With the accelerated aging of the population, the increasing number of cataract patients and delays in cataract surgery pose challenges for limited healthcare resources and governments. Thus, more efficient and effective surgical techniques are needed to provide reliable outcomes and improve cataract throughput. In the present study, we compared the efficiency of P-IOL vs M-IOL in our ambulatory surgery center. We found that application of the P-IOL significantly reduced the total surgery time both in the 1-OR and 2-OR scenarios. Using our designed model, it was estimated that the switch from M-IOL to P-IOL could increase the throughput by 5.2 - 7.7% and increase the revenue by 284,352 to 426,528 USD without additional staffing and operating rooms.
Years ago, nearly all cataract surgeries required inpatient hospitalization. Recently, an increasing number of cataract surgeries have been performed at ambulatory surgery centers in China, improving cataract throughput and convenience for patients and surgeons. In addition, performing cataract surgeries at ambulatory surgery centers enhances surgeon productivity, decreasing out-of-pocket patient costs, and per-case costs for insurers [12]. In 2015, an ambulatory surgery center was established in our hospital to perform routine cataract surgeries, substantially improving cataract throughput. With the acceleration of aging of the population in China and worldwide, the cataract patients will double in 30 years, posing challenges for healthcare systems and limited healthcare resources. For routine cataract surgery, the average surgery time is as short as 10-20 minutes. Therefore, even small changes in the efficiencies of operating processes and surgical techniques can quickly add to meaningful differences in cataract throughput and efficiency of the healthcare system.
To provide better operating conditions, P-IOL delivery systems were developed. The perceived benefits of P-IOL delivery systems include the elimination of IOL injector loading variability, avoidance of potential IOL loading errors, lower risk for instrument contamination and reduced operation time [10, 11, 13-15]. In this study, our data showed that, in a 1-OR scenario, application of the P-IOL system reduced the average total case time by 1.3 min (-7.7%) relative to the M-IOL system. The reduction of the total case time was largely the result of the reductions in operating setup time, tear down time, surgery time and IOL delivery time. The reductions in operating setup time might be ascribed to that the injector in the M-IOL group is reusable, and more time is needed to confirm the sterilization of the injector, open the sterilized package and check whether the injector is normal. In a 2-OR scenario, application of the P-IOL system reduced average total case time by 0.9 min (-7.8%) relative to the M-IOL system. The reduction of the total case time was the result of the reductions in surgery time and IOL delivery time, rather than surgery delay time. This outcome was somewhat different from previous findings that the reduction of surgery delay time also contributed to the reduction of total cases [10], which might be ascribed to the staff structure optimization in our institution, according to which a circulating nurse and a resident were in one operating room. Thus, they cooperated well and had sufficient time to prepare the surgery equipment and patients.
The staff and operating room are both valuable and expensive. Maximization of staff and operation room efficiency could provide medical serves to more patients. In this study, the efficiency and revenue implications of introducing a preloaded delivery system for an IOL model were used to evaluate the changes in cataract throughput and hospital revenue from switching from the M-IOL delivery system to the P-IOL system. Within a 1-OR center, if the total case time savings per surgery day exceeds the mean time between the start of the operating setup time and the completion of the operating’s tear down with the preloaded system, then an additional case, or cases, can be added to the surgery day without additional staffing. In a 2-OR center, if the total surgeon time savings per surgery day exceeds the total surgery time with the preloaded system, then an additional case, or cases, can be added to the surgery day without additional staffing. Thus, by switching from the M-IOL system to the P-IOL system, annual throughput will increase by 5.2% (960 cases) in the 1-OR scenario and 7.7% (1440 cases) in the 2-OR scenario. Similarly, Jones, et al. reported that, in a single-OR cataract surgery center in Canada, the cataract throughput increased by 9.9% (36 cases per year) by switching from the M-IOL system to the P-IOL system without increasing staff or surgeon capacity. In 2-OR cataract surgery centers (France and the USA), the cataract throughput will increase by 5.7% (90 per year in France) and 4.0% (96 per year in the USA), respectively.
The cost of cataract surgery per case varies widely depending on location and setting in which the surgery is performed. A study of nine European countries showed that the cost of cataract surgery per case ranged from 344 to 1177 USD. In our ambulatory surgery center, the average cost of cataract surgery is 296.2 USD, which means 296.2 USD of revenue for the hospital. Switching from the M-IOL delivery system to the P-IOL system, the hospital could increase its revenue by 284,352 USD in the 1-OR scenario and 426,528 USD in the 2-OR scenario. In contrast, for hospitals like our ambulatory surgery center, for which the salaries for the surgeon and staff depend on the throughput, translating from the M-IOL delivery system to the preloaded system could potentially increase the input of the surgeons and staff.
Although the findings are promising, the current study had several limitations. First, the present study was limited by the data collection being performed at a single ambulatory surgery center by a single observer over a short period of time, thereby limiting the generalizability of the findings. Second, in the present study, the surgeon loaded the M-IOL himself, while in hospitals in which the staff helps to load the M-IOL, the surgery time is expected to be further reduced. Third, for feasibility reasons, only one type of IOL was compared in this study. In the future, a more detailed record of the different types of IOL from various manufactories would provide better data for decision making. Fourth, the present study focused on the influence on cataract throughput and revenue by the application of P-IOL, and we did not specifically track patient outcomes before and after implementation of P-IOL or M-IOL. The surgeon did not anecdotally note evidence of increased intraoperative or postoperative complications.