Cost-Effectiveness of Retinal Detachment Repair - PMC

Treatment and prevention of RD is extremely cost-effective when compared to other treatment of other retinal diseases regardless of treatment modality. RD treatment costs did not vary widely, suggesting providers can tailor patient treatments solely on the basis of optimizing anticipated results since there were not overriding differences in financial impact.

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In the non-facility, ASC surgery setting, weighted cost for PR ranged from $1,961 to $3,565 depending on the success rate of primary repair. The weighted costs for SB, PPV and laser prophylaxis were $4,873, $5,793 and $1,255, respectively. Dollars per line saved ranged from $139 to $982. The dollars per line-year saved ranged from $7&#;$49 and the dollars per QALY saved ranged from $232 to $1,637.

In the facility, hospital surgery setting, weighted cost for PR ranged from $3,726 to $5,901 depending on estimated success rate of primary repair. Weighted cost for SB was $6,770, for PPV was $7,940 and for laser prophylaxis was $1,955. The dollars per line saved ranged from $217 to $1,346 depending on the procedure. Dollars per line-year saved ranged from $11 to $67. Dollars per QALY saved ranged from $362 to $2,243.

Published clinical trials (index studies) of pneumatic retinopexy (PR), scleral buckling (SB), pars plana vitrectomy (PPV) and laser prophylaxis were used to quantitate surgical management and visual benefits. Markov analysis, with data from the Center of Medicare and Medicaid Services (CMS), was used to calculate adjusted costs of primary repair by each modality in a hospital-based and ambulatory surgery center (ASC) setting.

Few studies comparing cost-effectiveness of retinal reattachment surgery to other ophthalmologic or general medical treatments, or among techniques have been published. 14 , 19 , 20 Generally, cost considerations have not been a factor in clinical decision-making in choosing retinal reattachment treatments. Previous studies have outlined similar cost analyses for age-related macular degeneration (AMD), 20 diabetic macular edema (DME) 21 and retinal vein occlusion (RVO), 22 but treatment of RD has never been subjected to such an analysis of various treatment options.

Rhegmatogenous retinal detachment (RD), the most common type of retinal detachment, has long been the defining target of surgical retinal efforts. 1 In , the Medicare database reported a total of 21,762 RD repair procedures. 2 Untreated, retinal detachment usually leads to substantial, frequently severe, permanent vision loss, that might be accompanied by painful hypotony and phthisis. Many highly successful treatment options constitute the standard armamentarium including scleral buckling (SB), vitrectomy (PPV), and pneumatic retinopexy (PR). Many clinical trials and series comparing these methods of retinal detachment repair have shown comparable success rates, but have enumerated factors that are helpful in choosing the most suitable technique for certain subsets of patients. 3 &#; 19

Methods

Representative index studies were identified to ascertain representative anatomic success rates for each treatment modality of RD repair including PR,8,14&#;19 SB,4&#;8,10&#;13 PPV with or without SB4&#;12 and laser prophylaxis of RD.23 Based on these studies our models assumed 60%, 75%, or 90% success for PR, 85% success for SB, and 90% success for PPV with or without SB. Medicare fee data for were acquired from the Centers for Medicare and Medicaid Services (CMS) to ascertain the allowable cost (in United States dollars) associated with each procedure, study or office visit.24&#;28 The costs were calculated for both facility (hospital-based with surgery performed in a hospital operating room) practice in the geographic area of Miami, FL, and also for a non-facility (i.e. office based clinical services with surgery performance in an ambulatory surgery center (ASC)) in the same geographic area to demonstrate the range of potential reimbursement. The purpose in this dichotomy was to calculate the range of maximum and minimum possible incident costs for the various procedures. The permutations of a practice utilizing facility-based clinic visits with ASC-based surgery, and non-facility-based clinic visits and hospital based surgery would fall in between these limits. PR and laser prophylaxis costs were calculated as if done in an office, without the use of an operating room or anesthesiologist in both models. It should be noted, the differential of professional fees of facility versus non-facility costs is only relevant for clinical visits, not for surgical and treatment procedures.

The dollars per relative value unit (RVU) used (conversion factor) was $34.023 since that was the established rate for most of .25 The cost for a given provider service is an equation that considers work (w) RVUs (professional fees), practice expense (pe) RVUs, and malpractice (mp) RVUs, each of which are subject to geographic modifiers that adjust for costs and relative malpractice risk.25

A Markov analysis29 was performed to generate a cost for each procedure based on the anatomic success rates of index studies, but also for three different hypothetical success rates for PR. Four hypothetical treatment groups were modeled and analyzed (Figure 1) for each of the two different practice setting permutations described above.

Figure 1. Decision Model Used in Markov Analysis.

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PPV = pars plana vitrectomy, SB = scleral buckling. RD = retinal detachment. Phakic patients (assumed to be 70% of total cohort) were expected to require cataract surgery after PPV

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The first model was treatment with PR (in an office, without hospital or anesthesia fees); failures were treated by PPV with or without SB (costs are the same), and any subsequent re-operations treated with PPV. The second model was treatment with SB; failures were treated by PPV, and subsequent failures treated with PPV. The third model was treatment with primary PPV; failures were treated by PPV with or without SB, and subsequent failures were treated with PPV. For contrast, a final model was treatment of laser prophylaxis (also assumed to be done in an office without operating room or anesthesia fees) for a retinal break (assuming 95% success), with failures treated initially with SB, and subsequent failures treated with PPV to provide a sense of the cost of prophylactic therapy as well.

All phakic PPV patients were assumed to also require cataract surgery (phacoemulsification with intraocular lens implantation). The incidence of patients who were phakic was assumed to be 70% for all groups, a frequency of previous RD treatment cohort studies.7,17

The current procedural terminology (CPT) codes used for the procedures were as follows: for PR, for SB, for PPV, for PPV in cases of re-operation, and for laser demarcation of retinal breaks (Table 1). In addition to the costs of the RD repair procedure, the cost for associated cataract surgery (CE) (CPT code ), and one level 4 new patient visit (CPT code ) and three level 3 follow up visits (CPT code ) were added to the total cost to represent one year of continued treatment. In any instance, if the scenario called for PPV following a previous PPV (i.e. ), the &#;78 modifier was applied so that only 70% of the total reimbursement fee was applied for that procedure. If the PPV followed a SB, or if the SB followed PR or laser for a retinal break, the &#;58 modifier was used so the more complex procedure was calculated at 100% of the Medicare allowable. The reimbursement schedules for procedures are based on the CMS terminology for procedures done in hospital or in an ASC, but only CE, SB, and PPV were ever modeled to be performed in an operating suite setting. PR and laser prophylaxis of RD were modeled as performed in the clinic setting regardless of practice setting permutation. The setting of CE was considered to be the same as the setting of RD repair, thus the calculations for facility-based RD repair includes CE under hospital-based billing, and the calculations for non-facility-based RD repair includes CE in an ASC.

Table 1.

Medicare Allowable Costs for Retinal Detachment Repair and Associated Treatments

Facility, Hospital Operating Room Surgery Non-Facility, ASC Surgery Procedure CPT Code Professional Non-technical Anesthesia Total Professional Nontechnical Anesthesia Total PR $901 $1,442 &#; $2,343 $1,005 $0 &#; $1,005 SB $1,493 $2,914 $255 $4,662 $1,493 $1,635 $255 $3,383 PPV $1,892 $2,914 $255 $5,061 $1,892 $1,635 $255 $3,782 PPV +/&#; SB $1,563 $2,914 $255 $4,732 $1,563 $1,635 $255 $3,453 Laser prophylaxis of RD $583 $411 &#; $994 $615 $0 &#; $615 Cataract surgery $769 $1,730 $153 $2,652 $769 $971 $153 $1,893 Level 4 new patient visit $145 $128 &#; $273 $183 $0 &#; $183 Level 3 follow up visit $55 $74 &#; $128 $79 $0 &#; $79 Open in a new tab

Anesthesia professional fees (when applicable) were calculated based on the sum of base units and time units, multiplied by the conversion factor 25.52.28 CPT code , anesthesia for vitreoretinal surgery is weighed as 6 base units. One time unit is 15 minutes and an estimated one hour was applied for vitreoretinal cases. Thus, the anesthesia professional fee for vitreoretinal cases was calculated as $255. In cataract surgery, CPT code is weighed as 4 base units, and the cases were estimated to use 2 time units, for a total of $153 in anesthesia professional fees.

We assumed that an untreated retinal detachment results in 20/400, but that a successful repair preserves 20/25 for a macular sparing RD and 20/80 for a macula off RD. We also assumed that 70% of RDs are macular involving and 30% are macular sparing. We purposely chose the highest number reported for macular involving rates, and also chose what are probably better natural history assumptions, so that, if anything, our model for all procedures errs on the side of being less cost-effective. Patients undergoing reoperations were assumed to retain 20/400, thus representing a failure to yield any better vision compared to natural history. Based on this calculation, a retinal detachment repair was calculated to save 5.9 lines of vision, likely an underestimate. Furthermore, we assumed that the visual acuity (VA) results were the same regardless of the technique.17 An average age of 62 years old was used based on previous literature.7 Years of life expectancy were derived from actuarial tables of the Social Security Administration.30 Quality-adjusted life year (QALY) data were adapted from previously published articles; a conversion of 0.03 QALYs per line-year of vision saved was applied.31

Calculations and analysis were performed using Microsoft Excel (Microsoft Corporation, Seattle, WA) software.

takes place by using the laser to create a microscopic burn in the target tissue. The laser spots are usually applied in 1 of 3 patterns.

Before the procedure, you will be given eye drops to dilate your pupils. Rarely, you will receive a shot of a local anesthetic. The shot may be unpleasant. You will be awake and painless during the procedure.

You will be seated with your chin in a chin rest. A special lens will be Reflected into your eye. The lens acts as mirror that help the surgeon aim the laser. You will be instructed to look straight forward or at a target light with your other eye.

The doctor will aim the laser at the area of the retina. With every pulse of the laser, you will see a flash of light. Depending on the condition being treated, there may just be a few pulses, or as many as 500.

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