Factors influencing the success of rural cataract surgery programs in China:The study of hospital administration and relative productivity (SHARP)

PURPOSE. To explore factors potentially influencing the success or failure of rural Chinese hospitals in increasing cataract surgical output and quality. METHODS. Focus groups (FGs, n = 10) were conducted with hospital administrators, doctors, and nurses at 28 county hospitals in Guangdong Province. Discussions explored respondents' views on increasing surgical volume and quality and improving patient satisfaction. Respondents numerically ranked possible strategies to increase surgical volume and quality and patient satisfaction. FG transcripts were independently coded by two reviewers utilizing the constant comparative method following the grounded theory approach, and numerical responses were scored and ranked. RESULTS. Ten FGs and 77 ranking questionnaires were completed by 33 administrators, 23 doctors, and 21 nurses. Kappa values for the two coders were greater than 0.7 for all three groups. All groups identified a critical need for enhanced management training for hospital directors. Doctors and nurses suggested reducing surgical fees to enhance uptake, although administrators were resistant to this. Although doctors saw the need to improve equipment, administrators felt current material conditions were adequate. Respondents agreed that patient satisfaction was generally high, and did not view increasing patient satisfaction as a priority. CONCLUSIONS. Our findings highlight agreements and disagreements among the three stakeholder groups about improving surgical output and quality, which can inform strategies to improve cataract programs in rural China. Respondents' beliefs about high patient satisfaction are not in accord with other studies in the area, highlighting a potential area for intervention. © 2013 The Association for Research in Vision and Ophthalmology, Inc.

Methodologic rigor of clinical trials on surgical management of eyes with coexisting cataract and glaucoma.

OBJECTIVE:

To assess the methodologic quality of published studies of the surgical management of coexisting cataract and glaucoma.

DESIGN:

Literature review and analysis.

METHOD:

We performed a systematic search of the literature to identify all English language articles pertaining to the surgical management of coexisting cataract and glaucoma in adults. Quality assessment was performed on all randomized controlled trials, nonrandomized controlled trials, and cohort studies. Overall quality scores and scores for individual methodologic domains were based on the evaluations of two experienced investigators who independently reviewed articles using an objective quality assessment form.

MAIN OUTCOME MEASURES:

Quality in each of five domains (representativeness, bias and confounding, intervention description, outcomes and follow-up, and statistical quality and interpretation) measured as the percentage of methodologic criteria met by each study.

RESULTS:

Thirty-six randomized controlled trials and 45 other studies were evaluated. The mean quality score for the randomized, controlled clinical trials was 63% (range, 11%-88%), and for the other studies the score was 45% (range, 3%-83%). The mean domain scores were 65% for description of therapy (range, 0%-100%), 62% for statistical analysis (range, 0%-100%), 58% for representativeness (range, 0%-94%), 49% for outcomes assessment (range, 0%-83%), and 30% for bias and confounding (range, 0%-83%). Twenty-five of the studies (31%) received a score of 0% in the bias and confounding domain for not randomizing patients, not masking the observers to treatment group, and not having equivalent groups at baseline.

CONCLUSIONS:

Greater methodologic rigor and more detailed reporting of study results, particularly in the area of bias and confounding, could improve the quality of published clinical studies assessing the surgical management of coexisting cataract and glaucoma.

Surgical strategies for coexisting glaucoma and cataract: an evidence-based update.

OBJECTIVE:

To assess short- and long-term control of intraocular pressure (IOP) with different surgical treatment strategies for coexisting cataract and glaucoma.

DESIGN:

Systematic literature review and analysis.

METHOD:

We performed a search of the published literature to identify all eligible articles pertaining to the surgical management of coexisting cataract and glaucoma in adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting different approaches was graded by consensus as good, fair, weak, or insufficient.

MAIN OUTCOME MEASURES:

Short-term (24 hours or fewer) and long-term (more than 24 hours) IOP control.

RESULTS:

The evidence was good that long-term IOP is lowered more by combined glaucoma and cataract operations than by cataract operations alone. On average, the IOP was 3 to 4 mmHg lower in the combined groups with fewer medications required. The evidence was weak that extracapsular cataract extraction (ECCE) alone results in short-term increase in IOP and was insufficient to determine the short-term impact of phacoemulsification cataract extraction (PECE) on IOP in glaucoma patients. The evidence was weak that short-term IOP control was better with ECCE or PECE combined with an incisional glaucoma procedure compared with ECCE or PECE alone. The evidence was also weak (but consistent) that long-term IOP is lowered by 2 to 4 mmHg after ECCE or PECE. Finally, there was weak evidence that combined PECE and trabeculectomy produces slightly worse long-term IOP control than trabeculectomy alone, and there was fair evidence that the same is true for ECCE combined with trabeculectomy.

CONCLUSIONS:

There is strong evidence for better long-term control of IOP with combined glaucoma and cataract operations compared with cataract surgery alone. For other issues regarding surgical treatment strategies for cataract and glaucoma, the available evidence is limited or conflicting.

Outcomes of surgical bleb revision for complications of trabeculectomy.

OBJECTIVE: To describe the results of revision surgery for complications of trabeculectomy in a case series from an academic glaucoma service. DESIGN: Retrospective case series. PARTICIPANTS: A total of 177 eyes of 167 adult patients who underwent revision of trabeculectomy at the Wilmer Eye Institute between 1994 and 2007. METHODS: Three indications for surgery were identified: hypotony without leak, bleb leak, and bleb dysesthesia. Revision was deemed successful when all of the following were true: the primary indication was eliminated, further intraocular pressure (IOP)-lowering surgery was not required, no major complication occurred, and a new bleb-related problem did not develop. Patients with less than 3 months of follow-up were excluded unless failure occurred earlier. Surgical procedures included variations on excision of thin or leaking conjunctiva with advancement. MAIN OUTCOME MEASURES: Change in IOP, change in visual acuity, need for further IOP-lowering surgery, and complications after bleb revision. RESULTS: Subjects' mean age was 67+/-14 years, 54% were female, and mean follow-up was 2.8+/-2.7 years, with a mean interval from trabeculectomy to revision of 3.5+/-3.7 years. Overall success rate was 63% (112/177), which was slightly higher for leak repair (65%; 64/98) and hypotony (63%; 32/51) than for dysesthesia (57%; 16/28) indications. By Kaplan-Meier analysis, overall cumulative success rates at 1, 2, 5, and 10 years after bleb revision were 80%, 75%, 50%, and 41%, respectively. IOP and visual acuity improved significantly in both hypotony and leak groups (P values ranging from 0.004 to <0.0001). Additional IOP-lowering surgery was required in 9%. In multivariate regression analysis adjusting for age, gender, and number of prior surgeries, patients with glaucoma other than primary open-angle glaucoma were twice as likely to have failed bleb revision. CONCLUSIONS: Surgical bleb revision often provides successful resolution of bleb-related complications. Most patients maintain IOP control without need for further IOP-lowering surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Willingness to pay for potential enhancements to a low-cost cataract surgical package in rural southern China.

PURPOSE: To assess determinants of patients' willingness to pay (WTP) for potential components of a multi-tiered cataract surgical package offered by a non-governmental organization (NGO) in rural China. DESIGN: Cross-sectional study. METHODS: Demographic and clinical data were collected from 505 patients presenting for cataract screening or surgery in Yangjiang, China. Willingness to pay for potential enhancements to the current surgery package was assessed using a bidding format with random payment cards. RESULTS: Among 426 subjects (84.4%) completing interviews, the mean age was 73.9 ± 7.3 years, 67.6% were women and 73% (n = 310) would pay for at least one offering, with 33-38% WTP for each item. Among those who would pay, the mean WTP for food was US$1.68 ± 0.13, transportation US$3.24 ± 0.25, senior surgeon US$50.0 ± 3.36 and US$89.4 ± 4.19 for an imported intra-ocular lens (IOL). The estimated total recovery from these enhancements under various assumptions would be US$20-50 (compared to the current programme price of US$65). In multivariate models, WTP for the senior surgeon increased with knowledge of a person previously operated for cataract (OR = 2.13, 95% CI 1.42-3.18, p < 0.001). Willingness to pay for the imported IOL increased with knowledge of a previously operated person (OR = 1.85, 95% CI 1.24-2.75, p < 0.01) and decreased with age >75 years (OR = 0.61, 0.40-0.93, p < 0.05). CONCLUSIONS: Opportunities exist to increase cataract programme revenues through multi-tiered offerings in this setting, allowing greater subsidization of low-income patients. Personal familiarity with cataract surgery is important in determining WTP. © 2011 The Authors. Acta Ophthalmologica © 2011 Acta Ophthalmologica Scandinavica Foundation.

Prevention of Cataract Blindness in Rural China.

China has undergone dramatic economic and social reforms during last 30 years, leading to a notably higher level of living standards and health care access for Chinese citizens. However, China's cataract surgical rate of 780 cases/y per million population trails Asian neighbors with lower income levels such as India and Vietnam. Eye care providers and patients encounter many barriers in gaining access to one another.Hands-on training programs conducted by international nongovernmental organizations and the government have helped to increase the number of qualified cataract surgeons in rural area, but establishing a residency training system that produces ophthalmologists capable of performing independent surgery is the only sustainable way to meet the increasing demand for surgery from an aging population. The New Rural Cooperative Medical System has successfully reduced the financial burden of cataract surgery for the rural population; however, reimbursement for outpatient treatment of leading eye diseases is needed.Community outreach screening combined with education is essential in rural areas' increased demand for surgery. Methods to optimize the yield from such screening must still be devised and proven, however. Improvements in the hospital administration and management structure are also needed to improve the efficiency of China's rural hospitals in delivering high-quality, low-cost cataract surgical services.

Compliance with follow-up after cataract surgery in rural China.

PURPOSE:

To evaluate reasons for non-compliance with post-cataract surgical follow-up in rural China, and assess the impact of incentives on improving compliance.

METHODS:

Patients having undergone cataract surgery more than 3 months previously at cataract surgery training hospitals in Guangdong were invited by telephone and advertisements to a hospital-based study examination, with compensation for travel costs (US$7). Information on prior post-surgical follow up was collected by questionnaire at the hospital or by telephone. Logistic regression was used to assess predictors of post-operative attendance with or without compensation.

RESULTS:

Among 518 eligible patients, 426 (82.2%) underwent interviews and 342 (66.0%) attended the compensated study examination. Ninety nine participants (23.2%) reported previously returning for uncompensated follow-up ≥ 3 months post-operatively, and 225 (52.8%) had returned for any prior post-operative examination. Uncompensated follow-up at ≥ 3 months was associated with higher income (P = 0.037), and recalling instruction by a doctor to follow-up (P = 0.001), while age, gender, travel cost, and post-operative satisfaction and vision were not associated. Younger (P = 0.002) patients and those reporting being instructed to follow up (P = 0.008) were more likely to return for the compensated research examination. Among all interviewed subjects, only 170 (39.9%) reported knowing they were to return to hospital.

CONCLUSIONS:

Modest compensation, advertisements and telephone contact can increase medium-term follow-up rates after cataract surgery by three-fold. Better communication of specific targets for follow-up may improve follow-up compliance.

Work-related training and the probability of transitioning from non-permanent to permanent employment

It is widely believed that work-related training increases a worker’s probability of moving up the job-quality ladder. This is usually couched in terms of effects on wages, but it has also been argued that training increases the probability of moving from non-permanent forms of employment to more permanent employment. This hypothesis is tested using nationally representative panel data for Australia, a country where the incidence of non-permanent employment, and especially casual employment, is high by international standards. While a positive association between participation in work-related training and the subsequent probability of moving from either casual or fixed-term contract employment to permanent employment is observed among men, this is shown to be driven not by a causal impact of training on transitions but by differences between those who do and do not receive training; i.e., selection bias.

Specialty Registrars’ Experience of Managing Head and Neck Cancer Patients

Objective The aim of this study was to collate and compare data on the training of Specialty Registrars in Restorative Dentistry (StRs) in the management of head and neck cancer (HANC) patients across different training units within the UK and Ireland. Methods Current trainees were invited to complete an online questionnaire by the Specialty Registrars in Restorative Dentistry Group (SRRDG). Participants were asked to rate their confidence and experience of assessing and planning treatment for HANC patients, attending theatre alone and manufacturing surgical obturators, and providing implants for appropriate cases. Respondents were also asked to appraise clinical and didactic teaching at their unit, and to rate their confidence of passing a future Intercollegiate Specialty Fellowship Examination (ISFE)-station assessing knowledge of head and neck cancer. Results Responses were obtained from 21 StRs (n=21) training within all five countries of the British Isles. Most respondents were based in England (76%), with one StR in each of Scotland, Wales, Northern Ireland and the Republic of Ireland. A third (33%) were in their 5th year of training. Almost half of the StRs indicated that they were confident of independently assessing (48%) new patients with HANC, with fewer numbers reporting confidence in treatment planning (38%). The majority (52%) of respondents indicated that they were not confident of attending theatre alone and manufacturing a surgical obturator. A third (33%) rated their experience of treating HANC patients with implants as ‘poor’ or ‘very poor’, including three StRs in their 5th year of training. Less than one third (<33%) rated didactic teaching in maxillofacial prosthodontics at their unit as ‘good’ or ‘excellent’, and only 7 StRs indicated that they were confident of passing an ISFE-station focused on HANC. Conclusion Experience and training regarding patients with head and neck cancer is inconsistent for StRs across the UK and Ireland with a number of trainees reporting a lack of clinical exposure.

The African Pediatric Fellowship Program: Training in Africa for Africans

Africa has a significant burden of childhood disease, with relatively few skilled health care professionals. The African Paediatric Fellowship Programme was developed by the Department of Pediatrics and Child Health at the University of Cape Town to provide relevant training for African child health professionals, by Africans, within Africa. Trainees identified by partner academic institutions spend 6 months to 2 years training in the Department of Pediatrics and allied disciplines. They then return to their home institution to build practice, training, research, and advocacy. From 2008 to 2015, 73 physicians have completed or are completing training in general pediatrics or a pediatric subspecialty. At 1 year posttraining, 98% to 100% are practicing back in their home institution. The impact of the returning fellows is evident from their practice interventions, research collaborations, and positions as stakeholders who can change health care policies. Thirty-three centers in 13 African countries are partners with the program, and the program template is now followed by other partner sites in Africa. Increasing and retaining the skills pool of African child health specialists is building a network of motivated, highly skilled clinicians who are equipped to advance child health in Africa.

Continuing the fight in reducing the risk of surgical site infections in the perioperative environment

Assessing risk has become part of the process of supporting patients andmaintaining safety in the healthcare setting. The risk of healthcare associatedinfections (HCAIs) has long been well documented and surgical site infection (SSI)is recognised as one of the most prevalent (Tanner & Khan 2008, Wilson 2013a).