining their Quality – Adjusted Life – Years (QALY) methodology. The difficulty of this is that while we have measured vision outcomes using chart acuity for more than 160 years, this method is a poor psychophysical threshold and, contrary to popular belief, has never been validated against visual performance. To the contrary, studies such as the Smith-Kettlewell Foundation’s measurement of visual decline in normal eyes of aging individuals (60 – 90) demonstrate that it only very poorly detects the severe decline in vision performance, even in these “normal eyes"(1). While ophthalmic surgeons and optometrists have utilized this measurement as justification for what we do, it would be similar to the orthopedic surgeon evaluating the outcome of their surgical manipulation or joint implantation by measuring the position of the limb before and after surgery but failing to measure the range of motion, stability of the joint, strength of the joint, the pain associated with operation of the joint, or the performance of that joint in a number of desired daily activities (playing golf, hitting a tennis ball). I recognize that for FDA trials in which ophthalmologists participate, recompensed by pharmaceutical companies, very often quality-of-life visual function questionnaires are recorded as well as measurements of visual acuity. However at meetings, patient reported outcomes are never reported. Why? because “docs don’t want to hear about this.” I have informally polled approximately 200 retina specialists, 100 cataract surgeons and more than 50 LASIK surgeons, but outside of such pharmaceutical trials, VFQ’s are never performed in the office. I have read the Brown's book, “Evidence – Based to Value –-Based Medicine” published in 2005 and applaud their work in their attempt to prove to the rest of the medical world “that the benefit ophthalmology provides for them (these baby boomers) and society as a whole is enormous but won't be rewarded unless we educate those who determine our compensation and formulate regulations to ophthalmology's value." In order to define the value that our surgical procedures and office work provide to our patients, we must proceed beyond the mere measurement of chart acuity or chart contrast sensitivity measurements. Enabling that direction, I have invented an iPad-based application that allows the patient to easily record answers to standard visual function questionnaires (such as the NEIVFQ-25) in large print while sitting in the waiting room, waiting to see the doctor. The results are uploaded to the cloud where they can be compared against prior measurements, measurements of other patients, or other’s results as well for research. The app also provides printouts that are meant to be given to the patient providing general recommendations to assist the tasks for which they have noted difficulties (and acknowledging the physician’s concern and caring). I believe that apps such as this should be strongly recommended for physicians to add to their examinations in justifying the office and operating room procedures for which we ask reimbursement. Certainly as David Parke has commiserated with me, in the future we will just be relegated to the Wall Street Journal’s list of overpaid clinicians. In the zero-sum dollars competition for medical care allocated payments we have to use every method feasible to demonstrate to the world our value at a time when the baby boomers need us the most. I would encourage you to publish an article regarding this and perhaps other related apps and encourage their use. Stephen Sinclair Sinclair Retina Associates (http://sinclairretinaassociates.com) Sinclair Technologies (http://sinclairtechnologiesllc.com) 200 E. State Street, Suite 301 Media, Pa. 19063 610-892-1708 [email protected]

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