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Commission weighs into debate over cataract standard

cataract surgery collaborative care

The commission responsible for developing Australia’s first Cataract Clinical Care Standard has responded to criticism over the document and says it was “perplexed” when RANZCO and the Australian Society of Ophthalmologists (ASO) changed their stance to no longer offer their endorsement.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) says it has been disappointed by recent coverage featuring reaction from the sector about the new standard, launched in August.

It comes after RANZCO and the ASO publicly stated they would not endorse it. In particular, the college took issue with what it perceived as the inclusion of 6/12 visual acuity as a measure for cataract, and a recommendation to offer all patients bilateral same day surgery. The ASO took aim at the consultation process, while RANZCO also stated it was “disappointed the ACSQHC have not listened to the experts”.

However, the ACSQHC believes elements of the standard and its process for developing them have been “inaccurately presented” and has since “moved to clarify what the standard says, and the events regarding consultation”.

The commission said its first concern related to comments that the standard promotes visual acuity of 6/12 as ”the most important determinant for surgical intervention” and “a prioritisation factor for cataract surgery”.

“The standard simply does not make this recommendation and to say it does so is factually incorrect,” CEO Adjunct Professor Debora Picone said.

“The standard indicates that visual acuity is one aspect of a visual examination that should be taken into account. The commission is not aware of any guideline that recommends against assessing visual acuity when determining the impact of cataract on visual function – it is one of several factors to consider, as stated in the standard.”

In response to comments the standard recommends same or following day second eye surgery be routinely discussed, Picone said the standard in fact recommends the timing of second-eye surgery is discussed, as appropriate to the clinical circumstances of the patient.

In most cases, she said this may result in a decision to schedule second eye surgery some weeks after the first operation, which may avoid unnecessary delays for patients, particularly those for whom refractive differences may be considerable after the first eye surgery. In others, it may be the patient’s decision to wait and see.

The commission said the standard states that “there is limited evidence to support second-eye surgery on the same or next day”, however there are circumstances when this is appropriate, with appropriate precautions and informed patient consent.

“The standard clearly leaves this assessment to the treating clinician and suggests that they offer informed consent to the patient about the options suitable in their individual circumstances,” Picone said.

Consultation and endorsement 

The commission also responded to the ASO’s comment that it “falsely claims” to be consultative and RANZCO’s statement that it has not “listened to the experts”.

Picone said the ACSQHC consulted extensively with both RANZCO and the ASO and has met with their representatives several times to discuss their feedback, including before, during and after public consultation.

“Both organisations provided feedback as part of the public consultation process after which the document was revised taking all feedback into account. Changes proposed by RANZCO during public consultation to Quality Statement 4: Indications for cataract surgery, were accepted verbatim by the commission,” she said.

“Both RANZCO and ASO initially endorsed the standard but withdrew endorsement some months later, despite no changes having been made in the interim and with no change in the evidence base. The commission remains perplexed as to the basis for changes in endorsement without a change in clinical practice recommendations.”

Ultimately, however, Picone said clinical care standards describe best practice care and priorities for quality improvement – they do not aim to describe current practice, “which may be in need of improvement”.

“Best practice and current practice can differ, as in the case of post-operative prophylactic antibiotic eye drops, routinely prescribed by ophthalmologists against current recommendations,” she said.

“Similarly, prioritisation for non-urgent elective cataract surgery based on clinical need is not currently widespread and it is surprising that ophthalmologists do not support such a model for improving equity of care.”

Finally, Picone said the commission took seriously the need to consult respectfully with all stakeholders.

“We particularly appreciate RANZCO’s participation in discussions about the standard and its support for the intent of the document,” she said.

RANZCO and the ASO said they had nothing further to add.

More reading

Debate deepens over Australia’s first Cataract Clinical Care Standard

Survey provides insight into Australian cataract surgery landscape

Cataract Kids Australia and orthoptists

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