The pursuit of better work practices

Cataract surgery with lens implant is nowadays recognised as the commonest surgical procedure worldwide. It is no secret that in Malta we have a waiting list of over four years to have one’s cataract removed, with over 4,000 patients nervously waiting for this relatively quick operation. Most of these patients have to wait twice as long in order to have both eyes done.

At the same time, one must also consider that in developed countries people are living longer and, since cataract is essentially an age-related condition, the demand for cataract surgery is bound to increase.

In these times of cash constraints and national austerity measures, there are and will be increasing pressures to restrict health-care expenditure. Therefore, alternative methods to manage disease efficiently while maintaining quality of care are more than welcome.

Recently, in one of the most peer-reviewed journals dealing with eye diseases, the Journal of Cataract and Refractive Surgery of June 2011, Vol 37, pages 992 - 1014, a group of ophthalmologists from Helsinki published two articles on the benefits and drawbacks of performing cataract surgery on both eyes at the same session (simultaneous) as compared with spacing out the surgeries (sequential), as is customary.

The Helsinki bilateral cataract surgery study group firstly carried out a randomised controlled clinical trial, comparing the visual outcome of bilateral cataract surgery performed on the same day with those after sequential bilateral cataract surgery performed four to six weeks apart. Certain patients with particular ocular or medical conditions were excluded from the study.

The conclusions were that individuals from both groups had similar visual results and complications, irrespective of whether cataract surgery was performed simultaneously or sequentially.

In the second report, a detailed cost analysis of both groups was presented. While the surgical outcomes and patient satisfaction were similar in both groups, it was confirmed that sequential cataract surgery is more expensive than simultaneous surgeries. In health-care costs alone, €449 per patient were saved when resorting to simultaneous cataract surgery and if travel, paid home care costs and cost of working time were included this amounted to a total of €849 per patient.

In the past, when cataract surgery was not as refined as today, the risk of post-operative intraocular infection with potentially disastrous results was high on the list of worries for every eye surgeon and, therefore, the concept of simultaneous bilateral surgery was preposterous. However, nowadays, with the advent of keyhole sutureless surgery and better sterilisation techniques, the risk of post-operative infection is much lower, amounting to about 0.08 per cent.

Thus, such surgery is very safe in a selected group of patients. Also, in the eventuality of a rare case of post-operative intraocular infection, modern treatment strategies are highly effective.

We already perform several ocular procedures as simultaneous bilateral, including almost all refractive excimer laser and implant surgery.

Simultaneous surgery reduces the time spent by patients and medical staff in the overall process. One surgical event that is shorter than two put together.

Fewer post-operative visits, reduced administrative paperwork, less temporary disability and sick leave and reduced reliance on the support of family and friends are just some of the advantages. In this regard, the true economic saving of simultaneous bilateral cataract surgery goes far beyond one can imagine.

We also often underestimate the emotional stress or physical handicap that surgery and the post-operative period entail for certain patients. It goes without saying that for these individuals, eliminating a second intervention may be extremely desirable.

We as health professionals should all be more open-minded and receptive to new concepts as long as they are well documented. We should be encouraged to continuously audit our work practices in order to identify ways and means to improve the service we all endeavour to deliver to our patients. The cost effectiveness of new practices is an important component in the equation of a good proposition, especially in the times we are living in.

With the working environment and equipment being significantly improved since we migrated to Mater Dei Hospital, the health providers have a duty to the health authorities to economise on the service we provide as long as this is not detrimental to the patients. We have made major changes in our work practices, such as the increase in day case surgery, especially with high tech keyhole surgery being introduced in most surgical fields, but we definitely need to continue looking at ways and means to maximise our output without harming the recipient.

As long as a work practice is safe, time-efficient and cost-effective, then one is to recommend and adopt it.

The author is a consultant ophthalmic surgeon.