Outpatient is in and inpatient is out in Germany

By Stefanie Petrou Binder MD

Heidelberg — The past ten years have seen some major changes in how cataract and refractive surgery is performed in Germany, reported Martin Wenzel MD, at the annual meeting of the DGII Annual Meeting (German-Speaking Organisation of Intraocular Lens Implantation and Refractive Surgery).

Dr Wenzel presented data from a ten year survey conducted in co-operation with the BVA (Berufsverband der Augenärze). The survey included input from 248 surgeons and medical centres detailing operative preferences.

According to survey results, LASIK represents the biggest change within the last ten years in the German ophthalmic surgery scene. Four years ago, 5,702 refractive surgeries were performed in Germany. Today, that number has more than doubled to 12,343, for which LASIK can largely be credited.

LASIK accounted for 73% of refractive surgeries performed in 2001. Intraocular contact lens (ICL) and clear lens exchange (CLE) procedures accounted for 7% each. PRK accounted for 4%. Other refractive procedures made up the remaining 9%.

According to the survey, there were virtually no medical facilities that housed LASIK in 1991. In 1998 the numbers slowly rose to 7%, and by last year increased to 22%. A similar increase could be noted for centres in which CLE procedures were performed, rising from 14% in 1998 to 25% in 2001. ICL implantations increased from 8% to 15% over the same period.

Overall, 50% of German medical facilities today perform some kind of refractive surgery compared to less than 20% in 1991. Decreased numbers were observed in centres performing either radial keratotomy procedures or PRK, both experiencing a dip of about 3%.

Inpatient is out in cataract
On another front, German eye surgeons are no longer opting for inpatient cataract surgery in general hospitals providing assigned beds. German law has rendered this once popular and convenient set-up economically unviable.

Assigned beds are available to ophthalmic surgeons in private practice who either operate in their own surgical practice or in a general hospital that provides assigned beds. The hospital reserves these beds for the surgeon in case his patients should require them. The government is now seeking to reduce the use of assigned beds in cataract surgery to alleviate some of the strain on the health budget.

The number of assigned bed hospitals has fallen by 11% since 1998. While they used to constitute an even third of the total number of medical facilities performing ophthalmic operations, hospitals with assigned beds now make up only 22%.

Meanwhile, offices with surgical units have gone up 7%, constituting 32% of such medical facilities. The remaining 46% of medical facilities performing ophthalmic surgery is evenly divided between clinics and private surgical practices which use assigned beds.

Of the 316,977 cataract operations performed in German centres in 2001, 57% were performed in out-patient clinics and offices. The shift to private-practice and outpatient-centre cataract surgery is expected to continue as these new laws take effect, reducing compensation for surgeons performing cataract surgeries in assigned bed hospitals by almost half.

This change has proven convenient for patients who are now operated on close to home. However, it has been a staggering blow for the hospitals targeted by the change, Dr Wenzel noted.
More than 80% of outpatient procedures now take place in the private practice setting and some four in five of these operations are cataract surgery. Of the surgically active private practitioners, almost all perform ambulatory surgeries. By contrast, however, only a few clinics do so.

IOL Preferences
The survey indicated that German eye surgeons most frequently chose PMMA lenses, followed by hydrophobic acrylate, hydrophilic acrylate and silicone lenses in 2001. There was no significant difference in distribution among surgeons in private practices, clinics or hospitals with assigned beds.
PMMA lenses were much more frequently used in 1998 — in almost 60% of surgeries. They were followed by acrylate and silicone lenses in near even proportions.

The majority of surgeons performed corneo-scleral incisions in 2001. The clinics, however, revealed a stronger tendency to do clear corneal incisions. Perilimbal incisions did not account for more than some 20% to 30%. This pattern has not changed in recent years.
Peribulbar injection is now used in 80% of cases making it the most commonly used method of anaesthesia. Some surgeons opt for IV-drip or intubation narcosis (ITN)

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