Cost effectiveness of a single-function treatment center for cataract surgery

Day care versus in-patient surgery for age-related cataract

BACKGROUND

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract living in lower income countries. With the increased number of people with cataract, it is important to review the evidence on the effectiveness of day care cataract surgery.

OBJECTIVES

To provide authoritative, reliable evidence regarding the safety, feasibility, effectiveness and cost-effectiveness of day case cataract extraction by comparing clinical outcomes, cost-effectiveness, patient satisfaction or a combination of these in cataract operations performed in day care versus in-patient units.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2015), EMBASE (January 1980 to August 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to August 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 August 2015.

SELECTION CRITERIA

We included randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

We included two trials. One study was conducted in the USA in 1981 (250 people randomised and completed trial) and one study conducted in Spain in 2001 (1034 randomised, 935 completed trial). Both trials used extracapsular cataract extraction techniques that are not commonly used in higher income countries now. Most of the data in this review came from the larger trial, which we judged to be at low risk of bias.The mean change in visual acuity (in Snellen lines) of the operated eye four months postoperatively was similar in people given day care surgery (mean 4.1 lines standard deviation (SD) 2.3, 464 participants) compared to people treated as in-patients (mean 4.1 lines, SD 2.2, 471 participants) (P value = 0.74). No data were available from either study on intra-operative complications.Wound leakage, intraocular pressure (IOP) and corneal oedema were reported in the first day postoperatively and at four months after surgery. There was an increased risk of high IOP in the day care group in the first day after surgery (risk ratio (RR) 3.33, 95% confidence intervals (CI) 1.21 to 9.16, 935 participants) but not at four months (RR 0.61, 95% CI 0.14 to 2.55, 935 participants). The findings for the other outcomes were inconclusive with wide CIs. There were two cases of endophthalmitis observed at four months in the day care group and none in the in-patient group. The smaller study stated that there were no infections or severe hyphaemas.In a subset of participants evaluated for quality of life (VF14 questionnaire) similar change in quality of life before and four months after surgery was observed (mean change in VF14 score: day care group 25.2, SD 21.2, 150 participants; in-patient group: 23.5, SD 25.7, 155 participants; P value = 0.30). Subjective assessment of patient satisfaction in the smaller study suggested that participants preferred to recuperate at home, were more comfortable in their familiar surroundings and enjoyed the family support that they received at home. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay.

AUTHORS' CONCLUSIONS

This review provides evidence that there is cost saving with day care cataract surgery compared to in-patient cataract surgery. Although effects on visual acuity and quality of life appeared similar, the evidence with respect to postoperative complications was inconclusive because the effect estimates were imprecise. Given the wide-spread adoption of day care cataract surgery, future research in cataract clinical pathways should focus on evidence provided by high quality clinical databases (registers), which would enable clinicians and healthcare planners to agree clinical and social indications for in-patient care and so make better use of resources.

Day care versus in-patient surgery for age-related cataract

BACKGROUND

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract found in the developing world. With the increased number of people with cataract there is an urgent need for cataract surgery to be made available as a day care procedure.

OBJECTIVES

To provide reliable evidence for the safety, feasibility, effectiveness and cost-effectiveness of cataract extraction performed as day care versus in-patient procedure.

SEARCH STRATEGY

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 5), MEDLINE (January 1950 to May 2011), EMBASE (January 1980 to May 2011), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to May 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 23 May 2011.

SELECTION CRITERIA

We included randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

We included two trials (conducted in Spain and USA), involving 1284 people. One trial reported statistically significant differences in early postoperative complication rates in the day care group, with an increased risk of increased intraocular pressure, which had no clinical relevance to visual outcomes four months postoperatively. The mean change in visual acuity (Snellen lines) of the operated eye four months postoperatively was 4.1 (standard deviation (SD) 2.3) for the day care group and 4.1 (SD 2.2) for the in-patient group and not statistically significant. The four-month postoperative mean change in quality of life score measured using the VF14 showed minimal differences between the two groups. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay. One study only reported hotel costs for the non-hospitalised participants making aggregation of data on costs impossible.

AUTHORS' CONCLUSIONS

This review provides some evidence that there is a cost saving but no significant difference in outcome or risk of postoperative complications between day care and in-patient cataract surgery. This is based on one detailed and methodologically sound trial conducted in the developed world. The success, safety and cost-effectiveness of cataract surgery as a day care procedure appear to be acceptable. Future research may well focus on evidence provided by high quality clinical databases and registers which would enable clinicians and healthcare planners to agree clinical and social indications for in-patient care and so make better use of resources, by selecting day case surgery unless these criteria are met.

The cumulative burden of oral corticosteroid side effects and the economic implications of steroid use

Oral corticosteroids (OCS) are a key part of therapy regimens for a diverse variety of conditions. Despite their efficacy, they are associated with a wide variety of adverse events. The purpose of this review was to identify the range of adverse events that have been reported to be related to oral corticosteroids, examine the factors that influence their incidence and estimate the economic burden caused by these adverse events. In 61 identified studies, 21 different categories of OCS related adverse events were reported with increased fracture risk being the category most frequently described. Most studies that examined factors linked to the incidence of OCS related adverse events found that dose, age, gender, duration of use, treatment history, smoking habits or cholesterol level were influential in determining risk. Additionally, a cumulative economic analysis of selected adverse events found the annual cost of treating these events in the UK to be at least 165 pounds per patient taking OCS. The clinical and economic burden of OCS related adverse events highlights the need for OCS sparing therapies to be developed.

Global Cost-effectiveness of Cataract Surgery

OBJECTIVE

To determine the cost-effectiveness of cataract surgery worldwide and to compare it with the cost-effectiveness of comparable medical interventions.

DESIGN

Meta-analysis.

PARTICIPANTS

Approximately 12,000 eyes in the studies selected.

METHODS

Articles were identified by searching the literature using the phrase cataract surgery, in combination with the terms cost, cost-effectiveness, and cost-utility. Terms used for the comparable medical interventions search included epileptic surgery, hip arthroplasty, knee arthroplasty, carpal tunnel surgery, and defibrillator implantation. The search was restricted to the years 1995 through 2006. Cataract surgery costs were converted to 2004 United States dollars (US$). Cost-utility was calculated using: (1) costs discounted at 3% for 12 years with a discounted quality-adjusted life years (QALY) gain of 1.25 years, and (2) costs discounted at 3% for 5 years with a discounted QALY gain of 0.143 years. The Cataract Surgery Affordability Index (CSAI) for each country was calculated by dividing the cost of cataract surgery by the gross national income per capita for the year 2004.

MAIN OUTCOME MEASURES

Cost-utility in 2004 US$/QALY and affordability of cataract surgery relative to the United States.

RESULTS

Cost-utility values for cataract surgery (first eye) varied from $245 to $22,000/QALY in Western countries and from $9 to $1600 in developing countries. In developed countries, the cost-effectiveness of cataract surgery estimated by Choosing Interventions That Are Cost Effective ranged from, in international dollars (I$), I$730 to I$2400/disability-adjusted life years (DALY) averted, and I$90 to I$370/DALY averted in developing countries. The CSAI varied from 17% to 189% in developed countries and 29% to 133% in developing countries compared with the United States. The cost-utility of other comparable medical interventions was: epileptic surgery, $4000 to $20,000/QALY; hip arthroplasty, $2300 to $4800/QALY; knee arthroplasty, $6500 to $12,700/QALY; carpal tunnel surgery, $140 to $280/QALY; and defibrillator implantation, $700 to $23,000/QALY.

CONCLUSIONS

The cost-utility of cataract surgery varies substantially, depending how the benefit is assessed and on the duration of the assumed benefit. Cataract surgery is comparable in terms of cost-effectiveness to hip arthroplasty, is generally more cost-effective than either knee arthroplasty or defibrillator implantation, and is cost-effective when considered in absolute terms. The operation is considerably cheaper in Europe and Canada compared with the United States and is affordable in many developing countries, particularly India.

Simultaneous bilateral cataract surgery: Financial differences among nations and jurisdictions

PURPOSE

To identify and measure financial pressures surrounding unilateral and simultaneous bilateral cataract surgery in Canada and other Western nations to understand financial factors that may affect simultaneous bilateral cataract surgery.

SETTING

Eye Foundation of Canada, York Finch Eye Associates, Humber River Regional Hospital, University of Toronto, Toronto, Ontario, Canada.

METHODS

Schedules of physician benefits from 4 Canadian provinces and public and private sectors in the United States were applied to a consistent template for unilateral and simultaneous bilateral cataract surgery. Well-known surgeons from the United Kingdom, Australia, Japan, and Israel provided additional information. The data were analyzed for similarities and differences to identify financial factors that may influence surgeons and anesthesiologists regarding simultaneous bilateral cataract surgery.

RESULTS

Simultaneous bilateral cataract surgery yielded approximately 15% greater efficiency in the number of daily operations. Ophthalmologists' surgical fees were variably discounted for the second cataract surgery, up to 100% in some jurisdictions. Financial incentive issues were compounded by widely differing reimbursement schemes across regions. Anesthesiologists were generally reimbursed for simultaneous bilateral cataract surgery through additional time units of pay, not for additional surgical complexity. Simultaneous bilateral cataract surgery led to greater administrative, laboratory, and nursing efficiencies for institutions with minimal increases in overall complexity.

CONCLUSIONS

Results show that discounting second-eye cataract surgery in simultaneous bilateral cataract surgery was a financial deterrent. Although increased efficiency was a slight incentive to ophthalmologists and surgical centers, anesthesiologists experienced significant financial disincentives.

Feasibility of day-case vitreoretinal surgery

PURPOSE

The indications for vitreoretinal (VR) surgery are increasing as equipment and techniques available improve. In order to decrease demand on limited health resources, day-case surgery would be beneficial in many cases. This study combines a retrospective and prospective arm to examine the feasibility and safety of routine day-case VR surgery.

METHODS

One hundred consecutive patients (50 retrospective and 50 prospective) undergoing VR surgery within the Royal Berkshire NHS trust were included. The retrospective arm aimed to identify the frequency and type of acute ophthalmic or medical intervention during postop overnight stay and the results were used to alter management in the prospective group. The prospective group consisted of patients undergoing a mixture of overnight stay and day-case surgery. All patients in the prospective group had routine subtenon marcaine anaesthesia together with prophylactic pre-operative intravenous acetazolamide. Patients deemed fit postoperatively were offered overnight ward discharge, with obligatory next-day review.

RESULTS

In the retrospective arm, 56% required oral nonsteroidal analgesia on the day of surgery and one patient required narcotic analgesia. Twenty-two per cent patients required intraocular pressure (IOP) control on the day of surgery and one patient required medical intervention in the form of urinary catheterisation. Nineteen patients required intervention on next-day review. In the prospective arm, 86% preferred day case and were suitable, 6% were suitable for day-case but preferred overnight stay and 8% were deemed not fit for discharge. No patient required narcotic analgesics. No patient discharged returned as a casualty overnight. Only one patient required topical beta-blocker for the control of IOP on next-day review.

CONCLUSIONS

These data suggest that many patients who are hospitalised overnight for VR surgery could be safely treated as day cases. Such a shift in the pattern of care for VR surgery could provide a significant improvement in health-care efficiency and minimise patient inconvenience.

Day care versus in-patient surgery for age-related cataract

BACKGROUND

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract found in the developing world. With the increased number of people with cataract there is an urgent need for cataract surgery to be made available as a day care procedure.

OBJECTIVES

To provide reliable evidence regarding the safety, feasibility, effectiveness and cost-effectiveness of cataract extraction performed as day care versus in-patient procedure.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library (Issue 3 2004), MEDLINE (1966 to July 2004), EMBASE (1980 to August 2004) and LILACS (July 2004).

SELECTION CRITERIA

This review includes randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation.

DATA COLLECTION AND ANALYSIS

Although two trials are included in the review, adequate data were available for only one trial and therefore pooling of data from studies was not attempted. A descriptive summary is presented.

MAIN RESULTS

Two trials, involving a total of 1284 people, are included in this review. One trial reported statistically significant differences in early postoperative complication rates in the day care group, with an increased risk of increased intraocular pressure, which had no clinical relevance to visual outcomes four months postoperatively. The mean change in visual acuity (Snellen lines) of the operated eye four months postoperatively was 4.1 (standard deviation (SD) 2.3) for the day care group and 4.1 (SD 2.2) for the in-patient group and not statistically significant. The four-month postoperative mean change in quality of life score measured using the VF14 showed minimal differences between the two groups. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay. One study only reported hotel costs for the non-hospitalised participants making aggregation of data on costs impossible.

AUTHORS' CONCLUSIONS

This review provides some evidence that there is a cost saving but no significant difference in outcome or risk of postoperative complications between day care and in-patient cataract surgery. This is based on one detailed and methodologically sound trial conducted in the developed world. The success, safety and cost-effectiveness of cataract surgery as a day care procedure appear to be acceptable but additional well-designed trials are required to confirm these perceptions.

Quality care and practice variation: the roles of practice guidelines and public profiles

Goals of the quality-of-care initiative are to improve the structure, process, and outcome of health care. The effectiveness of methods to improve quality have been largely unverified. Most methods are costly to implement and time-consuming to perform; some threaten professional autonomy. The characteristic feature of modern medicine that fuels the debate over quality is the variation in the delivery of health care. This review examines the "variation phenomenon" in medicine and the roles that practice guidelines and physician profiling have in improving health care, in general, and for adult cataract, in particular.

Value-based medicine: evidence-based medicine and beyond

Value-based medicine is the practice of medicine emphasizing the value received from an intervention. Value is measured by objectively quantifying: 1) the improvement in quality of life and/or 2) the improvement in length of life conferred by an intervention. Evidence-based medicine often measures the improvement gained in length of life, but generally ignores the importance of quality of life improvement or loss. Value-based medicine incorporates the best features of evidence-based medicine and takes evidence-based data to a higher level by incorporating the quality of life perceptions of patients with a disease in concerning the value of an intervention. Inherent in value-based medicine are the costs associated with an intervention. The resources expended for the value gained in value-based medicine is measured with cost-utility analysis in terms of the US dollars/QALY (money spent per quality-adjusted life-year gained). A review of the current status and the likely future of value-based medicine is addressed herein.

Day care versus in-patient surgery for age-related cataract

BACKGROUND

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract found in the developing world. With the increased number of people with cataract there is an urgent need for cataract surgery to be made available as a day-care procedure.

OBJECTIVES

The objective of this review is to provide reliable evidence regarding the safety, feasibility, effectiveness and cost-effectiveness of cataract extraction performed as day-care versus in-patient procedure.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group trials register) on The Cochrane Library (Issue 4 2002), MEDLINE (1966 to November 2002), EMBASE (1980 to November 2002) and LILACS (November 2002).

SELECTION CRITERIA

This review includes randomised controlled trials comparing day-care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation.

DATA COLLECTION AND ANALYSIS

Although two trials are included in the review, adequate data were available for only one trial and therefore pooling of data from studies was not attempted. A descriptive summary is presented.

MAIN RESULTS

Two trials, involving a total of 1284 people, are included in this review. One trial reported statistically significant differences in early postoperative complication rates in the day-care group, with an increased risk of increased intraocular pressure, which had no clinical relevance to visual outcomes four months postoperatively. The mean change in visual acuity (Snellen lines) of the operated eye four months postoperatively was 4.1 (standard deviation (SD) 2.3) for the day-care group and 4.1 (SD 2.2) for the in-patient group and not statistically significant. The four-month postoperative mean change in quality of life score measured using the VF14 showed minimal differences between the two groups. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay. One study only reported hotel costs for the non-hospitalised participants making aggregation of data on costs impossible.

REVIEWER'S CONCLUSIONS

This review provides some evidence that there is a cost saving but no significant difference in outcome or risk of postoperative complications between day-care and in-patient cataract surgery. This is based on one detailed and methodologically sound trial conducted in the developed world. The success, safety and cost-effectiveness of cataract surgery as a day-care procedure appears to be acceptable but additional well-designed trials are required to confirm these perceptions.

Health care economic analyses

Health care economic analyses are becoming increasingly important as health care costs consume an increasing proportion of the gross domestic product (GDP). Among the different forms of health care economic analysis are (1) cost-minimization analysis, (2) cost-benefit analysis, (3) cost-effectiveness analysis, and (4) cost-utility analysis. Cost-utility analysis is the most sophisticated because it incorporates the value (improvement in quality of life and length of life) conferred by an intervention for the resources expended. The different types of analyses of importance to the clinician are addressed herein.

Health care economic analyses and value-based medicine

Health care economic analyses are becoming increasingly important in the evaluation of health care interventions, including many within ophthalmology. Encompassed with the realm of health care economic studies are cost-benefit analysis, cost-effectiveness analysis, cost-minimization analysis, and cost-utility analysis. Cost-utility analysis is the most sophisticated form of economic analysis and typically incorporates utility values. Utility values measure the preference for a health state and range from 0.0 (death) to 1.0 (perfect health). When the change in utility measures conferred by a health care intervention is multiplied by the duration of the benefit, the number of quality-adjusted life-years (QALYs) gained from the intervention is ascertained. This methodology incorporates both the improvement in quality of life and/or length of life, or the value, occurring as a result of the intervention. This improvement in value can then be amalgamated with discounted costs to yield expenditures per quality-adjusted life-year ($/QALY) gained. $/QALY gained is a measure that allows a comparison of the patient-perceived value of virtually all health care interventions for the dollars expended. A review of the literature on health care economic analyses, with particular emphasis on cost-utility analysis, is included in the present review. It is anticipated that cost-utility analysis will play a major role in health care within the coming decade.

Outcome of 1000 consecutive clinic- and hospital-based cataract surgeries in a Danish county

PURPOSE

To evaluate the homogeneity and quality of cataract surgery in a Danish county.

SETTING

Four private eye clinics and the Department of Ophthalmology, Hillerød Hospital, Frederiksborg County, Denmark.

METHODS

This prospective study comprised 1012 consecutive cases of age-related cataract; 48% of the surgeries were performed in the hospital and 52%, at 1 of 4 clinics. Demographic and clinical data were recorded on standardized data sheets at referral, surgery, and final refraction. Main outcome measures were change in best corrected visual acuity (BCVA), refractive power at final refraction, surgery-related complications, and waiting time for surgery and final refraction.

RESULTS

The hospital group had greater dispersion of age (P < .001) and higher frequency of general health problems (P < .005) and glaucoma (P < .01) than the clinic group. Fifty-four percent of surgeries were by phacoemulsification and 46%, by extracapsular cataract extraction (ECCE). In general, phacoemulsification was prevalent at the hospital and ECCE at the clinics. No difference was found between groups in visual acuity at final refraction. Of all patients, 87.1% attained a BCVA of 0.5 or better and of the best cases, 96.2%. Zonule or capsule rupture with or without vitreous loss occurred more often in the hospital group (P < .05), while the incidence of postoperative complications was identical in the 2 groups. One cases of retinal detachment was found. Time from referral to final refraction was shorter at clinics, while waiting time from surgery to final refraction was shorter at the hospital (P < .001).

CONCLUSION

Dividing cataract surgery between hospital and private clinics seems to be a satisfactory model for meeting the increasing demand for cataract surgery.

Phacoemulsification in eyes with pseudoexfoliation

PURPOSE

To compare intraoperative and postoperative complications in eyes with and without pseudoexfoliation having cataract surgery by phacoemulsification.

SETTING

Department of Ophthalmology, National Hospital, Oslo, Norway.

METHODS

Of 1152 consecutive phacoemulsification procedures, 164 cases with pseudoexfoliation (Group 1) and 916 cases without (Group 2) were followed for 4 months after cataract surgery in a prospective study. Of all cataract operations performed during that time, 96.2% were phacoemulsification procedures; 90.4 and 97.4% in eyes with and without pseudoexfoliation, respectively (P < .0005).

RESULTS

The frequency of capsular/zonular tear or vitreous loss was 9.6 and 3.7% in Groups 1 and 2, respectively (P = .0002). A visual acuity of 0.5 or better was achieved in 86.5% of eyes in Group 1 and 92.4% in Group 2 (P = .02). There were no statistically significant between-group differences in the frequency of a postoperative inflammatory response 1 day (6.7 versus 4.4%), 1 week (2.4 versus 1.6%), or 4 months (1.8 versus 0.9%) postoperatively.

CONCLUSION

Phacoemulsification was safe in most eyes with pseudoexfoliation even though significantly more complications occurred intraoperatively in these eyes. The low frequency of an inflammatory response indicates that the presence of pseudoexfoliation does not significantly increase the risk of inflammation.