Implementation of a Free Cataract Surgery Program in Rural China: A Community-Based Randomized Interventional Study

doi:10.1016/j.ophtha.2012.07.087

Ophthalmology

Volume 120, Issue 2, February 2013, Pages 260-265

Presented as a poster at: Association for Research in Vision and Ophthalmology Annual Meeting, Fort Lauderdale, Florida, May 2012.

https://doi.org/10.1016/j.ophtha.2012.07.087 Get rights and content

Purpose

To identify effective methods to increase the number of cataract surgeries in a rural setting in Pucheng County of Shaanxi Province, northwestern China.

Design

Community-based randomized interventional study.

Participants

Four hundred thirty-two patients 50 years of age or older with operable cataract who had not undergone surgery 3 months after participation in a cataract outreach screening program.

Methods

Three hundred fifty-five (82.2%) patients eligible for surgery, but not scheduling it on their own, were contacted and were assigned randomly into 4 groups. Participants in group 1 (n = 86) were given informative reminders by telephone or in person by a trained facilitator about undergoing low-cost cataract surgery. Group 2 (n = 86) was offered free cataract surgery. Group 3 (n = 90) was offered free surgery and reimbursement of transportation expenses. Group 4 (n = 93) was provided with free rides from home to hospital in addition to the reminder and free surgery.

Main Outcome Measures

Number of participants undergoing cataract surgery after interventions.

Results

In total, 94 patients (26.5%) underwent cataract surgery after interventions. In group 1, 13 patients (14.4%) underwent surgery, which was significantly lower than the number in group 2 (n = 25 [27.8%]; P = 0.027), group 3 (n = 28 [31.1%]; P = 0.012), and group 4 (n = 26 [28%]; P = 0.038). There were no significant differences between groups 2 and 3 (P = 0.768) or between groups 2 and 4 (P = 0.869).

Conclusions

Provision of free cataract surgery was twice as effective as giving patients an informative reminder when it came to increasing the uptake of cataract surgery. However, offering reimbursement of transportation expenses or provision of free rides had minimal added impact on the response rate of participants to undergo cataract surgery.

Financial Disclosure(s)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Section snippets

Patients and Methods

This study was conducted in the Pucheng County Hospital of Shaanxi Province in northwestern China. Pucheng County is a moderate income rural area (1654 km² area) with a population of 767 678 (2010 census),¹⁶ situated northeast of the Guanzhong Plain Shaanxi Province, roughly 110 km from the city of Xi'an. Most people in Pucheng County are farmers. The mean per capita annual income in 2008 in Pucheng County was 2355 RMB/person, which was less than the overall mean per capita income in Shaanxi

Study Participants

Of the 432 patients (mean age±standard deviation, 70.8±7.0 years; 73.2% women) who did not undergo cataract surgery after initial screening, 56 (13.0%) could not be contacted because of a change in the residential address. An additional 21 patients (4.9%) declined to participate in the study. In total, 355 patients (82.2%) were enrolled. The mean age±standard deviation was 70.6±6.6 years, and 73.8% of the participants were women. Overall, 86 participants were allocated randomly to group 1, 86

Discussion

This study was designed based on the results of previous studies that evaluated potential barriers to patients undergoing cataract surgery in rural China.1, 13, 14, 15 Unoperated cataract remains the leading cause of blindness in China as well the rest of the world.2, 19, 20 After the screening that preceded this study, the number of participants who underwent cataract surgery was low (20.1%), although low-cost cataract surgical services are readily available in Pucheng County. Likewise, low

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Cited by (29)

Six-Year Change in Cataract Surgical Coverage and Postoperative Visual Outcomes in Rural Southern China: The Yangxi Eye Study
2023, Asia-Pacific Journal of Ophthalmology
The purpose of this study was to investigate a 6-year change in cataract surgical coverage (CSC), effective cataract surgical coverage (eCSC), and visual outcomes in an elderly population in rural southern China.
This is a prospective population-based study with a 6-year follow-up.
The study included rural residents aged 50 years and above in southern China with comprehensive eye examinations at baseline and follow-up in 2014 and 2020, respectively.
Five thousand six hundred thirty-eight participants underwent baseline examinations (mean age 66.1±10.2 y, 50.8% women); and 3141 (64.9%) of 4841 eligible survivors attended the 6-year follow-up. Cataract surgical coverage was 41.7% and 40.6% at baseline and follow-up, respectively, while eCSC were 32.6% and 26.6%. In multivariate models, the 6-year likelihood of cataract surgery decreased with older age [odds ratio (OR)=0.97 per year, 95% confidence interval (CI): 0.94, 0.99, P=0.012] and worse baseline presenting uncorrected visual acuity (PVA) in the worse-seeing eye (OR=0.35 per unit logarithm of the minimum angle of resolution (logMAR), 95% CI: 0.25, 0.48, P<0.001), and increased with prior cataract surgical history at baseline (OR=3.88, 95% CI: 1.91, 7.09, P<0.001). The likelihood of receiving effective cataract surgery decreased with worse baseline PVA in the worse eye (OR=0.49 per unit logMAR, 95% CI: 0.24, 0.97, P=0.042) and better-seeing eye (OR=0.68 per unit logMAR, 95% CI: 0.48, 0.95, P=0.026). Posterior capsular opacification was the main reason for PVA <6/18, reporting it in logMAR (0.5) in operated eyes (38.4% at baseline; 28.1% at follow-up).
World Health Organization has established a global target of increasing eCSC by 30% before 2030, but no increase was found in rural southern China between 2014 and 2020, let alone reaching the World Health Organization target of 56.3%. Strategies to improve surgery incidence should focus on older persons and those with worse preoperative PVA.
Strategies for cataract and uncorrected refractive error case finding in India: Costs and cost-effectiveness at scale
2022, The Lancet Regional Health - Southeast Asia
India has the largest number of individuals suffering from visual impairment and blindness in the world. Recent surveys indicate that demand-based factors prevent more than 80% of people from seeking appropriate eye services, suggesting the need to scale up cost-effective case finding strategies. We assessed total costs and cost-effectiveness of multiple strategies to identify and encourage people to initiate corrective eye services.
Using administrative and financial data from six Indian eye health providers, we conduct a retrospective micro-costing analysis of five case finding interventions that covered 1·4 million people served at primary eye care facilities (vision centers), 330,000 children screened at school, 310,000 people screened at eye camps and 290,000 people screened via door-to-door campaigns over one year. For four interventions, we estimate total provider costs, provider costs attributable to case finding and treatment initiation for uncorrected refractive error (URE) and cataracts, and the societal cost per DALY averted. We also estimate provider costs of deploying teleophthalmology capability within vision centers. Point estimates were calculated from provided data with confidence intervals determined by varying parameters probabilistically across 10,000 Monte Carlo simulations.
Case finding and treatment initiation costs are lowest for eye camps (URE: $8·0 per case, 95% CI: 3·4–14·4; cataracts: $13·7 per case, 95% CI: 5·6–27·0) and vision centers (URE: $10·8 per case, 95% CI: 8·0–14·4; cataracts: $11·9 per case, 95% CI: 8·8–15·9). Door-to-door screening is as cost-effective for identifying and encouraging surgery for cataracts albeit with large uncertainty ($11·3 per case, 95% CI: 2·2 to 56·2), and more costly for initiating spectacles for URE ($25·8 per case, 95% CI: 24·1 to 30·7). School screening has the highest case finding and treatment initiation costs for URE ($29·3 per case, 95% CI: 15·5 to 49·6) due to the lower prevalence of eye problems in school aged children. The annualized cost of operating a vision center, excluding procurement of spectacles, is estimated at $11,707 (95% CI: 8,722–15,492). Adding teleophthalmology capability increases annualized costs by $1,271 per facility (95% CI: 181 to 3,340). Compared to baseline care, eye camps have an incremental cost-effectiveness ratio (ICER) of $143 per DALY (95% CI: 93–251). Vision centers have an ICER of $262 per DALY (95% CI: 175–431) and were able to reach substantially more patients than any other strategy.
Policy makers are expected to consider cost-effective case finding strategies when budgeting for eye health in India. Screening camps and vision centers are the most cost-effective strategies for identifying and encouraging individuals to undertake corrective eye services, with vision centers likely to be most cost-effective at greater scale. Investment in eye health continues to be very cost-effective in India.
The study was funded by the Seva Foundation.
Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development
2015, The Lancet
Citation Excerpt :
Similarly, uptake of paediatric surgical services increased by five-fold in Sierra Leone after the introduction of a free health-care policy for children younger than 5 years.241 The removal of user fees for cataract surgery in rural China doubled uptake of services242 and contributed to poverty alleviation, especially in the poorest of the study population.216 In addition to official user fees for surgical services, two other types of OOP expenses are often encountered by households when accessing surgical and anaesthesia care in many LMICs.
Barriers to uptake of cataract surgery among elderly patients in rural China: a cross-sectional study
2024, BMJ Open
To investigate the individual and household-level factors influencing the willingness to pay for cataract surgery among patients aged 50 years and older in rural China: A cross-sectional study
2023, BMJ Open
Improving access to eye care in low and middle-income countries–challenges, opportunities, and the way forward
2023, Expert Review of Ophthalmology

View all citing articles on Scopus

: Manuscript no. 2012-251.

: Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

: Supported by The Project Vision Charity Foundation, Hong Kong, China. Project Vision had no role in the design or conduct of this research.

^⁎: Both Xiu Juan Zhang, MD, PhD, and Yuan Bo Liang, MD, PhD, contributed equally as first authors.

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Original articleImplementation of a Free Cataract Surgery Program in Rural China: A Community-Based Randomized Interventional Study

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Financial Disclosure(s)

Section snippets

Patients and Methods

Study Participants

Discussion

Ophthalmology

Ophthalmology

Models for improving cataract surgical rates in southern China

Br J Ophthalmol

Prevalence and causes of low vision and blindness in a rural Chinese adult population: the Handan Eye Study

Ophthalmology

China's CSR report in 2009 [in Chinese]Annex tables [downloadable file]

Project Vision: a new and sustainable model for eliminating cataract blindness in China

Clin Experiment Ophthalmol

Reasons for poor cataract surgery uptake—a qualitative study in rural South Africa

Trop Med Int Health

Poverty as a barrier to accessing cataract surgery: a study from Tanzania

Br J Ophthalmol

Understanding why patients with cataract refuse free surgery: the influence of rumours in Kenya

Trop Med Int Health

Follow-up survey of cataract surgical coverage and barriers to cataract surgery at Nkhoma, Malawi

Ophthalmic Epidemiol

Barriers to cataract surgical uptake in the Upper East Region of Ghana

Ghana Med J

Cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in Pakistan: the Pakistan National Blindness and Visual Impairment Survey

Br J Ophthalmol

Cataract in central Sri Lanka: cataract surgical coverage and self-reported barriers to cataract surgery

Clin Experiment Ophthalmol

Barriers to the uptake of cataract surgery in patients presenting to a hospital

Indian J Ophthalmol

A two-site, population-based study of barriers to cataract surgery in rural China

Invest Ophthalmol Vis Sci

Original article
Implementation of a Free Cataract Surgery Program in Rural China: A Community-Based Randomized Interventional Study