Day-case cataract surgery

Evaluation of day care versus inpatient cataract surgery performed at a Jiangsu public Tertiary A hospital

BACKGROUND

High cataract incidence and low cataract surgical rate are serious public health problems in China, despite the fact that efficient day care cataract surgery has been implemented in some public Tertiary A hospitals in China. In this study, we compared not only clinical outcomes, hospitalization time and total costs but also payment manners between day care and inpatient procedures for cataract surgery in a Jiangsu public Tertiary A hospital to put forward several instructional suggestions for the improvement of government medical policies.

METHODS

In total, 4151 day care cases and 2509 inpatient cases underwent the same cataract surgery in the day care ward and ordinary ward respectively, and were defined as two groups. General information, complications, postoperative best corrected visual acuity (BCVA), hospitalization time, total costs and especially payment method were analyzed to compare day care versus inpatient.

RESULTS

The general data display no significant differences (P > 0.05), and no significant difference between complications and postoperative BCVA were observed between the two groups (P > 0.05). The period of stay in hospital was significantly different (P < 0.001). The total costs were lower for day care than for inpatients (P < 0.001). To avoid sampling error, we analyzed the data of payment manner for each patient among this period. Day care patients tended to pay for the procedure using the Urban Employees Basic Medical Insurance (UEBMI) method, while inpatients tended to use the Out-of-Pocket Medical Treatment (OMT) payment method (P < 0.001).

CONCLUSION

Day surgery of cataract is more cost-effective and efficient than inpatient surgery with equivalent clinical outcomes. As an efficient therapeutic regimen, day care surgery should be further promoted and supported by the government policies.

Determinants of inappropriate hospitalization in cataract surgery in the south of Italy: a retrospective study

PURPOSE

To analyze the frequency of inappropriate hospitalization in cataract surgery and the type of related determinants.

METHODS

A nested retrospective case-control study was carried out on 2708 consecutive cataract surgery patients operated between January 2013 and December 2015. All cases with inappropriate hospitalization (day surgery or ordinary hospitalization) were compared with a control group of cases treated in an appropriate (day service) regimen. The predictive value for inappropriate admissions to the hospital was assessed using a logistic regression model. Significant variables from the univariate analysis were included in a multivariate model.

RESULTS

Forty-five cases (< 2%) of inappropriate hospital admissions were recorded. Residence, heart disease, tremors, anticoagulants, intraoperative floppy iris syndrome were not related to appropriateness, while psychotic disorder (OR 12.571, p = 0.018), anxiety-depressive syndrome (OR 7.818, p = 0.010) and use of antipsychotropic drugs (OR 7.724, p = 0.002) were related to the inappropriateness of admission by univariate and multivariate analysis. Previous systemic surgeries were predictors of ordinary hospitalization by logistic regression analysis. A greater presence of hypertension, diabetes mellitus and fellow eye pseudophakia was noticed in appropriate hospitalization cases.

CONCLUSIONS

This study detects the predictive role of psychiatric disorders as determinants of hospitalization inappropriateness in cataract surgery. The negative correlation between inappropriate hospitalization and conditions such as hypertension and diabetes points out that in the elderly population common diseases are effectively addressed, in contrast to the difficult management of psychiatric patients. Prior systemic interventions represent factors inducing transfer from day service to ordinary hospitalization, highlighting communication problems related to difficult coping with an outpatient surgery setting.

More frequent requests for day-case cataract surgery : An impressive mind switch in the Austrian population within 7 years

BACKGROUND

Cataract surgery is the most commonly performed elective surgical procedure worldwide. While the operation has been mainly conducted as day-case (outpatient) surgery throughout the world since the beginning of this millennium, this development has been much slower in Austria. The number of patients requesting day-case surgery has markedly increased in the last few years.

METHODS

Prior to the introduction of a day clinic at our department in 2007, we evaluated the patients' acceptance of day-case surgery using a questionnaire. At the time, less than half of the patients wished to undergo day-case surgery. Another survey was performed 7 years later to determine if there were any changes.

RESULTS

The desire for day-case surgery increased significantly from 38.8 to 87.1%. The mean age of the patients and their visual impairment had decreased. Home care improved, but not to the same extent. The number of patients who had to travel more than an hour to reach the hospital had significantly increased.

CONCLUSIONS

Improvements in perioperative limitations and most of all patients becoming accustomed to the idea have led to an impressive mind switch, culminating in a clear desire for day-case cataract surgery.

Out-patient cataract surgery. First experiences from a large hospital department

Out-patient cataract surgery was recently introduced as a routine procedure in our department. Background population, selection criteria and practical-administrative procedures for the first 33 patients are described. 19 females and 14 males, age range 45 to 90 years, were offered ambulatory surgery; 19 had extracapsular surgery and 27 intraocular lenses. Insignificant complications occurred in four cases, one of them related to the out-patient procedure. It definitely seems possible to offer this modality to selected patients without compromising medical ethics, and the results have been met with unanimous satisfaction by the patients.

Is day-case cataract surgery an attractive alternative from the patients' point of view? A questionnaire survey

Cataract surgery is the most common elective surgical procedure undertaken in elderly people. In many European countries and in the USA cataract surgery is normally a day-case procedure without an overnight stay in hospital, unlike the situation in Austria where fewer than 2% of patients are day cases. However, there is a lack of prospective studies on patients' need for and acceptance of day-case surgery. The aim of our study was therefore to evaluate patients' demand and suitability for outpatient surgery, based on analysis of preoperative questionnaires on availability of family and/or social support and on preoperative ophthalmologic examination. Among 500 consecutive patients with cataract, 154 (41.8%) chose a day-case procedure and 256 (58.2%) preferred inpatient admission. Patients preferring full admission were older (mean age 76.4+/-8.1 vs. 72.73+/-9.5 years, P<0.001), had worse visual acuity (0.55+/-0.20 vs. 0.66+/-0.23, P<0.001), were more likely to be female (63.9% vs. 47.0%, P=0.001), to live more than one hour away from the hospital (26.5% vs. 12.5%, P<0.001) and have no carer at home (43.0% vs. 6.5%, P<0.001). Patients favoring day-case surgery were more likely to be able to attend an ophthalmologic check-up 24 h after surgery (96.7% vs. 59.6%, p<0.001). The majority of patients indicated a preference for inpatient care, but this may be a reflection of their previous hospital experience and a matter of custom in the elderly population. Information, education and better organization of after-surgery services could help increase the attractiveness of cataract surgery as an outpatient procedure in Austria. Our findings could also be relevant to day-case services in medical care in general.

Cataract extraction in a major ophthalmic hospital: day-case or overnight stay?

PURPOSE

Cataract surgery is increasing in Australia and represents a significant burden on limited health resources. This study examines the frequency and outcomes of cataract surgery for patients who were hospitalized overnight compared with those treated as day surgery cases.

METHODS

Medical records of 671 consecutive admissions for cataract surgery at the Royal Victorian Eye and Ear Hospital were reviewed. Data analysed included demographic features, insurance status, length of hospitalization, ophthalmic conditions, medical conditions, social problems and planned surgical technique. Ophthalmic and anaesthetic complications, active ophthalmic and medical interventions were also studied.

RESULTS

Of the 671 patient admissions for cataract during the study period, 226 (33.4%) were hospitalized overnight. Factors significantly associated with overnight hospitalization in univariate analyses include older age, female sex, country residence, Veterans' Affairs insurance, monocular vision status, pre-existing ischaemic heart disease, pre-existing asthma/chronic obstructive lung disease, absence of carer, transportation problems, planned extra-capsular cataract extraction technique, ophthalmic complications and active ophthalmic and/or medical interventions. After adjusting for possible confounding factors using backwards stepwise multivariate logistic regression models all except pre-existing ischaemic heart disease and ophthalmic complications were significantly associated with overnight admission for cataract surgery. In total, 14 cases (2.1%) needed active ophthalmic and/or medical interventions, 13 overnight cases and one day case.

CONCLUSIONS

These data suggest that many patients who are hospitalized overnight for cataract surgery could be safely treated as day cases. Such a shift in the pattern of care for cataract surgery could provide a significant potential for health care savings.

Management of day-surgery patients with cataract attending a peripheral ophthalmic clinic

PURPOSE

To compare two organisational models of management for patients with cataract referred to a peripheral ophthalmic clinic who underwent day-surgery at a main eye hospital.

METHOD

Patients were randomised into two groups. The experimental group (n = 25) received pre-operative assessment by a trained ophthalmic nurse at the peripheral clinic immediately following diagnosis of cataract and diary-booking for surgery. The control group (n = 24) received a separate appointment for pre-operative assessment at the main hospital. For all patients, the first review appointment (3 or 5 days post-operatively) and all subsequent review was at the peripheral clinic. Outcome measures included: visual acuity, subjective visual function (VF-14), anxiety and depression (HADS), semi-structured interviews to ascertain patient satisfaction, and a cost-benefit analysis.

RESULTS

There were no significant differences at any time between the experimental and control groups with respect to visual acuity, subjective visual function or anxiety and depression. The experimental model was found to be more cost-effective and provided a less fragmented means of care delivery. The majority of patients in both groups expressed satisfaction with their care but, overall, the experimental model was preferred.

CONCLUSIONS

Nurse-led pre-operative assessment of patients with cataract at a peripheral ophthalmic clinic is safe, cost-effective and is preferred by patients.

The effects of EMLA and a topical formulation of 4% amethocaine (Ametop) on pain associated with retrobulbar injection

Retrobulbar block is commonly performed to provide anaesthesia for cataract extraction. This technique can cause significant discomfort. A prospective, randomised, placebo-controlled trial was carried out to investigate the efficacy of a eutectic mixture of local anaesthetics (EMLA) and a 4% amethocaine topical formulation (Ametop) in reducing the pain of retrobulbar injection. Ametop and EMLA proved to be of similar efficacy, both being superior to a placebo in alleviating the discomfort of retrobulbar block. No significant side-effects were observed with the use of either formulation.

Day case cataract surgery in the UK and USA: a comparative study

This study is a comparison of healthcare provision for day case cataract surgery in the UK and the USA. It commences with a brief history and the political influences on the development of healthcare in the USA and the UK, identifying recent changes. The high cost of the health system in the USA and the small amount of resources consumed by the NHS in the UK are examined. The service offered to patients requiring cataract surgery in the UK and the USA are compared and the increasing demand for this operation and the challenge of differing styles of nursing that day surgery requires are discussed. The study concludes by pointing out the consistent expansion of day surgery in both countries in recent years, and predicts that, in view of the patient satisfaction and economic benefit, the growth of day surgery in the future appears almost unlimited.

Development of day case cataract surgery: a literature review

There is increasing demand for day case cataract surgery. This review looks at the varying criteria for suitable patients and compares the use of local or general anaesthesia for day surgery. Preassessment clinics and the possible limitations of patient transport are discussed. Length of stay in the day unit, nurse involvement and discharge procedures are examined. Postoperative visits are reviewed. Studies show that the clinical outcome is not affected by outpatient surgery and that patients report a high level of satisfaction with their day care. Day case cataract surgery is safe and cost-effective and increased patient demand will become a significant factor favouring day case surgery in the future. Further research into patients' attitudes to the continuity of nursing care from preoperative assessment, through surgery to discharge, and whether this plays a part in their overall satisfaction, is recommended.

Results of out-patient cataract surgery in patients who live far from the surgeon

We have performed this prospective study to address the question of whether there is an association between the outcome following cataract surgery and the distance from the patient's home to the place of surgery. Three hundred and forty consecutive out-patient extracapsular cataract extractions were evaluated. According to the distance, the cases were grouped into two categories, 183 cases in the nearest group (Group 1) and 157 cases in the farthest group (Group 2). A best corrected visual acuity of 0.5 or better was achieved in 90% of patients, 6 between the groups. No significant differences in rates for operative and postoperative complications were identified. This study does not show that the distance from the patient's home to the surgical site has had any adverse effect of surgical outcome or in rates of complications.

Is measuring intraocular pressure necessary on the first post-operative day following uncomplicated cataract surgery?

A prospective study was undertaken to assess whether the level of intraocular pressure (IOP) on the first day after cataract surgery could be estimated by clinical examination only, thereby removing the need for applanation tonometry. A total of 70 patients underwent uncomplicated extracapsular cataract extraction and intraocular lens implantation. The following day a Consultant, Registrar and Senior House Officer were asked to identify those patients with significantly raised IOP (> 27 mmHg) using slit lamp examination only. A fourth examiner, masked to the assessments of the three observers, measured the IOP using the Goldmann applanation tonometer. Pressures of > 27 mmHg by Goldmann tonometry were found in 10 patients (14%) of which 8 (80%) were missed by all three ophthalmologists. Formal measurement of IOP appears a necessary part of the post-operative assessment after uncomplicated cataract surgery.

Patient satisfaction following vitreoretinal surgery

A postal questionnaire was used to study patient satisfaction in 149 consecutive patients undergoing vitreoretinal surgery in Southampton. Of the 123 patients who responded, 70 (60%) felt that their vision improved following surgery. Fifty-eight patients (47%) stated that their vision was not as good as they had hoped it would be, and multiple logistic regression analysis showed that this response reflected a poorer visual outcome in this group. Despite this, 116 (94%) of those replying stated that the operation had been worth while. All 5 patients who felt that their operations had not been worth while had undergone retinal detachment surgery. This high level of satisfaction may be attributable to realistic expectations, as 116 patients (94%) replied that the procedures had been adequately explained.

Do patients like day case cataract surgery?

One hundred and fifty consecutive questionnaires following day case cataract surgery showed that 87% of the patients would choose day surgery again. The questionnaires were directed at the patients' attitudes to day surgery for their cataracts. There was overwhelming acceptance of the travelling and inconvenience involved.

Patient perceptions and social impact. Preliminary results of the Bristol MRC Study

One hundred and nine inpatients were compared with 84 day cases by means of specially designed questionnaires presented at set times by staff other than the operating surgeon. The aim was to highlight patient attitudes, expectations and satisfaction with a standard method of endocapsular cataract extraction and posterior chamber lens implant under local anaesthetic as either a day case (DC) or an inpatient (IP). The results showed a high patient acceptance of whichever method of management was chosen. Both groups appeared satisfied with their treatment and the final result. The cost of DC and IP treatment was assessed.

A double-masked evaluation of lignocaine-prilocaine cream (EMLA) used to alleviate the pain of retrobulbar injection

A randomised, placebo controlled, double-masked study was undertaken in 115 patients undergoing cataract surgery to assess the efficacy of the anaesthetic cream EMLA (eutetic mixture of local anaesthetic, lignocaine-prilocaine) in alleviating the pain of retrobulbar injection. Sixty three patients received the EMLA cream and 52 the placebo cream. The pain was assessed objectively by the anaesthetist, who observed the reaction of the patient on needle insertion, and subjectively by the patient. Significantly lower pain scores were recorded in patients treated with EMLA cream (anaesthetist's observation: p less than 0.01, patient's assessment: p less than 0.006). No patients experienced serious side effects in either treatment group.

Public hospital day-case surgery in a dedicated facility

The first dedicated, public hospital day-case eye surgery unit opened in Melbourne in June 1987. This report details the mode of operation of this unit, and analyses the 218 procedures performed in the first 15 months of operation, and includes an assessment of the level of patient acceptance.

Outpatient penetrating keratoplasty

Elective penetrating keratoplasty has been performed on an outpatient basis on 37 patients since July 1987. The commonest indications have been herpetic keratitis, keratoconus, and pseudophakic or aphakic corneal oedema. Local anaesthesia, with little or no sedation, was used in most cases, and only three patients had a general anaesthetic. Accompanying procedures have included anterior vitrectomy, extracapsular cataract extraction with posterior chamber lens implantation and IOL exchange. The results demonstrate that outpatient keratoplasty is a safe, effective alternative to hospitalisation, and has a very high level of patient acceptance.

Day-case cataract surgery

The results of a series of 40 cataract extractions with lens implantation performed on day-case patients under local anaesthesia are reported. The ways in which modern surgical techniques have rendered this a safe procedure are described, and the potential benefits of day-case intraocular surgery are discussed.

Outpatient keratoplasty

Outpatient keratoplasty in 103 patients (46 males and 57 females ranging in age from 1 to 90 years) produced no instances of infection, shallow or flat anterior chambers, or anterior synechia formation. Postoperative discomfort was minimal.

Comparison between the complications of cataract surgery following local anaesthesia with short stay and general anaesthesia with a five-day hospitalisation

In December 1979 97 patients underwent intracapsular cataract extraction under local anaesthetic with planned discharge on the day after operation. Twenty-three of these patients had a prolonged stay in hospital, and five of these required early operative intervention following surgical complications. Sixteen patients did not attain a visual acuity better than 6/18. The visual outcome and postoperative course are compared with those of a similar group of patients who stayed in hospital for five days after intracapsular cataract extraction.