Managing limited healthcare resources for cataract surgery

This editorial by Parul Desai, MSc, PhD, FRCS, FRCOphth, FFPH, examines the allocation of limited healthcare resources for cataract surgery in England and how decisions are made regarding unilateral versus bilateral surgery. She says that there has been a focus on reducing the volume of surgery performed, and more specifically on reducing second eye surgery, while continuing to emphasize effectiveness and clinical value. Prioritization for surgery has become a significant issue again and a greater emphasis is being placed on having clinicians demonstrate appropriate care and clinical need.

She notes that a paper in the June 2012 issue of the British Journal of Ophthalmology considers not only the question of the impact of unilateral or bilateral surgery on functioning but also when second eye surgery is likely to confer the most benefit. The authors demonstrate that bilateral cataract surgery is associated with greater visual functioning over unilateral cataract surgery only when the fellow eye has significant cataract or poor presenting visual acuity.

Dr. Desai says these findings provide further evidence regarding the role of visual acuity as the primary determinant of vision-specific functioning, both of which are central to demonstrating surgical need and benefit. The nature of the relationship between the two highlights the question of whether visual acuity could serve as a high-level indicator for vision-specific functioning for broad assessments of the timing and value of surgical intervention. She notes that an approach commonly adopted to improve health service efficiency is to apply clinical thresholds for interventions in order to ensure that only those people most likely to benefit are offered treatment. She says it is imperative that any processes for setting such thresholds are clinically driven.

She states that assessment of both the need for and benefit (outcome) from cataract surgery is collectively based on vision-related functioning in daily activities and visual acuity testing, together with examination of the eye for any contributory factors. However, she says that demonstrating need and benefit is not straightforward, and this is particularly the case for intervention in early cataract. The relationship between acuity and vision-specific functioning demonstrated in the study offers an opportunity for reviewing how these measures may be applied in busy clinic settings to provide assurance that appropriate, quality care has been provided.

She emphasizes that the value of visual acuity as an indicator of vision-specific functioning should not be overlooked for the purposes of routine clinical audit and for monitoring surgical activity. However, the burden associated with collection of this or other relevant data should be considered and not underestimated.

She concludes that the challenges for eye health professionals are: to reach consensus on how need and effectiveness may be best demonstrated; determine whether this may be achieved through use of a broad routine indicator supplemented at regular intervals by more detailed examination in samples of patients; and to engage in a constructive dialogue with health services managers to ensure an appropriate balance between meeting needs equitably, and maintaining quality and realizing efficiencies, within the context of increasing demands on and competing priorities for health service resources.