May 2019


Presentation Spotlight
Patient preferences and costs
The Finnish perspective

by Stefanie Petrou Binder, MD EyeWorld Contributing Writer

“As doctors, we try to produce the best possible well-being within an affordable healthcare system. Although it seems very simple, there are many things to consider in the real world.”
—Anja Tuulonen, MD

Simply delivering more healthcare services does not guarantee well-being. Considering access to adequate and equal health services, Finnish ophthalmologist Anja Tuulonen, MD, said it is time to embrace “good enough” as the new optimum.
“We are all both tax payers and patients, and in these roles, we might have different preferences. No one wants to pay more taxes, but as patients we think that we have the right to receive all available services. But who has the power to decide what is ‘best’ both for the individual patient and the society? In a world of finite resources, how can we share the cake equally and cost-effectively?” Dr. Tuulonen said at the 36th Congress of the European Society of Cataract and Refractive Surgeons.

The conundrum

One might say that amping up the healthcare system through higher taxes or taking on debt would solve all problems and improve well-being. Real-world scenarios speak to the contrary. “There is much evidence that western countries spend more money on healthcare than ever before, produce more services than ever before, people are healthier and live longer than ever before, however, these come along with even higher demand and exponential increase of costs,” she said.
If the available resources cannot keep up with the rise in new interventions and technical developments, where do we draw the line? And even if an individual patient is treated with what is thought to be top-of-the-line treatments and technologies, would it be at the expense of another patient who might benefit much more from the same resource? If and when the same money cannot be spent twice, who decides?
One way to explain it would be to say that we are trying to do too much. “There is a widely ignored issue with overdiagnosis and overtreatment. Simply delivering more tests and care does not provide improved well-being, especially if the diagnosis is unwarranted. I would also like to challenge the thinking that giving a diagnosis makes a patient happy. We should be focused on the patient’s well-being, reserve our resources for those who need it most, and avoid overdiagnostics,” she said.

Targeting patient well-being

One definition of well-being hits the mark best: the ability to adapt and to self-manage in the face of social, physical, and emotional challenges. According to Dr. Tuulonen, healthcare alone accounts for only 10 to 20% of improved well-being in the western countries. Other factors that contribute to a person’s well-being include education, income, consumption patterns, roads, and clean water, to name a few. She suggests that if we are overspending on healthcare, we might counterintuitively influence other factors responsible for well-being.
“As doctors, we try to produce the best possible well-being within an affordable healthcare system. Although it seems very simple, there are many things to consider in the real world. Measuring well-being involves developing an instrument that is not overly sensitive, but sensitive enough to pick up differences in health-related quality of life, e.g., in early glaucoma. However, too many specialized questionnaires with too many questions will overburden patients and undermine response rates,” she said.
The 15D instrument of general health-related quality of life creates a health profile using questions on mobility, vision, speech, elimination, breathing, sleeping, vitality, mental function, eating, usual activities, discomfort, sexual activity, depression, distress, and hearing.
Open angle glaucoma patients who used more resources actually reported worse health-related quality of life in early glaucoma, according to an 11-year retrospective study in which patients were treated with 28% more medications, 46% higher follow-up costs (more frequent testing), three times more laser therapy, and twice the amount of surgery. The investigators found, overall, there was no difference in quality of life or in any clinical outcomes.1

Dividing the cake equitably

Tays Eye Center at Tampere University Hospital set out to adjust the increasing need to limited resources by undertaking a national benchmarking of eye services. It prioritizes permanently blinding eye diseases, especially AMD, glaucoma, and diabetic retinopathy (vs. cataract, which does not cause permanent blindness), sets a standard for identifying the highest-risk patients, and standardizes care of usual patients to facilitate sustainability. The group works with a healthcare budget cap and presides over multidisciplinary teams, and more.
“In Finland, we prioritize and stratify patients based on risk of permanent blindness, keeping cost in mind. We do a lot of shared care and more and more in patient self-care. Finally, the main thing is to evaluate what we are doing both on the ‘individual’ (citizen and patient) level and on the ‘system’ level, i.e., are we reaching the set goals of reduced visual disability and best possible well-being with sustainable costs. What we need are adequate and equal health services. ‘Good enough’ is the new optimum,” Dr. Tuulonen said.

About the doctor

Anja Tuulonen, MD
Director, Tays Eye Centre
Tampere University Hospital
Tampere, Finland


1. Hagman J. Resource utilization in the treatment of open angle glaucoma in Finland: an 11-year retrospective analysis. Doctoral dissertation. University of Oulu. 2012.

Financial interests

Tuulonen: None

Contact information


Patient preferences and costs The Finnish perspective Patient preferences and costs The Finnish perspective
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