Priming Your Practice for Success
Early and ongoing teamwork figures heavily into patient acceptance of femtosecond laser technology.
"I don't consider myself an early adopter of femtosecond laser-assisted cataract surgery," says John Davidson, MD. As he explains it, he followed the technology from the sidelines for about 2 years before he was convinced it had reached a point in safety and efficacy to be a worthwhile investment for the practice. When he and his practice partner, Joel Corwin, MD, at Miramar Eye Specialists Medical Group in Ventura, Calif., came to that conclusion, they accelerated their efforts to learn as much as possible about what it would take to make the technology profitable in practice. According to their research, other practices and surgery centers were finding they needed to use the laser in 20 to 30 cases per month to break even on their expenditures.
Dr. Davidson continued to talk with cataract surgeons about their experiences with femtosecond lasers. He visited several practices to observe procedures, attended laser user meetings and set up appointments during industry meetings to 'test drive' lasers and talk with engineers about their products' specifications, capabilities and outcomes. "Once we decided to purchase a laser, I made a pact with myself to read something about femtosecond cataract surgery every day, whether it was a user manual, articles in journals, trade publications or online," he says. "All of that prompted me to ask questions."
Early Steps Toward Integration
Several years earlier, Dr. Davidson had already asked and answered one key question: How could he change his practice so it would perform optimally in the era of refractive cataract surgery? "In 2005, when CMS approved billing for presbyopia-correcting IOLs, I was seeing 100 patients some days," he says. "I wanted to personally speak with each cataract patient about the new lens options, but it was very disruptive to the daily flow. Because of that, I made the decision to give up the half of my practice that involved general ophthalmology patients in order to focus on surgery. This allowed me to spend time with patients and build a surgical referral-only practice."
With laser-assisted cataract surgery taking off, one of the first steps he took was to hire a refractive cataract surgery counselor to help ensure patients were adequately educated about their options. Also, the surgery center built out what had been a staff break room to house the laser.
In addition, Dr. Davidson collaborated with the entire staff to plan how to talk to patients about the advanced technology. "We concentrated on developing phraseology based upon what we were hearing and reading that was already working in other practices," he says. "As with advanced technology IOLs (ATIOLs), our goal when talking to patients is to emphasize how the technology benefits them, not necessarily the technology specifications."
Choosing a Laser Platform
After doing their research, Drs. Davidson and Corwin decided to purchase the Alcon LenSx® Laser. Several attributes of the LenSx Laser platform stood out:
▪ The laser doesn't have a fixed patient bed. "This is important for patient safety, comfort and flow," Dr. Davidson says. "We administer IV sedation while patients are on a gurney in the LenSx Laser room, and then move the gurney to the OR."
▪ The laser's variable numerical aperture is designed to optimize precise cutting of the cornea and the lens. "Some femtosecond lasers typically have only one numerical aperture, which is optimal for either the cornea or the lens but not both, whereas the LenSx Laser is designed to address both," Dr. Davidson explains.
▪ The user interface sequentially presents the necessary steps for planning incisions. "I felt that certain other user interfaces displayed numerous parameters without an obvious sequence, so it was difficult to know if I was finished focusing on what I needed to do before moving to the next step and before depressing the foot pedal," Dr. Davidson says.
▪ With the curved SoftFit™ Patient Interface, the natural curvature of the cornea can conform to a soft contact lens insert. "The SoftFit Patient Interface reduces corneal distortion and striae," Dr. Davidson notes. "Patients are more comfortable, less energy can be used, the rate of free-floating capsulotomies is increased and procedure time is reduced."1
Dr. Davidson is also looking forward to the new matrix phacofragmentation patterns for the LenSx Laser, which are expected in the near future. "Currently we can perform up to three chops, which divide the lens into six segments, and zero to eight concentric cylinders that divide the lens into microfragments. I'm expecting the new fragmentation patterns to exceed these bounds, further reducing phaco time and collateral tissue inflammation."
Beyond the technical aspects of the LenSx Laser, Dr. Davidson also felt comfortable partnering with Alcon. "During my 20-year career, the company has demonstrated that its commitment to innovation and making sure it has the best technology available," he says. "The LenSx Laser is designed with extensibility, so I was confident Alcon would keep up with and surpass whatever other companies were doing. Making such a large investment, you really have to consider future viability." The development of the company's SoftFit Patient Interface is just one example of Alcon's dedication to innovation and continued improvement, he says.
|On Target with Case Volume|
Richard A. Lewis, MD, and his partners in Capital City Surgery Center in Sacramento, Calif., began using their LenSx Laser at the end of last year. "We have a good setup for this because we have a third OR where we were able to place the laser," he says. They chose Alcon's LenSx Laser platform because of their long standing positive relationship with the company. "Also, the laser was the first to be FDA cleared for use in cataract surgery and had broad applications," he says. "Many centers were recommending it, and there was a great deal of momentum behind it."
The partners' goal was to use the laser in 20% of the cataract surgeries performed in the center. "I have a slightly different patient base because of my dual focus on glaucoma care, but I've been using the laser in 10-20% of my cataract cases," Dr. Lewis says. "As a center, we're doing more than that, so we're right on target."
Dr. Lewis cited staff education and patient education, which both require focused teamwork, and anticipating and managing the surgeon learning curve as crucial for meeting the case volume target. "First, everyone in the office and ASC — including technicians, front desk personnel and surgical coordinators — has to be comfortable with the concept of femtosecond laser-assisted cataract surgery and what it involves because all of them will be talking to patients about it. Next, you have to create an OR environment in which everyone, including the pre-op nurses and anesthesia team, is working together to incorporate the laser.
"The surgeon needs to recognize that he'll be working through a learning curve as well," concludes Dr. Lewis.
From Planning to Execution
With the LenSx Laser installed in early May of this year, it was time for Dr. Davidson to begin navigating the technology learning curve and see how effective the teamwide preparations would be. "The technique of laser-assisted cataract surgery requires a comprehensive and systematic approach to gain mastery and confidence with its application," says Dr. Davidson. He took his time in the LenSx Laser room and in the OR with his first cases to adjust to the nuances that make laser-assisted surgery different from the traditional approach, such as visualization with bubbles in the anterior chamber and lens, finetuning laser energy settings to promote easy opening of incisions, disassembly of nuclei in pre-chopped lenses and cortical cleanup without "handles."
"Initially, the laser portion added 10 minutes to each case in the LenSx Laser room and an extra 8 to 20 minutes in the OR," he says. "We were simultaneously integrating the ORA System* (WaveTec Vision) for intraoperative wavefront aberrometry, so that figured into the added OR time." Dr. Davidson says he was very comfortable with all of the steps in the laser room and OR by the time he had performed 100 cases. After that point, using the laser and ORA added just 5 minutes in the LenSx Laser room, which is about the same time that it takes to turn over the OR, and 2 to 5 minutes in the OR.
The addition of the refractive cataract surgery counselor not only saved physician time but also fueled patient acceptance of the laser. "Patients' interest in incorporating the laser into their lens replacement procedure has vastly exceeded our expectations," Dr. Davidson says, providing this breakdown of his numbers. The number of LenSx Laser cases jumped from 26 in May to 56 in July (see Table 1).
The counselor checks the schedule for upcoming cataract surgery consultations and calls those patients to say she is mailing an information package, which includes a welcome letter, information on ATIOLs and the LenSx Laser, and a vision questionnaire to fill out and bring with them. She encourages patients to call her with any questions. During the consults, she talks to them about all of the information as well as pricing while they are dilating. "This has been working great," Dr. Davidson says. "It allows my discussion with patients to be customized and focused. I make my recommendation based on the patient's visual needs, wants and eye health. I don't discuss pricing. If they ask me, I say they can discuss that with the counselor, so we can focus our discussion on the best plan for their vision."
|MONTH||NO. OF LENSX LASER CASES||LENSX LASER ADOPTION RATE|
|August||56 (in 3 weeks)||39%|
A main barrier to surgeon adoption of laser-assisted surgery has been the perceived amount of chair time required, but "it's not as much as you might think," Dr. Davidson says. "I spend less time introducing laser and lens options since patients aren't hearing about them for the first time. That allows a more relaxed and thorough examination and a focused discussion, which I finish with a solid recommendation. I point out that the laser is the first major improvement in cataract surgery since phacoemulsification, and I review how there are two ways we can perform the surgery. 'One is the traditional method, which involves a one-size-fits-all blade. The other uses a 3-D guided, computer-controlled laser to perform incisions in the cornea and lens. As an instrument in my hand, the laser can be more precise than a blade because the laser incisions are customized to the dimensions of your eye.' I also talk about being able to soften the cataract with the laser more gently than with the traditional ultrasound. 'The laser creates less 'shock waves' to the surrounding tissues, so we expect it to induce less swelling and allow faster recovery of vision.'"
In addition to the 54% patient acceptance rate achieved in just a few months, Dr. Davidson sees other positive signs. The practice has been receiving favorable feedback from referring physicians, and patients are giving the procedure high grades on a postop survey used to measure patient satisfaction. "One of the most important things I've learned from this experience is that successful incorporation of LenSx Laser surgery is heavily dependent upon teamwork," he says. "The staffs in the office and surgery center have learned new skills, flow protocols, concepts and key phrases to use with patients. They've also been working harder and longer hours to meet the increasing volume of patients choosing the LenSx Laser and ATIOLs. They do a wonderful job of preparing the patients for every step of the process, which relieves patient anxiety and provides them with a premium experience."
Dr. Davidson has made it a point to continue improving the patient journey through ongoing collaboration with the staff. They meet frequently to share how things are working in each department and share new ideas. ▪
1. Multicenter prospective clinical study. Alcon data on fi le.
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