One downside of increasing life expectancy is an increase in the prevalence of age-related disease. And, as readers well know, many of the most common ocular diseases (cataract, macular degeneration, glaucoma) have a strong correlation with age.
The population in the UK is expected to continue to grow over the next few decades (see table 1). More importantly, as with many western countries, the proportion of the population old enough to present a high risk of eye diseases is set to increase. In 2010, there were estimated to be 4.9 million UK residents over 75 years of age and some 1.4 million aged over 85 years. By 2035, the total aged over 75 years is expected to be 8.9 million, with 3.5 million aged over 85 years. When you consider that around 30% of people aged 65 years or older have a visually impairing cataract in one or both eyes, and almost everyone aged over 85 still phakic shows evidence of cataract, then the pressure on ophthalmology to treat cataracts is increasing alarmingly.
To underline this, the previous president of the Royal College of Ophthalmologists (RCO), Professor Carrie MacEwen, was heard on BBC News in 2016 describing the situation as ‘a perfect storm of increased demand, caused by more eye disease in an ageing population requiring long term care.’
NICE Revised Guidance on Referral
As budgets tightened, some authorities introduced much stricter requirements for referral, mostly based around the drop in high contrast (Snellen) acuity. Sometimes, there were different acuity levels to be reached for referral of the second eye compared to the first and there was variation between different geographical locations as to what was acceptable to refer. According to NICE, such different local policies led to a reported threefold variation in the number of people having cataract surgery across different areas of England.
Many cataracts have significant impact on vision without a major impact on high contrast letters – for example those with early posterior subcapsular cataract often report disabling glare that prevents safe driving in some conditions while still maintaining reasonable high contrast acuity and so were ineligible for referral under some local guidelines.
The launch of the revised NICE guidelines for cataract referral (applicable in England and Wales) was welcomed by eye care professionals as it emphasised that the majority of patients with symptomatic cataract would benefit from surgery and importantly, that delaying surgery until any chosen acuity threshold is reached would not be cost effective. This applied to each eye considered for any individual patient.
So, the NICE guidance appeared to contradict some of the stricter CCG guidelines based on acuity cut-off. However, some clinicians predicted that NICE referrals might not necessarily result in cataract treatment depending upon the adherence to CCG budgeted rules.
The Way Forward
Aware of the potential challenges to treat the significant numbers of cataract patients in the coming years, and with ophthalmologist numbers unlikely to rise to meet increasing demand, the RCO commissioned the Way Forward Project which continues to analyse published literature and interviews with clinicians and commissioners to see what can be done to improve the efficiency of cataract services in order to cater for the growing patient demand.
One key finding already published is that ‘a growth in prevalent cataract between 2015 and 2035 leads us to anticipate an increase of around 50% in the numbers of cataract operations we are to be expected to perform over the next 20 years (25% increase over the next 10 years).’1 This is quite an increase and undoubtedly, when considered against potential demand for lifesaving treatments, has led some to push cataracts further down the priority list.
But, is limiting cataract surgery the answer? The evidence suggests not, as the RCO point out, ‘Cost-utility analyses of cataract surgery, and second eye surgery have shown it to be good value and cataract surgery also has indirect societal and health-economic advantages in improving well-being, reducing isolation and premature need for care while also reducing falls and road traffic accidents.2-9
Others have suggested GPs should act as a filter to limit referral rates. However, the RCO notes that ‘published comparisons of GP and optometry referrals for cataract surgery suggest optometrists may be better placed to help patients decide if they wish to be referred for cataract surgery than GPs.’ I do not think any of us would argue with that finding.
It will be interesting to see what flexibility is in the existing systems to allow for greater cataract treatment numbers. Some suggestions are already highlighted such as cost-saving increased staffing and sensible time management. ‘Higher volume may require more staff, but the additional productivity will pay the entire year’s salary in the first few weeks.’ Also, ‘on one site the staff leave when the job is done so there is a real team feeling to get on with the job; on the other site they have to stay until their shift officially ends, so we all drag our heels, there is no motivation to get finished.’
Unjustified Screening
Predictions of patients being declined surgery despite meeting NICE referral criteria have proved to be accurate, and the story has recently received the attention of the national press, largely thanks to an investigation by the BMJ.10 The journal revealed ‘Among the 185 CCGs that provided data (95% response rate), the investigation found that almost 2,900 prior approval requests or individual funding requests for cataract surgery were rejected last year, more than double the number two years ago. Although the proportion of prior requests for cataract surgery being rejected has fallen since 2016-17, the absolute number is rising.’ Worryingly, it seems that there is a great variation between CCGs, with some having a good treatment rate while others, such as Telford and Wrekin and Coastal West Sussex, rejecting more than one in five (22%) patients seeking funding for an operation.
The findings have prompted the current president of the RCO, Mike Burdon, who also chaired NICE’s guideline committee, to state it was his mission before he stepped down as president in a year’s time to convince CCGs to ‘stop rationing cataract surgery and not to label it a procedure of “limited clinical value”. This approach was unjustified, whatever way you look at it.’ He added that it was a false economy for CCGs to apply criteria for cataract surgery as a way to control costs.
Such a high-profile news story at a time when funding reviews are likely does offer some hope that us primary care ECPs may continue to refer when it is of benefit to the patient rather than to the accountant at the CCG.
Not Just Acuity
The importance of considering cataract impact upon more than high contrast acuity is discussed in an interesting recent paper in JAMA Ophthalmology.11 It is becoming increasingly obvious that the role played by light sensitive ganglion cells in the retina in calibrating the body clock of humans helps to maintain good health. Disruption of this signalling is now being associated with a wide range of mental and physical diseases, so much so that the World Health Organisation has cited shift work as a major risk factor for poor health. Cataract interferes with body clock regulation, though I suspect the weight of this argument for extraction might not convince a CCG at present.
Support Services
This February, Optegra announced a partnership with Primary Eyecare Services (PES) that will enable all accredited optometrists to refer cataract patients directly to Optegra hospitals, found throughout the country. This partnership, which has been supported by LOCSU, is interesting in that it recognises the role of the referring optometrist as integral. The scheme will pay a fee to the referring clinician and also return the patient for post-operative care to the community optometrist who initiated the referral.
As Optegra ophthalmic consultant Mr Shafiq Rehman explained to me, ‘the scheme will operate in England and within the catchment areas of each Optegra Eye Hospital.’ It is open to any accredited optometrist who has completed the WOPEC cataract module. The scheme is ‘relevant for all cataract patient referrals, whether private or NHS, and initial referral is at the discretion of the referring optometrist – in line with local CCG guidance.’ When I asked if such a model might be used for other referrals in future, Rehman went on to say, ‘Yes – most definitely. Other conditions such as glaucoma and age-related macular degeneration in particular may lend themselves to stronger linkage between ophthalmology and optometry.’
• Share your cataract referral experiences at bill.harvey@markallengroup.com.
References
1 Royal College of Ophthalmologists. The Way Forward: Cataract. Downloadable from; https://www.rcophth.ac.uk/wp-content/uploads/2015/...
2 Sach TH, Foss AJ, Gregson RM, et al. Second-eye cataract surgery in elderly women: a cost-utility analysis conducted alongside a randomized controlled trial. Eye 2010; 24(2): 276-83.
3 Frampton G, Harris P, Cooper K, Lotery A, Shepherd J. The clinical effectiveness and cost-effectiveness of second-eye cataract surgery: a systematic review and economic evaluation. Health technology assessment (Winchester, England) 2014; 18(68): 1-205, v-vi.
4 Rasanen P, Krootila K, Sintonen H, et al. Cost-utility of routine cataract surgery. Health Qual Life Outcomes 2006; 4: 74.
5 Sach TH, Foss AJ, Gregson RM, et al. Falls and health status in elderly women following first eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial. The British Journal of Ophthalmology 2007; 91(12): 1675-9.
6 Laidlaw DA, Harrad RA, Hopper CD, et al. Randomised trial of effectiveness of second eye cataract surgery. Lancet (London, England) 1998; 352(9132): 925-9.
7 Mennemeyer ST, Owsley C, McGwin G, Jr. Reducing older driver motor vehicle collisions via earlier cataract surgery. Accid Anal Prev 2013; 61: 203-11.
8 Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study. Age Ageing 2014; 43(3): 341-6.
9 Meuleners LB, Hendrie D, Lee AH, Ng JQ, Morlet N. The effectiveness of cataract surgery in reducing motor vehicle crashes: a whole population study using linked data. Ophthalmic epidemiology 2012; 19(1): 23-8.
10 Gareth Iacobucci. News Analysis. BMJ 2019;365:l2326 doi: 10.1136/bmj.l2326 (Published 29 May 2019)
11 Chellappa S et al. Association of Intraocular Cataract Lens Replacement with Circadian Rhythms, Cognitive Function, and Sleep in Older Adults. JAMA Ophthalmology. doi:10.1001/jamaophthalmol.2019.1406 (Published online May 23, 2019)