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Original Investigation
December 15, 2016

Cost and Expected Visual Effect of Interventions to Improve Follow-up After Cataract SurgeryProspective Review of Early Cataract Outcomes and Grading (PRECOG) Study

Author Affiliations
  • 1Division of Preventive Ophthalmology, Zhongshan Ophthalmic Center, State Key Laboratory, Sun Yat-Sen University, Guangzhou, China
  • 2Orbis International, New York, New York
  • 3Center for Public Health, Queen’s University Belfast, Belfast, Northern Ireland
  • 4Medwin Group, St Louis, Missouri
  • 5Help Me See, New York, New York
  • 6Instituto Mexicano de Oftalmologia, Querétaro, Mexico
  • 7The Fred Hollows Foundation, Sydney, Australia
  • 8Regional Office in the Western Pacific, World Health Organization, Manila, Philippines
  • 9The Brien Holden Vision Institute, Durban, South Africa
  • 10Lions Aravind Institute of Community Ophthalmology, Madurai, India
  • 11Latin America Regional Office, VISION 2020, International Agency for the Prevention of Blindness, Miami, Florida
  • 12Centre for Eye Research Australia, Melbourne, Australia
JAMA Ophthalmol. Published online December 15, 2016. doi:10.1001/jamaophthalmol.2016.4735
Key Points

Question  Are interventions to increase low rates of follow-up after cataract surgery in low- and middle-income countries cost-effective?

Findings  In this cohort of 2316 patients who attended follow-up after cataract surgery in 8 countries in Asia, Africa, and Latin America, the maximum proportions whose visual acuity might improve with glasses or necessary treatment after surgery and the corresponding incremental cost of improving visual acuity in 1 patient were increased from no follow-up to spontaneous follow-up. A telephone intervention and transportation subsidies to increase follow-up rates were not cost-effective.

Meaning  Telephone calls or transport subsidies to increase follow-up in low- and middle-income countries may not be cost-effective; instead, patients should be reminded at the time of surgery to return for follow-up.

Abstract

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.

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