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Cover Stories | Mar 2010

Decision Time

Do certain types of patients take longer than others to schedule LASIK surgery?

Refractive surgeons have long tried to understand why some patients delay their decision to have LASIK after their consultation. Reasons typically involve lingering fear, concern over cost, and/or waiting for a specific event to occur. We were curious to understand the impact of time on the decision process and if the delay in signing up for surgery is influenced by demographic or physiological patient characteristics. Our goal was to see if any differences emerged that might prove instructive for surgeons and their staff to do a better job in the consultative and follow-up process. We retrospectively analyzed demographic data on more than 11,000 LASIK procedures performed at the Gordon Binder Weiss Eye Institute from 1997 through 2008. All cases performed by Dr. Binder were entered into a commercially available database (Outcomes Analysis Software, Inc., San Diego, CA). Because of the large amount of data available, we chose to limit our analysis to two issues. First, from the time of the initial consultation, how long do patients typically take to decide to schedule surgery? Second, are there differences in the characteristics of these patients that could meaningfully affect how we educate and/or follow up with them around the time of the consultation?

Slightly more than one-third of patients scheduled to have their procedure within 2 weeks of the consultation, which we classify as “immediately.” Another 25% of patients had their procedure within 1 month of their consultation. This is a clear indicator that the majority of patients who are serious enough to have a consultation intend to have the procedure right away. Three of every 10 patients, however, delayed until sometime between 1 and 4 months. Nearly one in 10 patients waited between 6 months and 1 year after their consultation to have their surgery. This distribution is summarized in Figure 1.

We then examined similar data in subgroups of patients based on criteria tracked in the patient database. Using the same time points, we wanted to see if there were any significant differences in decision time based on the identified criteria. We had data on contact lens wear (failures vs never worn), age (older than 40 years vs younger than 40 years), gender, type of refractive error (myopia vs hyperopia), occupation, and even the year(s) they had surgery (1998-1999 vs 2004-2008). Although the data from each of the subgroups appear to follow the same basic pattern as the entire group (Figure 2), there were some interesting deviations.

Contact Lens Failures
This group of patients was the least likely to convert to surgery in the first 2 weeks and showed a greater percentage converting between 4 months and 1 year, a difference that was not significant (P > .06). Conversely, patients who never wore contact lenses tended to convert within 2 weeks at 41%, a rate slightly higher than the overall average (37%), but the difference was not significant.

Refractive Error and Age
Taken as a whole, patients with myopia and those with hyperopia converted similarly to each other and nearly identically to the overall average. The same finding occured in those younger than 40 years of age compared with those older than 40. When we further distilled the data, we discovered that myopic patients younger than 25 years tended to convert much sooner—45% immediately—than those older than 40 years. This subgroup showed the fastest conversion overall.

Although surgeons tend to stereotype engineers as “picky” when it comes to understanding refractive surgery for themselves, these individuals did not take appreciably longer to convert than all patients in this analysis. In this database, engineers were the number-one career group undergoing refractive surgery.

Year of Surgery
On a relative basis, patients who had surgery between 2004 and 2008 took longer to decide and schedule the procedure than those who had surgery between 1998 and 1999. One may assume that LASIK and PRK were new procedures in these early years and few surgeons were offering the procedures. The interest was very high due to the known issues with radial keratotomy and lack of new procedures for vision correction for the general public.

We do not know what happened to those patients who had been seen by us and entered into our database but who did not undergo surgery. Certainly, some of them went to other centers, whereas others may have never undergone surgery. If they had surgery at a date more than a year after their consultation, they would have appeared in the database. One patient returned for surgery more than 2 years after his initial consultation!

Our belief is that, although most surgeons are good at converting immediate interest expressed by a patient into a procedure, there should be greater awareness and understanding by the refractive community that many patients choose to wait and that this phenomenon is normal, given the high level of deliberation by consumers. Because approximately 40% of patients take longer than 1 month to decide to have surgery, it seems prudent that refractive practices dedicate more of their resources toward continuing the relationship that was built during the consultation. There is a fine line between “staying in touch” and “annoying” a prospective patient. It is critical to understand the difference between the two. There is ample opportunity for refractive practices to make prospective patients in their database—and the overall community—aware of the latest research, outcomes, and quality-of-life improvement from LASIK and other procedures. Whether it is the traditional newsletter or the “become a fan” page on Facebook, surgeons have an array of tools to help individuals interested in LASIK learn more and stay informed.

From our perspective, what is most important is that surgeons remember that LASIK represents a life-changing decision for most people. The data make it clear that candidates—even with all the education they receive during a thorough examination and consultation—still can take a significant amount of time to decide to have surgery. The only way to maintain contact with these patients during this process is to maintain an active and regularly updated and maintained patient database.

Perry S. Binder, MD, MS, is a clinical professor, nonsalaried, for the Department of Ophthalmology at the University of California, Irvine. He is the owner of Outcomes Analysis Software. Dr. Binder may be reached at (619) 702-7938; garrett23@aol.com.

Shareef Mahdavi is the president of SM2 Strategic. He acknowleged no financial interest in the product or company mentioned herein. Mr. Mahdavi may be reached at (925) 425-9900; shareef@sm2strategic.com.

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