Cataract surgery is one of the most commonly performed surgeries in the United States, with approximately 3.5 million performed in the United States each year.1–3 Although considered safe and effective, the procedure is not without complications, including posterior capsule rupture (PCR).4 Complications of PCR are also associated with other postoperative complications, including retinal detachment, endophthalmitis, and reduced visual acuity.5–7 There are little data regarding the added cost to the individual and health care system when a PCR occurs. A 2012 study by Qatarneh et al. from the United Kingdom calculated an average estimated added cost of £405.8.8 However, this represents costs in a different health care system than the current model in the United States. The purpose of this study is to analyze the added financial burden to the U.S. health care system when a PCR occurs during cataract surgery at an academic center. This is the first study to analyze the cost of a complication such as posterior capsule rupture using a cohort of patients living in the United States.
Patients and Methods
All cataract extractions (CEs) performed at the University of Colorado Sue Anschutz-Rodgers Eye Center from January 1, 2014, to December 31, 2017, were retrospectively reviewed to identify posterior capsular complications with or without vitreous loss that occurred during routine cataract extraction cases. These cases were then compared to uncomplicated cataract surgeries to identify extra costs and extra visits incurred as a direct result of the complication. The cases were identified using the University of Colorado Cataract Outcomes Database (described in detail elsewhere).9 This study was approved by the Colorado Multiple Institutional Review Board. Each CE resulting in PCR as identified per medical chart review was further reviewed. Data collection included characteristics of the cataract and surgery (such as type of cataract, ocular comorbidities such as glaucoma and age-related macular degeneration, as well as other types of combined surgeries), all surgical complications, CE operative time, number of postoperative visits with the surgeon, number of additional related visits with other physicians, subsequent ophthalmic studies, and subsequent operative procedures. Exclusion criteria included cases with combined phacoemulsification and an additional procedure (ie, vitrectomy or keratoplasty), known posterior polar cataracts, suspected PCR prior to surgery, patients with co-managed care outside of our University setting (limiting evaluation of total visits and extra imaging studies), phacomorphic glaucoma with severe corneal edema limiting visualization, and traumatic cataracts.
Billing codes were gathered for each case, including facility fees for additional postoperative visits more than three (the standard at the institution); consultations with other subspecialties; and subsequent studies, procedures, and surgeries related to the complication. Average national Medicare reimbursement rates for each of these billing codes were obtained (Centers for Medicare and Medicaid Services Physician Fee Schedule search tool: Calendar year 2017 National Payment Amount for Facility Price).10 The cost of the additional operating time needed to complete the CE was combined with these billing costs to tabulate a final cost related to the PCR.
The cost of additional operating time was calculated by multiplying excess operating time by the cost to use the institution's operating room. Excess time was calculated as the number of minutes above the institution's mean CE operating time. The average uncomplicated case length at the institution was 22.50 minutes, which included resident, fellow, and attending cases. In fiscal year 2014, the operating room cost was $11.70 per minute. Thus: Additional Cost = (Operating Time Minutes – Mean Operating Time Minutes) × $11.70/min.
Calculations include the number of non-billed postoperative encounters (billing code 99024) above the average expected number of visits for an uncomplicated case as these additional visits represent extra time patients spent in the clinic and the extra resources required to facilitate the visit (ie, technician support, cleaning, etc.) This included the number of un-charged visits per patient with both the surgeon and other ophthalmologists at the institution. Additional costs also included any additional amount billed in the 15-month period following the initial complication if medically related to the surgical complication.
A cohort of 8,113 eyes were analyzed. Forty-five eyes were identified with PCR, resulting in a PCR rate of 0.55%. Eleven eyes were excluded from this data analysis, as they did not meet PCR inclusion criteria (three planned vitrectomies, two traumatic cataracts, one co-managed with a non-University optometrist, one capsular violation from previous intravitreal injection, one congenital posterior polar cataract, one planned combined phacoemulsification and penetrating keratoplasty, one planned combined phacoemulsification and endothelial keratoplasty, and one phacomorphic glaucoma with severe corneal edema). The total cost of the 34 included CEs with PCR was $37,776.42, resulting in an average of $1,111.07 per case (range: $122.85 to $4,697.58; standard deviation [SD] ± $1,021.20). Case data are shown in Table 1 and described further below.
Additional Costs Associated With Cases of PCR Included in the Study
The average complicated case length was 61.43 minutes (range: 21 to 191 minutes). In comparison to a mean of 22.50 minutes for uncomplicated cases, this resulted in an excess operating room time cost of $455.48 (SD ± $407.37) per case.
Additional billed costs from non-99024 codes as determined by billing extracted from clinical or surgical encounters incurred an additional mean cost of $655.59 per case (range: $0 to $2,726.13; SD ± $767.21). Additional costs included a combination of necessary imaging studies (ie, macular optical coherence tomography), clinic procedures (ie, barrier laser retinopexy), and operating room surgeries (ie, pars plana vitrectomy).
The number of excess unbilled postoperative encounters with the operating surgeon averaged 2.76 (range: 0 to 8). An average of 3.06 visits (range: 0 to 14) were also required with an ophthalmologist of another subspecialty. As a result of the PCR, 22 of 34 patients (65%) required a referral to another ophthalmic subspecialist within the institution (22 retina, two glaucoma, one uveitis).
The majority of PCRs occurred during phacoemulsification (22/34) or irrigation and aspiration (7/34); whereas, three occurred due to a radialized capsulorrhexis and two during intraocular lens (IOL) insertion. Other complications in CE with PCR cases included retained lens fragments (n = 12), elevated intraocular pressure (n = 18), cystoid macular edema (n = 1), inverted IOL and temporary uveitis-glaucoma-hyphema syndrome (n = 1), dropped IOL (n = 1), suprachoroidal hemorrhage (n = 2), and no-light-perception vision (n = 1) (Table 2). Five patients did not have an IOL placed at the time of initial surgery due to one or more of these complications.
Additional Complications Among Cases of PCR Included in the Study
By using cost analysis in this study, one can extrapolate an estimated total national annual cost of PCRs. There are approximately 3.5 million cataract surgeries performed per year in the United States, with an incidence of PCR between 0.46% and 1%.11,12 We roughly estimate an additional added cost burden of $16 million to $35 million per year in the United States if our institutional costs could be applied as an average for the nation.
PCRs represent one of the most concerning complications in cataract surgery. The incidence of PCR tends to be higher during early training of phacoemulsification, including with residents at academic institutions and with experienced surgeons transitioning from extracapsular cataract extraction to phacoemulsification.13–16 This study is the first in the United States to attempt to quantify the extra costs associated with managing this complication.
There are several limitations to this study. It uses the average national reimbursement rate from the Centers for Medicare and Medicaid Services; however, regional variations exist. Facility fees also vary widely based on ophthalmic practice setting, with fees diverging between public versus private institutions and hospital-based versus clinic-based offices. The non-conformity that exists in the United States reimbursement model creates difficulties in assessing true costs. Our estimates are based on one academic institution and physician referral patterns, and comfort dealing with complications are variable across practices. The average cost per minute for operating time at the University of Colorado may differ from that of other facilities and institutions. Referral patterns are often physician-dependent, so the number of subspecialty visits may also vary from one practice to another. In addition, the incidence of PCR can differ from one institution to another and varies depending on surgical skill and experience, which are factors beyond the scope of this study.
There are other costs, both tangible and intangible, associated with any surgical complication that were not included in this study. These include the transportation costs associated with additional visits, which can require the patient's friends and family members to leave work. As cataract surgery carries with it high expectations for good outcomes, complications can also result in an emotional burden to the patient when expectations are not met. This study does not account for additional costs that may be incurred by the patient or the cost of delayed rehabilitation, if needed. Finally, the study does not account for the potential costs of litigation, which could occur particularly if vision is lost. These costs are difficult to quantify with an average dollar amount.
As mentioned in the results, we estimate an additional cost burden of more than $1,100 per case of PCR at our institution with a fairly wide range of potential cost depending on the specifics of the case. Minimizing complications through improved surgical education and experience may help to lower this cost.
- Wier LM, Steiner CA, Owens PL. Surgeries in hospital-owned out-patient facilities, 2012. HCUP Statistical Brief #188. February2015. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb188-Surgeries-HospitalOutpatient-Facilities-2012.pdf.
- Rutkow IM. Surgical operations in the United States. Then (1983) and now (1994). Arch Surg. 1997;132(9):983–990. doi:10.1001/archsurg.1997.01430330049007 [CrossRef] PMID:9301611
- Gong D, Jun L, Tsai JC. Trends in Medicare service volume for cataract surgery and the impact of the Medicare physician fee schedule. Health Serv Res. 2017;52(4):1409–1426. doi:10.1111/1475-6773.12535 [CrossRef] PMID:27471114
- American Academy of Ophthalmology. Basic and clinical science course (BCSC) Section 11: Lens and Cataract. San Francisco, CA, 2016–2017.
- Petousis V, Sallam AA, Haynes RJ, et al. Risk factors for retinal detachment following cataract surgery: The impact of posterior capsular rupture. Br J Ophthalmol. 2016;100(11):1461–1465. doi:10.1136/bjophthalmol-2015-307729 [CrossRef] PMID:26858087
- Haripriya A, Chang DF, Ravindran RD. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: results from 2 million consecutive cataract surgeries. J Cataract Refract Surg. 2019;45(9):1226–1233. doi:10.1016/j.jcrs.2019.04.018 [CrossRef] PMID:31371152
- Sparrow JM, Taylor H, Qureshi K, Smith R, Birnie K, Johnston RLUK EPR user group. The Cataract National Dataset electronic multi-centre audit of 55,567 operations: risk indicators for monocular visual acuity outcomes. Eye (Lond). 2012;26(6):821–826. doi:10.1038/eye.2012.51 [CrossRef] PMID:22441022
- Qatarneh D, Mathew RG, Palmer S, Bunce C, Tuft S. The economic cost of posterior capsule tear at cataract surgery. Br J Ophthalmol. 2012;96(1):114–117. doi:10.1136/bjo.2010.200832 [CrossRef] PMID:21362773
- Bonnell LN, SooHoo JR, Seibold LK, et al. One-day postoperative intraocular pressure spikes after phacoemulsification cataract surgery in patients taking tamsulosin. J Cataract Refract Surg. 2016;42(12):1753–1758. doi:10.1016/j.jcrs.2016.10.009 [CrossRef] PMID:28007106
- Centers for Medicare and Medicaid Services. Physician Fee Schedule Search. 2019; https://www.cms.gov/apps/physician-fee-schedule/. Accessed June 25, 2019.
- Gimbel HV, Sun R, Ferensowicz M, Anderson Penno E, Kamal A. Intraoperative management of posterior capsule tears in phacoemulsification and intraocular lens implantation. Ophthalmology. 2001;108(12):2186–2189. doi:10.1016/S0161-6420(01)00716-3 [CrossRef] PMID:11733256
- Chen M, Lamattina KC, Patrianakos T, Dwarakanathan S. Complication rate of posterior capsule rupture with vitreous loss during phacoemulsification at a Hawaiian cataract surgical center: A clinical audit. Clin Ophthalmol. 2014;8:375–378. doi:10.2147/OPTH.S57736 [CrossRef] PMID:24523578
- Briszi A, Prahs P, Hillenkamp J, Helbig H, Herrmann W. Complication rate and risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Graefes Arch Clin Exp Ophthalmol. 2012;250(9):1315–1320. doi:10.1007/s00417-012-2003-y [CrossRef] PMID:22527309
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Additional Costs Associated With Cases of PCR Included in the Study
|Average extra operating room time||$455.48|
|Average additional studies/surgery||$655.59|
|Average total additional cost||$1,111.07|
|Total additional cost||$37,775.02|
|Average extra 99024 visits||2.76|
|Average referral visits||3.06|
Additional Complications Among Cases of PCR Included in the Study
|Elevated IOP||18 (53%)|
|Retained Lens Fragment||12 (35%)|
| (Cortex – 8, nuclear – 3, epinuclear 1)|
|Suprachoroidal Hemorrhage||2 (6%)|
|No Light Perception||1 (3%)|
|Light Perception Only||1 (3%)|
|Dropped IOL||1 (3%)|
|Cystoid Macular Edema||1 (3%)|
|Chronic Panuveitis||1 (3%)|
|Inverted IOL||1 (3%)|
| (Temporary uveitis-glaucoma-hyphema syndrome)|
|No Complications||7 (21%)|