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Debate deepens over Australia’s first Cataract Clinical Care Standard

The release of the nation’s first Cataract Clinical Care Standard has been met with mixed reaction, drawing both opposition and support across the ophthalmic sector.

Ultimately, it has failed to win the support of the Australian Society of Ophthalmologists (ASO) and RANZCO, with the college citing two major issues. However, proponents of the standard have questioned the interpretation of some aspects.

Meanwhile, Optometry Australia has endorsed the final standard, along with Orthoptics Australia and Vision Australia, among others.

The Australian Commission for Safety and Quality in Health Care (ACSQHC) has spent several years developing the inaugural Cataract Clinical Care Standard, which was launched in August. Conjoint Professor Anne Duggan, ACSQHC chief medical officer, said it would ensure cataract treatment was appropriate and more efficient, with clear identification of patients more likely to benefit from surgery.

In a memo to fellows and trainees, president Professor Nitin Verma said RANZCO won’t endorse the standard because it didn’t agree with the inclusion of 6/12 visual acuity as a measure for cataract, and the recommendation to offer all patients bilateral same day surgery.

The standard was released 17 August, with only some ophthalmic bodies endorsing the final document.

RANZCO applauded the ACSQHC for developing the standard, which it described as “robust”, aside from the two matters it disagreed with.

“In particular, our concern regarding Snellen acuity as a prioritisation factor for cataract surgery does not align with any international standard,” Verma said.

“The survey of the [RANZCO] fellowship earlier this year showed that over 80% of the respondents advised that a correct acuity of 6/12 is not the most important determinant for surgical intervention, while 54% dismissed Snellen acuity as an appropriate measure to prioritise patients for surgery.”

Prof Nitin Verma.

Further, RANZCO “strongly disagreed” with the need to routinely discuss same or following day second-eye surgery. Around 96% of respondents to the fellowship survey do not provide such a service.

“A similar percentile have views that same day sequential cataract surgery should not be offered as a routine alternative to surgery performed on separate days,” Verma said. Although he acknowledged these were only part of the standards, he said RANZCO resisted parts of the standards being used in isolation by hospitals or private health insurers to determine funding for cataract patients.

“We remain disappointed the ACSQHC have not listened to the experts when making a final decision about the standards, as apart from these issues, they are very robust,” Verma said.

ASO vice president Dr Peter Sumich said the standard was “a poke in the eye” to ophthalmologists from RANZCO and the ASO who have “universally denounced it”.

Dr Peter Sumich.

“Whilst falsely claiming to be consultative, it became clear it was a bureaucratic creation designed to allow manipulation of public hospital waiting lists to suit administrators,” Sumich said.

“It is beyond embarrassing for the ACSQHC that their document purporting to represent current standards is out of step with contemporary Australian clinical practice from day one.”

Prioritisation and efficiency

Professor Konrad Pesudovs, formerly foundation chair of Optometry and Vision Science at Flinders University, now SHARP Professor at UNSW, supports the standard.

He was part of the ACSQHC committee who developed the standard and said it was the work of a group of stakeholders involved in the cataract patient pathway, not only surgeons.

“Surgeons have a very important role in performing operations, but they don’t have a role in public health, primary care or in the community,” he said.

“This is important because this is where Australia’s problem with cataract exists. We have 10 times as many people in the age groups that get cataract today than we had 30 years ago, but we don’t do any more public cataract surgery than we did then.”

Prof Konrad Pesudovs.

He said three things were required: more public cataract surgery; ensuring the right people – most disabled – get surgery first; and greater efficiencies in service delivery. The standard helps address the final two points – prioritisation and efficiency. Pesudovs, whose opinions are his own and don’t represent any organisation, suggested objections to a visual acuity criterion of 6/12 may be misplaced.

He said it was not a recommended criterion. It reads: ”Visual acuity of 6/12 or worse may provide a useful objective measure of visual impairment but may significantly underestimate function – for example in conditions of high or low light. Glare or contrast sensitivity may be disabling without an impact on visual acuity. Some patients will have higher visual needs, such as occupational activities.”

Pesudovs said this was a wholly appropriate position.

“The problem of the right people not getting cataract surgery remains. Therefore, the standard includes a section on the prioritisation for cataract surgery.”

It includes Pesudovs’ Cataract Impact Model of prioritisation, on page 28.

“We take clinical measures of vision, cataract grades and vision-related activity limitation questionnaire data and combine it in a model that ranks people in terms of need for surgery. This type of sophisticated prioritisation model can ensure the right people are directed to hospitals where RANZCO surgeons can do their job and take cataracts out,” Pesudovs said.

Regarding bilateral sequential cataract surgery, he said the standard proposed it be used more widely.

“This is a safe approach in the era of intracameral antibiotics that eliminates the issue of increased falls, and its associated mortality and morbidity, that occurs between first eye and second eye cataract surgery,” Pesudovs said.

“Bilateral sequential cataract surgery also offers significant efficiencies in terms of public hospital process in clinical appointments and admissions. This would help us to get more surgery done.”

More reading

RANZCO won’t endorse new Cataract Clinical Care Standard

Survey provides insight into Australian cataract surgery landscape

A black and white case? Snellen acuity and cataract surgery

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