Indicadores no âmbito da Oftalmologia e optimização dos resultados das cirurgias às cataratas

Joaquim Murta, MD, PhD

HCPCRIO (CHUC)

Coimbra, Portugaljmurta@netcabo.pt

• Cataract surgery is the most frequently performed surgical procedure in Ophthalmology (Nanavaty MA, Wearne MJ. Clin Experiment Ophthalmol. 2010 5: 462-6)

• 17 million persons bilateraly blind due to cataracts ( Conglon et al. JAMA 2003 15: 2057- 60)

The ideal cataract surgery would allow

patients to detect and

recognize large and small objects,

of high and low contrast,

at all distances and

under all lighting conditions

New Challenge for Cataract Surgery

Patients will be able to undergo a refractive surgical procedure, adressing all components of their refractive errors:

- nearsightedness

- farsightedness

- astigmatism

- presbyopia

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Refractive and keratometric values were measured before surgery in patients having cataract extraction

4540 eyes (mean age 60.59 ±9.87 years; range 32-87)

Descriptive statistics of refractive and keratometriccylinder data

≥ 1.25 D in 29% of eyes

N = 4540 eyes

High impact in vision even for relatively low amounts [Charman WN 1993, Wolfsohn JS et al 2011]

Distance VA decreased with increasing uncorrected astigmatism[Wolfsohn JS et al 2011]

Near VA and reading speed decreased

WHAT’S THE IMPACT OF ASTIGMATISM IN VISION?

It has been argued that 0.50 - 0.75 D might be well although visualdiscomfort might arise during attention-requiring tasks

[Wiggins & Daum, 1991]

Presbyopia: The Largest Ophthalmic Market

Sources: US Census Bureau, Market-Scope 2009 Presbyopia Report

Wealthy Nations: 90 Million People

Affects 1.04 billion people globally (Holden BA et al. Arch Ophthalmol. 2008;126:1739)

The treatment and correction of presbyopia remains a significant challenge for ophthalmologists

• Monovision Corrective lenses; Surgery

• Cornea Multifocal corneal excimer laser ablationCK, …

• Sclera

• Refractive lens exchange Multifocal IOL

Accommodating IOL

Two thirds found reduced CS at highest spatial frequencies for multifocal IOLs

Diffractive designs, particulary aspheric diffractive IOLs, affect CS less than concentric refractive designs

Halos and glare at night were the most commoly reported visual symptomsfollowed by dysphotopsia (positive and negative) shadows and waxy vision

Overall satisfaction was good ranging from 61.8 to 100 %

Dissatisfaction with multifocal IOLs most commonly related to blurred vision or photopic phenomenaassociated with RESIDUAL AMETROPIA, the development of PCO, large pupil size and dry eye

Trifocal diffractive IOLs reportedly smooth out the defocus curve

Introduction• Dysphotopsia - important

cause of dissatisfactionafter multifocal IOLs

• Dysphotopsia improve over time due to neuroadaptation

• Can we document theoccurrence ofneuroadaptation?

Purpose• Assess changes in the visual

cortex during a 6 month follow-up after multifocal IOL implantation

• Functional magnetic resonance imaging – non invasive method for studying brain activity in vivo: when we see an image there is an increase of oxygenated blood, creating an increase in the BOLD signal

Curr Opin Ophthalmol 2015.26:249-254

• Since 2003, refractive cataract surgery (presbyopia, astigmatism, FLACS) has grown to 350 000 surg per year

• Only small portion of patients (25%) will elect to pay for refractive cataract surgery

• 11% all cataract surgery (USA) are premium

• To satisfy demanding patients with high expectations consistent with their out-of-pocket expense, a surgeon must deliver very good results

• High capital costs excimer and femtosecond lasers

VERION™ Reference

Unit

VERION™ Digital Marker

VERION™ Digital Marker ORA™

aberrometry

Professor da Harvard Business School

At its core is maximizing value for patients: that is, achieving the best outcomes at the lowest cost.

We must move away from a supply-driven health care organized around what physicians do to toward a patient-centered system organized around what patients need.

We must shift the focus from the volume and profitability of services provided—physician visits, hospitalizations, procedures, and tests—to the patient outcomes achieved.

And we must replace today’s fragmented system, in which every local provider offers a full range of services, with a system in which services for particular medical conditions are concentrated in health-delivery organizations and in the right locations to deliver high-value care.

ICHOM

ICHOM

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From knowledge to market

* The Health Cluster Portugal (HCP) (www.healthportugal.com) is a private non-profit

association that currently brings together over 174 members, including R&D institutions,

universities, hospitals, organisations from civil society, and companies in the areas of

pharmaceuticals, biotechnology, medical technologies, and services.

* Together, these organisations develop innovative projects in areas such as translational and

clinical research, active and healthy ageing and eHealth, with the purpose of turning

knowledge into new solutions that contribute to the improvement of human health.

* HCP members work to make Portugal the right place to invest and build partnerships in

Health.

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174 Members

Hospitals

Companies: Pharma & Biotech

2000 PhDs

8500 physicians8000 beds

1250 M€ turnover80 M€ in R&D4000 employees

570 M€ turnover30 M€ in R&D6000 employees

R&D Institutions + Universities3100 researchers in Health

17 M€ in R&D

130 PhDs

30 PhDs

Companies: MedTech & Services

HCP: from knowledge to marketHCP: from knowledge to market

A PROJECT OF THE OPHTHALMOLOGY SUB-CLUSTER OF THE HEALTH CLUSTER PORTUGAL

* To evaluate the clinical results of different Ophthalmological Centers in Portugal, validating efficiency andrationalizing the costs without loss of quality, shifting the focus of income of the Units away from the volumeand profitability of services provided (physician visits, hospitalizations, procedures and tests) onto the patientoutcomes achieved, thereby creating value for the patient together with a culture of self-assessment andimprovement. The Payers (State, Private Companies or Industry) will significantly benefit through this HealthCare System based on value;

* To create an interaction between Clinicians and Researchers from different organizations and institutions,giving rise to huge new business opportunities and collaboration with industry;

* To recognize and promote the excellence of Portuguese Ophthalmology, increasing Health Tourism,promoting both the treatment of patients from other countries in Portugal and training activities by PortugueseOphthalmologists in foreign countries;

* To give Portuguese Ophthalmology in building the global acknowledgment of Portuguese Medicine.

OPHTHALMOLOGY SUB-CLUSTER - HEALTH CLUSTER PORTUGAL

PUBLIC HOSPITALS• Centro Hospitalar de São João• Centro Hospitalar do Porto• Hospital de Braga• Centro Hospitalar da Universidade de Coimbra • Centro Hospitalar de Lisboa Central• Centro Hospitalar de Lisboa Norte

PRIVATE HOSPITALS • CUF (5 Units)• Luz Saúde (3 Units)

SOCIEDADE PORTUGUESA DE OFTALMOLOGIA (SPO)

CATARACT: joining a truly international set of leading providers!AGE MACULAR DEGENERATION: pioneering...

Malaysian National Registry, Malaysia

Aravind Eye Care System, India

Sheba Medical Center, Ramat Gan, Israel

Humanitas,Milan, Italy

Erasmus, Rotterdam, NetherlandsBergman Clinics, Naarden, Netherlands

St Erik´s, Stockholm, SwedenSahlgrenska, Gothenburg, Sweden

Imperial Hospital, London, UKRoyal Free, London, UKWest Suffolk, Suffolk, UKAneurin Bevan Health Board, UKRamsay UK Healthcare, UK

Hospital CUF Braga, Braga, PortugalCentro Hospitalar do Porto, Porto, PortugalCentro Hospitalar de São João, Porto, PortugalHospital CUF Porto, Porto, PortugalCentro Hospitalar e Universitário de Coimbra, Coimbra, PortugalClínica Idealmed, Coimbra, PortugalHospital CUF Vila Franca, Vila Franca de Xira, PortugalCentro Hospitalar Lisboa Norte, Lisboa, PortugalCentro Hospitalar Lisboa Central, Lisboa, PortugalHospital CUF Infante Santo, Lisboa, Portugal,Hospital CUF Descobertas, Lisboa, Portugal

Prospective CAT Sites Prospective AMD Sites

Cataract Surgery Standard Set

Cataract Surgery Standard Set

• A 2016 study found that physicians spent two hours doing computer work for every hour spent face to face with a patient – whatever the brand of medical software;

• Physicians devoted half of their patient time facing the screen to do electronic tasks;

• These tasks were spilling over after hours

PROMPTLYMaking Outcomes available

Work with usfounders@promptlyhealth.com

Part of the ICHOM Technological HubWho we are

A Portuguese start-up focusing on unlocking the power of outcomes-based care

At the forefront of the outcomes implementation agenda

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Who we are

H2020 IMI PainCare H2020 ProEmpower Diabetes Facial Paralysis

IncorporatingICHOM SS for phase III in 2019

IncorporatingICHOM SS for Peds ptsin 2019

Platform – CRO | PRE-OPERATIVE

Platform – CRO | PRE-OPERATIVE

Platform – CRO | PRE-OPERATIVE

Platform – CRO | INTRA OPERATIVE

Platform – CRO | INTRA OPERATIVE

Platform – CRO | EARLY POST SURGERY

Platform – CRO | LATE POST SURGERY

Platform – CRO | LATE POST SURGERY

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Platform – CRO | LATE POST SURGERY

Standardized questionnaires tailored to each medical condition

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Value proposition

Platform – Disease creation

Platform – PROM Cataract (CatQuest-S9)

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Platform – PROM AMD (Brief IVI)

ICHOM-Cataract in our Institutions

• Ethics Committee Approval + RGPD

• Going beyond the minimum standard set• Premium IOLs, biometry, …

• Structured data collection and automatic submission to ICHOM, integrated in the clinical workflow (Promptly)

• Pilot + staged rollout• Endpoint ≥80% of cataract surgeries

TAKE-HOME MESSAGE:

“If you don’t continuously strive for perfectionyou will lose your surgical patients”

jmurta@netcabo.pt

THANK YOU