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Cataracts are the leading cause of blindness globally, and the most common correctable eye disease causing blindness and sight loss in New Zealand.[[1,2]] Across high-income countries, cataract surgery is one of the most commonly performed surgical procedures.[[3]] Cataract surgery improves vision, with numerous secondary benefits including improved quality of life, slower rates of cognitive decline, and reduced risk of falls, hip fractures, and road traffic injuries.[[4–7]] Conversely, under-treatment of cataracts results in negative economic consequences, as there is lower employment participation from patients and their families that care for them.[[8]] It is for these reasons that public spending on cataract surgery yields a significant return on investment, with the cost per quality-adjusted life year (QALY) gained ranking as one of the most favourable of any healthcare intervention.[[9]] New Zealand specific evidence also shows the high cost-effectiveness of cataract surgery at NZ$4380 per QALY gained (95% uncertainty interval: 2410 to 7210), including for expedited cataract surgery where waiting time is shortened by 12 months.[[10]]

However, New Zealand’s surgical intervention rate (SIR) for cataract surgery ranks lower than many other high-income countries in the Organisation for Economic Co-operation and Development (OECD).[[3]] In 2018, New Zealand’s SIR was recorded at 373/100,000 population. In the same year, the United Kingdom (UK) had a SIR of 782/100,000 population, whilst Australia and Canada both had SIRs of over 1,000/100,000 population.[[3]] Comparisons using OECD data must be done cautiously, as data from New Zealand and the UK only includes publicly funded surgery, whereas Australia and Canada include all cataract surgeries. Nonetheless, New Zealand ranked 28th out of 32 OECD countries with available SIR estimates.[[3]] New Zealand’s overall SIR, including private surgeries, is estimated at 800/100,000 population. This still ranks poorly by international comparison.[[11]]

View Table 1.

The combination of a growing and ageing population, lost operating time due to the COVID-19 pandemic, and geographical disparities, is driving up an unmet demand for cataract surgery in New Zealand.[[12]] Ethnic inequalities also require attention; research suggests Māori patients present with more visually mature cataracts and may have higher rates of intra-operative complications.[[12,13]] Furthermore, the significant carbon footprint associated with cataract surgery requires leadership and action from ophthalmologists.[[14]]

These factors necessitate disruptive change in the delivery of publicly funded cataract surgery. Here, we explore strategic ways in which the “status quo” could be disrupted to facilitate greater efficiency, equity, and sustainability of cataract surgery in New Zealand.

Prioritisation

In any public health system with finite resources, prioritisation is necessary to ensure fair and timely access to surgery. For cataract surgery in New Zealand, this is assessed through the Clinical Priority Assessment Criteria (CPAC) score—a value of 0 to 100 is generated based on visual acuity, cataract morphology, and an “Impact on Life” questionnaire.

However, current use of the CPAC score leads to grossly unequal access to cataract surgery based on geographical location. From 2014–2019, the SIR varied significantly between regions, ranging from 95 to 737/100,000 population/year.[[12]] Over the same timeframe, rates of declined referrals for surgery ranged from 7% to 48% between regions.[[12]] CPAC thresholds differ between district health boards (DHBs), and fluctuate over time in response to demand and capacity, though the specific criteria for changes in threshold are not published.[[12,15]] RANZCO regularly collects CPAC thresholds across New Zealand—in October 2021 they ranged from 45 to 61.

Furthermore, the “Impact on Life” questionnaire currently used in generating a CPAC score is not well suited in assessing vision-related quality of life (VRQoL), with poor correlation between score and change in post-operative visual acuity, as well as unsatisfactory statistical validation.[[16]] Other scoring systems, such as the Catquest-9SF questionnaire, have demonstrated more credibility at assessing VRQoL.[[16]]

Introducing a national threshold that incorporates a validated VRQoL questionnaire would represent a more equitable and patient-centred approach to prioritisation, as well as ending the “postcode lottery” that currently exists for cataract surgery in New Zealand. The introduction of the new organisation that will replace DHBs (Health New Zealand) is well suited to create this national threshold and reduce geographic inequity.

Theatre efficiency and high-throughput units

Most cataract surgeries are performed under local anaesthesia and follow a standardised procedure—these unique factors are well suited to high-volume surgery. The number of cataract operations performed on a four-hour public list varies within New Zealand hospitals. Personal communications suggest that most units complete between 3–7 cataracts per list using phacoemulsification. Substantial variation is also observed in the UK, where an average of seven cataracts per list with a range of 5–14 was recorded across five UK hospitals.[[17]] In contrast, surgeons at the Aravind Eye Care System (AECS) in India can perform 10–16 cases per hour using manual small incision cataract surgery (MSICS).[[18]] Their visual outcome and safety data are equivalent to high-income countries.[[18–21]] Though there are important differences in surgical technique and health settings, there is clearly scope for improved efficiency in New Zealand theatres.

In the UK, Sunderland Eye Infirmary (SEI) is well recognised for running a best practice high-throughput unit.[[22,23]] They achieve up to 14 cataracts per list and 170–180 surgeries per week with two dedicated theatres. Amongst numerous structural, procedural, and cultural factors attributed to SEI’s efficiency, three key factors were identified by one observer.[[22]] Firstly, they employ higher numbers of nursing staff who facilitate the flow of patients, and nurses have increased responsibilities, including skin preparation and surgical consent. Secondly, patients are risk-assessed and stratified into three types of lists: consultant-only high-volume lists (with up to 14 cataracts per list), complex-sedation lists (with 8–10 cataracts per list) and training lists (with 6–8 cataracts per list depending on trainee experience). Finally, the physical design of the unit facilitates efficient patient flow and minimises downtime between operations.[[22]] Furthermore, patients are waitlisted and undergo pre-operative assessment with biometry on the same, initial visit.

Establishing similar high-throughput cataract surgery units in New Zealand, as well as adopting key learnings from AECS and SEI in existing units, could improve New Zealand’s SIR and preserve a balance of high-quality teaching with high-volume surgery.

An additional consideration is whether all ophthalmologists should perform cataract surgery. A Canadian cohort study of over one million cataract surgeries demonstrated that highly diversified surgeons (more than 50% non-cataract procedures) had almost three times as many adverse events as cataract-exclusive and moderately diversified surgeons (1–50% non-cataract procedures).[[24]] A retrospective Swedish study also demonstrated an association between the rate of capsule complications and surgeon operating volume.[[25]] Whilst New Zealand will require a growing number of cataract surgeons to elevate our SIR, treating cataract surgery as a sub-speciality may improve efficiency, safety, and visual outcomes.

Immediately sequential bilateral cataract surgery (ISBCS)

ISBCS is safe and effective compared to traditional delayed sequential surgery, with equivalent visual outcomes and complication rates.[[26]] Major advantages of ISBCS include faster visual rehabilitation, fewer clinic visits, decreased waiting times for surgery, higher productivity, and an estimated cost-saving of over 30% for the healthcare system.[[26,27]] ISBCS is already widely accepted and performed in countries such as Sweden and Finland.[[28]] The COVID-19 pandemic has also acted as a catalyst for increasing rates of ISBCS by minimising the number of patient encounters.[[29]] In the public hospitals of New Zealand, where CPAC determines access to cataract surgery, ISBCS is usually only considered for patients with two severe cataracts or requiring general anaesthesia; however, it is increasingly performed in the private sector.

Careful patient selection is crucial in ISBCS. Important factors are reproducible optical biometry, low risk of intra- and post-operative complications, and adequate home support.[[27]] Routinely offering ISBCS to appropriate patients would be a safe and cost-effective strategy to meet the rising demand for cataract surgery. Redesign of the public access criteria would be necessary to facilitate this.

Post-operative follow-up

Current practice regarding post-operative follow-up varies amongst DHBs. A typical regimen may involve a face-to-face review on post-operative day 1 (POD1), then again two to four weeks later, followed by a final visit to a community optometrist for refraction.

The current literature does not support the practice of POD1 follow-up after uneventful phacoemulsification cataract surgery by an experienced surgeon in patients without ocular co-morbidities.[[30]] Furthermore, rationalisation of post-operative follow-up is supported by widespread clinical practice abroad; the standard of care in the UK does not include a POD1 review unless there is co-existent pathology.[[31]]

Rationalisation of post-operative follow-up at a national level has the capacity for significant savings and increased efficiency without compromising safety. Alternatives to the face-to-face POD1 visit are telephone consults, or elimination of the clinical encounter entirely for appropriate patients with a low threshold for review in case of complaints.[[30]] There is also scope to utilise other healthcare professionals in post-operative care. In the UK, only 11% of all post-operative patients are seen by an ophthalmologist at any point; 57% are seen by hospital nurse practitioners or optometrists, and 27% are discharged immediately following surgery and followed up by community optometrists.[[31]]

However, post-operative review provides the opportunity for a feedback-loop with trainee surgeons as to the outcome of their surgery, and to become familiar with the usual post-operative course. It is therefore an important educational encounter in training hospitals, but could be rationalised to teaching lists only.

Strategies for cost-saving

The overall cost of cataract surgery in New Zealand is similar to Australia and the United States (US).[[32]] Surgeons at the AECS deliver cataract surgery at a fraction of the estimated cost in high-income countries.[[33]] Though there are important differences in health settings, factors contributing to the highly cost-effective care delivered by AECS that could be applied in New Zealand include: the use of standardised processes and instrumentation; bulk sourcing; appropriate re-use of equipment; and specialised nursing and support staff facilitating high-volume service delivery with optimal efficiency.

At present, there is substantial variability in practice across DHBs with differing operating equipment, intra-ocular lens (IOL) types and peri-operative treatment regimens. Developing standardised evidence-based protocols at a national level could significantly reduce costs, both by supporting PHARMAC to negotiate lower equipment prices, and by rationalising peri-operative treatment regimens.

For instance, there is widespread use of topical antibiotics post-operatively, despite low-level evidence for their efficacy in preventing endophthalmitis.[[34,35]] Stopping topical antibiotics could save money, reduce confusion for patients, decrease unnecessary consumption and greenhouse gas emissions, and may reduce the risk of antimicrobial resistance.

In patients with significant pre-existing astigmatism, a toric IOL may be considered. Toric IOLs correct for astigmatism and reduce lifetime economic costs by decreasing the need for glasses and contact lenses.[[36]] Thresholds for their use presently remains at the discretion of individual DHBs, with resultant geographic inequities and missed opportunities for cost reduction. This could be remedied by establishing a national standard and threshold for the use of toric IOLs. Similarly, extended depth of focus (EDOF) lenses improve functional vision and decrease the need for glasses. One type of EDOF lens is only $100 more expensive than a standard monofocal lens and could be considered for use within the public system.

Equity for Māori and Pasifika

Cataract-related vision loss is 1.5 to 2 times more prevalent in Māori in comparison to non-Māori up to age 84.[[37]] Similarly, Māori and Pasifika are listed for surgery on average 6–7 years younger than the national mean, with more advanced cataracts and worse pre-operative visual acuity.[[12,13]] In turn, this may result in higher rates of intra-operative complications in Māori patients.[[13]] Higher rates of diabetes, cardiopulmonary disease and smoking may contribute to earlier cataract development and must also be addressed.[[38]]

Given that Māori and Pasifika are waitlisted for surgery at equivalent rates to other ethnic groups, access to timely referral appears to be a key area for improvement.[[12]] Barriers to accessing timely referral include socio-economic deprivation and geographic accessibility.[[13]] For example, in patients from the Waikato Region defined as having remote access, Māori were 27% geographically further from an optometrist than New Zealand Europeans, and had worse visual acuity at the time of referral for surgery.[[39]] Funding optometry visits and improving accessibility to community optometry in more rural areas are two strategies worth exploring. Given higher rates of diabetes and associated cataract formation, upskilling community diabetes services may result in more prompt diagnoses and referrals. However, we recognise a need for further research to understand ethnic inequalities in cataract surgery, and the adoption of Te Tiriti o Waitangi principles in addressing disparities.[[40,41]]

Sustainability

Cataract surgery in New Zealand has a measurable carbon footprint (152 kgCO2e per procedure), equivalent to an economy seat on a one-hour flight.[[14]] Extrapolated over approximately 30,000 operations each year, this amounts to 4,500 tonnes of carbon, which would require 134 ha of growing forest to absorb. When the carbon footprint of cataract surgery was measured in Wellington hospitals, the most striking finding was that 84% of emissions were related to the consumption of single-use items such as gowns, drapes, surgical instruments, tubing and cassettes, gauze, dressings, eye shields and medications.[[14]] When a similar footprinting exercise was conducted in AECS, India, it was shown that reuse of many items, as well as limited local recycling or reprocessing, was able to reduce the overall footprint of cataract surgery to 6 kgCO2e per procedure, with similar large reductions in cost.[[42]] As outlined earlier, while we might presume trade-offs between safety or quality and cost-saving activities, recent reports of large cohorts at AECS show that post-operative endophthalmitis rates of 0.01% rival the rate of 0.04% reported in the United States registry.[[20,21]] This casts an interesting light on how operating theatre regulations and practice patterns may not be optimising safety, efficiency, cost-saving and environmental impact.[[43]]

In the near future, New Zealand health sector agencies will become accountable for their carbon footprint.[[44]] Initially, this will require measuring emissions and budgeting to offset emissions. Decarbonisation of the health sector will then be incentivised by the financial effects on our health systems. Ophthalmologists within this much larger system have several means to support decarbonisation. The travel emissions related to cataract surgery can be reduced with: “one-stop shop” pre-assessment with same-day surgery; longer operating lists (less staff travel per case); ISBCS; and phone and community-based follow up for suitable cases. The footprint related to pharmaceutical consumption can be reduced by: using topical anaesthesia wherever possible; avoiding single-use sterile drops when unnecessary; reusing bottles of liquid medications such as povidone-iodine and irrigating solutions for multiple cases; and, avoiding the prescription of any unnecessary post-operative drops such as antibiotics. Likewise, the consumption of surgical supplies can be reduced, and surgeons can have a powerful voice as leaders and advocates to their hospital management and industry suppliers.

Audit

A continuous audit cycle at both local and national levels is essential in improving efficiency, safety, and visual outcomes. To provide culturally appropriate and patient-centred care, patient reported outcome measures must also be central to this audit process. We should aspire to the Swedish National Cataract Register model, which has collected data on over one million surgeries since 1992.[[45]] A number of DHBs and private providers in New Zealand now use CatTrax, a web-based health intelligence platform, to manage their entire cataract pathway. CatTrax includes automated reporting on all relevant clinical and refractive outcome measures, including patient reported outcomes using the CatQuest-9SF and other assessment tools. CatTrax has enabled improvements in quality, access to cataract surgery and equity. To date, over 15,000 cataracts have been tracked using CatTrax in New Zealand.

Conclusion

Cataract surgery is a highly cost-effective treatment, but the surgical intervention rate in New Zealand ranks poorly compared with other high-income countries. We have presented several evidence-based strategies with overlapping benefits in access, equity, efficiency and sustainability. Key strategies include that Health New Zealand mandate a national CPAC threshold for surgical access, and that PHARMAC leverage cheaper access to surgical supplies using nationally agreed equipment standards, establishing high-throughput cataract units, offering ISBCS when appropriate, and rationalising post-operative care. As we transition to a new healthcare system, we should seize the opportunity to reimagine our public cataract service.

Summary

Abstract

Cataract surgery is a highly cost-effective treatment, but the surgical intervention rate in New Zealand ranks poorly compared with other high-income countries. The combination of a growing and ageing population, lost operating time due to the COVID-19 pandemic, and geographical disparities, is driving up an unmet demand for cataract surgery. We present several evidence-based strategies with overlapping benefits in access, equity, efficiency and sustainability. Key strategies include that Health New Zealand mandate a national prioritisation threshold for surgical access, and that PHARMAC leverage cheaper access to surgical supplies using nationally agreed equipment standards, establishing high-throughput cataract units, offering same day bilateral cataract surgery when appropriate, and rationalising post-operative care.

Aim

Method

Results

Conclusion

Author Information

Samuel Burridge: Ophthalmology Registrar, Taranaki Eye Centre, New Plymouth. Jonathan Wood: Ophthalmology Registrar, Department of Ophthalmology, Tairāwhiti District Health Board, Gisborne Jesse Gale: Ophthalmologist, Department of Surgery & Anaesthesia, University of Otago, Wellington. Albie Covello: Ophthalmologist, Taranaki Eye Centre, New Plymouth. James McKelvie: Ophthalmologist, Department of Ophthalmology, Waikato District Health Board, Hamilton. Graham Wilson: Ophthalmologist, Department of Ophthalmology, Tairāwhiti District Health Board, Gisborne.

Acknowledgements

The authors would like to thank Brian Kent-Smith and Derek Sherwood for their valuable feedback.

Correspondence

Samuel Burridge: Taranaki Eye Centre, 17 Weymouth Street, New Plymouth, 4310. (06) 758 3553.

Correspondence Email

samlburridge@gmail.com

Competing Interests

Nil.

1) Bourne RRA, Steinmetz JD, Saylan M, Mersha AM, Weldemariam AH, Wondmeneh TG, et al. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: The Right to Sight: An analysis for the Global Burden of Disease Study. Lancet Glob Heal [Internet]. 2021 Feb 1 [accessedaccessed 2021 Sep 1];9(2):e144-60. Available from: https://pubmed.ncbi.nlm.nih.gov/33275949/

2) Blind Low Vision NZ. Blindness and Low Vision in New Zealand – Latest statistics [Internet]. 2021 [accessed 2021 Aug 31]. Available from: https://blindlowvision.org.nz/information/statistics-and-research/

3) OECD Statistics. Health Care Utilisation: Surgical Procedures [Internet]. 2020 [accessed 2021 Aug 31]. Available from: https://stats.oecd.org/index.aspx?queryid=30167

4) Tseng VL, Yu F, Lum F, Coleman AL. Risk of fractures following cataract surgery in medicare beneficiaries. JAMA - J Am Med Assoc [Internet]. 2012 Aug 1 [accessed 2021 Sep 1];308(5):493-501. Available from: https://pubmed.ncbi.nlm.nih.gov/22851116/

5) Maharani A, Dawes P, Nazroo J, Tampubolon G, Pendleton N. Cataract surgery and age-related cognitive decline: A 13-year follow-up of the English Longitudinal Study of Ageing. PLoS One [Internet]. 2018 Oct 1 [accessed 2021 Sep 1];13(10). Available from: https://pubmed.ncbi.nlm.nih.gov/30307960/

6) Palagyi A, Morlet N, McCluskey P, White A, Meuleners L, Ng JQ, et al. Visual and refractive associations with falls after first-eye cataract surgery. J Cataract Refract Surg [Internet]. 2017 Oct 1 [accessedaccessed 2021 Sep 1];43(10):1313-21. Available from: https://pubmed.ncbi.nlm.nih.gov/29056303/

7) Schlenker M, Thiruchelvam D, Redelmeier D. Association of Cataract Surgery With Traffic Crashes. JAMA Ophthalmol [Internet]. 2018 Sep 1 [accessed 2021 Sep 1];136(9):998-1007. Available from: https://pubmed.ncbi.nlm.nih.gov/29955857/

8) Pezzullo L, Streatfeild J, Simkiss P, Shickle D. The economic impact of sight loss and blindness in the UK adult population. BMC Health Serv Res [Internet]. 2018 Jan 30 [accessed 2021 Sep 1];18(1). Available from: https://pubmed.ncbi.nlm.nih.gov/29382329/

9) Brown G, Brown M, Menezes A, Busbee B, Lieske H, Lieske P. Cataract surgery cost utility revisited in 2012: a new economic paradigm. Ophthalmology [Internet]. 2013 Dec [accessed 2021 Sep 1];120(12):2367-76. Available from: https://pubmed.ncbi.nlm.nih.gov/24246824/

10) Boyd M, Kvizhinadze G, Kho A, Wilson G, Wilson N. Cataract surgery for falls prevention and improving vision: modelling the health gain, health system costs and cost-effectiveness in a high-income country. Inj Prev [Internet]. 2020 Aug 1 [accessed 2021 Aug 31];26(4):302-9. Available from: https://pubmed.ncbi.nlm.nih.gov/31221667/

11) RANZCO. RANZCO Position Paper on Cataract Surgery in New Zealand [Internet]. 2020. Available from: https://ranzco.edu/wp-content/uploads/2020/10/Cataract-Surgery-Position-Paper-NZ_2020.pdf

12) Chilibeck C, Mathan JJ, Ng SG, McKelvie J. Cataract surgery in New Zealand: access to surgery, surgical intervention rates and visual acuity. N Z Med J. 2020 Oct;133(1524):40-9.

13) Newlands S, Hoy B, Wilson G. Cataract surgery in Hauora Tairāwhiti and need for improving access for Māori. Clin Experiment Ophthalmol [Internet]. 2019 Jan 1 [accessed 2021 Aug 31];47(1):145-7. Available from: https://pubmed.ncbi.nlm.nih.gov/29947162/

14) Latta M, Shaw C, Gale J. The carbon footprint of cataract surgery in Wellington. N Z Med J. 2021;134(1541).

15) Arrowsmith M. Response to your request for official information. Document number H201901181. Ministry of Health. 2019.

16) Li SS, Misra S, Wallace H, Hunt L, McKelvie J. Patient-reported quality of life for cataract surgery: prospective validation of the “Impact on Life” and Catquest-9SF questionnaires in New Zealand. N Z Med J. 2019 Oct;132(1503):34-45.

17) Roberts HW, Myerscough J, Borsci S, Ni M, O’Brart DPS. Time and motion studies of National Health Service cataract theatre lists to determine strategies to improve efficiency. Br J Ophthalmol [Internet]. 2018 Sep 1 [accessed 2021 Sep 12];102(9):1259-67. Available from: https://pubmed.ncbi.nlm.nih.gov/29175969/

18) Chang DF. 2020 ESCRS Ridley Medal Lecture: Compelling Lessons from the Greatest Team of Cataract Surgeons. 2020.

19) Ravindran RD, Gupta S, Haripriya A, Ravilla T, Ashok Vardhan S, Subburaman GBB. Seven-year trends in cataract surgery indications and quality of outcomes at Aravind Eye Hospitals, India. Eye [Internet]. 2021 Jul 1 [accessed 2021 Sep 7];35(7):1895–903. Available from: https://pubmed.ncbi.nlm.nih.gov/32913291/

20) Haripriya A, Chang DF, Ravindran RD. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries. J Cataract Refract Surg [Internet]. 2019 Sep 1 [accessed 2021 Sep 7];45(9):1226-33. Available from: https://pubmed.ncbi.nlm.nih.gov/31371152/

21) Pershing S, Lum F, Hsu S, Kelly S, Chiang MF, Rich WL, et al. Endophthalmitis after Cataract Surgery in the United States: A Report from the Intelligent Research in Sight Registry, 2013–2017. Ophthalmology [Internet]. 2020 Feb 1 [accessed 2021 Sep 7];127(2):151-8. Available from: https://pubmed.ncbi.nlm.nih.gov/31611015/

22) Hingorani M. Sunderland eye infirmary: a case study of high throughput cataract surgery [Internet]. UK Ophthalmological Alliance. 2018. Available from: https://uk-oa.co.uk/wp-content/uploads/2018/07/UKOA_Sunderland_Case_Study_June_2018.pdf

23) Lin PF, Naveed H, Eleftheriadou M, Purbrick R, Zarei Ghanavati M, Liu C. Cataract service redesign in the post-COVID-19 era [Internet]. Vol. 105, British Journal of Ophthalmology. Br J Ophthalmol; 2021 [accessed 2021 Sep 1]. p. 745-50. Available from: https://pubmed.ncbi.nlm.nih.gov/32703783/

24) Campbell RJ, El-Defrawy SR, Gill SS, Whitehead M, Campbell E de LP, Hooper PL, et al. Surgical Outcomes among Focused versus Diversified Cataract Surgeons. Ophthalmology [Internet]. 2021 Jun 1 [accessed 2021 Sep 12];128(6):827-34. Available from: https://pubmed.ncbi.nlm.nih.gov/33637327/

25) Zetterberg M, Montan P, Kugelberg M, Nilsson I, Lundström M, Behndig A. Cataract Surgery Volumes and Complications per Surgeon and Clinical Unit: Data from the Swedish National Cataract Register 2007 to 2016. In: Ophthalmology [Internet]. Elsevier; 2020 [accessed 2021 Sep 12]. p. 305-14. Available from: http://www.aaojournal.org/article/S0161642019321414/fulltext

26) Singh R, Dohlman TH, Sun G. Immediately sequential bilateral cataract surgery: Advantages and disadvantages [Internet]. Vol. 28, Current Opinion in Ophthalmology. Curr Opin Ophthalmol; 2017 [accessed 2021 Sep 12]. p. 81-6. Available from: https://pubmed.ncbi.nlm.nih.gov/27684294/

27) O’Brart DP, Roberts H, Naderi K, Gormley J. Economic modelling of immediately sequential bilateral cataract surgery (ISBCS) in the National Health Service based on possible improvements in surgical efficiency. BMJ Open Ophthalmol [Internet]. 2020 Jun 25 [accessed 2021 Sep 5];5(1). Available from: https://pubmed.ncbi.nlm.nih.gov/32617415/

28) Kessel L, Andresen J, Erngaard D, Flesner P, Tendal B, Hjortdal J. Immediate sequential bilateral cataract surgery: A systematic review and meta-analysis. J Ophthalmol [Internet]. 2015 [accessed 2021 Sep 5];2015. Available from: https://pubmed.ncbi.nlm.nih.gov/26351576/

29) Wang H, Ramjiani V, Raynor M, Tan J. Practice of immediate sequential bilateral cataract surgery (ISBCS) since COVID-19: a patient and surgeon survey [Internet]. Eye (Basingstoke). Nature Publishing Group; 2021 [accessed 2021 Sep 5]. p. 1. Available from: /pmc/articles/PMC8023778/

30) Grzybowski A, Kanclerz P. Do we need day-1 postoperative follow-up after cataract surgery? [Internet]. Vol. 257, Graefe’s Archive for Clinical and Experimental Ophthalmology. Graefes Arch Clin Exp Ophthalmol; 2019 [accessed 2021 Sep 15]. p. 855-61. Available from: https://pubmed.ncbi.nlm.nih.gov/30569320/

31) The Royal College of Ophthalmologists. The Way Forward - Cataract [Internet]. 2017. Available from: https://www.rcophth.ac.uk/wp-content/uploads/2018/10/RCOphth-Way-Forward-Cataract.pdf

32) International Federation of Health Plans. 2013 Comparative Price Report: Variation in Medical and Hospital Prices by Country [Internet]. 2013. Available from: http://www.ifhp.com/documents/2012iFHPPriceReportFINALMarch25.pdf

33) Le HG, Ehrlich JR, Venkatesh R, Srinivasan A, Kolli A, Haripriya A, et al. A sustainable model for delivering high-quality, efficient cataract surgery in southern India. Health Aff [Internet]. 2016 [accessed 2021 Sep 15];35(10):1783-90. Available from: https://pubmed.ncbi.nlm.nih.gov/27702949/

34) Råen M, Sandvik GF, Drolsum L. Endophthalmitis following cataract surgery: The role of prophylactic postoperative chloramphenicol eye drops. Acta Ophthalmol [Internet]. 2013 Mar [accessed 2021 Oct 2];91(2):118-22. Available from: https://pubmed.ncbi.nlm.nih.gov/22151787/

35) Friling E, Lundström M, Stenevi U, Montan P. Six-year incidence of endophthalmitis after cataract surgery: Swedish national study. J Cataract Refract Surg [Internet]. 2013 Jan [accessed 2021 Sep 15];39(1):15-21. Available from: https://pubmed.ncbi.nlm.nih.gov/23245359/

36) Pineda R, Denevich S, Lee WC, Waycaster C, Pashos CL. Economic evaluation of toric intraocular lens: A short- and long-term decision analytic model. Arch Ophthalmol [Internet]. 2010 Jul [accessed 2021 Sep 15];128(7):834-40. Available from: https://pubmed.ncbi.nlm.nih.gov/20625042/

37) Taylor P, Mapp K. Clear Focus — The economic impact of vision loss in New Zealand in 2009 Report by Access Economics Pty Limited for 2020 New Zealand Trust. 2010;(September).

38) Yoon JJ, Misra SL, Mcghee CNJ, Patel D V. Demographics and ocular biometric characteristics of patients undergoing cataract surgery in Auckland, New Zealand. Clin Exp Ophthalmol [Internet]. 2016 Mar 1 [accessed 2021 Sep 19];44(2):106-13. Available from: https://pubmed.ncbi.nlm.nih.gov/26284342/

39) Wilkinson B, McKelvie J. Evaluating barriers to access for cataract surgery in Waikato: analysis of calculated driving distance and visual acuity. N Z Med J [Internet]. 2021 [accessed 2021 Aug 31];105–12. Available from: https://pubmed.ncbi.nlm.nih.gov/34140717/

40) Freundlich SEN, McGhee CNJ. Should we be doing more to identify barriers to cataract surgery for Indigenous populations in New Zealand? Clin Exp Ophthalmol. 2020;48(7):1014-5.

41) RANZCO. Māori and Pasifika Eye Health. 2021.

42) Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg [Internet]. 2017 Nov 1 [accessed 2021 Sep 7];43(11):1391-8. Available from: https://pubmed.ncbi.nlm.nih.gov/29223227/

43) Chang DF. Needless Waste and the Sustainability of Cataract Surgery [Internet]. Vol. 127, Ophthalmology. Elsevier; 2020 [accessed 2021 Sep 7]. p. 1600-2. Available from: /pmc/articles/PMC7361054/

44) New Zealand Government. Public sector to be carbon neutral by 2025 [Internet]. Wellington; 2020. Available from: https://www.beehive.govt.nz/release/public-sector-be-carbon-neutral-2025

45) Behndig A, Montan P, Stenevi U, Kugelberg M, Lundström M. One million cataract surgeries: Swedish National Cataract Register 1992-2009. J Cataract Refract Surg [Internet]. 2011 [accessed 2022 Jan 20];37(8):1539-45. Available from: https://pubmed.ncbi.nlm.nih.gov/21782099/

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Cataracts are the leading cause of blindness globally, and the most common correctable eye disease causing blindness and sight loss in New Zealand.[[1,2]] Across high-income countries, cataract surgery is one of the most commonly performed surgical procedures.[[3]] Cataract surgery improves vision, with numerous secondary benefits including improved quality of life, slower rates of cognitive decline, and reduced risk of falls, hip fractures, and road traffic injuries.[[4–7]] Conversely, under-treatment of cataracts results in negative economic consequences, as there is lower employment participation from patients and their families that care for them.[[8]] It is for these reasons that public spending on cataract surgery yields a significant return on investment, with the cost per quality-adjusted life year (QALY) gained ranking as one of the most favourable of any healthcare intervention.[[9]] New Zealand specific evidence also shows the high cost-effectiveness of cataract surgery at NZ$4380 per QALY gained (95% uncertainty interval: 2410 to 7210), including for expedited cataract surgery where waiting time is shortened by 12 months.[[10]]

However, New Zealand’s surgical intervention rate (SIR) for cataract surgery ranks lower than many other high-income countries in the Organisation for Economic Co-operation and Development (OECD).[[3]] In 2018, New Zealand’s SIR was recorded at 373/100,000 population. In the same year, the United Kingdom (UK) had a SIR of 782/100,000 population, whilst Australia and Canada both had SIRs of over 1,000/100,000 population.[[3]] Comparisons using OECD data must be done cautiously, as data from New Zealand and the UK only includes publicly funded surgery, whereas Australia and Canada include all cataract surgeries. Nonetheless, New Zealand ranked 28th out of 32 OECD countries with available SIR estimates.[[3]] New Zealand’s overall SIR, including private surgeries, is estimated at 800/100,000 population. This still ranks poorly by international comparison.[[11]]

View Table 1.

The combination of a growing and ageing population, lost operating time due to the COVID-19 pandemic, and geographical disparities, is driving up an unmet demand for cataract surgery in New Zealand.[[12]] Ethnic inequalities also require attention; research suggests Māori patients present with more visually mature cataracts and may have higher rates of intra-operative complications.[[12,13]] Furthermore, the significant carbon footprint associated with cataract surgery requires leadership and action from ophthalmologists.[[14]]

These factors necessitate disruptive change in the delivery of publicly funded cataract surgery. Here, we explore strategic ways in which the “status quo” could be disrupted to facilitate greater efficiency, equity, and sustainability of cataract surgery in New Zealand.

Prioritisation

In any public health system with finite resources, prioritisation is necessary to ensure fair and timely access to surgery. For cataract surgery in New Zealand, this is assessed through the Clinical Priority Assessment Criteria (CPAC) score—a value of 0 to 100 is generated based on visual acuity, cataract morphology, and an “Impact on Life” questionnaire.

However, current use of the CPAC score leads to grossly unequal access to cataract surgery based on geographical location. From 2014–2019, the SIR varied significantly between regions, ranging from 95 to 737/100,000 population/year.[[12]] Over the same timeframe, rates of declined referrals for surgery ranged from 7% to 48% between regions.[[12]] CPAC thresholds differ between district health boards (DHBs), and fluctuate over time in response to demand and capacity, though the specific criteria for changes in threshold are not published.[[12,15]] RANZCO regularly collects CPAC thresholds across New Zealand—in October 2021 they ranged from 45 to 61.

Furthermore, the “Impact on Life” questionnaire currently used in generating a CPAC score is not well suited in assessing vision-related quality of life (VRQoL), with poor correlation between score and change in post-operative visual acuity, as well as unsatisfactory statistical validation.[[16]] Other scoring systems, such as the Catquest-9SF questionnaire, have demonstrated more credibility at assessing VRQoL.[[16]]

Introducing a national threshold that incorporates a validated VRQoL questionnaire would represent a more equitable and patient-centred approach to prioritisation, as well as ending the “postcode lottery” that currently exists for cataract surgery in New Zealand. The introduction of the new organisation that will replace DHBs (Health New Zealand) is well suited to create this national threshold and reduce geographic inequity.

Theatre efficiency and high-throughput units

Most cataract surgeries are performed under local anaesthesia and follow a standardised procedure—these unique factors are well suited to high-volume surgery. The number of cataract operations performed on a four-hour public list varies within New Zealand hospitals. Personal communications suggest that most units complete between 3–7 cataracts per list using phacoemulsification. Substantial variation is also observed in the UK, where an average of seven cataracts per list with a range of 5–14 was recorded across five UK hospitals.[[17]] In contrast, surgeons at the Aravind Eye Care System (AECS) in India can perform 10–16 cases per hour using manual small incision cataract surgery (MSICS).[[18]] Their visual outcome and safety data are equivalent to high-income countries.[[18–21]] Though there are important differences in surgical technique and health settings, there is clearly scope for improved efficiency in New Zealand theatres.

In the UK, Sunderland Eye Infirmary (SEI) is well recognised for running a best practice high-throughput unit.[[22,23]] They achieve up to 14 cataracts per list and 170–180 surgeries per week with two dedicated theatres. Amongst numerous structural, procedural, and cultural factors attributed to SEI’s efficiency, three key factors were identified by one observer.[[22]] Firstly, they employ higher numbers of nursing staff who facilitate the flow of patients, and nurses have increased responsibilities, including skin preparation and surgical consent. Secondly, patients are risk-assessed and stratified into three types of lists: consultant-only high-volume lists (with up to 14 cataracts per list), complex-sedation lists (with 8–10 cataracts per list) and training lists (with 6–8 cataracts per list depending on trainee experience). Finally, the physical design of the unit facilitates efficient patient flow and minimises downtime between operations.[[22]] Furthermore, patients are waitlisted and undergo pre-operative assessment with biometry on the same, initial visit.

Establishing similar high-throughput cataract surgery units in New Zealand, as well as adopting key learnings from AECS and SEI in existing units, could improve New Zealand’s SIR and preserve a balance of high-quality teaching with high-volume surgery.

An additional consideration is whether all ophthalmologists should perform cataract surgery. A Canadian cohort study of over one million cataract surgeries demonstrated that highly diversified surgeons (more than 50% non-cataract procedures) had almost three times as many adverse events as cataract-exclusive and moderately diversified surgeons (1–50% non-cataract procedures).[[24]] A retrospective Swedish study also demonstrated an association between the rate of capsule complications and surgeon operating volume.[[25]] Whilst New Zealand will require a growing number of cataract surgeons to elevate our SIR, treating cataract surgery as a sub-speciality may improve efficiency, safety, and visual outcomes.

Immediately sequential bilateral cataract surgery (ISBCS)

ISBCS is safe and effective compared to traditional delayed sequential surgery, with equivalent visual outcomes and complication rates.[[26]] Major advantages of ISBCS include faster visual rehabilitation, fewer clinic visits, decreased waiting times for surgery, higher productivity, and an estimated cost-saving of over 30% for the healthcare system.[[26,27]] ISBCS is already widely accepted and performed in countries such as Sweden and Finland.[[28]] The COVID-19 pandemic has also acted as a catalyst for increasing rates of ISBCS by minimising the number of patient encounters.[[29]] In the public hospitals of New Zealand, where CPAC determines access to cataract surgery, ISBCS is usually only considered for patients with two severe cataracts or requiring general anaesthesia; however, it is increasingly performed in the private sector.

Careful patient selection is crucial in ISBCS. Important factors are reproducible optical biometry, low risk of intra- and post-operative complications, and adequate home support.[[27]] Routinely offering ISBCS to appropriate patients would be a safe and cost-effective strategy to meet the rising demand for cataract surgery. Redesign of the public access criteria would be necessary to facilitate this.

Post-operative follow-up

Current practice regarding post-operative follow-up varies amongst DHBs. A typical regimen may involve a face-to-face review on post-operative day 1 (POD1), then again two to four weeks later, followed by a final visit to a community optometrist for refraction.

The current literature does not support the practice of POD1 follow-up after uneventful phacoemulsification cataract surgery by an experienced surgeon in patients without ocular co-morbidities.[[30]] Furthermore, rationalisation of post-operative follow-up is supported by widespread clinical practice abroad; the standard of care in the UK does not include a POD1 review unless there is co-existent pathology.[[31]]

Rationalisation of post-operative follow-up at a national level has the capacity for significant savings and increased efficiency without compromising safety. Alternatives to the face-to-face POD1 visit are telephone consults, or elimination of the clinical encounter entirely for appropriate patients with a low threshold for review in case of complaints.[[30]] There is also scope to utilise other healthcare professionals in post-operative care. In the UK, only 11% of all post-operative patients are seen by an ophthalmologist at any point; 57% are seen by hospital nurse practitioners or optometrists, and 27% are discharged immediately following surgery and followed up by community optometrists.[[31]]

However, post-operative review provides the opportunity for a feedback-loop with trainee surgeons as to the outcome of their surgery, and to become familiar with the usual post-operative course. It is therefore an important educational encounter in training hospitals, but could be rationalised to teaching lists only.

Strategies for cost-saving

The overall cost of cataract surgery in New Zealand is similar to Australia and the United States (US).[[32]] Surgeons at the AECS deliver cataract surgery at a fraction of the estimated cost in high-income countries.[[33]] Though there are important differences in health settings, factors contributing to the highly cost-effective care delivered by AECS that could be applied in New Zealand include: the use of standardised processes and instrumentation; bulk sourcing; appropriate re-use of equipment; and specialised nursing and support staff facilitating high-volume service delivery with optimal efficiency.

At present, there is substantial variability in practice across DHBs with differing operating equipment, intra-ocular lens (IOL) types and peri-operative treatment regimens. Developing standardised evidence-based protocols at a national level could significantly reduce costs, both by supporting PHARMAC to negotiate lower equipment prices, and by rationalising peri-operative treatment regimens.

For instance, there is widespread use of topical antibiotics post-operatively, despite low-level evidence for their efficacy in preventing endophthalmitis.[[34,35]] Stopping topical antibiotics could save money, reduce confusion for patients, decrease unnecessary consumption and greenhouse gas emissions, and may reduce the risk of antimicrobial resistance.

In patients with significant pre-existing astigmatism, a toric IOL may be considered. Toric IOLs correct for astigmatism and reduce lifetime economic costs by decreasing the need for glasses and contact lenses.[[36]] Thresholds for their use presently remains at the discretion of individual DHBs, with resultant geographic inequities and missed opportunities for cost reduction. This could be remedied by establishing a national standard and threshold for the use of toric IOLs. Similarly, extended depth of focus (EDOF) lenses improve functional vision and decrease the need for glasses. One type of EDOF lens is only $100 more expensive than a standard monofocal lens and could be considered for use within the public system.

Equity for Māori and Pasifika

Cataract-related vision loss is 1.5 to 2 times more prevalent in Māori in comparison to non-Māori up to age 84.[[37]] Similarly, Māori and Pasifika are listed for surgery on average 6–7 years younger than the national mean, with more advanced cataracts and worse pre-operative visual acuity.[[12,13]] In turn, this may result in higher rates of intra-operative complications in Māori patients.[[13]] Higher rates of diabetes, cardiopulmonary disease and smoking may contribute to earlier cataract development and must also be addressed.[[38]]

Given that Māori and Pasifika are waitlisted for surgery at equivalent rates to other ethnic groups, access to timely referral appears to be a key area for improvement.[[12]] Barriers to accessing timely referral include socio-economic deprivation and geographic accessibility.[[13]] For example, in patients from the Waikato Region defined as having remote access, Māori were 27% geographically further from an optometrist than New Zealand Europeans, and had worse visual acuity at the time of referral for surgery.[[39]] Funding optometry visits and improving accessibility to community optometry in more rural areas are two strategies worth exploring. Given higher rates of diabetes and associated cataract formation, upskilling community diabetes services may result in more prompt diagnoses and referrals. However, we recognise a need for further research to understand ethnic inequalities in cataract surgery, and the adoption of Te Tiriti o Waitangi principles in addressing disparities.[[40,41]]

Sustainability

Cataract surgery in New Zealand has a measurable carbon footprint (152 kgCO2e per procedure), equivalent to an economy seat on a one-hour flight.[[14]] Extrapolated over approximately 30,000 operations each year, this amounts to 4,500 tonnes of carbon, which would require 134 ha of growing forest to absorb. When the carbon footprint of cataract surgery was measured in Wellington hospitals, the most striking finding was that 84% of emissions were related to the consumption of single-use items such as gowns, drapes, surgical instruments, tubing and cassettes, gauze, dressings, eye shields and medications.[[14]] When a similar footprinting exercise was conducted in AECS, India, it was shown that reuse of many items, as well as limited local recycling or reprocessing, was able to reduce the overall footprint of cataract surgery to 6 kgCO2e per procedure, with similar large reductions in cost.[[42]] As outlined earlier, while we might presume trade-offs between safety or quality and cost-saving activities, recent reports of large cohorts at AECS show that post-operative endophthalmitis rates of 0.01% rival the rate of 0.04% reported in the United States registry.[[20,21]] This casts an interesting light on how operating theatre regulations and practice patterns may not be optimising safety, efficiency, cost-saving and environmental impact.[[43]]

In the near future, New Zealand health sector agencies will become accountable for their carbon footprint.[[44]] Initially, this will require measuring emissions and budgeting to offset emissions. Decarbonisation of the health sector will then be incentivised by the financial effects on our health systems. Ophthalmologists within this much larger system have several means to support decarbonisation. The travel emissions related to cataract surgery can be reduced with: “one-stop shop” pre-assessment with same-day surgery; longer operating lists (less staff travel per case); ISBCS; and phone and community-based follow up for suitable cases. The footprint related to pharmaceutical consumption can be reduced by: using topical anaesthesia wherever possible; avoiding single-use sterile drops when unnecessary; reusing bottles of liquid medications such as povidone-iodine and irrigating solutions for multiple cases; and, avoiding the prescription of any unnecessary post-operative drops such as antibiotics. Likewise, the consumption of surgical supplies can be reduced, and surgeons can have a powerful voice as leaders and advocates to their hospital management and industry suppliers.

Audit

A continuous audit cycle at both local and national levels is essential in improving efficiency, safety, and visual outcomes. To provide culturally appropriate and patient-centred care, patient reported outcome measures must also be central to this audit process. We should aspire to the Swedish National Cataract Register model, which has collected data on over one million surgeries since 1992.[[45]] A number of DHBs and private providers in New Zealand now use CatTrax, a web-based health intelligence platform, to manage their entire cataract pathway. CatTrax includes automated reporting on all relevant clinical and refractive outcome measures, including patient reported outcomes using the CatQuest-9SF and other assessment tools. CatTrax has enabled improvements in quality, access to cataract surgery and equity. To date, over 15,000 cataracts have been tracked using CatTrax in New Zealand.

Conclusion

Cataract surgery is a highly cost-effective treatment, but the surgical intervention rate in New Zealand ranks poorly compared with other high-income countries. We have presented several evidence-based strategies with overlapping benefits in access, equity, efficiency and sustainability. Key strategies include that Health New Zealand mandate a national CPAC threshold for surgical access, and that PHARMAC leverage cheaper access to surgical supplies using nationally agreed equipment standards, establishing high-throughput cataract units, offering ISBCS when appropriate, and rationalising post-operative care. As we transition to a new healthcare system, we should seize the opportunity to reimagine our public cataract service.

Summary

Abstract

Cataract surgery is a highly cost-effective treatment, but the surgical intervention rate in New Zealand ranks poorly compared with other high-income countries. The combination of a growing and ageing population, lost operating time due to the COVID-19 pandemic, and geographical disparities, is driving up an unmet demand for cataract surgery. We present several evidence-based strategies with overlapping benefits in access, equity, efficiency and sustainability. Key strategies include that Health New Zealand mandate a national prioritisation threshold for surgical access, and that PHARMAC leverage cheaper access to surgical supplies using nationally agreed equipment standards, establishing high-throughput cataract units, offering same day bilateral cataract surgery when appropriate, and rationalising post-operative care.

Aim

Method

Results

Conclusion

Author Information

Samuel Burridge: Ophthalmology Registrar, Taranaki Eye Centre, New Plymouth. Jonathan Wood: Ophthalmology Registrar, Department of Ophthalmology, Tairāwhiti District Health Board, Gisborne Jesse Gale: Ophthalmologist, Department of Surgery & Anaesthesia, University of Otago, Wellington. Albie Covello: Ophthalmologist, Taranaki Eye Centre, New Plymouth. James McKelvie: Ophthalmologist, Department of Ophthalmology, Waikato District Health Board, Hamilton. Graham Wilson: Ophthalmologist, Department of Ophthalmology, Tairāwhiti District Health Board, Gisborne.

Acknowledgements

The authors would like to thank Brian Kent-Smith and Derek Sherwood for their valuable feedback.

Correspondence

Samuel Burridge: Taranaki Eye Centre, 17 Weymouth Street, New Plymouth, 4310. (06) 758 3553.

Correspondence Email

samlburridge@gmail.com

Competing Interests

Nil.

1) Bourne RRA, Steinmetz JD, Saylan M, Mersha AM, Weldemariam AH, Wondmeneh TG, et al. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: The Right to Sight: An analysis for the Global Burden of Disease Study. Lancet Glob Heal [Internet]. 2021 Feb 1 [accessedaccessed 2021 Sep 1];9(2):e144-60. Available from: https://pubmed.ncbi.nlm.nih.gov/33275949/

2) Blind Low Vision NZ. Blindness and Low Vision in New Zealand – Latest statistics [Internet]. 2021 [accessed 2021 Aug 31]. Available from: https://blindlowvision.org.nz/information/statistics-and-research/

3) OECD Statistics. Health Care Utilisation: Surgical Procedures [Internet]. 2020 [accessed 2021 Aug 31]. Available from: https://stats.oecd.org/index.aspx?queryid=30167

4) Tseng VL, Yu F, Lum F, Coleman AL. Risk of fractures following cataract surgery in medicare beneficiaries. JAMA - J Am Med Assoc [Internet]. 2012 Aug 1 [accessed 2021 Sep 1];308(5):493-501. Available from: https://pubmed.ncbi.nlm.nih.gov/22851116/

5) Maharani A, Dawes P, Nazroo J, Tampubolon G, Pendleton N. Cataract surgery and age-related cognitive decline: A 13-year follow-up of the English Longitudinal Study of Ageing. PLoS One [Internet]. 2018 Oct 1 [accessed 2021 Sep 1];13(10). Available from: https://pubmed.ncbi.nlm.nih.gov/30307960/

6) Palagyi A, Morlet N, McCluskey P, White A, Meuleners L, Ng JQ, et al. Visual and refractive associations with falls after first-eye cataract surgery. J Cataract Refract Surg [Internet]. 2017 Oct 1 [accessedaccessed 2021 Sep 1];43(10):1313-21. Available from: https://pubmed.ncbi.nlm.nih.gov/29056303/

7) Schlenker M, Thiruchelvam D, Redelmeier D. Association of Cataract Surgery With Traffic Crashes. JAMA Ophthalmol [Internet]. 2018 Sep 1 [accessed 2021 Sep 1];136(9):998-1007. Available from: https://pubmed.ncbi.nlm.nih.gov/29955857/

8) Pezzullo L, Streatfeild J, Simkiss P, Shickle D. The economic impact of sight loss and blindness in the UK adult population. BMC Health Serv Res [Internet]. 2018 Jan 30 [accessed 2021 Sep 1];18(1). Available from: https://pubmed.ncbi.nlm.nih.gov/29382329/

9) Brown G, Brown M, Menezes A, Busbee B, Lieske H, Lieske P. Cataract surgery cost utility revisited in 2012: a new economic paradigm. Ophthalmology [Internet]. 2013 Dec [accessed 2021 Sep 1];120(12):2367-76. Available from: https://pubmed.ncbi.nlm.nih.gov/24246824/

10) Boyd M, Kvizhinadze G, Kho A, Wilson G, Wilson N. Cataract surgery for falls prevention and improving vision: modelling the health gain, health system costs and cost-effectiveness in a high-income country. Inj Prev [Internet]. 2020 Aug 1 [accessed 2021 Aug 31];26(4):302-9. Available from: https://pubmed.ncbi.nlm.nih.gov/31221667/

11) RANZCO. RANZCO Position Paper on Cataract Surgery in New Zealand [Internet]. 2020. Available from: https://ranzco.edu/wp-content/uploads/2020/10/Cataract-Surgery-Position-Paper-NZ_2020.pdf

12) Chilibeck C, Mathan JJ, Ng SG, McKelvie J. Cataract surgery in New Zealand: access to surgery, surgical intervention rates and visual acuity. N Z Med J. 2020 Oct;133(1524):40-9.

13) Newlands S, Hoy B, Wilson G. Cataract surgery in Hauora Tairāwhiti and need for improving access for Māori. Clin Experiment Ophthalmol [Internet]. 2019 Jan 1 [accessed 2021 Aug 31];47(1):145-7. Available from: https://pubmed.ncbi.nlm.nih.gov/29947162/

14) Latta M, Shaw C, Gale J. The carbon footprint of cataract surgery in Wellington. N Z Med J. 2021;134(1541).

15) Arrowsmith M. Response to your request for official information. Document number H201901181. Ministry of Health. 2019.

16) Li SS, Misra S, Wallace H, Hunt L, McKelvie J. Patient-reported quality of life for cataract surgery: prospective validation of the “Impact on Life” and Catquest-9SF questionnaires in New Zealand. N Z Med J. 2019 Oct;132(1503):34-45.

17) Roberts HW, Myerscough J, Borsci S, Ni M, O’Brart DPS. Time and motion studies of National Health Service cataract theatre lists to determine strategies to improve efficiency. Br J Ophthalmol [Internet]. 2018 Sep 1 [accessed 2021 Sep 12];102(9):1259-67. Available from: https://pubmed.ncbi.nlm.nih.gov/29175969/

18) Chang DF. 2020 ESCRS Ridley Medal Lecture: Compelling Lessons from the Greatest Team of Cataract Surgeons. 2020.

19) Ravindran RD, Gupta S, Haripriya A, Ravilla T, Ashok Vardhan S, Subburaman GBB. Seven-year trends in cataract surgery indications and quality of outcomes at Aravind Eye Hospitals, India. Eye [Internet]. 2021 Jul 1 [accessed 2021 Sep 7];35(7):1895–903. Available from: https://pubmed.ncbi.nlm.nih.gov/32913291/

20) Haripriya A, Chang DF, Ravindran RD. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries. J Cataract Refract Surg [Internet]. 2019 Sep 1 [accessed 2021 Sep 7];45(9):1226-33. Available from: https://pubmed.ncbi.nlm.nih.gov/31371152/

21) Pershing S, Lum F, Hsu S, Kelly S, Chiang MF, Rich WL, et al. Endophthalmitis after Cataract Surgery in the United States: A Report from the Intelligent Research in Sight Registry, 2013–2017. Ophthalmology [Internet]. 2020 Feb 1 [accessed 2021 Sep 7];127(2):151-8. Available from: https://pubmed.ncbi.nlm.nih.gov/31611015/

22) Hingorani M. Sunderland eye infirmary: a case study of high throughput cataract surgery [Internet]. UK Ophthalmological Alliance. 2018. Available from: https://uk-oa.co.uk/wp-content/uploads/2018/07/UKOA_Sunderland_Case_Study_June_2018.pdf

23) Lin PF, Naveed H, Eleftheriadou M, Purbrick R, Zarei Ghanavati M, Liu C. Cataract service redesign in the post-COVID-19 era [Internet]. Vol. 105, British Journal of Ophthalmology. Br J Ophthalmol; 2021 [accessed 2021 Sep 1]. p. 745-50. Available from: https://pubmed.ncbi.nlm.nih.gov/32703783/

24) Campbell RJ, El-Defrawy SR, Gill SS, Whitehead M, Campbell E de LP, Hooper PL, et al. Surgical Outcomes among Focused versus Diversified Cataract Surgeons. Ophthalmology [Internet]. 2021 Jun 1 [accessed 2021 Sep 12];128(6):827-34. Available from: https://pubmed.ncbi.nlm.nih.gov/33637327/

25) Zetterberg M, Montan P, Kugelberg M, Nilsson I, Lundström M, Behndig A. Cataract Surgery Volumes and Complications per Surgeon and Clinical Unit: Data from the Swedish National Cataract Register 2007 to 2016. In: Ophthalmology [Internet]. Elsevier; 2020 [accessed 2021 Sep 12]. p. 305-14. Available from: http://www.aaojournal.org/article/S0161642019321414/fulltext

26) Singh R, Dohlman TH, Sun G. Immediately sequential bilateral cataract surgery: Advantages and disadvantages [Internet]. Vol. 28, Current Opinion in Ophthalmology. Curr Opin Ophthalmol; 2017 [accessed 2021 Sep 12]. p. 81-6. Available from: https://pubmed.ncbi.nlm.nih.gov/27684294/

27) O’Brart DP, Roberts H, Naderi K, Gormley J. Economic modelling of immediately sequential bilateral cataract surgery (ISBCS) in the National Health Service based on possible improvements in surgical efficiency. BMJ Open Ophthalmol [Internet]. 2020 Jun 25 [accessed 2021 Sep 5];5(1). Available from: https://pubmed.ncbi.nlm.nih.gov/32617415/

28) Kessel L, Andresen J, Erngaard D, Flesner P, Tendal B, Hjortdal J. Immediate sequential bilateral cataract surgery: A systematic review and meta-analysis. J Ophthalmol [Internet]. 2015 [accessed 2021 Sep 5];2015. Available from: https://pubmed.ncbi.nlm.nih.gov/26351576/

29) Wang H, Ramjiani V, Raynor M, Tan J. Practice of immediate sequential bilateral cataract surgery (ISBCS) since COVID-19: a patient and surgeon survey [Internet]. Eye (Basingstoke). Nature Publishing Group; 2021 [accessed 2021 Sep 5]. p. 1. Available from: /pmc/articles/PMC8023778/

30) Grzybowski A, Kanclerz P. Do we need day-1 postoperative follow-up after cataract surgery? [Internet]. Vol. 257, Graefe’s Archive for Clinical and Experimental Ophthalmology. Graefes Arch Clin Exp Ophthalmol; 2019 [accessed 2021 Sep 15]. p. 855-61. Available from: https://pubmed.ncbi.nlm.nih.gov/30569320/

31) The Royal College of Ophthalmologists. The Way Forward - Cataract [Internet]. 2017. Available from: https://www.rcophth.ac.uk/wp-content/uploads/2018/10/RCOphth-Way-Forward-Cataract.pdf

32) International Federation of Health Plans. 2013 Comparative Price Report: Variation in Medical and Hospital Prices by Country [Internet]. 2013. Available from: http://www.ifhp.com/documents/2012iFHPPriceReportFINALMarch25.pdf

33) Le HG, Ehrlich JR, Venkatesh R, Srinivasan A, Kolli A, Haripriya A, et al. A sustainable model for delivering high-quality, efficient cataract surgery in southern India. Health Aff [Internet]. 2016 [accessed 2021 Sep 15];35(10):1783-90. Available from: https://pubmed.ncbi.nlm.nih.gov/27702949/

34) Råen M, Sandvik GF, Drolsum L. Endophthalmitis following cataract surgery: The role of prophylactic postoperative chloramphenicol eye drops. Acta Ophthalmol [Internet]. 2013 Mar [accessed 2021 Oct 2];91(2):118-22. Available from: https://pubmed.ncbi.nlm.nih.gov/22151787/

35) Friling E, Lundström M, Stenevi U, Montan P. Six-year incidence of endophthalmitis after cataract surgery: Swedish national study. J Cataract Refract Surg [Internet]. 2013 Jan [accessed 2021 Sep 15];39(1):15-21. Available from: https://pubmed.ncbi.nlm.nih.gov/23245359/

36) Pineda R, Denevich S, Lee WC, Waycaster C, Pashos CL. Economic evaluation of toric intraocular lens: A short- and long-term decision analytic model. Arch Ophthalmol [Internet]. 2010 Jul [accessed 2021 Sep 15];128(7):834-40. Available from: https://pubmed.ncbi.nlm.nih.gov/20625042/

37) Taylor P, Mapp K. Clear Focus — The economic impact of vision loss in New Zealand in 2009 Report by Access Economics Pty Limited for 2020 New Zealand Trust. 2010;(September).

38) Yoon JJ, Misra SL, Mcghee CNJ, Patel D V. Demographics and ocular biometric characteristics of patients undergoing cataract surgery in Auckland, New Zealand. Clin Exp Ophthalmol [Internet]. 2016 Mar 1 [accessed 2021 Sep 19];44(2):106-13. Available from: https://pubmed.ncbi.nlm.nih.gov/26284342/

39) Wilkinson B, McKelvie J. Evaluating barriers to access for cataract surgery in Waikato: analysis of calculated driving distance and visual acuity. N Z Med J [Internet]. 2021 [accessed 2021 Aug 31];105–12. Available from: https://pubmed.ncbi.nlm.nih.gov/34140717/

40) Freundlich SEN, McGhee CNJ. Should we be doing more to identify barriers to cataract surgery for Indigenous populations in New Zealand? Clin Exp Ophthalmol. 2020;48(7):1014-5.

41) RANZCO. Māori and Pasifika Eye Health. 2021.

42) Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg [Internet]. 2017 Nov 1 [accessed 2021 Sep 7];43(11):1391-8. Available from: https://pubmed.ncbi.nlm.nih.gov/29223227/

43) Chang DF. Needless Waste and the Sustainability of Cataract Surgery [Internet]. Vol. 127, Ophthalmology. Elsevier; 2020 [accessed 2021 Sep 7]. p. 1600-2. Available from: /pmc/articles/PMC7361054/

44) New Zealand Government. Public sector to be carbon neutral by 2025 [Internet]. Wellington; 2020. Available from: https://www.beehive.govt.nz/release/public-sector-be-carbon-neutral-2025

45) Behndig A, Montan P, Stenevi U, Kugelberg M, Lundström M. One million cataract surgeries: Swedish National Cataract Register 1992-2009. J Cataract Refract Surg [Internet]. 2011 [accessed 2022 Jan 20];37(8):1539-45. Available from: https://pubmed.ncbi.nlm.nih.gov/21782099/

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Cataracts are the leading cause of blindness globally, and the most common correctable eye disease causing blindness and sight loss in New Zealand.[[1,2]] Across high-income countries, cataract surgery is one of the most commonly performed surgical procedures.[[3]] Cataract surgery improves vision, with numerous secondary benefits including improved quality of life, slower rates of cognitive decline, and reduced risk of falls, hip fractures, and road traffic injuries.[[4–7]] Conversely, under-treatment of cataracts results in negative economic consequences, as there is lower employment participation from patients and their families that care for them.[[8]] It is for these reasons that public spending on cataract surgery yields a significant return on investment, with the cost per quality-adjusted life year (QALY) gained ranking as one of the most favourable of any healthcare intervention.[[9]] New Zealand specific evidence also shows the high cost-effectiveness of cataract surgery at NZ$4380 per QALY gained (95% uncertainty interval: 2410 to 7210), including for expedited cataract surgery where waiting time is shortened by 12 months.[[10]]

However, New Zealand’s surgical intervention rate (SIR) for cataract surgery ranks lower than many other high-income countries in the Organisation for Economic Co-operation and Development (OECD).[[3]] In 2018, New Zealand’s SIR was recorded at 373/100,000 population. In the same year, the United Kingdom (UK) had a SIR of 782/100,000 population, whilst Australia and Canada both had SIRs of over 1,000/100,000 population.[[3]] Comparisons using OECD data must be done cautiously, as data from New Zealand and the UK only includes publicly funded surgery, whereas Australia and Canada include all cataract surgeries. Nonetheless, New Zealand ranked 28th out of 32 OECD countries with available SIR estimates.[[3]] New Zealand’s overall SIR, including private surgeries, is estimated at 800/100,000 population. This still ranks poorly by international comparison.[[11]]

View Table 1.

The combination of a growing and ageing population, lost operating time due to the COVID-19 pandemic, and geographical disparities, is driving up an unmet demand for cataract surgery in New Zealand.[[12]] Ethnic inequalities also require attention; research suggests Māori patients present with more visually mature cataracts and may have higher rates of intra-operative complications.[[12,13]] Furthermore, the significant carbon footprint associated with cataract surgery requires leadership and action from ophthalmologists.[[14]]

These factors necessitate disruptive change in the delivery of publicly funded cataract surgery. Here, we explore strategic ways in which the “status quo” could be disrupted to facilitate greater efficiency, equity, and sustainability of cataract surgery in New Zealand.

Prioritisation

In any public health system with finite resources, prioritisation is necessary to ensure fair and timely access to surgery. For cataract surgery in New Zealand, this is assessed through the Clinical Priority Assessment Criteria (CPAC) score—a value of 0 to 100 is generated based on visual acuity, cataract morphology, and an “Impact on Life” questionnaire.

However, current use of the CPAC score leads to grossly unequal access to cataract surgery based on geographical location. From 2014–2019, the SIR varied significantly between regions, ranging from 95 to 737/100,000 population/year.[[12]] Over the same timeframe, rates of declined referrals for surgery ranged from 7% to 48% between regions.[[12]] CPAC thresholds differ between district health boards (DHBs), and fluctuate over time in response to demand and capacity, though the specific criteria for changes in threshold are not published.[[12,15]] RANZCO regularly collects CPAC thresholds across New Zealand—in October 2021 they ranged from 45 to 61.

Furthermore, the “Impact on Life” questionnaire currently used in generating a CPAC score is not well suited in assessing vision-related quality of life (VRQoL), with poor correlation between score and change in post-operative visual acuity, as well as unsatisfactory statistical validation.[[16]] Other scoring systems, such as the Catquest-9SF questionnaire, have demonstrated more credibility at assessing VRQoL.[[16]]

Introducing a national threshold that incorporates a validated VRQoL questionnaire would represent a more equitable and patient-centred approach to prioritisation, as well as ending the “postcode lottery” that currently exists for cataract surgery in New Zealand. The introduction of the new organisation that will replace DHBs (Health New Zealand) is well suited to create this national threshold and reduce geographic inequity.

Theatre efficiency and high-throughput units

Most cataract surgeries are performed under local anaesthesia and follow a standardised procedure—these unique factors are well suited to high-volume surgery. The number of cataract operations performed on a four-hour public list varies within New Zealand hospitals. Personal communications suggest that most units complete between 3–7 cataracts per list using phacoemulsification. Substantial variation is also observed in the UK, where an average of seven cataracts per list with a range of 5–14 was recorded across five UK hospitals.[[17]] In contrast, surgeons at the Aravind Eye Care System (AECS) in India can perform 10–16 cases per hour using manual small incision cataract surgery (MSICS).[[18]] Their visual outcome and safety data are equivalent to high-income countries.[[18–21]] Though there are important differences in surgical technique and health settings, there is clearly scope for improved efficiency in New Zealand theatres.

In the UK, Sunderland Eye Infirmary (SEI) is well recognised for running a best practice high-throughput unit.[[22,23]] They achieve up to 14 cataracts per list and 170–180 surgeries per week with two dedicated theatres. Amongst numerous structural, procedural, and cultural factors attributed to SEI’s efficiency, three key factors were identified by one observer.[[22]] Firstly, they employ higher numbers of nursing staff who facilitate the flow of patients, and nurses have increased responsibilities, including skin preparation and surgical consent. Secondly, patients are risk-assessed and stratified into three types of lists: consultant-only high-volume lists (with up to 14 cataracts per list), complex-sedation lists (with 8–10 cataracts per list) and training lists (with 6–8 cataracts per list depending on trainee experience). Finally, the physical design of the unit facilitates efficient patient flow and minimises downtime between operations.[[22]] Furthermore, patients are waitlisted and undergo pre-operative assessment with biometry on the same, initial visit.

Establishing similar high-throughput cataract surgery units in New Zealand, as well as adopting key learnings from AECS and SEI in existing units, could improve New Zealand’s SIR and preserve a balance of high-quality teaching with high-volume surgery.

An additional consideration is whether all ophthalmologists should perform cataract surgery. A Canadian cohort study of over one million cataract surgeries demonstrated that highly diversified surgeons (more than 50% non-cataract procedures) had almost three times as many adverse events as cataract-exclusive and moderately diversified surgeons (1–50% non-cataract procedures).[[24]] A retrospective Swedish study also demonstrated an association between the rate of capsule complications and surgeon operating volume.[[25]] Whilst New Zealand will require a growing number of cataract surgeons to elevate our SIR, treating cataract surgery as a sub-speciality may improve efficiency, safety, and visual outcomes.

Immediately sequential bilateral cataract surgery (ISBCS)

ISBCS is safe and effective compared to traditional delayed sequential surgery, with equivalent visual outcomes and complication rates.[[26]] Major advantages of ISBCS include faster visual rehabilitation, fewer clinic visits, decreased waiting times for surgery, higher productivity, and an estimated cost-saving of over 30% for the healthcare system.[[26,27]] ISBCS is already widely accepted and performed in countries such as Sweden and Finland.[[28]] The COVID-19 pandemic has also acted as a catalyst for increasing rates of ISBCS by minimising the number of patient encounters.[[29]] In the public hospitals of New Zealand, where CPAC determines access to cataract surgery, ISBCS is usually only considered for patients with two severe cataracts or requiring general anaesthesia; however, it is increasingly performed in the private sector.

Careful patient selection is crucial in ISBCS. Important factors are reproducible optical biometry, low risk of intra- and post-operative complications, and adequate home support.[[27]] Routinely offering ISBCS to appropriate patients would be a safe and cost-effective strategy to meet the rising demand for cataract surgery. Redesign of the public access criteria would be necessary to facilitate this.

Post-operative follow-up

Current practice regarding post-operative follow-up varies amongst DHBs. A typical regimen may involve a face-to-face review on post-operative day 1 (POD1), then again two to four weeks later, followed by a final visit to a community optometrist for refraction.

The current literature does not support the practice of POD1 follow-up after uneventful phacoemulsification cataract surgery by an experienced surgeon in patients without ocular co-morbidities.[[30]] Furthermore, rationalisation of post-operative follow-up is supported by widespread clinical practice abroad; the standard of care in the UK does not include a POD1 review unless there is co-existent pathology.[[31]]

Rationalisation of post-operative follow-up at a national level has the capacity for significant savings and increased efficiency without compromising safety. Alternatives to the face-to-face POD1 visit are telephone consults, or elimination of the clinical encounter entirely for appropriate patients with a low threshold for review in case of complaints.[[30]] There is also scope to utilise other healthcare professionals in post-operative care. In the UK, only 11% of all post-operative patients are seen by an ophthalmologist at any point; 57% are seen by hospital nurse practitioners or optometrists, and 27% are discharged immediately following surgery and followed up by community optometrists.[[31]]

However, post-operative review provides the opportunity for a feedback-loop with trainee surgeons as to the outcome of their surgery, and to become familiar with the usual post-operative course. It is therefore an important educational encounter in training hospitals, but could be rationalised to teaching lists only.

Strategies for cost-saving

The overall cost of cataract surgery in New Zealand is similar to Australia and the United States (US).[[32]] Surgeons at the AECS deliver cataract surgery at a fraction of the estimated cost in high-income countries.[[33]] Though there are important differences in health settings, factors contributing to the highly cost-effective care delivered by AECS that could be applied in New Zealand include: the use of standardised processes and instrumentation; bulk sourcing; appropriate re-use of equipment; and specialised nursing and support staff facilitating high-volume service delivery with optimal efficiency.

At present, there is substantial variability in practice across DHBs with differing operating equipment, intra-ocular lens (IOL) types and peri-operative treatment regimens. Developing standardised evidence-based protocols at a national level could significantly reduce costs, both by supporting PHARMAC to negotiate lower equipment prices, and by rationalising peri-operative treatment regimens.

For instance, there is widespread use of topical antibiotics post-operatively, despite low-level evidence for their efficacy in preventing endophthalmitis.[[34,35]] Stopping topical antibiotics could save money, reduce confusion for patients, decrease unnecessary consumption and greenhouse gas emissions, and may reduce the risk of antimicrobial resistance.

In patients with significant pre-existing astigmatism, a toric IOL may be considered. Toric IOLs correct for astigmatism and reduce lifetime economic costs by decreasing the need for glasses and contact lenses.[[36]] Thresholds for their use presently remains at the discretion of individual DHBs, with resultant geographic inequities and missed opportunities for cost reduction. This could be remedied by establishing a national standard and threshold for the use of toric IOLs. Similarly, extended depth of focus (EDOF) lenses improve functional vision and decrease the need for glasses. One type of EDOF lens is only $100 more expensive than a standard monofocal lens and could be considered for use within the public system.

Equity for Māori and Pasifika

Cataract-related vision loss is 1.5 to 2 times more prevalent in Māori in comparison to non-Māori up to age 84.[[37]] Similarly, Māori and Pasifika are listed for surgery on average 6–7 years younger than the national mean, with more advanced cataracts and worse pre-operative visual acuity.[[12,13]] In turn, this may result in higher rates of intra-operative complications in Māori patients.[[13]] Higher rates of diabetes, cardiopulmonary disease and smoking may contribute to earlier cataract development and must also be addressed.[[38]]

Given that Māori and Pasifika are waitlisted for surgery at equivalent rates to other ethnic groups, access to timely referral appears to be a key area for improvement.[[12]] Barriers to accessing timely referral include socio-economic deprivation and geographic accessibility.[[13]] For example, in patients from the Waikato Region defined as having remote access, Māori were 27% geographically further from an optometrist than New Zealand Europeans, and had worse visual acuity at the time of referral for surgery.[[39]] Funding optometry visits and improving accessibility to community optometry in more rural areas are two strategies worth exploring. Given higher rates of diabetes and associated cataract formation, upskilling community diabetes services may result in more prompt diagnoses and referrals. However, we recognise a need for further research to understand ethnic inequalities in cataract surgery, and the adoption of Te Tiriti o Waitangi principles in addressing disparities.[[40,41]]

Sustainability

Cataract surgery in New Zealand has a measurable carbon footprint (152 kgCO2e per procedure), equivalent to an economy seat on a one-hour flight.[[14]] Extrapolated over approximately 30,000 operations each year, this amounts to 4,500 tonnes of carbon, which would require 134 ha of growing forest to absorb. When the carbon footprint of cataract surgery was measured in Wellington hospitals, the most striking finding was that 84% of emissions were related to the consumption of single-use items such as gowns, drapes, surgical instruments, tubing and cassettes, gauze, dressings, eye shields and medications.[[14]] When a similar footprinting exercise was conducted in AECS, India, it was shown that reuse of many items, as well as limited local recycling or reprocessing, was able to reduce the overall footprint of cataract surgery to 6 kgCO2e per procedure, with similar large reductions in cost.[[42]] As outlined earlier, while we might presume trade-offs between safety or quality and cost-saving activities, recent reports of large cohorts at AECS show that post-operative endophthalmitis rates of 0.01% rival the rate of 0.04% reported in the United States registry.[[20,21]] This casts an interesting light on how operating theatre regulations and practice patterns may not be optimising safety, efficiency, cost-saving and environmental impact.[[43]]

In the near future, New Zealand health sector agencies will become accountable for their carbon footprint.[[44]] Initially, this will require measuring emissions and budgeting to offset emissions. Decarbonisation of the health sector will then be incentivised by the financial effects on our health systems. Ophthalmologists within this much larger system have several means to support decarbonisation. The travel emissions related to cataract surgery can be reduced with: “one-stop shop” pre-assessment with same-day surgery; longer operating lists (less staff travel per case); ISBCS; and phone and community-based follow up for suitable cases. The footprint related to pharmaceutical consumption can be reduced by: using topical anaesthesia wherever possible; avoiding single-use sterile drops when unnecessary; reusing bottles of liquid medications such as povidone-iodine and irrigating solutions for multiple cases; and, avoiding the prescription of any unnecessary post-operative drops such as antibiotics. Likewise, the consumption of surgical supplies can be reduced, and surgeons can have a powerful voice as leaders and advocates to their hospital management and industry suppliers.

Audit

A continuous audit cycle at both local and national levels is essential in improving efficiency, safety, and visual outcomes. To provide culturally appropriate and patient-centred care, patient reported outcome measures must also be central to this audit process. We should aspire to the Swedish National Cataract Register model, which has collected data on over one million surgeries since 1992.[[45]] A number of DHBs and private providers in New Zealand now use CatTrax, a web-based health intelligence platform, to manage their entire cataract pathway. CatTrax includes automated reporting on all relevant clinical and refractive outcome measures, including patient reported outcomes using the CatQuest-9SF and other assessment tools. CatTrax has enabled improvements in quality, access to cataract surgery and equity. To date, over 15,000 cataracts have been tracked using CatTrax in New Zealand.

Conclusion

Cataract surgery is a highly cost-effective treatment, but the surgical intervention rate in New Zealand ranks poorly compared with other high-income countries. We have presented several evidence-based strategies with overlapping benefits in access, equity, efficiency and sustainability. Key strategies include that Health New Zealand mandate a national CPAC threshold for surgical access, and that PHARMAC leverage cheaper access to surgical supplies using nationally agreed equipment standards, establishing high-throughput cataract units, offering ISBCS when appropriate, and rationalising post-operative care. As we transition to a new healthcare system, we should seize the opportunity to reimagine our public cataract service.

Summary

Abstract

Cataract surgery is a highly cost-effective treatment, but the surgical intervention rate in New Zealand ranks poorly compared with other high-income countries. The combination of a growing and ageing population, lost operating time due to the COVID-19 pandemic, and geographical disparities, is driving up an unmet demand for cataract surgery. We present several evidence-based strategies with overlapping benefits in access, equity, efficiency and sustainability. Key strategies include that Health New Zealand mandate a national prioritisation threshold for surgical access, and that PHARMAC leverage cheaper access to surgical supplies using nationally agreed equipment standards, establishing high-throughput cataract units, offering same day bilateral cataract surgery when appropriate, and rationalising post-operative care.

Aim

Method

Results

Conclusion

Author Information

Samuel Burridge: Ophthalmology Registrar, Taranaki Eye Centre, New Plymouth. Jonathan Wood: Ophthalmology Registrar, Department of Ophthalmology, Tairāwhiti District Health Board, Gisborne Jesse Gale: Ophthalmologist, Department of Surgery & Anaesthesia, University of Otago, Wellington. Albie Covello: Ophthalmologist, Taranaki Eye Centre, New Plymouth. James McKelvie: Ophthalmologist, Department of Ophthalmology, Waikato District Health Board, Hamilton. Graham Wilson: Ophthalmologist, Department of Ophthalmology, Tairāwhiti District Health Board, Gisborne.

Acknowledgements

The authors would like to thank Brian Kent-Smith and Derek Sherwood for their valuable feedback.

Correspondence

Samuel Burridge: Taranaki Eye Centre, 17 Weymouth Street, New Plymouth, 4310. (06) 758 3553.

Correspondence Email

samlburridge@gmail.com

Competing Interests

Nil.

1) Bourne RRA, Steinmetz JD, Saylan M, Mersha AM, Weldemariam AH, Wondmeneh TG, et al. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: The Right to Sight: An analysis for the Global Burden of Disease Study. Lancet Glob Heal [Internet]. 2021 Feb 1 [accessedaccessed 2021 Sep 1];9(2):e144-60. Available from: https://pubmed.ncbi.nlm.nih.gov/33275949/

2) Blind Low Vision NZ. Blindness and Low Vision in New Zealand – Latest statistics [Internet]. 2021 [accessed 2021 Aug 31]. Available from: https://blindlowvision.org.nz/information/statistics-and-research/

3) OECD Statistics. Health Care Utilisation: Surgical Procedures [Internet]. 2020 [accessed 2021 Aug 31]. Available from: https://stats.oecd.org/index.aspx?queryid=30167

4) Tseng VL, Yu F, Lum F, Coleman AL. Risk of fractures following cataract surgery in medicare beneficiaries. JAMA - J Am Med Assoc [Internet]. 2012 Aug 1 [accessed 2021 Sep 1];308(5):493-501. Available from: https://pubmed.ncbi.nlm.nih.gov/22851116/

5) Maharani A, Dawes P, Nazroo J, Tampubolon G, Pendleton N. Cataract surgery and age-related cognitive decline: A 13-year follow-up of the English Longitudinal Study of Ageing. PLoS One [Internet]. 2018 Oct 1 [accessed 2021 Sep 1];13(10). Available from: https://pubmed.ncbi.nlm.nih.gov/30307960/

6) Palagyi A, Morlet N, McCluskey P, White A, Meuleners L, Ng JQ, et al. Visual and refractive associations with falls after first-eye cataract surgery. J Cataract Refract Surg [Internet]. 2017 Oct 1 [accessedaccessed 2021 Sep 1];43(10):1313-21. Available from: https://pubmed.ncbi.nlm.nih.gov/29056303/

7) Schlenker M, Thiruchelvam D, Redelmeier D. Association of Cataract Surgery With Traffic Crashes. JAMA Ophthalmol [Internet]. 2018 Sep 1 [accessed 2021 Sep 1];136(9):998-1007. Available from: https://pubmed.ncbi.nlm.nih.gov/29955857/

8) Pezzullo L, Streatfeild J, Simkiss P, Shickle D. The economic impact of sight loss and blindness in the UK adult population. BMC Health Serv Res [Internet]. 2018 Jan 30 [accessed 2021 Sep 1];18(1). Available from: https://pubmed.ncbi.nlm.nih.gov/29382329/

9) Brown G, Brown M, Menezes A, Busbee B, Lieske H, Lieske P. Cataract surgery cost utility revisited in 2012: a new economic paradigm. Ophthalmology [Internet]. 2013 Dec [accessed 2021 Sep 1];120(12):2367-76. Available from: https://pubmed.ncbi.nlm.nih.gov/24246824/

10) Boyd M, Kvizhinadze G, Kho A, Wilson G, Wilson N. Cataract surgery for falls prevention and improving vision: modelling the health gain, health system costs and cost-effectiveness in a high-income country. Inj Prev [Internet]. 2020 Aug 1 [accessed 2021 Aug 31];26(4):302-9. Available from: https://pubmed.ncbi.nlm.nih.gov/31221667/

11) RANZCO. RANZCO Position Paper on Cataract Surgery in New Zealand [Internet]. 2020. Available from: https://ranzco.edu/wp-content/uploads/2020/10/Cataract-Surgery-Position-Paper-NZ_2020.pdf

12) Chilibeck C, Mathan JJ, Ng SG, McKelvie J. Cataract surgery in New Zealand: access to surgery, surgical intervention rates and visual acuity. N Z Med J. 2020 Oct;133(1524):40-9.

13) Newlands S, Hoy B, Wilson G. Cataract surgery in Hauora Tairāwhiti and need for improving access for Māori. Clin Experiment Ophthalmol [Internet]. 2019 Jan 1 [accessed 2021 Aug 31];47(1):145-7. Available from: https://pubmed.ncbi.nlm.nih.gov/29947162/

14) Latta M, Shaw C, Gale J. The carbon footprint of cataract surgery in Wellington. N Z Med J. 2021;134(1541).

15) Arrowsmith M. Response to your request for official information. Document number H201901181. Ministry of Health. 2019.

16) Li SS, Misra S, Wallace H, Hunt L, McKelvie J. Patient-reported quality of life for cataract surgery: prospective validation of the “Impact on Life” and Catquest-9SF questionnaires in New Zealand. N Z Med J. 2019 Oct;132(1503):34-45.

17) Roberts HW, Myerscough J, Borsci S, Ni M, O’Brart DPS. Time and motion studies of National Health Service cataract theatre lists to determine strategies to improve efficiency. Br J Ophthalmol [Internet]. 2018 Sep 1 [accessed 2021 Sep 12];102(9):1259-67. Available from: https://pubmed.ncbi.nlm.nih.gov/29175969/

18) Chang DF. 2020 ESCRS Ridley Medal Lecture: Compelling Lessons from the Greatest Team of Cataract Surgeons. 2020.

19) Ravindran RD, Gupta S, Haripriya A, Ravilla T, Ashok Vardhan S, Subburaman GBB. Seven-year trends in cataract surgery indications and quality of outcomes at Aravind Eye Hospitals, India. Eye [Internet]. 2021 Jul 1 [accessed 2021 Sep 7];35(7):1895–903. Available from: https://pubmed.ncbi.nlm.nih.gov/32913291/

20) Haripriya A, Chang DF, Ravindran RD. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries. J Cataract Refract Surg [Internet]. 2019 Sep 1 [accessed 2021 Sep 7];45(9):1226-33. Available from: https://pubmed.ncbi.nlm.nih.gov/31371152/

21) Pershing S, Lum F, Hsu S, Kelly S, Chiang MF, Rich WL, et al. Endophthalmitis after Cataract Surgery in the United States: A Report from the Intelligent Research in Sight Registry, 2013–2017. Ophthalmology [Internet]. 2020 Feb 1 [accessed 2021 Sep 7];127(2):151-8. Available from: https://pubmed.ncbi.nlm.nih.gov/31611015/

22) Hingorani M. Sunderland eye infirmary: a case study of high throughput cataract surgery [Internet]. UK Ophthalmological Alliance. 2018. Available from: https://uk-oa.co.uk/wp-content/uploads/2018/07/UKOA_Sunderland_Case_Study_June_2018.pdf

23) Lin PF, Naveed H, Eleftheriadou M, Purbrick R, Zarei Ghanavati M, Liu C. Cataract service redesign in the post-COVID-19 era [Internet]. Vol. 105, British Journal of Ophthalmology. Br J Ophthalmol; 2021 [accessed 2021 Sep 1]. p. 745-50. Available from: https://pubmed.ncbi.nlm.nih.gov/32703783/

24) Campbell RJ, El-Defrawy SR, Gill SS, Whitehead M, Campbell E de LP, Hooper PL, et al. Surgical Outcomes among Focused versus Diversified Cataract Surgeons. Ophthalmology [Internet]. 2021 Jun 1 [accessed 2021 Sep 12];128(6):827-34. Available from: https://pubmed.ncbi.nlm.nih.gov/33637327/

25) Zetterberg M, Montan P, Kugelberg M, Nilsson I, Lundström M, Behndig A. Cataract Surgery Volumes and Complications per Surgeon and Clinical Unit: Data from the Swedish National Cataract Register 2007 to 2016. In: Ophthalmology [Internet]. Elsevier; 2020 [accessed 2021 Sep 12]. p. 305-14. Available from: http://www.aaojournal.org/article/S0161642019321414/fulltext

26) Singh R, Dohlman TH, Sun G. Immediately sequential bilateral cataract surgery: Advantages and disadvantages [Internet]. Vol. 28, Current Opinion in Ophthalmology. Curr Opin Ophthalmol; 2017 [accessed 2021 Sep 12]. p. 81-6. Available from: https://pubmed.ncbi.nlm.nih.gov/27684294/

27) O’Brart DP, Roberts H, Naderi K, Gormley J. Economic modelling of immediately sequential bilateral cataract surgery (ISBCS) in the National Health Service based on possible improvements in surgical efficiency. BMJ Open Ophthalmol [Internet]. 2020 Jun 25 [accessed 2021 Sep 5];5(1). Available from: https://pubmed.ncbi.nlm.nih.gov/32617415/

28) Kessel L, Andresen J, Erngaard D, Flesner P, Tendal B, Hjortdal J. Immediate sequential bilateral cataract surgery: A systematic review and meta-analysis. J Ophthalmol [Internet]. 2015 [accessed 2021 Sep 5];2015. Available from: https://pubmed.ncbi.nlm.nih.gov/26351576/

29) Wang H, Ramjiani V, Raynor M, Tan J. Practice of immediate sequential bilateral cataract surgery (ISBCS) since COVID-19: a patient and surgeon survey [Internet]. Eye (Basingstoke). Nature Publishing Group; 2021 [accessed 2021 Sep 5]. p. 1. Available from: /pmc/articles/PMC8023778/

30) Grzybowski A, Kanclerz P. Do we need day-1 postoperative follow-up after cataract surgery? [Internet]. Vol. 257, Graefe’s Archive for Clinical and Experimental Ophthalmology. Graefes Arch Clin Exp Ophthalmol; 2019 [accessed 2021 Sep 15]. p. 855-61. Available from: https://pubmed.ncbi.nlm.nih.gov/30569320/

31) The Royal College of Ophthalmologists. The Way Forward - Cataract [Internet]. 2017. Available from: https://www.rcophth.ac.uk/wp-content/uploads/2018/10/RCOphth-Way-Forward-Cataract.pdf

32) International Federation of Health Plans. 2013 Comparative Price Report: Variation in Medical and Hospital Prices by Country [Internet]. 2013. Available from: http://www.ifhp.com/documents/2012iFHPPriceReportFINALMarch25.pdf

33) Le HG, Ehrlich JR, Venkatesh R, Srinivasan A, Kolli A, Haripriya A, et al. A sustainable model for delivering high-quality, efficient cataract surgery in southern India. Health Aff [Internet]. 2016 [accessed 2021 Sep 15];35(10):1783-90. Available from: https://pubmed.ncbi.nlm.nih.gov/27702949/

34) Råen M, Sandvik GF, Drolsum L. Endophthalmitis following cataract surgery: The role of prophylactic postoperative chloramphenicol eye drops. Acta Ophthalmol [Internet]. 2013 Mar [accessed 2021 Oct 2];91(2):118-22. Available from: https://pubmed.ncbi.nlm.nih.gov/22151787/

35) Friling E, Lundström M, Stenevi U, Montan P. Six-year incidence of endophthalmitis after cataract surgery: Swedish national study. J Cataract Refract Surg [Internet]. 2013 Jan [accessed 2021 Sep 15];39(1):15-21. Available from: https://pubmed.ncbi.nlm.nih.gov/23245359/

36) Pineda R, Denevich S, Lee WC, Waycaster C, Pashos CL. Economic evaluation of toric intraocular lens: A short- and long-term decision analytic model. Arch Ophthalmol [Internet]. 2010 Jul [accessed 2021 Sep 15];128(7):834-40. Available from: https://pubmed.ncbi.nlm.nih.gov/20625042/

37) Taylor P, Mapp K. Clear Focus — The economic impact of vision loss in New Zealand in 2009 Report by Access Economics Pty Limited for 2020 New Zealand Trust. 2010;(September).

38) Yoon JJ, Misra SL, Mcghee CNJ, Patel D V. Demographics and ocular biometric characteristics of patients undergoing cataract surgery in Auckland, New Zealand. Clin Exp Ophthalmol [Internet]. 2016 Mar 1 [accessed 2021 Sep 19];44(2):106-13. Available from: https://pubmed.ncbi.nlm.nih.gov/26284342/

39) Wilkinson B, McKelvie J. Evaluating barriers to access for cataract surgery in Waikato: analysis of calculated driving distance and visual acuity. N Z Med J [Internet]. 2021 [accessed 2021 Aug 31];105–12. Available from: https://pubmed.ncbi.nlm.nih.gov/34140717/

40) Freundlich SEN, McGhee CNJ. Should we be doing more to identify barriers to cataract surgery for Indigenous populations in New Zealand? Clin Exp Ophthalmol. 2020;48(7):1014-5.

41) RANZCO. Māori and Pasifika Eye Health. 2021.

42) Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg [Internet]. 2017 Nov 1 [accessed 2021 Sep 7];43(11):1391-8. Available from: https://pubmed.ncbi.nlm.nih.gov/29223227/

43) Chang DF. Needless Waste and the Sustainability of Cataract Surgery [Internet]. Vol. 127, Ophthalmology. Elsevier; 2020 [accessed 2021 Sep 7]. p. 1600-2. Available from: /pmc/articles/PMC7361054/

44) New Zealand Government. Public sector to be carbon neutral by 2025 [Internet]. Wellington; 2020. Available from: https://www.beehive.govt.nz/release/public-sector-be-carbon-neutral-2025

45) Behndig A, Montan P, Stenevi U, Kugelberg M, Lundström M. One million cataract surgeries: Swedish National Cataract Register 1992-2009. J Cataract Refract Surg [Internet]. 2011 [accessed 2022 Jan 20];37(8):1539-45. Available from: https://pubmed.ncbi.nlm.nih.gov/21782099/

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