Measuring the outcome of cataract surgery: the importance of the patient perspective.

Most eye care staff have had the pleasure of removing the pad from a patient’s eye after cataract surgery and seeing their joy at having their sight restored. However, when the outcome of cataract surgery is discussed prior to surgery, the first thing most people think about is visual acuity or complications. Whilst these are critically important, they are only part of the story

Improving the quality of cataract surgery.

Quality is a difficult concept to describe and there is no clear definition. People have different views of what quality means and describe it in different ways

Is quality affordable?

The question “Is quality affordable?” is loaded with dynamite!Can a person who lives on less than US $1 per day afford a high-quality cataract operation? If the answer is ‘No’, then do we offer that person poor or low-quality services? Do people living in poverty have a ‘right’ to high-quality eye or health care? If the answer is ‘Yes’, then at what price and who should pay? Should we ignore quality and focus on affordability? Or should we provide high-quality services in the hope that someone else will pay?These are difficult questions, which policy makers, managers, and clinicians must face and try to answer

An approach to assessing patient safety in hospitals in low-income countries.

OBJECTIVE: The aim of the study was to assess non-technical aspects of patient safety practices using non-participant observation in different clinical areas. DESIGN: Qualitative study using non-participant observation and thematic analysis. SETTING: Two eye care units in Uganda. PARTICIPANTS: Staff members in each hospital. MAIN OUTCOME MEASURES: A set of observations of patient safety practices by staff members in clinical areas that were then coded using thematic analysis. RESULTS: Twenty codes were developed that explained patient safety practices in the hospitals based on the observations. These were grouped into four themes: the team, the environment, patient-centred care and the process. The complexity of patient safety in each hospital was described using narrative reports to support the thematic analysis. Overall both hospitals demonstrated good patient safety practices however areas for improvement were staff-patient communication, the presence and use of protocols and a focus on consistent practice. CONCLUSIONS: This is the first holistic assessment of patient safety practices in a low-income setting. The methods allowed the complexity of patient safety to be understood and explained with areas of concern highlighted. The next step will be to develop a useful and easy to use tool to measure patient safety practices in low-income settings

A holistic approach to eye care for older people

Many eye diseases, such as cataract and age-related macular degeneration, occur more frequently as we advance in years. As a consequence, eye care workers are likely to encounter older people more frequently than any other group.The holistic approach to treating an older person involves considering the complete person, both physically and psychologically. You should consider every aspect of that person that has an impact on their health and wellbeing. This will greatly improve the outcome of the consultation and any subsequent treatment, both for the older patient and for the eye care worker.It is equally important to treat every older person who seeks care with respect, in a way that preserves his or her dignity and autonomy

The cost-utility of telemedicine to screen for diabetic retinopathy in India.

PURPOSE: To assess the cost-effectiveness of a telemedicine diabetic retinopathy (DR) screening program in rural Southern India that conducts 1-off screening camps (i.e., screening offered once) in villages and to assess the incremental cost-effectiveness ratios of different screening intervals. DESIGN: A cost-utility analysis using a Markov model. PARTICIPANTS: A hypothetical cohort of 1000 rural diabetic patients aged 40 years who had not been previously screened for DR and who were followed over a 25-year period in Chennai, India. METHODS: We interviewed 249 people with diabetes using the time trade-off method to estimate utility values associated with DR. Patient and provider costs of telemedicine screening and hospital-based DR treatment were estimated through interviews with 100 diabetic patients, sampled when attending screening in rural camps (n = 50) or treatment at the base hospital in Chennai (n = 50), and with program and hospital managers. The sensitivity and specificity of the DR screening test were assessed in comparison with diagnosis using a gold standard method for 346 diabetic patients. Other model parameters were derived from the literature. A Markov model was developed in TreeAge Pro 2009 (TreeAge Software Inc, Williamstown, MA) using these data. MAIN OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained from the current teleophthalmology program of 1-off screening in comparison with no screening program and the cost-utility of this program at different screening intervals. RESULTS: By using the World Health Organization threshold of cost-effectiveness, the current rural teleophthalmology program was cost-effective ($1320 per QALY) compared with no screening from a health provider perspective. Screening intervals of up to a frequency of screening every 2 years also were cost-effective, but annual screening was not (>$3183 per QALY). From a societal perspective, telescreening up to a frequency of once every 5 years was cost-effective, but not more frequently. CONCLUSIONS: From a health provider perspective, a 1-off DR telescreening program is cost-effective compared with no screening in this rural Indian setting. Increasing the frequency of screening up to 2 years also is cost-effective. The results are dependent on the administrative costs of establishing and maintaining screening at regular intervals and on achieving sufficient coverage

Barriers to hand hygiene in ophthalmic outpatients in Uganda: a mixed methods approach.

BACKGROUND: Healthcare-associated infection rates are high in low-income countries and are associated with significant morbidity. There is a paucity of published data on infection control practice, attitudes or resources in these settings, particularly in ophthalmology. The aim of this study is to understand current hand washing practices, barriers to hand washing and facilities available in two Ugandan specialist eye hospitals. This study was undertaken through non-participant observations of healthcare worker hand washing practices, documentation of hand hygiene facilities and semi-strucutured interviews with clinical staff. RESULTS: Eighty percent of the WHO opportunities for hand washing were missed through lack of attempted hand hygiene measures. Facilities for hand hygiene were inadequate with some key clinical areas having no provisions for hand hygiene. Training on effective hand hygiene varied widely with some staff reporting no training at all. The staff did not perceive the lack of facilities to be a barrier to hand washing but reported forgetfulness, lack of time and a belief that they could predict when transmission might occur and therefore did not wash hands as often as recommended. CONCLUSIONS: Hand hygiene at the two observed sites did not comply with WHO-recommended standards. The lack of facilities, variable training and staff perceptions were observable barriers to effective hand hygiene. Simple, low-cost interventions to improve hand hygiene could include increased provision of hand towels and running water and improved staff education to challenge their views and perceived barriers to hand hygiene

Ocular morbidity and health seeking behaviour in Kwara state, Nigeria: implications for delivery of eye care services.

BACKGROUND: There is currently limited information as to which conditions are most prevalent in communities in developing countries. This makes effective planning of eye services difficult. METHODS: 3,899 eligible individuals were recruited and examined in a cross-sectional survey in Asa Local Government Area, Nigeria. Those who self-reported an ocular morbidity were also asked about their health-seeking behaviour. Health records of local facilities were reviewed to collect information on those presenting with ocular morbidities. RESULTS: 25.2% (95% CI: 22.0-28.6) had an ocular morbidity in at least one eye. Leading causes were presbyopia and conditions affecting the lens and conjunctiva. The odds of having an ocular morbidity increased with age and lower educational attainment. 10.1% (7.7-13.0) self-reported ocular morbidity; 48.6% (40.4-56.8) of them reported seeking treatment. At the facility level, 344 patients presented with an ocular morbidity over one month, the most common conditions were red (26.3%) or itchy (20.8%) eyes. CONCLUSION: Ocular morbidities, including many non vision impairing conditions, were prevalent with a quarter of the population affected. The delivery of eye care services needs to be tailored in order to address this need and ensure delivery in a cost-effective and sustainable manner

Factors affecting cataract surgical coverage and outcomes: a retrospective cross-sectional study of eye health systems in sub-Saharan Africa.

BACKGROUND: Recently there has been a great deal of new population based evidence on visual impairment generated in sub-Saharan Africa (SSA), thanks to the Rapid Assessment of Avoidable Blindness (RAAB) survey methodology. The survey provides information on the magnitude and causes of visual impairment for planning services and measuring their impact on eye health in administrative "districts" of 0.5-5 million people. The survey results describing the quantity and quality of cataract surgeries vary widely between study sites, often with no obvious explanation. The purpose of this study was to examine health system characteristics that may be associated with cataract surgical coverage and outcomes in SSA in order to better understand the determinants of reducing the burden of avoidable blindness due to cataract. METHODS: This was a descriptive study using secondary and primary data. The outcome variables were collected from existing surveys. Data on potential district level predictor variables were collected through a semi-structured tool using routine data and key informants where appropriate. Once collected the data were coded and analysed using statistical methods including t-tests, ANOVA and the Kruskal-Wallis analysis of variance test. RESULTS: Higher cataract surgical coverage was positively associated with having at least one fixed surgical facility in the area; availability of a dedicated operating theatre; the number of surgeons per million population; and having an eye department manager in the facility. Variables that were associated with better outcomes included having biometry and having an eye department manager in the facility. CONCLUSIONS: There are a number of health system factors at the district level that seem to be associated with both cataract surgical coverage and post-operative visual acuity outcomes. This study highlights the needs for better indicators and tools by which to measure and monitor the performance of eye health systems at the district level. It is unlikely that epidemiological data alone is sufficient for planning eye health services within a district and health managers and study coordinators need to consider collecting supplementary information in order to ensure appropriate planning can take place