Value-Based Medicine

Sound the Trumpets

Even other physicians don’t know just what ophthalmologists do for our patients.

By Melissa M. Brown, MD, MN, MBA

Every ophthalmologist knows what we do and how much our patients appreciate what we do for them. But a major question is, what do our colleagues in medicine think about what we do? Unfortunately, many of them likely think most of what we do is refracting for glasses and fitting contact lenses. It’s crucial that we correct their misconceptions — both for ourselves and our patients.

Within the MD Ranks

Many medical schools do not even have a rotation through ophthalmology. Thus medical students can get through their entire four years without having seen cataract surgery, understanding what glaucoma is or knowing that AMD is the leading cause of vision loss in the United States. Few know how to effectively look at an optic nerve and discern the health of the retinal vessels, much less examine for diabetic retinopathy or even realize the benefits of papillary dilation or the use of an indirect ophthalmoscope for examination of the fundus.

An even more basic question is, what do our medical colleagues know about blindness? Do they realize that legally blind people lose their independence?¹ That they cannot drive and must depend upon others for shopping, doctor’s visits, for getting and taking their medicines, for cooking, cleaning, painting and household repairs? Do they know that many blind patients also lose their privacy¹ because they cannot read their mail, pay their bills without help or even perform proper personal hygiene?

The answer is probably not. And if they underestimate the affect of blindness upon quality of life, they will surely underestimate the patients value gain (improvement in quality of life or longevity, or both) conferred by our ophthalmic interventions.

The Facts of (Quality of) Life

Utility analysis allows us to quantify the quality of life associated with a disease and its severity with other diseases across all of medicine in the same scale. By convention, utility anchors typically range from 1.00 (normal health, or normal vision bilaterally) and 0.00 (death). The closer the utility is to 1.00, the better the quality-of-life, while the close the number is to 0.00, the poorer the quality of life.

Time trade-off utility analysis, the variant with seemingly the greatest reliability^2,3 and validity,⁴ calculates utility by subtracting from 1.0 the maximum proportion of theoretical remaining time of life, if any, a person is willing to trade in return for living the rest of the remaining time in normal health (with 20/20 or better vision bilaterally).¹ Thus, if a person expects to live another 20 years and is willing to trade four of the 20 in return for normal health during the 16 other years, the utility is (1.0 – 4/20 =) 0.80.

Patients tell us the quality-of-life associated with 20/200 vision or worse in the better-seeing eye (legal blindness in the United States) correlates most closely with a utility of 0.47.⁵ When ophthalmologists were asked to assume the same theoretical scenario of legal blindness, the mean associated utility was 0.73, while our non-ophthalmologist physicians thought the utility associated with 20/200 vision or worse in the good eye was 0.82. The general community estimated this at 0.86.⁵

What Does This Tell Us?

Ophthalmologists underestimate the affect of legal blindness upon patient quality-of-life diminution by almost 50% referent to patients with legal blindness, but non-ophthalmologist clinicians underestimate it by 64% referent to patients and the general public underestimates it by 74% referent to patients.

Overall, our non-ophthalmologist physician colleagues equate the quality-of-life associated with legal blindness to be similar to that of patients who have untreated moderate to severe migraine headaches (mean patient utility = 0.82).⁶ Nonetheless, people with migraines can typically function well with medications, while people who are legally blind are dependent upon others for many activities of daily living, including many private affairs. Ophthalmologists, when given the actual patient utilities, quickly realize why the utilities are so low. But how about our non-ophthalmologist colleagues? It’s a lot less likely.

What does it all mean? It means that our physician colleagues and the general public grossly underestimate the affect of legal blindness upon patient quality-of-life. They thus also grossly underestimate the great benefit of the many ophthalmic interventions that dramatically improve patient quality of life.^7,8

It’s Time To Speak Up

It is imperative we spread the word to our physician colleagues and to the general community about the dramatic diminution in patient quality of life associated with legal blindness, especially when compared with other health states.⁹ If we fail to do so, our relevance as a profession will be minimized. It could become more difficult to justify ophthalmic interventions in an era of tightening budgets — a scenario under which patients would suffer.

Moreover, a perception of reduced relevance could trigger a severe financial impact upon the profession itself, making it more difficult to attract the best and the brightest who have, to date, made some of the greatest advances encountered across all of medicine over the past decades.

If we do not “stick up for” the considerable importance of ophthalmic interventions in improving the quality-of-life of patients with severe vision loss, who will? And will the scenario I’ve described above make our healthcare system better than it is now?

I doubt it.
So go out and blow those trumpets. Patients deserve no less. The profession deserves no less. OM

References

1. Brown GC, Brown MM, Menezes A, Busbee BG, Lieske HB, Lieske PA. Cataract surgery cost-utility revisited in 2012. A new economic paradigm. Ophthalmology (in press).

2. Hollands H, Lam M, Pater J, Albiani D, Brown GC, Brown MM, Cruess AF, Sharma S. Reliability of the time trade-off technique of utility assessment in patients with retinal disease. Can J Ophthalmol 2001;36:202-209.

3. Brown GC, Brown MM, Sharma S, Beauchamp G, Hollands H. The reproducibility of ophthalmic utility values. Trans Am Ophthalmol Soc 2001;99:199-203.

4. Sharma S, Brown GC, Brown MM, Hollands H, Robbins R, Shah G. Validity of the time trade-off and standard gamble methods of utility assessment in retinal patients. Br J Ophthalmol 2002;86:493-496.

5. Brown GC, Brown MM, Sharma S. Difference between ophthalmologist and patient perceptions of quality-of-life associated with age-related macular degeneration. Can J Ophthalmol 2000;35:27-32.

6. Center for Value-Based Medicine. Time Tradeoff Utility Database. Flourtown, PA. Whitemarsh Press, 2013.

7. Busbee B, Brown MM, Brown GC, Sharma S. Incremental cost-effectiveness of initial cataract surgery. Ophthalmology 2002;109:606-612.

8. Brown GC, Brown MM, Brown H, Peet JS. A value-based medicine analysis of ranibizumab (MARINA Study) for the treatment of subfoveal neovascular macular degeneration. Ophthalmology 2008;115:1039-1045.

9. Brown MM, Brown GC, Sharma S, Busbee B, Brown H. Quality of life associated with visual loss. A time tradeoff utility analysis comparison with medical health states Ophthalmology 2003;110:1076-1081.

Melissa M. Brown, MD, MN, MBA, is president and CEO of the Center for Value-Based Medicine in Philadelphia. She can be reached via e-mail at mbrown@valuebasedmedicine.com.