Studies Overshadow Costs and Benefits of Laser-Assisted Cataract Surgery

Data from the randomized FEMCAT trial showed that laser-assisted cataract surgery failed to pass the cost-effectiveness test compared with standard phacoemulsification cataract surgery (PCS).

Femtosecond laser-assisted cataract surgery (FLACS) was not only more expensive than PCS, but also improved quality-adjusted life years (QALYs) less than PCS (0.788 vs. 0.792). The average surgery cost was €1,124 ($1,214) for FLACS and €565.50 ($610.75) for PCS. Total treatment costs at 12 months averaged €7,085 ($7,652) for FLACS and €6,502 ($7,023) for PCS.

Combining the high cost of FLACS with the low QALY resulted in a cost-utility ratio of -€136,476 ($147,394), Antoine Bénard, M.D., Ph.D., University of Bordeaux, France, and co-authors: reporting. JAMA Ophthalmology.

“In its current state of development, FLACS is not cost-effective and should not be reimbursed by the healthcare system,” the authors concluded. “Nevertheless, the investment in R&D is worth it, and more advanced femtosecond lasers could become a valuable option in cataract surgery in the future.”

According to the authors of the accompanying editorial, the study provided “conclusive evidence of the lack of incremental value” of FLACS and PCS.

“FLACS was introduced about 12 years ago with great excitement and anticipation,” writes Oliver Shine, M.D., MPH, Wilmer Eye Institute, Johns Hopkins University, Baltimore. “This was an elegant procedure that promised greater accuracy and improved clinical outcomes compared to conventional phacoemulsification in most commonly performed cataract surgeries.”

“Over the years, it has been argued that the promise was fulfilled based on small studies by enthusiastic early adopters,” Schein wrote. “However, the strength of the evidence for no incremental benefit is now considerable.”

Schein continued that the concept of value in healthcare depends on the individual’s point of view. His personal preference is that “the health outcome achieved is important to the patient relative to the cost of achieving that outcome.”

“In England and France … estimated difference in cost per case” [between FLACS and PCS] “From a surgeon’s perspective, the additional $300 per case probably doesn’t justify the additional time and expense of FLACS, especially when there is no known clinical benefit,” he said. added.

The enthusiasm around FLACS turned to disappointment when FEMCAT showed that FLACS was neither clinically superior nor cost-effective to PCS. A second randomized trial (FACT) showed that FLACS was not inferior to his PCS. The FACT investigator subsequently published two reports, both of which indicated that FLACS was less cost-effective than he PCS.

Combined results from two randomized trials showed clinical results of FLACS to be “below clinically meaningful differences,” Dr. Bénard and co-authors said.

FEMCAT’s French and British collaborators performed a prespecified cost-effectiveness analysis to calculate QALYs for FLACS and PCS. The researchers argue that “utility in health economics is a function of how individuals value their lives rather than how they rate their health. Analyzes do not necessarily have to reflect the results observed at efficacy endpoints, but rather may provide additional information.” Benefits that medical interventions bring to decision makers. ”

The analysis included 870 randomized patients, almost two-thirds of whom had undergone bilateral cataract surgery. Analysis showed that both the surgical cost and his total cost at 12 months were in favor of his PCS. The QALY difference also favored him for PCS, but the difference did not achieve statistical significance (−0.004, 95% CI −0.028 to 0.021).

The cost-effectiveness probability curves ranging from €0 to €100,000 showed little variation in the likelihood that FLACS was cost-effective (14–25%). For example, if you define acceptability using a low threshold of €30,000 per QALY (compared to the standard €50,000 to €100,000), the probability that FLACS will be cost effective is 15.7% .

Investigators also performed an information value analysis to estimate the expected value of perfect information (EVPI). EVPI is the opportunity cost of being wrong in deciding to reimburse an intervention that appears to be cost-effective or not to reimburse an intervention that is not. Cost effective. An analysis using a threshold of €30,000 per QALY found that he had an EVPI of €246,139,079 for an erroneous decision not to redeem FLACS.

“A cost-effectiveness analysis of the FACT trial, like ours, also reported very small differences in costs,” the authors write. “All of these results are very consistent, with FLACS and PCS results very close to each other, always in favor of FLACS, which is an indication of the robustness of our results.”

“We believe that the EVPI of around 250 million euros fully justifies the budget investment in developing more efficient lasers before the widespread use of this technology,” they added.

  • author['full_name']

    Charles Bankhead is Senior Editor in Oncology and also has urology, dermatology, and ophthalmology. In 2007 he joined MedPage Today. follow


This research was supported by the French Ministry of Social Affairs and Health.

Benard reported no industry affiliation.

Shine reported no industry affiliation.

Primary information

JAMA Ophthalmology

Source references: Bénard A, et al “Cost utility of the value of information analysis for femtosecond laser-assisted cataract surgery” JAMA Ophysicalmol 2023; DOI: 10.1001/jamaophysicalmol.2023.1716.

secondary source

JAMA Ophthalmology

Source Reference: Schein OD, “Femtosecond Laser-Assisted Cataract Surgery — Conclusive Evidence for Lack of Incremental Value” JAMA Ophthalmology 2023; DOI: 10.1001/jamaophysicalmol.2023.1828.

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