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Original Investigation | Clinical Sciences

Surgical Outcomes and Cost Basis for Resident-Performed Cataract Surgery in an Uninsured Patient Population FREE

Daniel B. Moore, MD1; Mark A. Slabaugh, MD1
[+] Author Affiliations
1Department of Ophthalmology, University of Washington, Seattle
JAMA Ophthalmol. 2013;131(7):891-897. doi:10.1001/jamaophthalmol.2013.202.
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Published online

Importance  In the past, resident physicians have provided care to indigent patients under the supervision of experienced physicians. General consensus exists regarding higher surgical costs of patient care at teaching hospitals. No study has examined the outcomes or the cost basis for resident physicians providing health care to an underserved population.

Objectives  To evaluate the visual results in uninsured patients undergoing cataract surgery performed by resident surgeons at a single institution and to determine the cost-effectiveness of care.

Design and Setting  A retrospective case series of consecutive uninsured patients undergoing cataract procedures performed by attending-supervised resident physicians at the University of Washington from July 1, 2005, through June 30, 2011. Data obtained included demographic information, preoperative and postoperative best-corrected visual acuity (BCVA) in the eye undergoing the procedure, and surgical complications. We calculated the costs of services rendered and normalized them to 2011 dollars. These data were incorporated into time–trade-off discounted utility values. Data were expressed as mean (SD).

Participants  One hundred forty-three consecutive patients.

Exposure  Cataract surgical procedures.

Main Outcomes and Measures  Costs of the surgical procedure and the utility value associated with the BCVA in the operated-on eye,

Results  The mean logMAR preoperative BCVA was 1.09 (0.74) (Snellen equivalent, 20/300). The best-recorded mean postoperative BCVA was 0.24 (0.42) (Snellen equivalent, 20/40), obtained at 3.77 (9.30) months. The final recorded mean BCVA was 0.27 (0.43) (Snellen equivalent, 20/40), obtained at a median (SD) follow-up of 16.32 (17.10) months. Four complications in 3 eyes required a second operation; 15 postoperative laser procedures were performed. The mean health care cost per patient was $3437.24 ($1334.68). Using these data, the mean utility value of cataract surgery in this population was 0.80 (0.12); the quality-adjusted life-years gained, 2.43 (1.87); and the discounted ratio of cost to utility, $1889.16 ($4800.62).

Conclusions and Relevance  These data support the success and cost-effectiveness of supervised, resident-performed cataract surgery in an underserved patient population. This study lends support for continuing this traditional scheme of surgical training and education. Further work must ensure that we remain aware of the balance between education and patient care.

Figures in this Article

There exists an innate social dichotomy between the need to provide adequate education to future physicians and the desire of each patient to receive competent care. Traditionally, balance was achieved by allowing training physicians to care primarily for indigent patients; however, changes in health care throughout the past several decades have necessarily and appropriately strained this relationship.1 The complex and interconnected roles among resident physicians, patients receiving care at training hospitals, and the supervising faculty remain unresolved,2,3 with the ethos of transparency and autonomy at the center of the discussion.

The literature regarding resident physician influence on patient cost and surgical outcomes is inconclusive. Although patients admitted under the care of residents are generally accepted as having higher medical costs, leading to decreased hospital profitability,4 some studies have suggested otherwise.5,6 Although some analyses have found increased patient morbidity at teaching compared with nonteaching hospitals,7 most recent reports indicate that no significant difference4,8,9 or decreased risk4,10 exists at teaching hospitals under the medical or surgical care of a resident. The general consensus regarding higher surgical costs in similar patient care at teaching hospitals is largely attributed to increased operative time for resident cases.5,6,8,1113

In addition to being the only level I trauma center in Washington State and a training site for the University of Washington Department of Ophthalmology residency program, Harborview Medical Center (HMC) serves as the Seattle metropolitan area “safety net” hospital and provides care to an expansive uninsured and immigrant population. The HMC serves patients who cannot otherwise pay for their health care via a well-established charity care program. The HMC provided charity care valued at $186 733 000 in 2010, the most recent year for which data are available.14 Cataract surgery services are provided under this program for patients with visual acuity poorer than 20/200 in the better-seeing eye or if a medical necessity for cataract surgery is deemed to exist. Medical necessity requests are evaluated on a case-by-case basis by supervising physicians and include indications such as phacomorphic glaucoma or cataract that impairs visualization and treatment of suspected proliferative diabetic retinopathy, among others.

To our knowledge, no studies have been performed examining the outcomes or the cost basis for resident physician involvement in the care of an underserved population. The purpose of this study was to evaluate the visual outcomes of these uninsured patients undergoing cataract operations by attending-supervised resident surgeons at a single institution and to determine the cost-effectiveness of their care.

A retrospective review was conducted of consecutive cataract procedures performed on uninsured patients by attending-supervised resident physicians at HMC from July 1, 2005, through June 30, 2011. This project was approved by the Human Subjects Division of the University of Washington institutional review board.

Patient medical records were selected using the 2 common Current Procedural Terminology codes for cataract surgery: 66982 (cataract surgery, complex) and 66984 (cataract surgery with intraocular lens, 1 stage). The only exclusion criterion was applied to patients who underwent cataract extraction combined with another planned incisional surgery (n = 4). Data collected included patient age, sex, race, primary language, preoperative best-corrected Snellen visual acuity (BCVA) in the eye undergoing the procedure, postoperative BCVA in that same eye, postoperative BCVA at the time of the most recent patient visit, the time (in months) that the most improved and most recent BCVA was obtained after surgery, ocular comorbidities, and surgical complications.

Medical Costs

The cost of the initial office visit, diagnostic testing including an A-scan of axial length, intraocular lens calculations, the allowable professional fee for facility-based surgery, the facility price of cataract surgery, and complications were all obtained using the Centers for Medicare & Medicaid Services 2011 physician fee schedule for Seattle, Washington.15 The institutional costs of anesthesia and operating room services were provided by HMC Financial Services as an estimate based on the costs for the billed Current Procedural Terminology code for the prior fiscal year. The medications included in the cost analysis were topical cycloplegics used for surgery and topical antibiotics and topical corticosteroids used for a 1-month postoperative period and were provided in 2011 dollars by the HMC pharmacy.

Utilities

We used a patient preference–based, time–trade-off method to quantify the utility value associated with the BCVA in the eye undergoing the procedure. By convention, a value of 1.00 is equivalent to permanent perfect vision and 0.26 is equivalent to no perception of light in either eye. Using this well-established method, the patient determines the quantity of time they would trade to have the quality of life associated with 20/20 vision.16,17 The quality-adjusted life-years (QALYs) gained for an intervention were calculated based on utility gain using the following formula:

QALY Gain = [(Outcome Utility – Baseline Utility) × Years of Benefit].

The ratio of cost to utility (cost-utility ratio) was derived by dividing the cost of an intervention by the QALY gain. Discounted cost utility in US dollars was determined by assuming a 3% discounting rate per year. Life expectancy was modeled from mortality data using US Social Security period life tables (http://www.ssa.gov/OACT/STATS/table4c6.html). All costs were in 2011 US dollars and were converted when necessary using the Consumer Price Index data for urban consumers.18 We performed a 1-way sensitivity analysis on the values of cost, utility, discount rate, and life expectancy. Unless otherwise indicated, data are expressed as mean (SD).

A total of 143 uninsured patients underwent cataract surgery performed by an ophthalmology resident at HMC during the study period. Baseline demographics and characteristics of the study population are displayed in Table 1. After conversion to logMAR units, the mean preoperative BCVA was 1.09 (0.74) (Snellen equivalent, 20/300; median, 20/200). The mean logMAR of the best-recorded postoperative BCVA was 0.24 (0.42) (Snellen equivalent, 20/40; median, 20/25), obtained at 3.77 (9.30) months. The final recorded mean logMAR BCVA of 0.27 (0.43) (Snellen equivalent, 20/40; median, 20/25) was obtained at 16.32 (17.10) months. Graphical analysis of the individual patient results and population-based visual acuity outcomes are shown in Figure 1 and Figure 2. Four complications occurred in 3 eyes, requiring a second operation, including 2 eyes with retained lens fragments requiring a subsequent pars plana vitrectomy/lensectomy and 1 patient undergoing an intraocular lens exchange for unexpected postoperative hyperopia. One of the patients who underwent pars plana lensectomy developed a rhegmatogenous retinal detachment on postoperative day 3 and required an additional subsequent pars plana vitrectomy. Fifteen postoperative laser procedures were performed, including 13 Nd:YAG laser–assisted capsulotomies for posterior capsular opacification and 2 Nd:YAG laser–assisted vitreolyses.

Table Graphic Jump LocationTable 1.  Baseline Demographic Characteristics of 143 Uninsured Patients Undergoing Resident-Performed Cataract Surgery
Place holder to copy figure label and caption
Figure 1.
Individual Outcomes in Best-Corrected Visual Acuity (BCVA) of Patients in an Underserved Population Undergoing Cataract Extraction

HM indicates hand motions.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Change in the Distribution of Best-Corrected Visual Acuity (BCVA) in an Underserved Population Undergoing Cataract Extraction

HM indicates hand motions.

Graphic Jump Location

The mean cost per patient was $3437.24 ($1334.68). Using visual acuity data of individual cases as described above, the mean calculated utility value of cataract surgery in this population was 0.80 (0.12), and the mean QALYs gained were 2.43 (1.87), yielding a discounted cost-utility ratio of $1889.16 ($4800.62). Because these findings are specific to the costs at our institution, we performed a separate analysis using a standard estimated cost of initial cataract surgery and associated complications from the PORT (US National Cataract Patient Outcomes Research Team) data.17,19 Using the PORT costs, a similar discounting method and our patient visual acuity data yielded a slightly higher discounted mean cost-utility ratio of $2118.84 ($1621.78).

We performed 1-way sensitivity analyses to evaluate the variability inherent to estimates of cost and utility value, resulting in moderate changes. When the total costs were increased by 25%, similar to variables used in other studies,17 the discounted cost-utility ratio was $2361.45 ($6000.77), whereas decreasing costs by 25% yielded a discounted cost-utility ratio of $1416.87 ($3600.46). Raising all utility values by 25% yielded a discounted cost-utility ratio of $1511.33 ($3840.50), whereas lowering them by 25% yielded a discounted cost-utility ratio of $2518.88 ($6400.82). To address the assumption that vision gained by a specific intervention will decrease in value over time, changes in the yearly discount rate were also analyzed. Varying the yearly discount rate resulted in a discounted cost-utility ratio of $1082.19 ($2477.16) for a 0% rate, $2892.70 ($7767.74) for a 5% rate, and $11 263.74 ($30 758.64) for a 10% rate. Provided that the mortality rate of our uninsured population may indeed vary from reported life tables, decreasing the life expectancy of each patient in the study resulted in a discounted cost-utility ratio of $2099.07 ($5334.02) for a 10% decrease and $2518.88 ($6400.82) for a 25% decrease. Although general consensus exists regarding the need to discount future benefits, the specified rate and whether the rates for costs and benefits should be different remains controversial.2022

We performed a graphical subgroup analysis to evaluate the discounted cost utility of cataract surgery when performed at various levels of preoperative BCVA (Figure 3). As expected, the cost utility was the best in patients with very poor preoperative BCVA. As in other studies, we found that cataract surgery remained a cost-effective intervention in patients with modest levels of preoperative visual impairment.

Place holder to copy figure label and caption
Figure 3.
Discounted Cost Utility as a Factor of Preoperative Best-Corrected Visual Acuity (BCVA) in an Underserved Population of Patients Undergoing Cataract Extraction

HM indicates hand motions.

Graphic Jump Location

The French philosopher and historian Michel Foucault described a “hidden contract” that exists between the hospitals where the poor are treated and the clinics where physicians are trained, stating: Through the evolving face of medicine during the past half century, the nature of this contract has changed, yet the question raised remains a significant concern in the ethical treatment of vulnerable patients at academic institutions. Our study provides some insight into this dilemma by evaluating cataract surgeries performed by attending-supervised resident physicians on uninsured patients at a single center. The results suggest this intervention is successful and highly cost-effective.

The most important moral problem raised by the idea of the clinic was the following: by what right can one transform into an object of clinical observation a patient whose poverty has compelled him to seek assistance at the hospital?23(p83)

Numerous reports in the United States and across the globe have unequivocally demonstrated that cataract surgery improves vision and quality of life,24 and others have shown its cost-effectiveness.25 Cost-effectiveness studies are becoming increasingly prominent as health care analyses attempt to provide comparative data to aid in the choices facing patients, providers, policymakers, and payers.26 Although no consensus exists regarding the standard for an intervention to be considered cost-effective, some authors have suggested an upper limit of $100 000/QALY27 or $50 000/QALY.28 Regardless of the stringency of criteria one chooses, the discounted cost-utility ratio of $1889.16 determined in this study appears highly cost-effective. Table 2 compares the effectiveness of our study with a sample of other reported interventions. However, an important distinction between our data and those in the sample interventions needs to be made: the costs in our study are an estimate of resource intensity required by the intervention, not a true estimate of cost reimbursement. The patients in our study are uninsured and health care is provided as a charity; therefore, the cost-effectiveness is a measure of the value, financing, and resource intensity of the intervention.

Table Graphic Jump LocationTable 2.  Comparative Effectiveness of Various Medical Interventions

The American Board of Ophthalmology has added a surgical competency to the 6 core competencies that the Accreditation Council for Graduate Medical Education requires all residents to master before graduation.42,43 Implementing adequate surgical training in an ophthalmology department is a sizeable task, and perhaps the single largest aspect is teaching phacoemulsification cataract surgery. Microsurgical technique permits only 1 operating surgeon at a time, patients are usually awake during the procedure, and surgical complications can have profound visual consequences. Furthermore, many academic programs have been increasing patient volume in response to declining reimbursement, adding a significant time constraint to the operating room.44

The influence of resident physicians on patient outcomes and costs of care remains undetermined, with universal consensus only regarding higher surgical costs for patients at teaching hospitals due to increased operative time for resident cases.5,6,8,1113 A recent report found that at the Lebanon Veterans Affairs Medical Center, Lebanon, Pennsylvania, resident surgeons took a mean of 12 minutes longer per cataract surgery at an added cost of $105 per case early in their training compared with attending physicians; the increased time and cost normalized as residents progressed to later stages of training.45 Despite any incremental costs associated with resident cataract surgery, it remained highly cost-effective in our patient population. To ensure that costs of care were not significantly different from other studies, the estimated cost of treatment, including complications, from the PORT data17,19 was incorporated into a separate analysis and suggested only a modest decrease in the discounted cost-utility ratio from our findings ($1889.16 vs $2118.84). The median postoperative BCVA of 20/25 achieved in our patients is consistent with prior large-scale cataract series in the United States,19,46 whereas the median preoperative BCVA of 20/200 in our series is significantly worse than the median acuity of 20/60 in other series.19,46 The considerable gain in visual acuity achieved by the patients in our study contributes to the cost-effectiveness of surgery in this population.

Multiple reports address surgical complications in resident cases, generally with supportive results. Although posterior capsular tear or vitreous loss occurs in 3.0% to 6.7% of cases,4751 the rates of retinal detachment (0.69%)50 and endophthalmitis (0.11%)52 among resident-performed operations are comparable to those of larger series with experienced surgeons. The uncommon rate of complications requiring additional surgery in our series compares favorably with the literature.19,46 The 9% occurrence of posterior capsular opacification requiring Nd:YAG capsulotomy is much lower than the 28% reported in the literature at 5 years,53 but the rate likely reflects the limited follow-up in our patient population (median [SD], 16.32 [17.10] months) rather than a lower incidence.

This study has several important limitations. As a retrospective study from a single institution, the sample size is relatively small. The ability to extrapolate the cost-effectiveness to patients undergoing cataract surgery with better preoperative visual acuity is somewhat limited owing to the small number of patients who were enrolled in our program at those levels of visual acuity. Patients had more severe disease at their initial examination than a typical US population, and follow-up was too short to capture the true rate of late postoperative complications, such as posterior capsular opacification, with accuracy. The life expectancy of our patient population may differ significantly from the mortality tables used in the analysis. If the life expectancy is significantly reduced in this uninsured population, as suggested by multiple observational studies,54,55 the discounted cost utility will also be proportionately increased. However, as suggested by the univariate analysis, decreasing the life expectancy by as much as 25% did not significantly alter the cost-effectiveness. The utility values applied in this study were not specifically based on patients with cataracts but on a large pooled population with visual loss from any cause.16 However, the degree of visual loss itself, rather than the underlying cause, has been shown to correlate most closely with utility values.16 Furthermore, altering the utility values to 25% with 1-way sensitivity analysis did not significantly alter the cost-effectiveness of the intervention. The increased case time associated with other studies of resident-performed surgery was not included in our calculations. Under this program, surgery is performed by senior residents with supervision by an attending physician, and other studies have noted that the extended case time associated with resident surgery normalizes with more advanced training, which should minimize this artifact.45

Given the cost and potential increase in risk associated with resident surgical education, surgical simulation and enhanced didactic time are being advocated as an adjunct to or as a substitute for some of the operating room experience. Studies are ongoing to determine whether this substitution will improve patient outcomes and allow for adequate or even superior surgical training.1,45 As the nature of surgical training evolves, our study provides evidence of the success and cost-effectiveness of resident-performed cataract surgery in an underserved patient population. Further work is needed in this area to ensure that we remain aware of the balance between education and patient care.

Corresponding Author: Mark A. Slabaugh, MD, Department of Ophthalmology, University of Washington, Box 359608, 325 Ninth Ave, Seattle, WA 98104 (mas12@u.washington.edu).

Submitted for Publication: October 25, 2012; final revision received January 2, 2013; accepted January 14, 2013.

Published Online: May 30, 2013. doi:10.1001/jamaophthalmol.2013.202

Author Contributions: Dr Slabaugh had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by an unrestricted educational grant from Research to Prevent Blindness.

O’Shea  JS.  Individual and social concerns in American surgical education: paying patients, prepaid health insurance, Medicare and Medicaid. Acad Med. 2010;85(5):854-862.
PubMed   |  Link to Article
Chen  AJ, Scott  IU, Greenberg  PB.  Disclosure of resident involvement in ophthalmic surgery. Arch Ophthalmol. 2012;130(7):932-934.
PubMed   |  Link to Article
Naseri  A.  Patient consent for resident involvement in surgical care. Arch Ophthalmol. 2012;130(7):917-918.
PubMed   |  Link to Article
Taylor  DH  Jr, Whellan  DJ, Sloan  FA.  Effects of admission to a teaching hospital on the cost and quality of care for Medicare beneficiaries. N Engl J Med. 1999;340(4):293-299.
PubMed   |  Link to Article
Hwang  CS, Wichterman  KA, Alfrey  EJ.  The cost of resident education. J Surg Res. 2010;163(1):18-23.
PubMed   |  Link to Article
Shine  D, Beg  S, Jaeger  J, Pencak  D, Panush  R.  Association of resident coverage with cost, length of stay, and profitability at a community hospital. J Gen Intern Med. 2001;16(1):1-8.
PubMed   |  Link to Article
Duggirala  AV, Chen  FM, Gergen  PJ.  Postoperative adverse events in teaching and nonteaching hospitals. Fam Med. 2004;36(7):508-513.
PubMed
Lavernia  CJ, Sierra  RJ, Hernandez  RA.  The cost of teaching total knee arthroplasty surgery to orthopaedic surgery residents. Clin Orthop Relat Res. 2000;380(380):99-107.
PubMed   |  Link to Article
Hwang  CS, Pagano  CR, Wichterman  KA, Dunnington  GL, Alfrey  EJ.  Resident versus no resident: a single institutional study on operative complications, mortality, and cost. Surgery. 2008;144(2):339-344.
PubMed   |  Link to Article
Rosenthal  GE, Harper  DL, Quinn  LM, Cooper  GS.  Severity-adjusted mortality and length of stay in teaching and nonteaching hospitals: results of a regional study. JAMA. 1997;278(6):485-490.
PubMed   |  Link to Article
Harrington  DT, Roye  GD, Ryder  BA, Miner  TJ, Richardson  P, Cioffi  WG.  A time-cost analysis of teaching a laparoscopic entero-enterostomy. J Surg Educ. 2007;64(6):342-345.
PubMed   |  Link to Article
Lee  SL, Sydorak  RM, Applebaum  H.  Training general surgery residents in pediatric surgery: educational value vs time and cost. J Pediatr Surg. 2009;44(1):164-168.
PubMed   |  Link to Article
Bridges  M, Diamond  DL.  The financial impact of teaching surgical residents in the operating room. Am J Surg. 1999;177(1):28-32.
PubMed   |  Link to Article
Ordos R, Huyck R. Charity care in Washington Hospitals. Washington State Department of Health, Center for Health Statistics, Hospital and Patient Data Systems. June 2011. http://www.doh.wa.gov/DataandStatisticalReports/HealthcareinWashington/HospitalandPatientData/HospitalPatientInformationandCharityCare/CharityCareinWashingtonHospitals.aspx. Accessed April 19, 2013.
Centers for Medicare & Medicaid Services (CMS). CMS home page. Physician fee schedule 2011, facility price, King County, Washington. http://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Accessed June 1, 2012.
Brown  GC.  Vision and quality-of-life. Trans Am Ophthalmol Soc. 1999;97:473-511.
PubMed
Busbee  BG, Brown  MM, Brown  GC, Sharma  S.  Incremental cost-effectiveness of initial cataract surgery. Ophthalmology. 2002;109(3):606-613.
PubMed   |  Link to Article
US Department of Labor, Bureau of Labor Statistics. Consumer price index. http://www.bls.gov/cpi. Accessed June 1, 2012.
Steinberg  EP, Tielsch  JM, Schein  OD,  et al.  National study of cataract surgery outcomes: variation in 4-month postoperative outcomes as reflected in multiple outcome measures. Ophthalmology. 1994;101(6):1140-1141.
PubMed
Brouwer  WB, Niessen  LW, Postma  MJ, Rutten  FF.  Need for differential discounting of costs and health effects in cost effectiveness analyses. BMJ. 2005;331(7514):446-448.
PubMed   |  Link to Article
Claxton  K, Sculpher  M, Culyer  A,  et al.  Discounting and cost-effectiveness in NICE: stepping back to sort out a confusion. Health Econ. 2006;15(1):1-4.
PubMed   |  Link to Article
Bos  JM, Postma  MJ, Annemans  L.  Discounting health effects in pharmacoeconomic evaluations: current controversies. Pharmacoeconomics. 2005;23(7):639-649.
PubMed   |  Link to Article
Foucault M. The Birth of the Clinic: An Archaeology of Medical Perception. Sheridan Smith AM, trans. New York, NY: Pantheon; 1973.
Lamoureux  EL, Fenwick  E, Pesudovs  K, Tan  D.  The impact of cataract surgery on quality of life. Curr Opin Ophthalmol. 2011;22(1):19-27.
PubMed   |  Link to Article
Lansingh  VC, Carter  MJ, Martens  M.  Global cost-effectiveness of cataract surgery. Ophthalmology. 2007;114(9):1670-1678.
PubMed   |  Link to Article
Morse  AR, Lee  PP.  Comparative effectiveness: insights on treatment options for open-angle glaucoma. Arch Ophthalmol. 2012;130(4):506-507.
PubMed   |  Link to Article
Laupacis  A, Feeny  D, Detsky  AS, Tugwell  PX.  How attractive does a new technology have to be to warrant adoption and utilization? tentative guidelines for using clinical and economic evaluations. CMAJ. 1992;146(4):473-481.
PubMed
Heudebert  GR, Centor  RM, Klapow  JC, Marks  R, Johnson  L, Wilcox  CM.  What is heartburn worth? a cost-utility analysis of management strategies. J Gen Intern Med. 2000;15(3):175-182.
PubMed   |  Link to Article
Chung  KC, Walters  MR, Greenfield  ML, Chernew  ME.  Endoscopic versus open carpal tunnel release: a cost-effectiveness analysis. Plast Reconstr Surg. 1998;102(4):1089-1099.
PubMed
Brown  GC, Brown  MM, Sharma  S, Tasman  W, Brown  HC.  Cost-effectiveness of treatment for threshold retinopathy of prematurity. Pediatrics. 1999;104(4):e47.
PubMed   |  Link to Article
Sharma  S, Hollands  H, Brown  GC, Brown  MM, Shah  GK, Sharma  SM.  The cost-effectiveness of early vitrectomy for the treatment of vitreous hemorrhage in diabetic retinopathy. Curr Opin Ophthalmol. 2001;12(3):230-234.
PubMed   |  Link to Article
Brown  GC, Brown  MM, Sharma  S.  Healthcare economic analyses. Retina. 2004;24(1):139-146.
PubMed   |  Link to Article
Membreno  JH, Brown  MM, Brown  GC, Sharma  S, Beauchamp  GR.  A cost-utility analysis of therapy for amblyopia. Ophthalmology. 2002;109(12):2265-2271.
PubMed   |  Link to Article
Brown  MM, Brown  GC, Lieske  HB, Lieske  PA.  Preference-based comparative effectiveness and cost-effectiveness: a review and relevance of value-based medicine for vitreoretinal interventions. Curr Opin Ophthalmol. 2012;23(3):163-174.
PubMed   |  Link to Article
Busbee  BG, Brown  MM, Brown  GC, Sharma  S.  Cost-utility analysis of cataract surgery in the second eye. Ophthalmology. 2003;110(12):2310-2317.
PubMed   |  Link to Article
Sharma  S, Brown  GC, Brown  MM, Hollands  H, Shah  GK.  The cost-effectiveness of grid laser photocoagulation for the treatment of diabetic macular edema: results of a patient-based cost-utility analysis. Curr Opin Ophthalmol. 2000;11(3):175-179.
PubMed   |  Link to Article
Gupta  OP, Brown  GC, Brown  MM.  A value-based medicine cost-utility analysis of idiopathic epiretinal membrane surgery. Am J Ophthalmol. 2008;145(5):923-928.
PubMed   |  Link to Article
Torrance  GW, Feeny  D.  Utilities and quality-adjusted life years. Int J Technol Assess Health Care. 1989;5(4):559-575.
PubMed   |  Link to Article
Brown  GC, Brown  MM, Sharma  S,  et al.  Incremental cost-effectiveness of laser therapy for visual loss secondary to branch retinal vein occlusion. Ophthalmic Epidemiol. 2002;9(1):1-10.
PubMed   |  Link to Article
Brown  MM, Brown  GC, Brown  HC, Peet  J.  A value-based medicine analysis of ranibizumab for the treatment of subfoveal neovascular macular degeneration. Ophthalmology. 2008;115(6):1039.5-1045.e5. doi:10.1016/j.ophtha.2007.08.033.
PubMed   |  Link to Article
Brown  MM, Brown  GC, Brown  HC, Irwin  B, Brown  KS.  The comparative effectiveness and cost-effectiveness of vitreoretinal interventions. Curr Opin Ophthalmol. 2008;19(3):202-207.
PubMed   |  Link to Article
Mills  RP, Mannis  MJ; American Board of Ophthalmology Program Directors’ Task Force on Competencies.  Report of the American Board of Ophthalmology Task Force on the Competencies. Ophthalmology. 2004;111(7):1267-1268.
PubMed   |  Link to Article
Lee  AG, Carter  KD.  Managing the new mandate in resident education: a blueprint for translating a national mandate into local compliance. Ophthalmology. 2004;111(10):1807-1812.
PubMed
Ament  CS, Henderson  BA.  Optimizing resident education in cataract surgery. Curr Opin Ophthalmol. 2011;22(1):64-67.
PubMed   |  Link to Article
Hosler  MR, Scott  IU, Kunselman  AR, Wolford  KR, Oltra  EZ, Murray  WB.  Impact of resident participation in cataract surgery on operative time and cost. Ophthalmology. 2012;119(1):95-98.
PubMed   |  Link to Article
Lum  F, Schein  O, Schachat  AP, Abbott  RL, Hoskins  HD  Jr, Steinberg  EP.  Initial two years of experience with the AAO National Eyecare Outcomes Network (NEON) cataract surgery database. Ophthalmology. 2000;107(4):691-697.
PubMed   |  Link to Article
Woodfield  AS, Gower  EW, Cassard  SD, Ramanthan  S.  Intraoperative phacoemulsification complication rates of second- and third-year ophthalmology residents: a 5-year comparison. Ophthalmology. 2011;118(5):954-958.
PubMed   |  Link to Article
Blomquist  PH, Morales  ME, Tong  L, Ahn  C.  Risk factors for vitreous complications in resident-performed phacoemulsification surgery. J Cataract Refract Surg. 2012;38(2):208-214.
PubMed   |  Link to Article
Rutar  T, Porco  TC, Naseri  A.  Risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Ophthalmology. 2009;116(3):431-436.
PubMed   |  Link to Article
Khatibi  A, Naseri  A, Stewart  JM.  Rate of rhegmatogenous retinal detachment after resident-performed cataract surgery is similar to that of experienced surgeons. Br J Ophthalmol. 2008;92(3):438. doi:10.1136/bjo.2007.125633.
PubMed   |  Link to Article
Bhagat  N, Nissirios  N, Potdevin  L,  et al.  Complications in resident-performed phacoemulsification cataract surgery at New Jersey Medical School. Br J Ophthalmol. 2007;91(10):1315-1317.
PubMed   |  Link to Article
Hollander  DA, Vagefi  MR, Seiff  SR, Stewart  JM.  Bacterial endophthalmitis after resident-performed cataract surgery. Am J Ophthalmol. 2006;141(5):949-951.
PubMed   |  Link to Article
Schaumberg  DA, Dana  MR, Christen  WG, Glynn  RJ.  A systematic overview of the incidence of posterior capsule opacification. Ophthalmology. 1998;105(7):1213-1221.
PubMed   |  Link to Article
Kennickell  AB.  What is the difference? evidence on the distribution of wealth, health, life expectancy, and health insurance coverage. Stat Med. 2008;27(20):3927-3940.
PubMed   |  Link to Article
Chandler  M.  The rights of the medically uninsured: an analysis of social justice and disparate health outcomes. J Health Soc Policy. 2006;21(3):17-36.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Individual Outcomes in Best-Corrected Visual Acuity (BCVA) of Patients in an Underserved Population Undergoing Cataract Extraction

HM indicates hand motions.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Change in the Distribution of Best-Corrected Visual Acuity (BCVA) in an Underserved Population Undergoing Cataract Extraction

HM indicates hand motions.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Discounted Cost Utility as a Factor of Preoperative Best-Corrected Visual Acuity (BCVA) in an Underserved Population of Patients Undergoing Cataract Extraction

HM indicates hand motions.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Baseline Demographic Characteristics of 143 Uninsured Patients Undergoing Resident-Performed Cataract Surgery
Table Graphic Jump LocationTable 2.  Comparative Effectiveness of Various Medical Interventions

References

O’Shea  JS.  Individual and social concerns in American surgical education: paying patients, prepaid health insurance, Medicare and Medicaid. Acad Med. 2010;85(5):854-862.
PubMed   |  Link to Article
Chen  AJ, Scott  IU, Greenberg  PB.  Disclosure of resident involvement in ophthalmic surgery. Arch Ophthalmol. 2012;130(7):932-934.
PubMed   |  Link to Article
Naseri  A.  Patient consent for resident involvement in surgical care. Arch Ophthalmol. 2012;130(7):917-918.
PubMed   |  Link to Article
Taylor  DH  Jr, Whellan  DJ, Sloan  FA.  Effects of admission to a teaching hospital on the cost and quality of care for Medicare beneficiaries. N Engl J Med. 1999;340(4):293-299.
PubMed   |  Link to Article
Hwang  CS, Wichterman  KA, Alfrey  EJ.  The cost of resident education. J Surg Res. 2010;163(1):18-23.
PubMed   |  Link to Article
Shine  D, Beg  S, Jaeger  J, Pencak  D, Panush  R.  Association of resident coverage with cost, length of stay, and profitability at a community hospital. J Gen Intern Med. 2001;16(1):1-8.
PubMed   |  Link to Article
Duggirala  AV, Chen  FM, Gergen  PJ.  Postoperative adverse events in teaching and nonteaching hospitals. Fam Med. 2004;36(7):508-513.
PubMed
Lavernia  CJ, Sierra  RJ, Hernandez  RA.  The cost of teaching total knee arthroplasty surgery to orthopaedic surgery residents. Clin Orthop Relat Res. 2000;380(380):99-107.
PubMed   |  Link to Article
Hwang  CS, Pagano  CR, Wichterman  KA, Dunnington  GL, Alfrey  EJ.  Resident versus no resident: a single institutional study on operative complications, mortality, and cost. Surgery. 2008;144(2):339-344.
PubMed   |  Link to Article
Rosenthal  GE, Harper  DL, Quinn  LM, Cooper  GS.  Severity-adjusted mortality and length of stay in teaching and nonteaching hospitals: results of a regional study. JAMA. 1997;278(6):485-490.
PubMed   |  Link to Article
Harrington  DT, Roye  GD, Ryder  BA, Miner  TJ, Richardson  P, Cioffi  WG.  A time-cost analysis of teaching a laparoscopic entero-enterostomy. J Surg Educ. 2007;64(6):342-345.
PubMed   |  Link to Article
Lee  SL, Sydorak  RM, Applebaum  H.  Training general surgery residents in pediatric surgery: educational value vs time and cost. J Pediatr Surg. 2009;44(1):164-168.
PubMed   |  Link to Article
Bridges  M, Diamond  DL.  The financial impact of teaching surgical residents in the operating room. Am J Surg. 1999;177(1):28-32.
PubMed   |  Link to Article
Ordos R, Huyck R. Charity care in Washington Hospitals. Washington State Department of Health, Center for Health Statistics, Hospital and Patient Data Systems. June 2011. http://www.doh.wa.gov/DataandStatisticalReports/HealthcareinWashington/HospitalandPatientData/HospitalPatientInformationandCharityCare/CharityCareinWashingtonHospitals.aspx. Accessed April 19, 2013.
Centers for Medicare & Medicaid Services (CMS). CMS home page. Physician fee schedule 2011, facility price, King County, Washington. http://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Accessed June 1, 2012.
Brown  GC.  Vision and quality-of-life. Trans Am Ophthalmol Soc. 1999;97:473-511.
PubMed
Busbee  BG, Brown  MM, Brown  GC, Sharma  S.  Incremental cost-effectiveness of initial cataract surgery. Ophthalmology. 2002;109(3):606-613.
PubMed   |  Link to Article
US Department of Labor, Bureau of Labor Statistics. Consumer price index. http://www.bls.gov/cpi. Accessed June 1, 2012.
Steinberg  EP, Tielsch  JM, Schein  OD,  et al.  National study of cataract surgery outcomes: variation in 4-month postoperative outcomes as reflected in multiple outcome measures. Ophthalmology. 1994;101(6):1140-1141.
PubMed
Brouwer  WB, Niessen  LW, Postma  MJ, Rutten  FF.  Need for differential discounting of costs and health effects in cost effectiveness analyses. BMJ. 2005;331(7514):446-448.
PubMed   |  Link to Article
Claxton  K, Sculpher  M, Culyer  A,  et al.  Discounting and cost-effectiveness in NICE: stepping back to sort out a confusion. Health Econ. 2006;15(1):1-4.
PubMed   |  Link to Article
Bos  JM, Postma  MJ, Annemans  L.  Discounting health effects in pharmacoeconomic evaluations: current controversies. Pharmacoeconomics. 2005;23(7):639-649.
PubMed   |  Link to Article
Foucault M. The Birth of the Clinic: An Archaeology of Medical Perception. Sheridan Smith AM, trans. New York, NY: Pantheon; 1973.
Lamoureux  EL, Fenwick  E, Pesudovs  K, Tan  D.  The impact of cataract surgery on quality of life. Curr Opin Ophthalmol. 2011;22(1):19-27.
PubMed   |  Link to Article
Lansingh  VC, Carter  MJ, Martens  M.  Global cost-effectiveness of cataract surgery. Ophthalmology. 2007;114(9):1670-1678.
PubMed   |  Link to Article
Morse  AR, Lee  PP.  Comparative effectiveness: insights on treatment options for open-angle glaucoma. Arch Ophthalmol. 2012;130(4):506-507.
PubMed   |  Link to Article
Laupacis  A, Feeny  D, Detsky  AS, Tugwell  PX.  How attractive does a new technology have to be to warrant adoption and utilization? tentative guidelines for using clinical and economic evaluations. CMAJ. 1992;146(4):473-481.
PubMed
Heudebert  GR, Centor  RM, Klapow  JC, Marks  R, Johnson  L, Wilcox  CM.  What is heartburn worth? a cost-utility analysis of management strategies. J Gen Intern Med. 2000;15(3):175-182.
PubMed   |  Link to Article
Chung  KC, Walters  MR, Greenfield  ML, Chernew  ME.  Endoscopic versus open carpal tunnel release: a cost-effectiveness analysis. Plast Reconstr Surg. 1998;102(4):1089-1099.
PubMed
Brown  GC, Brown  MM, Sharma  S, Tasman  W, Brown  HC.  Cost-effectiveness of treatment for threshold retinopathy of prematurity. Pediatrics. 1999;104(4):e47.
PubMed   |  Link to Article
Sharma  S, Hollands  H, Brown  GC, Brown  MM, Shah  GK, Sharma  SM.  The cost-effectiveness of early vitrectomy for the treatment of vitreous hemorrhage in diabetic retinopathy. Curr Opin Ophthalmol. 2001;12(3):230-234.
PubMed   |  Link to Article
Brown  GC, Brown  MM, Sharma  S.  Healthcare economic analyses. Retina. 2004;24(1):139-146.
PubMed   |  Link to Article
Membreno  JH, Brown  MM, Brown  GC, Sharma  S, Beauchamp  GR.  A cost-utility analysis of therapy for amblyopia. Ophthalmology. 2002;109(12):2265-2271.
PubMed   |  Link to Article
Brown  MM, Brown  GC, Lieske  HB, Lieske  PA.  Preference-based comparative effectiveness and cost-effectiveness: a review and relevance of value-based medicine for vitreoretinal interventions. Curr Opin Ophthalmol. 2012;23(3):163-174.
PubMed   |  Link to Article
Busbee  BG, Brown  MM, Brown  GC, Sharma  S.  Cost-utility analysis of cataract surgery in the second eye. Ophthalmology. 2003;110(12):2310-2317.
PubMed   |  Link to Article
Sharma  S, Brown  GC, Brown  MM, Hollands  H, Shah  GK.  The cost-effectiveness of grid laser photocoagulation for the treatment of diabetic macular edema: results of a patient-based cost-utility analysis. Curr Opin Ophthalmol. 2000;11(3):175-179.
PubMed   |  Link to Article
Gupta  OP, Brown  GC, Brown  MM.  A value-based medicine cost-utility analysis of idiopathic epiretinal membrane surgery. Am J Ophthalmol. 2008;145(5):923-928.
PubMed   |  Link to Article
Torrance  GW, Feeny  D.  Utilities and quality-adjusted life years. Int J Technol Assess Health Care. 1989;5(4):559-575.
PubMed   |  Link to Article
Brown  GC, Brown  MM, Sharma  S,  et al.  Incremental cost-effectiveness of laser therapy for visual loss secondary to branch retinal vein occlusion. Ophthalmic Epidemiol. 2002;9(1):1-10.
PubMed   |  Link to Article
Brown  MM, Brown  GC, Brown  HC, Peet  J.  A value-based medicine analysis of ranibizumab for the treatment of subfoveal neovascular macular degeneration. Ophthalmology. 2008;115(6):1039.5-1045.e5. doi:10.1016/j.ophtha.2007.08.033.
PubMed   |  Link to Article
Brown  MM, Brown  GC, Brown  HC, Irwin  B, Brown  KS.  The comparative effectiveness and cost-effectiveness of vitreoretinal interventions. Curr Opin Ophthalmol. 2008;19(3):202-207.
PubMed   |  Link to Article
Mills  RP, Mannis  MJ; American Board of Ophthalmology Program Directors’ Task Force on Competencies.  Report of the American Board of Ophthalmology Task Force on the Competencies. Ophthalmology. 2004;111(7):1267-1268.
PubMed   |  Link to Article
Lee  AG, Carter  KD.  Managing the new mandate in resident education: a blueprint for translating a national mandate into local compliance. Ophthalmology. 2004;111(10):1807-1812.
PubMed
Ament  CS, Henderson  BA.  Optimizing resident education in cataract surgery. Curr Opin Ophthalmol. 2011;22(1):64-67.
PubMed   |  Link to Article
Hosler  MR, Scott  IU, Kunselman  AR, Wolford  KR, Oltra  EZ, Murray  WB.  Impact of resident participation in cataract surgery on operative time and cost. Ophthalmology. 2012;119(1):95-98.
PubMed   |  Link to Article
Lum  F, Schein  O, Schachat  AP, Abbott  RL, Hoskins  HD  Jr, Steinberg  EP.  Initial two years of experience with the AAO National Eyecare Outcomes Network (NEON) cataract surgery database. Ophthalmology. 2000;107(4):691-697.
PubMed   |  Link to Article
Woodfield  AS, Gower  EW, Cassard  SD, Ramanthan  S.  Intraoperative phacoemulsification complication rates of second- and third-year ophthalmology residents: a 5-year comparison. Ophthalmology. 2011;118(5):954-958.
PubMed   |  Link to Article
Blomquist  PH, Morales  ME, Tong  L, Ahn  C.  Risk factors for vitreous complications in resident-performed phacoemulsification surgery. J Cataract Refract Surg. 2012;38(2):208-214.
PubMed   |  Link to Article
Rutar  T, Porco  TC, Naseri  A.  Risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Ophthalmology. 2009;116(3):431-436.
PubMed   |  Link to Article
Khatibi  A, Naseri  A, Stewart  JM.  Rate of rhegmatogenous retinal detachment after resident-performed cataract surgery is similar to that of experienced surgeons. Br J Ophthalmol. 2008;92(3):438. doi:10.1136/bjo.2007.125633.
PubMed   |  Link to Article
Bhagat  N, Nissirios  N, Potdevin  L,  et al.  Complications in resident-performed phacoemulsification cataract surgery at New Jersey Medical School. Br J Ophthalmol. 2007;91(10):1315-1317.
PubMed   |  Link to Article
Hollander  DA, Vagefi  MR, Seiff  SR, Stewart  JM.  Bacterial endophthalmitis after resident-performed cataract surgery. Am J Ophthalmol. 2006;141(5):949-951.
PubMed   |  Link to Article
Schaumberg  DA, Dana  MR, Christen  WG, Glynn  RJ.  A systematic overview of the incidence of posterior capsule opacification. Ophthalmology. 1998;105(7):1213-1221.
PubMed   |  Link to Article
Kennickell  AB.  What is the difference? evidence on the distribution of wealth, health, life expectancy, and health insurance coverage. Stat Med. 2008;27(20):3927-3940.
PubMed   |  Link to Article
Chandler  M.  The rights of the medically uninsured: an analysis of social justice and disparate health outcomes. J Health Soc Policy. 2006;21(3):17-36.
PubMed   |  Link to Article

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