Variations in Cataract Management: Patient and Economic Outcomes Earl P. Steinberg, Marilyn Bergner, Alfred Sommer, M.D., Gerard F Anderson, Eric B. Bass, M.D., Joseph Canner, Alan Ael. Gittelsohn, Jonathan Javitt, M.D., Margaret M. Kolb, Neil R. Powe, M.D., Donald M. Steinwachs, James M. Tielsch, andJonathan P Weiner Cataracts are the leading cause of blindness, and especially avoidable blindness, in the United States. To minimize the visual and functional impairment caused by cataracts, more than one million cataract extractions are performed each year on Medicare beneficiaries, making cataract extraction the most common surgical procedure performed on elderly individuals in this country. The costs of cataract surgery and the associated visual rehabilitation are estimated to total $2.5 billion annually. These costs are growing rapidly due to the increased number This research is being supported by grant no. 1 PO1-HS06280 from the Agency for Health Care Policy and Research. Address correspondence and requests for reprints to Earl P. Steinberg, M.D., M.P.P., Associate Professor of Medicine, Departments of Medicine and Health Policy and Management, Johns Hopkins University, 1830 E. Monument Street, Room 8068, Baltimore, MD 21205. Members of the interdisciplinary PORT, all at Johns Hopkins University, are: Marilyn Bergner, Ph.D., Professor, Health Policy and Management; Alfred Sommer, M.D., Professor, Ophthalmology; Gerard F. Anderson, Ph.D., Associate Professor, Health Policy and Management; Eric B. Bass, M.D., M.P.H., Instructor, medicine; Joseph Canner, B.S., Statistician/Analyst, Medicine; Alan M. Gittelsohn, Ph.D., Professor, Biostatistics; Jonathan Javitt, M.D., Assistant Professor, Ophthalmology at Georgetown University, Washington, DC; Margaret M. Kolb, Dr.P.H., Research Associate, Health Policy and Management; Neil R. Powe, M.D., M.P.H., M.B.A., Assistant Professor, Medicine; Donald M. Steinwachs, Ph.D., Professor, Health Policy and Management; James M. Tielsch, Ph.D., Assistant Professor, Ophthalmology; and Jonathan P. Weiner, Dr.P.H., Associate Professor, Health Policy and Management.
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of elderly persons in the United States and the increased rate at which cataract extractions are being performed nationwide. Data from several sources suggest that substantial variation exists across different metropolitan areas, not only in the rate of cataract surgery, but also in the approaches taken by ophthalmologists in the preoperative, intraoperative, and postoperative management of patients with cataracts. For example, some ophthalmologists regularly do specular microscopy and B-scan ultrasound as part of their preoperative evaluation, while others do not. This leads to considerable variation in the cost of preoperative evaluation and possibly to variation in the stage at which cataracts are extracted. Variation also exists in the surgical technique (intracapsular, extracapsular, and phacoemulsification) used to extract a cataract. Postoperative management of cataract patients varies as well, for example, in terms of the frequency of follow-up visits and the use of YAG laser capsulotomy. These types of variations in clinical practice have attracted increasing attention in recent years, largely due to recognition of the likelihood that observed variations in practice may be indicators of over- or undertreatment and may have important clinical, economic, and policy implications. In September 1989, we received funding from what is now the Agency for Health Care Policy and Research (AHCPR) to form a multidisciplinary team to study variations in the management of cataracts, the consequences of such variation, and potential interventions that could be employed in response to such variation. The specific goals of our patient outcome research team (PORT) are: 1. To identify the extent of variation in the pre-, intra-, and postoperative management of Medicare beneficiaries with cataract(s); 2. To examine the clinical and functional outcomes, level of patient satisfaction, and cost associated with alternative cataract management strategies; 3. To determine the values placed on specific clinical and functional outcomes by patients and ophthalmologists; 4. To define "appropriate" or "optimal" management strategies for different categories of cataract patients, and delineate the specific factors, including patient and physician characteristics, that determine why a particular management strategy is considered to be "optimal" for a particular category of patient;
PORT: Cataract Managmnt
729
5. To develop insight into the provider characteristics and local market factors associated with various cataract management strategies, and to develop insight into the factors underlying or motivating current patterns of practice; 6. To develop an intervention strategy that is capable of bringing actual practice into closer compliance with "optimal" management strategies (i.e., to reduce variability in practice in ways that will optimize patient and economic outcomes); and 7. To develop a plan for evaluating the effect of the intervention. To accomplish these goals, we plan to collect and analyze data from a variety of sources. One arduous task will be to review and synthesize the clinical literature related to cataract surgery-a literature that we estimate to consist of approximately 3,000 potentially relevant articles published during the past ten years. Our primary objective in this literature synthesis is to estimate the probability that each of many potential outcomes will occur in a specified type of patient who is managed in a particular way. Since most of the cataract surgery literature consists of observational studies, rather than randomized clinical trials, we will need to adapt traditional meta-analysis techniques for use in our project. We also plan to perform extensive analyses of Medicare claims data (Parts A and B) to help define the extent of variation in several aspects of management of individuals with cataract(s), to identify factors associated with such variation, to estimate the frequency with which various complications occur during or after surgery, and to estimate the direct costs associated with alternative strategies for managing patients with cataracts. Because the vast majority of cataract surgery is performed in the outpatient setting, Part B data are critical for performing these analyses. Two of the benefits of using Medicare claims data for such analyses relate to (1) the large number of cases available for analysis (approximately 50,000 cases per year in the 5 percent Part B sample), and (2) the fact that such cases are representative of the total population of elderly patients undergoing cataract surgery in the United States. Analyses of Medicare claims data related to cataract surgery are limited in several ways, however. For example, only beneficiaries who have undergone cataract surgery (not patients with cataracts who have not undergone cataract surgery) are easily identified in the claims data; only services for which a bill is submitted are included in the data set;
730
HSR: Health Services Research 25:5 (December 1990)
and only quite serious complications, such as those requiring hospitalization, are likely to be identified. Although we expect a high degree of accuracy in our ability to use Medicare claims data to identify patients who have undergone a cataract extraction, we are less confident of the accuracy with which the specific type of procedure used to extract a cataract is coded, and we will need to develop approaches for determining which complications identified in the Medicare claims are attributable to the index eye, let alone to the cataract extraction under study. We hope that funds will be available to undertake studies to clarify these areas of uncertainty. The third major source of data in our project will derive from abstractions of patient records and interviews with patients and ophthalmologists in each of three different sites across the country. We plan to abstract 1,000 patient records and to interview 200 patients in each site. In addition, approximately 300 ophthalmologists across the three sites will be interviewed. These data will provide insight into physician practice patterns, the health and functional status of patients undergoing cataract surgery, the priorities and expectations such patients have regarding the benefits of cataract surgery, the dinical and functional outcomes of patients who undergo cataract surgery, as well as the costs associated with the surgery and the utility values patients and ophthalmologists associate with actual and potential outcomes. Although these data will be extremely valuable in our analysis, the sample will not be representative of the entire United States since it is derived from only three sites. We also intend to conduct a national survey of ophthalmologists in order to gain a better understanding of patterns of practice and of the beliefs and motivations underlying those patterns. Such insights could prove to be extremely valuable in the development of an effective intervention designed to modify ophthalmologists' practice patterns in the future. Finally, we also have established a strong liaison with the American Academy of Ophthalmology and have convened an expert national advisory panel, consisting of both ophthalmologists and optometrists, to provide critical review and advice regarding all major aspects of our study. This panel will help us identify pertinent disease and procedure codes to be used in our analysis of Medicare claims data, assist us in interpreting the results of our claims data analysis and the findings from our literature review, and guide us in the design and interpretation of our primary data collection efforts. We also anticipate that this panel will provide helpful advice to our team regarding the design of decision-analytic models that will help clarify the anticipated outcomes of alternative strategies for managing cataract patients with particular
PORT Cataract Management
731
clinical characteristics. Utilizing such analyses, we plan to work with our advisory panel on the design of an intervention aimed at shaping patients' and ophthalmologists' behavior in the future. We hope that the comprehensiveness of our study, the national status of the ophthalmologists and optometrists on our advisory panel, and the close working relationship we have with the American Academy of Ophthalmology will increase the impact our project will have on the future management of cataracts in the United States.
728
HSR: Health Services Research 25:5 (December 1990)
of elderly persons in the United States and the increased rate at which cataract extractions are being performed nationwide. Data from several sources suggest that substantial variation exists across different metropolitan areas, not only in the rate of cataract surgery, but also in the approaches taken by ophthalmologists in the preoperative, intraoperative, and postoperative management of patients with cataracts. For example, some ophthalmologists regularly do specular microscopy and B-scan ultrasound as part of their preoperative evaluation, while others do not. This leads to considerable variation in the cost of preoperative evaluation and possibly to variation in the stage at which cataracts are extracted. Variation also exists in the surgical technique (intracapsular, extracapsular, and phacoemulsification) used to extract a cataract. Postoperative management of cataract patients varies as well, for example, in terms of the frequency of follow-up visits and the use of YAG laser capsulotomy. These types of variations in clinical practice have attracted increasing attention in recent years, largely due to recognition of the likelihood that observed variations in practice may be indicators of over- or undertreatment and may have important clinical, economic, and policy implications. In September 1989, we received funding from what is now the Agency for Health Care Policy and Research (AHCPR) to form a multidisciplinary team to study variations in the management of cataracts, the consequences of such variation, and potential interventions that could be employed in response to such variation. The specific goals of our patient outcome research team (PORT) are: 1. To identify the extent of variation in the pre-, intra-, and postoperative management of Medicare beneficiaries with cataract(s); 2. To examine the clinical and functional outcomes, level of patient satisfaction, and cost associated with alternative cataract management strategies; 3. To determine the values placed on specific clinical and functional outcomes by patients and ophthalmologists; 4. To define "appropriate" or "optimal" management strategies for different categories of cataract patients, and delineate the specific factors, including patient and physician characteristics, that determine why a particular management strategy is considered to be "optimal" for a particular category of patient;
PORT: Cataract Managmnt
729
5. To develop insight into the provider characteristics and local market factors associated with various cataract management strategies, and to develop insight into the factors underlying or motivating current patterns of practice; 6. To develop an intervention strategy that is capable of bringing actual practice into closer compliance with "optimal" management strategies (i.e., to reduce variability in practice in ways that will optimize patient and economic outcomes); and 7. To develop a plan for evaluating the effect of the intervention. To accomplish these goals, we plan to collect and analyze data from a variety of sources. One arduous task will be to review and synthesize the clinical literature related to cataract surgery-a literature that we estimate to consist of approximately 3,000 potentially relevant articles published during the past ten years. Our primary objective in this literature synthesis is to estimate the probability that each of many potential outcomes will occur in a specified type of patient who is managed in a particular way. Since most of the cataract surgery literature consists of observational studies, rather than randomized clinical trials, we will need to adapt traditional meta-analysis techniques for use in our project. We also plan to perform extensive analyses of Medicare claims data (Parts A and B) to help define the extent of variation in several aspects of management of individuals with cataract(s), to identify factors associated with such variation, to estimate the frequency with which various complications occur during or after surgery, and to estimate the direct costs associated with alternative strategies for managing patients with cataracts. Because the vast majority of cataract surgery is performed in the outpatient setting, Part B data are critical for performing these analyses. Two of the benefits of using Medicare claims data for such analyses relate to (1) the large number of cases available for analysis (approximately 50,000 cases per year in the 5 percent Part B sample), and (2) the fact that such cases are representative of the total population of elderly patients undergoing cataract surgery in the United States. Analyses of Medicare claims data related to cataract surgery are limited in several ways, however. For example, only beneficiaries who have undergone cataract surgery (not patients with cataracts who have not undergone cataract surgery) are easily identified in the claims data; only services for which a bill is submitted are included in the data set;
730
HSR: Health Services Research 25:5 (December 1990)
and only quite serious complications, such as those requiring hospitalization, are likely to be identified. Although we expect a high degree of accuracy in our ability to use Medicare claims data to identify patients who have undergone a cataract extraction, we are less confident of the accuracy with which the specific type of procedure used to extract a cataract is coded, and we will need to develop approaches for determining which complications identified in the Medicare claims are attributable to the index eye, let alone to the cataract extraction under study. We hope that funds will be available to undertake studies to clarify these areas of uncertainty. The third major source of data in our project will derive from abstractions of patient records and interviews with patients and ophthalmologists in each of three different sites across the country. We plan to abstract 1,000 patient records and to interview 200 patients in each site. In addition, approximately 300 ophthalmologists across the three sites will be interviewed. These data will provide insight into physician practice patterns, the health and functional status of patients undergoing cataract surgery, the priorities and expectations such patients have regarding the benefits of cataract surgery, the dinical and functional outcomes of patients who undergo cataract surgery, as well as the costs associated with the surgery and the utility values patients and ophthalmologists associate with actual and potential outcomes. Although these data will be extremely valuable in our analysis, the sample will not be representative of the entire United States since it is derived from only three sites. We also intend to conduct a national survey of ophthalmologists in order to gain a better understanding of patterns of practice and of the beliefs and motivations underlying those patterns. Such insights could prove to be extremely valuable in the development of an effective intervention designed to modify ophthalmologists' practice patterns in the future. Finally, we also have established a strong liaison with the American Academy of Ophthalmology and have convened an expert national advisory panel, consisting of both ophthalmologists and optometrists, to provide critical review and advice regarding all major aspects of our study. This panel will help us identify pertinent disease and procedure codes to be used in our analysis of Medicare claims data, assist us in interpreting the results of our claims data analysis and the findings from our literature review, and guide us in the design and interpretation of our primary data collection efforts. We also anticipate that this panel will provide helpful advice to our team regarding the design of decision-analytic models that will help clarify the anticipated outcomes of alternative strategies for managing cataract patients with particular
PORT Cataract Management
731
clinical characteristics. Utilizing such analyses, we plan to work with our advisory panel on the design of an intervention aimed at shaping patients' and ophthalmologists' behavior in the future. We hope that the comprehensiveness of our study, the national status of the ophthalmologists and optometrists on our advisory panel, and the close working relationship we have with the American Academy of Ophthalmology will increase the impact our project will have on the future management of cataracts in the United States.
