Study Identifies Cost Drivers for Different Forms of Endothelial Keratoplasty

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New research published in Ophthalmologyidentified cost drivers of endothelial keratoplasty (EK) procedures that could explain cornea surgeons’ practice patterns and influence patient-care decisions.

EK is the preferred cornea transplant technique in the United States and can take several different forms, including Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK).

Results showed “use of preloaded grafts for DMEK, DMEK compared to DSAEK, and isolated EK compared to EK combined with cataract surgery,” were all linked with reductions in day-of-surgery cost and surgical time.

Shahzad I. Mian, M.D.

Although DMEK is considered superior to DSAEK thanks to better postoperative visual acuity, fewer rejection episodes, and a faster recovery time, complication rates are largely comparable for both procedures, wrote first author Jenna Goldstein, corresponding author Shahzad I. Mian, M.D., of the Kellogg Eye Center of the University of Michigan and colleagues.

However, as EK procedures become more frequent, associated costs are growing.

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In 2019, totals approached $340 million, underscoring the need to better understand drivers of costs associated with different EK types. Previous research has shown preloaded grafts could cut down surgical time and reduce net costs, but these findings were based on small sample sizes, authors noted.

In this analysis, which was published earlier this month, Goldstein, Mian and colleagues used time-driven activity-based costing (TDABC) to elucidate factors associated with EK costs and surgery lengths. Researchers evaluated any cost savings linked with use of preloaded grafts during the procedure and those associated with concurrent cataract surgery.

The economic analysis included data from the University of Michigan Kellogg Eye Center, collected between 2016 to 2018.

A total of 559 EK surgical cases were included. Of these, 355 were DMEK and 204 were DSAEK.

Preloaded grafts saved $457.19 in total and DMEK saved $349.97 compared with DSAEK. Meanwhile, simultaneous cataract surgery added $855.17 in day-of-surgery costs.

Overall, DMEK cost $392.31 less than DSAEK and required 16.94 fewer minutes. In addition, DMEK procedures that used preloaded corneal grafts cost $460.19 less and were 14.16 minutes shorter.

Compared with DMEK, fewer DSAEKs had simultaneous cataract extraction (169 versus 47, respectively), and more than half of DMEKs utilized preloaded corneal grafts.

“Given that outcomes for [pre-stripped donor corneal tissues for DMEK (pDMEK)] are similar to those of [non-preloaded] DMEK with less risk of damage to donor tissues and at a lower cost, it is reasonable to consider pDMEK as the standard of care. This would allow for standardization of tissues, simplification of surgery, and better allocation of resources, while also shortening surgery time and reducing provider costs,” wrote Goldstein, Mian and their colleagues..

Despite a higher day-of cost for concurrent cataract procedures, researchers note the incremental cost is significantly cheaper than performing an independent cataract surgery. In addition, as the current analysis excluded both pre- and post-operative care, investigators were unable to calculate total costs, leading them to conclude “potential cost savings from combining surgeries may be even greater than hypothesized above as clinical care can be combined.”

Results may not be generalizable to private practice ophthalmologists, marking a limitation to the study. The study was also retrospective in nature, meaning researchers could not control for variables like surgery complexity.