Day care versus in-patient surgery for age-related cataract

Methodological quality of the review: High confidence

Author: Fedorowicz Z, Lawrence D, Gutierrez P, Van Zuuren EJ.

Region: Spain and United States of America (USA)

Sector: Age-related cataracts

Sub-sector: Surgery: day care and in-patient.

Type of cataract: Age-related cataract

Equity focus: None specified

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis methods: Not applicable

Background

With the development of phacoemulsification from the 1990s onwards and the increasing use of local anaesthesia in cataract extraction, there has been an increased trend towards the treatment of cataract patients as day cases as opposed to the classic in-patient treatment model. Day care centres can now offer day case cataract extractions, usually performed under local anaesthesia. However, there have been concerns about the quality of service provided by day care centres, one major concern being whether the day care treatment model has the same clinical outcome as the classic in-patient procedure, and whether there exists a higher risk of intra and/or post-operative complications.

Research objectives

The objective of this review was to provide reliable evidence regarding the safety, feasibility, effectiveness and cost-effectiveness of day case cataract extraction by comparing clinical outcomes, cost-effectiveness and/or patient satisfaction in cataract operations performed in day care versus in-patient units.

Main findings

Authors included two randomized controlled trials (RCTs) comparing day care and in-patient surgery for age-related cataract. One review is from the USA and one is from Spain. Authors reported the following results:

One trial reported statistically significant differences in early postoperative complication rates in the day care group, with an increased risk of increased intraocular pressure, which had no clinical relevance to visual outcomes four months postoperatively. The mean change in visual acuity (Snellen lines) of the operated eye four months postoperatively was 4.1 (standard deviation (SD) 2.3) for the day care group and 4.1 (SD 2.2) for the in-patient group and not statistically significant. The four-month postoperative mean change in quality of life score measured using the VF14 showed minimal differences between the two groups. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay. One study only reported hotel costs for the non-hospitalized participants making aggregation of data on costs impossible.

Authors concluded that: ‘the small number of trials in this review found that in developed countries at least, there is some evidence that day surgery for this type of cataract extraction may not only be cheaper but just as effective as hospitalization and overnight stay for cataract extraction’. The review provides some evidence that there is a cost saving, but no significant difference in outcome or risk of postoperative complications between day care and in-patient cataract surgery.

In developed, high-income settings, the authors suggest further exploring issues of thresholds for in-patient cataract surgery and the issue of cost shifting, (in other words, evaluating whether adoption of the day care model in fact shifts cost burdens from the health service onto the community). In developing, low-income settings, authors suggest that further research should concentrate on researching safety, outcomes, type of surgical procedure and costs, in order to assess the applicability of the day care treatment model to low-income settings. They also note that further trials should pay greater attention to the detail of their design and reporting and ‘consider using the CONSORT statement to ensure that important factors such as random allocation sequence, masked assessment and dealing with withdrawals are included’.

Methodology

Authors included randomized controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation.

The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 5, part of the Cochrane library, MEDLINE (1950-2011), EMBASE (1980 – May 2011), LILACS (1982 -2011), the mRCT and ClinicalTrials.gov. No date or language restrictions were applied to searches. Reference lists of relevant articles and the review author’s personal database of trial reports were also searched. Reviewers contacted investigators of included studies for details of additional published and unpublished trials.

Two authors independently assessed the abstracts and full text of studies resulting from the searches, and collected outcome data of included studies. Additionally, the authors independently assessed the risk of bias in all included studies using the Cochrane Collaboration’s tool for assessing risk of bias as described in Chapter 8, section 8.5 in the Cochrane Handbook for Systematic Reviews of Interventions (2011).

It was noted that due heterogeneity identified in the two studies, statistical analysis was not appropriate. Only one study assessed in the review provided adequate data and as a result no meta-analysis was performed.

Applicability/external validity

The review itself only covered two developed country settings; therefore results would only apply to similar high-income settings/developed countries. The authors reported the need to conduct further research in developing countries to further research safety, outcomes, type of surgical procedure and costs and to assess the applicability of the day care treatment model to low-income settings.

Geographic focus

The review only covers two developed country contexts (Spain and the USA). The review (especially its coverage of Castells 2011) would be a useful reference in informing the design of future research on day care versus in-patient cataract surgery in developing country settings.

Quality assessment

The authors conducted a reasonably comprehensive search for evidence, appropriately reporting the method used and reporting the characteristics of included studies, including quality assessment. The review was internally sound and the methodological limitations of the included studies are addressed in the review. The review only covered two studies, both of which are from developed country contexts, but could serve as a useful guide for further research into day care cataract surgery in developing country settings and informing the design of future research on day care versus in-patient cataract surgery in developing country settings. Overall, based on the methods used, this study was awarded high confidence in the conclusions about the effects of this review.