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• W2034477002 abstract "Cataract surgery is the most frequently performed surgical procedure in many developed countries, providing significant, long-term, and cost-effective improvements in the quality of life for patients of all ages.1Lundström M. Wendel E. Duration of self assessment benefit of cataract extraction: a long term study.Br J Ophthalmol. 2005; 89: 1017-1020Crossref PubMed Scopus (29) Google Scholar, 2Busbee B.G. Brown M.M. Brown G.C. Sharma S. Incremental cost-effectiveness of initial cataract surgery.Ophthalmology. 2002; 109: 606-613Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar Advances in cataract surgery techniques and technologies over the last decades have led to improved patient safety and better surgical outcomes, resulting in significant changes in the frequency with which cataract surgery is performed. Longitudinal, population-based data on cataract surgery rates in the United States are limited. In this issue, Klein et al3Klein B.E.K. Howard K.P. Lee K.E. Klein R. Changing incidence of lens extraction over twenty years: the Beaver Dam Eye Study.Ophthalmology. 2014; 121: 5-9Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar provide timely, informative, population-based data on the changing incidence of cataract surgery in Beaver Dam, Wisconsin, during the 20-year period when cataract surgery shifted from planned extracapsular cataract extraction to small-incision phacoemulsification. Klein et al report that the age- and sex-adjusted incidence of cataract surgery increased 6.5-fold between 1988-90 and 2008-10 (1.8% vs. 11.7%) in Beaver Dam residents aged 43 to 86 years. The greatest increases were seen in the most recent 5-year interval (between 2003-05 and 2008-10) in persons older than 65 years of age and in persons with a visual acuity better than 20/40 or without a clinically significant cataract as determined at an examination 5 years before cataract surgery. The strengths of this study include its population basis, 2 decades of cataract surgery incidence, a standardized assessment of cataract status and visual acuity, avoidance of inclusion and recall bias, and adjustment for multiple potential risk factors. Its limitations include a small cohort size (4926 residents), a lack of geographic and racial diversity (99% white), and the interpretation of preoperative cataract status and visual acuity based on measurements performed up to 5 years before cataract surgery. The World Health Organization has set a cataract surgery rate of 3000 per million people per year as the minimum necessary to eliminate cataract blindness.4World Health OrganizationGlobal Initiative for Elimination of Avoidable Blindness. World Health Organization, Geneva, Switzerland2000Google Scholar This rate is greatly exceeded in many developed countries (7000–11 000 per million persons),5Taylor H.R. Hien T.V. Keefe J.E. Visual acuity thresholds for cataract surgery and changing Australian population.Arch Ophthalmol. 2006; 124: 1750-1753Crossref PubMed Scopus (38) Google Scholar, 6Behnig A. Montan P. Stenevi U. et al.Once million cataract surgeries: Swedish National Cataract Register 1992-2009.J Cataract Refract Surg. 2011; 37: 1539-1545Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar, 7Gollogly H.E. Hodge D.O. St. Sauver J.L. Erie J.C. Increasing incidence of cataract surgery: population-based study.J Cataract Refract Surg. 2013; 39: 1383-1389Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar and surgery rates are steadily increasing. Increasing cataract surgery rates have been explained, in part, by an aging demographic structure, reduced thresholds of visual impairment as an indication for surgery, increased frequency of second eye surgery, and increasing expectations by patients for better vision. What can we learn from the Beaver Dam Eye Study? First, the rising cataract surgery rates observed in Beaver Dam also were seen during the same time period in other areas of the United States and in many developed countries, albeit of a significantly lesser magnitude. Across the Mississippi river and 220 miles to the west of Beaver Dam, population-based data from Olmsted County, Minnesota (population 144 248 in 2010), showed a lower, but steady 2.5-fold increase in the rate of incident cataract surgery over the same time period (4400 surgeries/million residents in 1990 and 10 000 in 2010).7Gollogly H.E. Hodge D.O. St. Sauver J.L. Erie J.C. Increasing incidence of cataract surgery: population-based study.J Cataract Refract Surg. 2013; 39: 1383-1389Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Furthermore, Olmsted County modeling showed that cataract surgery increased at a greater rate than could be attributed to changing demographics alone. Nationally, using U.S. Medicare beneficiary data, the rate of cataract surgery in persons older than 65 years of age increased 2.4-fold between 19878Javitt J.C. Kendix M. Tielsch J.M. et al.Geographic variation in utilization of cataract surgery.Med Care. 1995; 33: 90-105Crossref PubMed Scopus (90) Google Scholar and 2004.9Schein O.D. Cassard S.D. Tielsch J.M. Gower E.W. Cataract surgery among Medicare beneficiaries.Ophthalmic Epidemiology. 2012; 19: 257-264Crossref PubMed Scopus (88) Google Scholar In Australia, cataract surgery rates increased 1.4-fold between 2000 and 2005.5Taylor H.R. Hien T.V. Keefe J.E. Visual acuity thresholds for cataract surgery and changing Australian population.Arch Ophthalmol. 2006; 124: 1750-1753Crossref PubMed Scopus (38) Google Scholar Rising surgery rates in the U.S. senior population are not unique to ophthalmology. In orthopedic surgery, improved surgical techniques and implant technologies have led to a 1.6- to 2.7-fold increase in total knee and hip arthroplasties over a comparable time period.10Singh J.A. Epidemiology of knee and hip arthroplasty: a systematic review.Open Orthop J. 2011; 5: 80-85Crossref PubMed Scopus (111) Google Scholar Although cataract surgery rates were on the rise in Beaver Dam, rates in Sweden had stabilized between 2002 and 2009 at 8000 to 9000 procedures per million persons. 6Behnig A. Montan P. Stenevi U. et al.Once million cataract surgeries: Swedish National Cataract Register 1992-2009.J Cataract Refract Surg. 2011; 37: 1539-1545Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar How were our Nordic colleagues able to accomplish this while at the same time slowly decreasing the surgery backlog, increasing the rate of second eye surgery, and operating on eyes with better preoperative Snellen visual acuity? The reason is multifactorial, but includes a limit on the number of annual cataract surgeries placed by many of Sweden's 22 counties/regions and increased competition for eye care resources from other fields within ophthalmology, primarily in the management of age-related macular degeneration. In 2008, the county of Stockholm removed the limit on the annual number of cataract surgeries allowed. Of note, cataract surgery rates subsequently increased in that area (Lundström M, personal communication, 2013). Second, a reduced threshold of visual impairment is increasingly being used as an indication for surgery by surgeons, patients, and payers. Better preoperative vision before surgery has been documented in Beaver Dam, Olmsted County,7Gollogly H.E. Hodge D.O. St. Sauver J.L. Erie J.C. Increasing incidence of cataract surgery: population-based study.J Cataract Refract Surg. 2013; 39: 1383-1389Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Australia,5Taylor H.R. Hien T.V. Keefe J.E. Visual acuity thresholds for cataract surgery and changing Australian population.Arch Ophthalmol. 2006; 124: 1750-1753Crossref PubMed Scopus (38) Google Scholar Denmark,11Kessel L. Haargaard B. Boberg-Ans G. Henning V. Time trends in indications for cataract surgery.J Clin Exp Ophthalmol. 2012; 2: 174Google Scholar England,12Keenan T. Rosen P. Yeates D. Goldacre M. Time trends and geographical variation in cataract surgery rates in England: study of surgical workload.Br J Ophthalmol. 2007; 91: 901-904Crossref PubMed Scopus (66) Google Scholar and Sweden.6Behnig A. Montan P. Stenevi U. et al.Once million cataract surgeries: Swedish National Cataract Register 1992-2009.J Cataract Refract Surg. 2011; 37: 1539-1545Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar In Sweden, for example, the fraction of residents with a Snellen visual acuity of 20/40 or better in the eye planned for surgery has increased from 56% in 1992 to 78% in 2009.6Behnig A. Montan P. Stenevi U. et al.Once million cataract surgeries: Swedish National Cataract Register 1992-2009.J Cataract Refract Surg. 2011; 37: 1539-1545Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar Not surprisingly, lower visual thresholds for surgery are associated with increased surgery rates. In Australia, when the visual impairment threshold changed from less than 20/200 to less than 20/30, cataract surgery rates increased approximately 5-fold.5Taylor H.R. Hien T.V. Keefe J.E. Visual acuity thresholds for cataract surgery and changing Australian population.Arch Ophthalmol. 2006; 124: 1750-1753Crossref PubMed Scopus (38) Google Scholar However, one needs to remember that Snellen acuity alone is a functionally incomplete measure of visual function, and other quantifiable factors such as contrast sensitivity and glare contribute to patient visual dissatisfaction. It is important for readers to note that the comments by Klein et al3Klein B.E.K. Howard K.P. Lee K.E. Klein R. Changing incidence of lens extraction over twenty years: the Beaver Dam Eye Study.Ophthalmology. 2014; 121: 5-9Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar regarding preoperative visual acuity threshold and cataract status are based on measurements performed up to 5 years before cataract surgery. Although the authors think that it “seems unlikely” over a 5-year period “that a rapid change occurred in development of lens opacity and/or decreased vision related to cataract prior to surgery,” previous data from the Age-Related Eye Disease Study Research Group13Koo E.K. Chang J.R. Agron E. et al.Ten-year incidence rates of age-related cataract in the Age-Related Eye Disease Study (AREDS): AREDS report no. 33.Ophthalmic Epidemiol. 2013; 20: 71-81Crossref PubMed Scopus (18) Google Scholar report the 5-year cumulative incidence of progression from a grade of no or mild lens opacity at baseline to a moderate cataract of any kind to be approximately 24% among participants aged 55 to 80 years. Rather than mistakenly infer that cataract surgery is being performed in eyes without a cataract, it is more likely that Beaver Dam ophthalmologists and their patients—similar to their colleagues and patients in Olmsted County and in other countries—have reduced their visual impairment threshold for cataract surgery. Why are we observing an increasing demand for cataract surgery at lower visual impairment thresholds in nearly all age groups? Columnist Rich Karlgaard14Karlgaard R. Gilder's Triumph. Knowledge and Power.Forbes. July 15, 2013; : p 30Google Scholar recently cited George Gilder, author of Wealth and Poverty, who argued that in economics, increased demand is due to increased supply. “The key is not an increase in the same supply, but rather an increase in a new, inventive supply that exceeds people's expectations and takes them to new heights in their lives.”14Karlgaard R. Gilder's Triumph. Knowledge and Power.Forbes. July 15, 2013; : p 30Google Scholar This statement, in my opinion, aptly describes cataract surgery over the last decades. Through improved technologies and techniques, today's ophthalmologists can safely and quickly remove a cloudy crystalline lens and fairly predictably decrease or eliminate postoperative spherical and astigmatic error. Our ability to provide a new, innovative cataract surgery “supply” has provided better outcomes, improved quality of life, and exceeded patient expectations, consequently, and quite naturally this has driven increased patient “demand” for our service. To paraphrase Steve Jobs, “People don't know what they want until you show it to them.”15The 100 greatest Steve Jobs quotes. By Stephan Nale. Oct 2012 Permalink. Available at: www.complex.com/tech/2012/10/steve-jobs-quotes/unintended-consequences. Accessed October 28, 2013.Google Scholar For many patients, after first-eye cataract surgery, the previously minimally symptomatic 20/30 fellow eye now no longer seems adequate when compared with the new pseudophakic eye. The benefits of first-eye surgery seem to have changed our patients' perceptions of disability and visual functioning in the fellow eye. This is evidenced by the significant increase in second-eye surgery in most surveys, now accounting for approximately 40% of all cataract operations. This is for good reason. Bilateral cataract surgery is cost-effective, improves patient satisfaction, and has better outcomes than surgery in one eye only.2Busbee B.G. Brown M.M. Brown G.C. Sharma S. Incremental cost-effectiveness of initial cataract surgery.Ophthalmology. 2002; 109: 606-613Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 16Lundström M. Stenevi U. Thorburn W. Quality of life after first and second-eye surgery; five-year data collected by the Swedish National Cataract Register.J Cataract Refract Surg. 2001; 27: 1553-1559Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar, 17Tan A.C.S. Tay W.T. Zheng Y.F. et al.The impact of bilateral or unilateral cataract surgery on visual functioning; when does second eye cataract surgery benefit patients?.Br J Ophthalmol. 2012; 96: 846-851Crossref PubMed Scopus (24) Google Scholar Disturbed motion perception, disturbed stereoacuity, and disturbances from anisometropia are reported disabilities that persist after unilateral cataract surgery or with a cataract in the fellow eye after first-eye surgery.18Lundström M. Albrecht C. Previous cataract surgery in a defined Swedish population.J Cataract Refract Surg. 2003; 29: 50-56Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Perhaps because of the documented benefits of bilateral cataract surgery, in the last 7 years we have seen a doubling of the rate of second-eye surgery in Olmsted County residents within the first 3 months after first-eye surgery (60% vs. 28%), with 86% of residents now undergoing second-eye surgery within 2 years of first-eye surgery.7Gollogly H.E. Hodge D.O. St. Sauver J.L. Erie J.C. Increasing incidence of cataract surgery: population-based study.J Cataract Refract Surg. 2013; 39: 1383-1389Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Is more always better in cataract surgery? William Falk19Falk W. The Week. June 21, 2013, Vol. 13 Issue 622, p. 16.Google Scholar writes that “if humans can, we will – whether or not we should.” Human history amply demonstrates our tendency to race ahead of our ability to think through all of the consequences of our actions. This has been the case recently with the capabilities of drone technology and Internet metadata-analysis. The many documented benefits of cataract surgery have led to an ever-increasing demand for cataract surgery and, as a consequence, steadily higher surgery rates and an increasing need for more resources. Is this appropriate? I believe it is. To do otherwise is to encourage mediocrity. Continued improvements in cataract surgery “supply” have naturally and appropriately stimulated patient “demand” for better vision. Predicting if or when cataract surgery rates will level off or decline is difficult. Placing limits on the annual number of cataract surgeries performed or shifting more cost to the patient will be contentious. Regardless, it is our responsibility as surgeons to continue to innovate, to improve safety and outcomes, and to reduce costs so that we enhance the value of cataract surgery for every patient we serve." @default.
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• W2034477002 title "Rising Cataract Surgery Rates: Demand and Supply" @default.
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