A systematic review of the accessibility, acceptability, safety, efficiency, clinical effectiveness, and cost-effectiveness of private cataract and orthopedic surgery clinics

Author: Akpinar I, Kirwin E, Tjosvold L, Chojecki D, Round J.

Geographical coverage: Canada, the UK, Australia, Austria, Denmark, Italy, the Netherlands, and Norway

Sector: Cataract and orthopedic surgery

Sub-sector: Safety and clinical effectiveness

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background:

The expansion of information and communication technologies (ICTs) has significantly transformed the higher education landscape and offers new opportunities for inclusive learning. However, despite international conventions and institutional policies on equity, students with disabilities often face difficulties in accessing ICT-based education. These issues are compounded by a lack of universally designed digital platforms, insufficient awareness among educators, and inconsistent implementation of accessibility standards. While ICT has the potential to enhance educational access, its benefits are unevenly distributed, leaving many disabled students marginalised. The COVID-19 pandemic further exacerbated these disparities by exposing systemic limitations in digital learning environments. This highlighted the importance of addressing technological and pedagogical gaps to promote equity in higher education.

Objective: To identify differences in outcomes between public- and private-sector provision of cataract and orthopaedic surgical procedures within publicly funded health systems.

Main findings:

The review included 29 articles from Canada, the UK, Australia, Austria, Denmark, Italy, the Netherlands, and Norway. The methodological quality of the included studies varied. Results on wait times consistently showed shorter durations for patients in private facilities. However, there was significant concern regarding “cherry-picking”, where private facilities selectively admit healthier and less complex patients, thereby increasing the burden on public facilities with more complex cases and exacerbating health inequities.

Safety and clinical effectiveness outcomes were mixed. While some studies suggested better safety indicators in private clinics, this was often linked to the lower preoperative risk profiles of patients rather than differences in care quality. Similarly, clinical outcomes such as complication and readmission rates varied across studies, with some indicating better results in private settings and others showing the opposite. Efficiency was often higher in private clinics, measured by shorter lengths of stay and higher surgical throughput, although these too may be influenced by patient selection. Cost data were sparse, with only two studies directly addressing costs or cost-effectiveness. One study suggested private clinics were less costly, and another found private contracting for joint replacements to be cost-effective under specific assumptions.

Methodology:

Searches were conducted in Medline, Embase, EBSCO EconLit, and grey literature sources (Google Advanced, The King’s Fund, OECD, European Observatory, Commonwealth Fund, Conference Board of Canada, Fraser Institute, INAHTA, and CADTH) to identify relevant studies published in English from January 2000 onwards. Studies were included if they involved adult patients undergoing cataract or orthopaedic surgery and reported one or more of the following outcomes: accessibility, acceptability, safety/quality of care, clinical effectiveness, efficiency, and cost/cost–benefit/cost-effectiveness of private/public surgical facilities.

Two reviewers independently screened the articles, extracted relevant data, and critically appraised the quality of the included studies using the JBI Critical Appraisal Checklist and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022. Disagreements between the reviewers were resolved through discussion or by consulting a third reviewer. The findings were synthesised narratively.

Applicability/external validity:

The review authors noted that several studies did not provide detailed patient information, such as ethnic group and case severity, patient selection issues, treatment effectiveness, and complications. This limits the generalisability of some studies and constrains the conclusions that can be drawn regarding the evidence’s relevance to local decision making.

Geographic focus: The review did not apply any geographical limits. The included studies were conducted in Canada, the UK, Australia, Austria, Denmark, Italy, the Netherlands, and Norway.

Summary of quality assessment: Overall, there is medium confidence in the review’s conclusions. The searches were comprehensive. Inclusion and exclusion criteria were clearly defined, and two reviewers independently screened the articles and extracted data. Study quality was assessed using established tools. Characteristics of included studies were well-documented, and findings were synthesised narratively. However, the search was limited to articles published in English only, and the review did not provide a list of excluded studies. In addition, the review did not report findings by risk of bias status, nor did it indicate checking reference lists or contacting authors.