What does a good cataract service look like?

by Stephen Duckett

Published by Croakey, Sunday 28 April

People who live in a wealthy part of Sydney are far more likely to have cataract surgery than people living in a poorer area of that city.

The wealthy suburb of Warringah had a standardised cataract procedure rate of 2,404 per 100,000 population, about 12 percent above the national rate of 2,138. In contrast, Parramatta in Sydney’s west had a rate of 1,577 – about 25 percent below the national rate.

This variation in the rate of use of cataract procedures is unlikely to be related to need; as a general rule, people in poorer areas are more likely to have poorer health and thus need more health services than those in wealthier areas.

This huge variation in the rate of cataract procedures is not limited to Sydney but occurs widely across geographic areas. There is also a big variation in the rate of cataracts undertaken in the public versus private sectors.

About 71 percent of cataract surgery occurs is performed on privately funded patients. This is a significantly higher figure than might be expected given that only 45 per cent of the population that hold insurance for private hospital care.

Mapping variation

The Second Australian Atlas of Healthcare Variation showed an almost four-fold variation in utilisation rates.

The reasons for this difference are unclear: there may be under-provision in the public sector; it may be that people needing cataract surgery are more likely to obtain insurance coverage; or this may be a case of supplier-induced demand – meaning that the health services and professionals involved in providing cataract surgery are more likely to encourage uptake in wealthier areas.

One way of influencing this variation is to hold hospitals and day procedure centres which admit patients for cataract procedures accountable for their performance.

The Australian Commission on Safety and Quality in Health Care has recently concluded a public consultation on a new Cataract Clinical Care Standard. The Commission described Clinical Standards:

“A Clinical Care Standard is a small number of quality statements that describe the care patients should be offered by health professionals and health services for a specific clinical condition or defined clinical pathway in line with current best evidence.”

Standards thus help to inform consumers about what they might expect in their treatment – if their care is according to the standard – but also sets the standard for hospitals, day procedure centres and the specialists who provide treatment.

Conversely, if hospital or day procedure centres aren’t providing care in line with the Standard, this might lead to intervention by state health departments or other regulators.

The Draft Cataract Clinical Standard has eight ‘quality statements’ covering expectations about: primary care assessment and referral; patient information and shared decision making; access to ophthalmology assessment; indications for cataract surgery;  prioritisation for cataract surgery; second-eye surgery; preventive eye medicines; and postoperative care.

The Grattan Institute submission on the standard takes a broad view of quality, focussing on appropriateness of and access to care, and proposes three main inclusions.

1. Patient Reported Outcome Measures

Firstly, a start should be made on addressing the apparent variability in thresholds for performing cataract procedures. The proposed starting point for that is to use PROMs, Patient Reported Outcome Measures. Patients should be asked to report on their eyesight issues before and after surgery. That way we can identify which hospitals tend to admit patients with relatively better eyesight. We can also see which providers are relatively better – or relatively worse – at achieving improvements in eyesight.

2. Providers publish numbers of procedures

Secondly, the submission also proposes that providers publish the number of procedures they undertake. There is a volume-outcome relationship in cataract surgery – hospitals that do more have better outcomes. Volume is also an easy surrogate quality measure for the public to understand.

3. Public hospitals publish waiting times

Thirdly, in a move directed at public providers, Grattan proposes that public hospitals publish their waiting times – including the wait from a referral from a general practitioner to first see a specialist – and that hospitals which can’t manage their waiting times should not be seen as a good provider.

The Australian Commission on Safety and Quality in Health Care is now collating responses to its consultation, including the Grattan Institute submission. How it will respond won’t be known until the final standard is released later this year.

However, the aim of the Grattan submission was to sharpen up the Draft in key areas of interest to consumers – especially information about quality and waiting times.

Expect opposition

There will be pushback on both these issues, partly because hospitals and surgeons are often uncomfortable about being held to account for quality variation, shrouding their fear of accountability behind spurious statistical arguments.

For private hospitals and day procedure centres, publishing outcomes – or even the volume of procedures performed – may impact adversely on their bottom line, again a reason for them to oppose an expectation of publication of outcomes in a form which allows comparison.

For public hospitals, Grattan proposed publication of full waiting time data, including the wait from referral from a general practitioner. These waits can be quite long and politically embarrassing, again a reason why the idea will be opposed, but of course, why consumers should support such publication.

But if Grattan’s ideas are accepted, we should begin to see improvements in waiting times and outcomes as hospitals are held to account in the court of public opinion, and by exposure of their inadequacies to their peers.