Is there overutilisation of cataract surgery in England?
Is there overutilisation of cataract surgery in England?
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DOI：
10.1136/bjo.2007.136150
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发表时间：
2009-01-01
影响因子：
4.1
通讯作者：
Lewsey, J.
中科院分区：
文献类型：
--
作者：
Black, N.;Browne, J.;Lewsey, J.
目的：1989年至2004年，英国白内障手术率增加了3.7倍，人们担心这是否伴随着阈值的过度下降，以至于一些手术是不合适的。目的是衡量手术对患者的代表性样本的影响，以确定是否过度使用手术正在发生。设计：前瞻性队列评估术前和术后3个月。设置：10个供应商（四家NHS医院、三家NHS治疗中心、三家独立部门治疗中心）。861例接受第一眼（569）或第二眼（292）白内障手术的患者提供了术前数据，其中745例（87%）完成了术后问卷调查。结果：总体上，视觉功能得到改善（平均VF-14评分从83.2（SD 17.3）增加到93.7（SD 13.2））。自我报告的一般健康状况恶化（术前20.3%一般或较差，术后25%），反映在平均EQ 5D评分中（0.82 vs 0.79; p = 0.003）。66例（8.9%）患者报告了至少1例并发症，但这可能高估了真实发生率。如果手术的适当性是基于VF-14评分增加5.5（对应于患者报告“稍微好一点”），则30%的手术将被视为不适当。如果采用增加12.2（患者报告“好多了”），则不适当的比例为49%。使用不同的方法来确定最小重要差异，不适当的比例将接近20%。虽然25%的患者的视觉功能（VF-14）评分没有变化或恶化，但93.1%的患者将手术结果评为“好”、“非常好”或“极好”，93.5%的患者认为他们的眼部问题“更好”。这部分反映了VF-14的有效性不足。结论：白内障手术提供的改善伴随着视功能阈值的降低。然而，在衡量白内障手术对视觉功能和生活质量的影响方面存在方法上的困难，这意味着不可能确定白内障手术是否过度使用。
Objectives: Following a 3.7-fold increase in the rate of cataract surgery in the UK between 1989 and 2004, concern has been raised as to whether this has been accompanied by an excessive decline in the threshold such that some operations are inappropriate. The objective was to measure the impact of surgery on a representative sample of patients so as to determine whether or not overutilisation of surgery is occurring.Design: Prospective cohort assessed before and 3 months after surgery.Setting: Ten providers (four NHS hospitals, three NHS treatment centres, three independent sector treatment centres) from across England.Participants: 861 patients undergoing first eye (569) or second eye (292) cataract surgery provided preoperative data of whom 745 (87%) completed postoperative questionnaires.Main outcome measures: Patient-reported visual function (VF-14); general health status and quality of life (EQ5D); postoperative complications; overall view of the operation and its impact.Results: Overall, visual function improved (mean VF-14 score increased from 83.2 (SD 17.3) to 93.7 ( SD 13.2)). Self-reported general health status deteriorated (20.3% fair or poor before surgery compared with 25% afterwards) which was reflected in the mean EQ5D score (0.82 vs 0.79; p = 0.003). At least one complication was reported by 66 (8.9%) patients, though this probably overestimated the true incidence. If the appropriateness of surgery is based on an increase in VF-14 score of 5.5 (that corresponds to patients' reporting being "a little better''), 30% of operations would be deemed inappropriate. If an increase of 12.2 (patients' reports of being "much better'') is adopted, the proportion inappropriate is 49%. Using a different approach to determining a minimally important difference, the proportion inappropriate would be closer to 20%. Although visual function (VF-14) scores were unchanged or deteriorated in 25% of patients, 93.1% rated the results of the operation as "good,'' "very good'' or "excellent,'' and 93.5% felt their eye problem was "better.'' This partly reflects inadequacies in the validity of the VF-14.Conclusions: Improvement in the provision of cataract surgery has been accompanied by a reduction in the visual function threshold. However, methodological difficulties in measuring the impact of cataract surgery on visual function and quality of life mean it is impossible to determine whether or not overutilisation of cataract surgery is occurring.