RESUMO
IMPORTANCE: Some experts recommend increasing low rates of follow-up after cataract surgery in low- and middle-income countries using various interventions. However, little is known about the cost and effect of such interventions. OBJECTIVE: To examine whether promoting follow-up after cataract surgery creates economic value. DESIGN, SETTING, AND PARTICIPANTS: The Prospective Review of Early Cataract Outcomes and Grading (PRECOG) is a cohort study with data from patients undergoing cataract surgery from January 19, 2010, to April 18, 2012. Final follow-up was completed on August 10, 2012. Data were collected before surgery, at discharge, and at follow-up at least 40 days after surgery from 27 centers in 8 countries in Asia, Africa, and Latin America. Each center enrolled 40 to 120 consecutive patients undergoing cataract surgery. If patients did not return to the hospital for the follow-up visit, hospitals could use telephone calls or transportation subsidies to increase follow-up rate. Data were analyzed from December 2013 to January 2016. MAIN OUTCOMES AND MEASURES: Cost of interventions (telephone calls and transportation subsidies) to increase follow-up at least 40 days after surgery, visual acuity (VA) in the eye undergoing cataract surgery, presence of complications, patient and facility costs per visit, and willingness to pay for treatment or glasses if needed. The maximum incremental cost of improving VA in 1 patient (incremental cost-effect ratio [ICER]) was calculated for spontaneous follow-up (compared with no follow-up) and follow-up with the telephone and transportation interventions. Expected ICERs were estimated including only those patients willing to pay. RESULTS: Among 2487 patients (1068 men [42.9%]; 1405 women [56.5%]; 14 missing [0.6%]; mean [SD] age, 68.4 [11.3] years), 2316 (93.1%) received follow-up, of whom 369 (16.0%) were seen in an outside facility or home and were in the cost-effectiveness analysis as unable to follow up. A grand mean (a mean of means of the different countries) of 56.3% of patients needed glasses, of whom 56.9% were willing to pay, and 1.6% had treatable complications, of whom 39.4% were willing to pay. Maximum proportions with improved VA (and corresponding ICERs) were 0.08 for no follow-up, 0.45 ($151.56) for spontaneous follow-up, 0.53 ($164.46) for a telephone intervention, and 0.53 ($133.07) for a transportation intervention. These results were most sensitive to the cost of follow-up. Expected proportions (ICERs) were 0.08, 0.27 ($232.69), 0.30 ($456.22), and 0.30 ($206.47), respectively. CONCLUSIONS AND RELEVANCE: Most patients benefiting from follow-up after cataract surgery returned spontaneously when requested at discharge. Use of telephone calls or transportation subsidies to increase follow-up in low- and middle-income countries may not be cost-effective.
RESUMO
BACKGROUND: Poor follow-up after cataract surgery in developing countries makes assessment of operative quality uncertain. We aimed to assess two strategies to measure visual outcome: recording the visual acuity of all patients 3 or fewer days postoperatively (early postoperative assessment), and recording that of only those patients who returned for the final follow-up examination after 40 or more days without additional prompting. METHODS: Each of 40 centres in ten countries in Asia, Africa, and Latin America recruited 40-120 consecutive surgical cataract patients. Operative-eye best-corrected visual acuity and uncorrected visual acuity were recorded before surgery, 3 or fewer days postoperatively, and 40 or more days postoperatively. Clinics logged whether each patient had returned for the final follow-up examination without additional prompting, had to be actively encouraged to return, or had to be examined at home. Visual outcome for each centre was defined as the proportion of patients with uncorrected visual acuity of 6/18 or better minus the proportion with uncorrected visual acuity of 6/60 or worse, and was calculated for each participating hospital with results from the early assessment of all patients and the late assessment of only those returning unprompted, with results from the final follow-up assessment for all patients used as the standard. FINDINGS: Of 3708 participants, 3441 (93%) had final follow-up vision data recorded 40 or more days after surgery, 1831 of whom (51% of the 3581 total participants for whom mode of follow-up was recorded) had returned to the clinic without additional prompting. Visual outcome by hospital from early postoperative and final follow-up assessment for all patients were highly correlated (Spearman's rs=0·74, p<0·0001). Visual outcome from final follow-up assessment for all patients and for only those who returned without additional prompting were also highly correlated (rs=0·86, p<0·0001), even for the 17 hospitals with unprompted return rates of less than 50% (rs=0·71, p=0·002). When we divided hospitals into top 25%, middle 50%, and bottom 25% by visual outcome, classification based on final follow-up assessment for all patients was the same as that based on early postoperative assessment for 27 (68%) of 40 centres, and the same as that based on data from patients who returned without additional prompting in 31 (84%) of 37 centres. Use of glasses to optimise vision at the time of the early and late examinations did not further improve the correlations. INTERPRETATION: Early vision assessment for all patients and follow-up assessment only for patients who return to the clinic without prompting are valid measures of operative quality in settings where follow-up is poor. FUNDING: ORBIS International, Fred Hollows Foundation, Helen Keller International, International Association for the Prevention of Blindness Latin American Office, Aravind Eye Care System.