Optimising the cataract surgical pathway: A Health Services Approach

The Australian healthcare system is struggling to keep up with the rising incidence of cataract. The growing backlog of surgical candidates at public hospitals is leading to growing number of older people with unoperated cataract in society. As surgery remains only effective treatment method in cataract patients to restore or maintain vision, attention must be focused on finding more efficient ways of providing this service. This thesis focuses on identifying the gaps and inefficiencies of the current Australian cataract surgical system.Using a health services research approach; four independent studies were conducted on different areas of the current patient pathway to cataract surgery, focusing on the public healthcare sector. A cross-sectional study investigated the referral criteria used by primary eyecare clinicians in the community. A separate hospital-based study examined the scope and accuracy of cataract referral letter content in providing adequate information to triage referrals ahead of clinic assessment. A discrete choice experiment was administered to gain insight into considerations that inform patient choice on where to access surgical services. Finally, a prospective cohort study investigated whether patient-reported outcomes (i.e. visual disability, satisfaction and quality of life) could be predicted using a comprehensive range of preoperative, intraoperative and postoperative factors.Deficiencies in service provision and delivery of care were noted at multiple points of the current pathway to cataract surgery. Referrals to public hospitals are poorly targeted and the information is insufficient to triage patients ahead of their clinic assessment. The total wait for surgery (from referral to procedure) is increasing, being closer to two years for the majority of patients. Highly valued attributes of cataract surgical services are not available to patients in the public system, despite a willingness to pay these features. Dissatisfaction with postsurgical outcomes was present in up to one-quarter of patients. Prediction of patients likely to be dissatisfied was possible using the following preoperative factors: anisometropia, mood, gender and visual disability. The findings presented in this thesis expand our understanding of the context of cataract surgery in Australia and can inform best use of available resources and optimal management of cataract patients