1
|
Wu X, Wu Y, Tu Z, Cao Z, Xu M, Xiang Y, Lin D, Jin L, Zhao L, Zhang Y, Liu Y, Yan P, Hu W, Liu J, Liu L, Wang X, Wang R, Chen J, Xiao W, Shang Y, Xie P, Wang D, Zhang X, Dongye M, Wang C, Ting DSW, Liu Y, Pan R, Lin H. Cost-effectiveness and cost-utility of a digital technology-driven hierarchical healthcare screening pattern in China. Nat Commun 2024; 15:3650. [PMID: 38688925 PMCID: PMC11061155 DOI: 10.1038/s41467-024-47211-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024] Open
Abstract
Utilization of digital technologies for cataract screening in primary care is a potential solution for addressing the dilemma between the growing aging population and unequally distributed resources. Here, we propose a digital technology-driven hierarchical screening (DH screening) pattern implemented in China to promote the equity and accessibility of healthcare. It consists of home-based mobile artificial intelligence (AI) screening, community-based AI diagnosis, and referral to hospitals. We utilize decision-analytic Markov models to evaluate the cost-effectiveness and cost-utility of different cataract screening strategies (no screening, telescreening, AI screening and DH screening). A simulated cohort of 100,000 individuals from age 50 is built through a total of 30 1-year Markov cycles. The primary outcomes are incremental cost-effectiveness ratio and incremental cost-utility ratio. The results show that DH screening dominates no screening, telescreening and AI screening in urban and rural China. Annual DH screening emerges as the most economically effective strategy with 341 (338 to 344) and 1326 (1312 to 1340) years of blindness avoided compared with telescreening, and 37 (35 to 39) and 140 (131 to 148) years compared with AI screening in urban and rural settings, respectively. The findings remain robust across all sensitivity analyses conducted. Here, we report that DH screening is cost-effective in urban and rural China, and the annual screening proves to be the most cost-effective option, providing an economic rationale for policymakers promoting public eye health in low- and middle-income countries.
Collapse
Affiliation(s)
- Xiaohang Wu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Yuxuan Wu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Zhenjun Tu
- School of Computer Science and Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zizheng Cao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Miaohong Xu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Yifan Xiang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Duoru Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Ling Jin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Lanqin Zhao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Yingzhe Zhang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Yu Liu
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Pisong Yan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Weiling Hu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Jiali Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Lixue Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Xun Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Ruixin Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Jieying Chen
- School of Computer Science and Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wei Xiao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Yuanjun Shang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Peichen Xie
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Dongni Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Xulin Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Meimei Dongye
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Chenxinqi Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
| | - Daniel Shu Wei Ting
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Yizhi Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China.
| | - Rong Pan
- School of Computer Science and Engineering, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Haotian Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Vision Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China.
- Hainan Eye Hospital and Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou, Hainan, China.
- Center for Precision Medicine and Department of Genetics and Biomedical Informatics, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, Guangdong, China.
| |
Collapse
|
2
|
Xiang Y, Wang X, Cao X, Wei F, Chen Y, Ran J, Long Z, Tan Q, Lai Z, Liu L, Zhao D, Xiong L, Tang B, Wan W, Hu K. Efficacy of cataract surgeries performed during blindness prevention programs in Chongqing, China: a multicenter prospective study. BMC Ophthalmol 2023; 23:353. [PMID: 37563617 PMCID: PMC10413487 DOI: 10.1186/s12886-023-03082-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/14/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTIVE To determine the efficacy of cataract surgeries in blindness prevention programs in Chongqing. METHODS During February-December 2019, we prospectively enrolled 487 patients (592 eyes) undergoing cataract surgery during blindness prevention programs in 6 Chongqing district/county hospitals (experimental group) and 481 patients (609 eyes) undergoing cataract surgery in the First Affiliated Hospital of Chongqing Medical University (controls). Uncorrected visual acuity (UCVA), refractive status, best corrected visual acuity (BCVA), slit lamp examination, and visual function/quality of life (VF-QOL) questionnaire scores were evaluated preoperatively, and at 1 and 6 months postoperatively. RESULTS In the experimental group, UCVA, BCVA, and VF-QOL scores at 1 and 6 months were better than the preoperative values (P < 0.05), but lower than the control-group values (P < 0.05). Rates of good UCVA and BCVA outcomes (≤ 0.5 logMAR) in the experimental group were 76.2% and 87.6%, respectively, at 1 month and 68.9% and 83.1%, respectively, at 6 months. Most eyes in the experimental (82.1%) and control (89.5%) groups had refractive errors within ± 1 D at 1 month. At 6 months, posterior capsule opacification (PCO) was more common in the experimental group (20.9% vs. 15.0%, P < 0.05). At 6 months, the main causes of visual impairment (UCVA > 0.5 logMAR) in the experimental group were uncorrected refractive errors (33.0%), PCO (29.5%), and fundus diseases (33.9%). CONCLUSION Cataract surgeries in blindness prevention programs in Chongqing significantly improved visual acuity, VF, and QOL, but underperformed compared to surgeries in the tertiary teaching hospital.
Collapse
Affiliation(s)
- Yongguo Xiang
- Chongqing Medical University, Chongqing, People's Republic of China
| | - Xiaoqin Wang
- People's Hospital of Tongliang District, Tongliang District, Chongqing, People's Republic of China
| | - Xiaochuan Cao
- People's Hospital of Tongliang District, Tongliang District, Chongqing, People's Republic of China
| | - Fang Wei
- Youyang County People's Hospital, Youyang County, Chongqing, People's Republic of China
| | - Yu Chen
- Youyang County People's Hospital, Youyang County, Chongqing, People's Republic of China
| | - Jianchuan Ran
- Qianjiang Central Hospital, Qianjiang District, Chongqing, People's Republic of China
| | - Zhengqin Long
- Qianjiang Central Hospital, Qianjiang District, Chongqing, People's Republic of China
| | - Qunwu Tan
- Wushan County People's Hospital, Wushan County, Chongqing, People's Republic of China
| | - Zhenying Lai
- Wushan County People's Hospital, Wushan County, Chongqing, People's Republic of China
| | - Li Liu
- People's Hospital of Dazu District, Dazu District, Chongqing, People's Republic of China
| | - Desheng Zhao
- People's Hospital of Dazu District, Dazu District, Chongqing, People's Republic of China
| | - Liang Xiong
- People's Hospital of Jiangbei District, Jiangbei District, Chongqing, People's Republic of China
| | - Bin Tang
- People's Hospital of Jiangbei District, Jiangbei District, Chongqing, People's Republic of China
| | - Wenjuan Wan
- Chongqing Medical University, Chongqing, People's Republic of China.
- Chongqing Key Laboratory of Ophthalmology, Chongqing Branch (Municipality Division) of National Clinical Research Center for Ocular Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing Eye Institute, Chongqing, People's Republic of China.
| | - Ke Hu
- Chongqing Medical University, Chongqing, People's Republic of China.
- Chongqing Key Laboratory of Ophthalmology, Chongqing Branch (Municipality Division) of National Clinical Research Center for Ocular Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing Eye Institute, Chongqing, People's Republic of China.
| |
Collapse
|
3
|
Ramke J, Silva JC, Gichangi M, Ravilla T, Burn H, Buchan JC, Welch V, Gilbert CE, Burton MJ. Cataract services for all: Strategies for equitable access from a global modified Delphi process. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000631. [PMID: 36962938 PMCID: PMC10021896 DOI: 10.1371/journal.pgph.0000631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 11/22/2022] [Indexed: 02/24/2023]
Abstract
Vision loss from cataract is unequally distributed, and there is very little evidence on how to overcome this inequity. This project aimed to engage multiple stakeholder groups to identify and prioritise (1) delivery strategies that improve access to cataract services for under-served groups and (2) population groups to target with these strategies across world regions. We recruited panellists knowledgeable about cataract services from eight world regions to complete a two-round online modified Delphi process. In Round 1, panellists answered open-ended questions about strategies to improve access to screening and surgery for cataract, and which population groups to target with these strategies. In Round 2, panellists ranked the strategies and groups to arrive at the final lists regionally and globally. 183 people completed both rounds (46% women). In total, 22 distinct population groups were identified. At the global level the priority groups for improving access to cataract services were people in rural/remote areas, with low socioeconomic status and low social support. South Asia and Sub-Saharan Africa were the only regions in which panellists ranked women in the top 5 priority groups. Panellists identified 16 and 19 discreet strategies to improve access to screening and surgical services, respectively. These mostly addressed health system/supply side factors, including policy, human resources, financing and service delivery. We believe these results can serve eye health decision-makers, researchers and funders as a starting point for coordinated action to improve access to cataract services, particularly among population groups who have historically been left behind.
Collapse
Affiliation(s)
- Jacqueline Ramke
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Juan Carlos Silva
- Pan American Health Organization, World Health Organization, Bogotá, Colombia
| | | | | | - Helen Burn
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John C. Buchan
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Vivian Welch
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada
| | - Clare E. Gilbert
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Moorfields Eye Hospital, London, United Kingdom
| | | |
Collapse
|
4
|
Olawoye OO, Fawole O, Ashaye AO, Chan VF, Azuara-Blanco A, Congdon N. Effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria. Br J Ophthalmol 2023; 107:30-36. [PMID: 34362773 DOI: 10.1136/bjophthalmol-2021-319355] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/23/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE To determine the effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria. METHODOLOGY This was a prospective study in which two cohort of participants were recruited in Nigeria: 1 from 24 outreach screenings and another from consecutive patients presenting spontaneously to a tertiary eye clinic in Nigeria. Sociodemographic and clinical data were obtained from participants and compared. RESULTS Our sample consisted of 120 patients with glaucoma or suspected glaucoma (6.38% of 1881 screenees) recruited from the 24 outreach screenings, and another 123 patients with glaucoma who presented spontaneously at the eye clinic. Participants from the screenings were significantly older (p=0.012), less educated (p<0.001), had lower incomes (p<0.001), lower glaucoma knowledge scores and were less aware of their glaucoma (both p<0.001) and were more likely to be dependent on relations and children (p=0.002) compared with clinic participants. Of the 120 patients identified at the screenings and referred to the clinic for definitive care, 39 (32.5%) presented at the clinic within 3 months. Reasons for poor uptake of referral services were lack of a felt need and lack of money for transportation. Considering only patients who accepted referral, they were still less educated (p<0.001), poorer (p=0.001) and less knowledgeable about glaucoma (p=0.003) than spontaneous clinic presenters. CONCLUSION Outreach screening improved equity of access but its effects were somewhat reduced by poor uptake of referral care. Interventions such as free transportation and educational efforts may improve the uptake of referral services and maximise equity gains.
Collapse
Affiliation(s)
- Olusola Oluyinka Olawoye
- Department of Ophthalmology, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria .,Centre for Public Health School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Olufunmilayo Fawole
- Department of Epidemiology and Medical Biostatistics, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria
| | - Adeyinka O Ashaye
- Department of Ophthalmology, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria
| | - Ving Fai Chan
- Centre for Public Health School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Augusto Azuara-Blanco
- Centre for Public Health School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Nathan Congdon
- Centre for Public Health School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.,Preventive Ophthalmology, Zhongshan Ophthalmic Center, Guangdong, China.,Orbis International, New York, New York, USA
| |
Collapse
|
5
|
Wu X, Xu D, Ma T, Li ZH, Ye Z, Wang F, Gao XY, Wang B, Chen YZ, Wang ZH, Chen JL, Hu YT, Ge ZY, Wang DJ, Zeng Q. Artificial Intelligence Model for Antiinterference Cataract Automatic Diagnosis: A Diagnostic Accuracy Study. Front Cell Dev Biol 2022; 10:906042. [PMID: 35938155 PMCID: PMC9355278 DOI: 10.3389/fcell.2022.906042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Cataract is the leading cause of blindness worldwide. In order to achieve large-scale cataract screening and remarkable performance, several studies have applied artificial intelligence (AI) to cataract detection based on fundus images. However, the fundus images they used are original from normal optical circumstances, which is less impractical due to the existence of poor-quality fundus images for inappropriate optical conditions in actual scenarios. Furthermore, these poor-quality images are easily mistaken as cataracts because both show fuzzy imaging characteristics, which may decline the performance of cataract detection. Therefore, we aimed to develop and validate an antiinterference AI model for rapid and efficient diagnosis based on fundus images. Materials and Methods: The datasets (including both cataract and noncataract labels) were derived from the Chinese PLA general hospital. The antiinterference AI model consisted of two AI submodules, a quality recognition model for cataract labeling and a convolutional neural networks-based model for cataract classification. The quality recognition model was performed to distinguish poor-quality images from normal-quality images and further generate the pseudo labels related to image quality for noncataract. Through this, the original binary-class label (cataract and noncataract) was adjusted to three categories (cataract, noncataract with normal-quality images, and noncataract with poor-quality images), which could be used to guide the model to distinguish cataract from suspected cataract fundus images. In the cataract classification stage, the convolutional-neural-network-based model was proposed to classify cataracts based on the label of the previous stage. The performance of the model was internally validated and externally tested in real-world settings, and the evaluation indicators included area under the receiver operating curve (AUC), accuracy (ACC), sensitivity (SEN), and specificity (SPE). Results: In the internal and external validation, the antiinterference AI model showed robust performance in cataract diagnosis (three classifications with AUCs >91%, ACCs >84%, SENs >71%, and SPEs >89%). Compared with the model that was trained on the binary-class label, the antiinterference cataract model improved its performance by 10%. Conclusion: We proposed an efficient antiinterference AI model for cataract diagnosis, which could achieve accurate cataract screening even with the interference of poor-quality images and help the government formulate a more accurate aid policy.
Collapse
Affiliation(s)
- Xing Wu
- Senior Department of Ophthalmology, The Third Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Di Xu
- Beijing Airdoc Technology Co., Ltd., Beijing, China
| | - Tong Ma
- Beijing Airdoc Technology Co., Ltd., Beijing, China
| | - Zhao Hui Li
- Senior Department of Ophthalmology, The Third Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zi Ye
- Senior Department of Ophthalmology, The Third Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Fei Wang
- Health Management Institute, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xiang Yang Gao
- Health Management Institute, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Bin Wang
- Beijing Airdoc Technology Co., Ltd., Beijing, China
| | | | - Zhao Hui Wang
- IKang Guobin Healthcare Group Co., Ltd., Beijing, China
| | - Ji Li Chen
- Department of Ophthalmology, Shanghai Shibei Hospital of Jing’an District, Shanghai, China
| | - Yun Tao Hu
- Department of Ophthalmology, Beijing Tisnghua Changgung Hospital, Beijing, China
| | - Zong Yuan Ge
- Beijing Airdoc Technology Co., Ltd., Beijing, China
| | - Da Jiang Wang
- Senior Department of Ophthalmology, The Third Medical Center of Chinese PLA General Hospital, Beijing, China
- *Correspondence: Da Jiang Wang, ; Qiang Zeng,
| | - Qiang Zeng
- Health Management Institute, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Da Jiang Wang, ; Qiang Zeng,
| |
Collapse
|
6
|
Shetti S, Pradeep TG, Devappa N. Barriers for the uptake of cataract surgery: A rural community-based study. AFRICAN VISION AND EYE HEALTH 2022. [DOI: 10.4102/aveh.v81i1.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
7
|
Malik M, Strang N, Campbell P, Jonuscheit S. Exploring eye care pathways, patient priorities and economics in Pakistan: A scoping review and expert consultation study with thematic analysis. Ophthalmic Physiol Opt 2022; 42:694-716. [PMID: 35318687 PMCID: PMC9310639 DOI: 10.1111/opo.12977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 11/29/2022]
Abstract
Purpose As the prevalence of eye diseases increases, demand for effective, accessible and equitable eye care grows worldwide. This is especially true in lower and middle‐income countries, which have variable levels of infrastructure and economic resources to meet this increased demand. In the present study we aimed to review the literature on eye care in Pakistan comprehensively, with a particular focus on eye care pathways, patient priorities and economics. Methods A systematic scoping review was performed to identify literature relating to eye care in Pakistan. Searches of relevant electronic databases and grey literature were carried out. The results were analysed through a mixed methods approach encompassing descriptive numerical summary and thematic analysis. To consolidate results and define priority areas for future study, expert consultation exercises with key stakeholders were conducted using qualitative semi‐structured interviews. Results One hundred and thirty‐two papers (published and unpublished) were included in the final review. The majority (n = 93) of studies utilised a quantitative design. Seven interlinked themes were identified: eye care pathways, burden of eye disease, public views on eye‐related issues, workforce, barriers to uptake of eye care services, quality of eye care services and economic impact of blindness. Research priorities included investigating the eye care workforce, the quality and efficiency of current eye care services, eye care services available in rural Pakistan and the costs and benefits related to eye care provision and sustaining eye care programmes. Conclusions To the best of our knowledge, this is the first review to synthesise evidence from papers across the field relating to eye care in Pakistan. As such, this work provides new insights into the achievements of the national eye health programme, challenges in eye care in Pakistan and priority areas for future research.
Collapse
Affiliation(s)
- Manal Malik
- Department of Vision Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Niall Strang
- Department of Vision Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Pauline Campbell
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Sven Jonuscheit
- Department of Vision Sciences, Glasgow Caledonian University, Glasgow, UK
| |
Collapse
|
8
|
Nathaniel G, Eze U, Adio A. Vision 2020 – The right to sight: How much has been achieved in Nigeria? And what next? NIGERIAN JOURNAL OF MEDICINE 2022. [DOI: 10.4103/njm.njm_187_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
9
|
Yoshizaki M, Ramke J, Zhang JH, Aghaji A, Furtado JM, Burn H, Gichuhi S, Dean WH, Congdon N, Burton MJ, Buchan J. How can we improve the quality of cataract services for all? A global scoping review. Clin Exp Ophthalmol 2021; 49:672-685. [PMID: 34291550 DOI: 10.1111/ceo.13976] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cataract is a leading cause of blindness and vision impairment globally. Cataract surgery is one of the most frequently performed operations worldwide, but good quality services are not universally available. This scoping review aims to summarise the nature and extent of published literature on interventions to improve the quality of services for age-related cataract globally. METHODS We used the dimensions of quality adopted by WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we added planetary health. On 17 November 2019, we searched MEDLINE, Embase and Global Health for manuscripts published since 1990, without language or geographic restrictions. We included studies that reported quality-relevant interventions and excluded studies focused on technical aspects of surgery or that only involved children (younger than 18 years). Screening of titles/abstracts, full-text review and data extraction were performed by two reviewers independently. Studies were grouped thematically and results synthesised narratively. RESULTS Most of the 143 included studies were undertaken in high-income countries (n = 93, 65%); 29 intervention groups were identified, most commonly preoperative education (n = 17, 12%) and pain/anxiety management (n = 16, 11%). Efficiency was the quality element most often assessed (n = 58, 41%) followed by people-centredness (n = 40, 28%), while integration (n = 4) and timeliness (n = 3) were infrequently reported, and no study reported outcomes related to planetary health. CONCLUSION Evidence on interventions to improve quality of cataract services shows unequal regional distribution. There is an urgent need for more evidence relevant to low- and middle-income countries as well as across all quality elements, including planetary health.
Collapse
Affiliation(s)
- Miho Yoshizaki
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jacqueline Ramke
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Justine H Zhang
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ada Aghaji
- Department of Ophthalmology, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - João M Furtado
- Division of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Helen Burn
- Department of Ophthalmology, Stoke Mandeville Hospital, Aylesbury, United Kingdom
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya
| | - William H Dean
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Department of Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - Nathan Congdon
- Centre for Public Health, Queens University Belfast, Belfast, United Kingdom.,Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.,Orbis International, New York, USA
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Moorfields Eye Hospital, London, United Kingdom
| | - John Buchan
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|
10
|
Reis T, Lansingh V, Ramke J, Silva JC, Resnikoff S, Furtado JM. Cataract as a Cause of Blindness and Vision Impairment in Latin America: Progress Made and Challenges Beyond 2020. Am J Ophthalmol 2021; 225:1-10. [PMID: 33412124 DOI: 10.1016/j.ajo.2020.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To provide an update of cataract as a cause of vision loss in Latin America and to analyze sex inequalities in cataract surgical coverage (CSC) and effective CSC (eCSC) in the region. DESIGN Population-based systematic review with longitudinal comparisons. METHODS The Latin American and Caribbean Health Sciences Literature (LILACS) and PubMed databased were searched for population-based studies reporting cataract blindness, surgical coverage, and outcomes published between January 2014 and December 2019. Information on the number of surgeries performed from the 2014-2016 period was obtained from ministries of health and was used for calculation of the cataract surgical rate (CSR). Sources such as Rapid Assessment of Avoidable Blindness (RAAB) and Rapid Assessment of Cataract Surgical Services data were reanalyzed to calculate sex inequality in CSC and eCSC by subtracting the rate in women from the rate in men. RESULTS Cataract was the cause of 29.8%-77.6% of cases of blindness in the included studies; the CSR improved in 10 countries. The CSC pinhole visual acuity of 3/60 varied from 24.1% in Peru to 97.1% in Argentina, and the median absolute gender inequality CSC pinhole visual acuity 3/60 was -0.7%. The eCSC pinhole visual acuity 3/60 varied from 14.8% in Guatemala to 92.1% in Argentina, and the median absolute gender inequality eCSC pinhole visual acuity 3/60 was -0.8%. CONCLUSIONS Cataract remains a leading cause of blindness in Latin America. Coverage is suboptimal, and surgical results are also below target levels in many countries. Incentives for a better distribution of human resources, adequate training of ophthalmologists, and the inclusion of vision services in universal health care coverage could reduce the burden of cataract in Latin America.
Collapse
Affiliation(s)
- Tulio Reis
- Division of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Van Lansingh
- HelpMeSee, New York City, New York, USA; Instituto Mexicano de Oftalmología, Queretaro, Mexico
| | - Jacqueline Ramke
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Juan Carlos Silva
- Eye Care Program, Pan-American Health Organization, Bogotá, Colombia
| | - Serge Resnikoff
- Brien Holden Vision Institute and School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | - João M Furtado
- Division of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
| |
Collapse
|
11
|
Efficacy, safety and visual outcomes of cataract surgeries performed during blindness prevention programs in different locations in Kenya. Graefes Arch Clin Exp Ophthalmol 2021; 259:1215-1224. [PMID: 33512611 DOI: 10.1007/s00417-021-05084-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/03/2021] [Accepted: 01/15/2021] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To determine the visual outcomes achieved in terms of efficacy and safety during high-volume cataract surgery programs in different locations in Kenya. METHODS Eight hundred eighty-one eyes of 849 patients underwent extracapsular cataract extraction with intraocular lens implantation in a retrospective, observational, consecutive cohort study on patients who underwent cataract surgery in five programs that a Spanish non-governmental organization conducted between 2013 and 2019 for the prevention of blindness in different geographical areas of Kenya: Thika, Athi River, Kissi, Bagavathi, and Nakuru. The programs were carried out by Spanish and Kenyan surgeons working together. RESULTS Mean age was 66.81 ± 14.47 years. Fifty-one percent of the operated eyes (447 eyes) were women. 94% of patients belonged to six ethnic groups. The mean uncorrected distance visual acuity (UDVA) before surgery was 1.98 ± 0.98 logMAR (20/2000), which changed to 0.82 ± 0.68 logMAR (20/150) 3 months after surgeries. The corrected distance visual acuity (CDVA) was 0.4 ± 0.53 logMAR (20/50) 3 months after surgery, 77.5% of the patients had good visual outcomes, and 6.3% had poor outcomes. Preoperative UDVAs were significantly different with respect to the different geographical areas (Kruskal-Wallis; p < 0.001). The most common intraoperative complication was posterior capsule rupture (incidence, 4.2%, 37 of 881), and the most serious complication was expulsive hemorrhage (incidence, 0.1%, 1 of 881). CONCLUSIONS Cataract programs performed in a middle-income country with the proper technique and standardized protocols of action improved the visual outcome of the patients. Dissimilar baseline status was found in different areas regarding preoperative visual acuities. Training programs of local surgeons should be reinforced.
Collapse
|
12
|
Yoshizaki M, Ramke J, Furtado JM, Burn H, Gichuhi S, Gordon I, Aghaji A, Marques AP, Dean WH, Congdon N, Buchan J, Burton MJ. Interventions to improve the quality of cataract services: protocol for a global scoping review. BMJ Open 2020; 10:e036413. [PMID: 32788187 PMCID: PMC7422650 DOI: 10.1136/bmjopen-2019-036413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/15/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Cataract is the leading cause of blindness globally and a major cause of vision impairment. Cataract surgery is an efficacious intervention that usually restores vision. Although it is one of the most commonly conducted surgical interventions worldwide, good quality services (from being detected with operable cataract to undergoing surgery and receiving postoperative care) are not universally accessible. Poor quality understandably reduces the willingness of people with operable cataract to undergo surgery. Therefore, it is critical to improve the quality of care to subsequently reduce vision loss from cataract. This scoping review aims to summarise the nature and extent of the published literature on interventions to improve the quality of services for primary age-related cataract globally. METHODS AND ANALYSIS We will search MEDLINE, Embase and Global Health for peer-reviewed manuscripts published since 1990, with no language, geographic or study design restrictions. To define quality, we have used the elements adopted by the WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we have added the element of planetary health. We will exclude studies focused on the technical aspects of the surgical procedure and studies that only involve children (<18 years). Two reviewers will screen all titles/abstracts independently, followed by a full-text review of potentially relevant articles. For included articles, data regarding publication characteristics, study details and quality-related outcomes will be extracted by two reviewers independently. Results will be synthesised narratively and presented visually using a spider chart. ETHICS AND DISSEMINATION Ethical approval was not sought, as our review will only include published and publicly accessible information. We will publish our findings in an open-access peer-reviewed journal and develop an accessible summary of the results for website posting. A summary of the results will be included in the ongoing Lancet Global Health Commission on Global Eye Health. REGISTRATION DETAILS Open Science Framework (https://osf.io/8gktz).
Collapse
Affiliation(s)
- Miho Yoshizaki
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jacqueline Ramke
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - João M Furtado
- Division of Ophthalmology, Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, São Paulo, Brazil
| | - Helen Burn
- Department of Ophthalmology, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya
| | - Iris Gordon
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ada Aghaji
- Department of Ophthalmology, University of Nigeria, Nsukka, Enugu, Nigeria
| | - Ana P Marques
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - William H Dean
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Ophthalmology, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Nathan Congdon
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - John Buchan
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Moorfields Eye Hospital, London, UK
| |
Collapse
|
13
|
Yashadhana A, Zhang JH, Yasmin S, Morjaria P, Holland P, Faal H, Burton MJ, Ramke J. Action needed to improve equity and diversity in global eye health leadership. Eye (Lond) 2020; 34:1051-1054. [PMID: 32203245 PMCID: PMC7413372 DOI: 10.1038/s41433-020-0843-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/06/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- Aryati Yashadhana
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Justine H Zhang
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.,Manchester Royal Eye Hospital, Manchester, UK
| | | | - Priya Morjaria
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Holland
- International Agency for the Prevention of Blindness, London, UK
| | - Hannah Faal
- Department of Ophthalmology, University of Calabar, Calabar, Nigeria
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.,Moorfields Eye Hospital, London, UK
| | - Jacqueline Ramke
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK. .,School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand.
| |
Collapse
|
14
|
Ryu SY, Kim J, Hong JH, Chung EJ. Incidence and characteristics of cataract surgery in South Korea from 2011 to 2015: A nationwide population-based study. Clin Exp Ophthalmol 2019; 48:319-327. [PMID: 31867796 DOI: 10.1111/ceo.13705] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/12/2019] [Accepted: 12/14/2019] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Detailed incidence data for cataract surgery in the general population are limited, yet important for determining the surgical needs of the community and formulation of healthcare policies. BACKGROUND To report incidence rates of cataract surgery in South Korea. DESIGN Nationwide, retrospective population-based study. PARTICIPANTS This study involved the entire population of South Korea (n = 47 990 761); 2 236 107 eyes of 1 591 176 patients confirmed as having cataract surgery from 1 January 2011 to 31 December 2015 were included. METHODS Data for all patients who underwent primary cataract surgery in South Korea were retrieved using Korean Electronic Data Interchange and Korean Standard Classification of Diseases-7 codes. Annual incidence rates were calculated and adjusted to the national population data for the corresponding year. MAIN OUTCOME MEASURES The average incidence of cataract surgery during the 5-year study period was estimated using population data from the 2010 Korean census. RESULTS The incidence of cataract surgery increased from 8.54/1000 person-years in 2011 to 9.67/1000 person-years in 2015. The probability of second-eye surgery within 12 months after the first-eye surgery increased from 42.98% in 2011 to 48.01% in 2015. In total, 85.72% of surgeries were performed in non-rural areas: 43.18% in individuals with a higher household income and 76.65% in primary healthcare centres. The rate of vitrectomy for posterior capsular rupture was 0.72%. CONCLUSIONS AND RELEVANCE The incidence of cataract surgery in South Korea is increasing over time. Our findings are expected to aid in the formulation of future healthcare policies concerning cataract surgery in South Korea.
Collapse
Affiliation(s)
- Sun Young Ryu
- Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea.,Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Jiwon Kim
- Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Jung Hwa Hong
- Department of Research and Analysis, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Eun Jee Chung
- Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| |
Collapse
|
15
|
Raznahan M, Emamian MH, Alipour F, Hashemi H, Zeraati H, Fotouhi A. Horizontal inequity in the utilization of cataract surgery in Iran: Shahroud Eye Cohort Study, 2009-2014. Med J Islam Repub Iran 2019; 33:116. [PMID: 31934575 PMCID: PMC6946921 DOI: 10.34171/mjiri.33.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Since there was no evidence about economic inequity in utilization of cataract surgery in developing countries, such as Iran, this study was designed to measure horizontal inequity in the utilization of cataract surgery and its changes in an Iranian middleaged population in 2009 and 2014. Methods: Using data from the first and second phases of Shahroud Eye Cohort Study (2009-2014), the economic inequity in the utilization of cataract surgery in an Iranian middle-aged population aged 40-64 years in 2009 and 2014 was evaluated. The horizontal inequity index (HI) was determined using the indirect standardization method based on a nonlinear (probit) model and the concentration index (C) was decomposed into the contribution of each factor. The analyses were performed using STATA software version 12/SE, and significance level was set at less than 0.05. Results: The HI in the utilization of cataract surgery increased from 0.080 (95% CI: 0.011-0.098) in 2009 to 0.166 (95% CI: 0.0821- 0.228) in 2014. Decomposition of changes in the concentration index showed that among need and non-need variables, older age and economic status (being among the wealthiest 20%) were the greatest contributors, with shares of 67.5% and 57.5%%, respectively, which led to pro-rich inequity during the study periods. Conclusion: The present study demonstrated that utilization of cataract surgery did not have an equal distribution among economic quintiles, despite considering equal needs based on cataract severity. Results demonstrated that older age and economic status were the greatest contributors to HI increase in 2009 and 2014.
Collapse
Affiliation(s)
- Maedeh Raznahan
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
- Deputy of Research, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hassan Emamian
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Fateme Alipour
- Eye Research Center, Farabi Eye Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | - Hojjat Zeraati
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Akbar Fotouhi
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
16
|
Ramke J, Kyari F, Mwangi N, Piyasena M, Murthy G, Gilbert CE. Cataract Services are Leaving Widows Behind: Examples from National Cross-Sectional Surveys in Nigeria and Sri Lanka. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16203854. [PMID: 31614715 PMCID: PMC6843674 DOI: 10.3390/ijerph16203854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/06/2019] [Accepted: 10/10/2019] [Indexed: 11/25/2022]
Abstract
The Sustainable Development Goals aim to leave no one behind. We explored the hypothesis that women without a living spouse—including those who are widowed, divorced, separated, and never married—are a vulnerable group being left behind by cataract services. Using national cross-sectional blindness surveys from Nigeria (2005–2007; n = 13,591) and Sri Lanka (2012–2014; n = 5779) we categorized women and men by marital status (married/not-married) and place of residence (urban/rural) concurrently. For each of the eight subgroups we calculated cataract blindness, cataract surgical coverage (CSC), and effective cataract surgical coverage (eCSC). Not-married women, who were predominantly widows, experienced disproportionate cataract blindness—in Nigeria they were 19% of the population yet represented 56% of those with cataract blindness; in Sri Lanka they were 18% of the population and accounted for 54% of those with cataract blindness. Not-married rural women fared worst in access to services—in Nigeria their CSC of 25.2% (95% confidence interval, CI 17.8–33.8%) was far lower than the best-off subgroup (married urban men, CSC 80.0% 95% CI 56.3–94.3); in Sri Lanka they also lagged behind (CSC 68.5% 95% CI 56.6–78.9 compared to 100% in the best-off subgroup). Service quality was also comparably poor for rural not-married women—eCSC was 8.9% (95% CI 4.5–15.4) in Nigeria and 37.0% (95% CI 26.0–49.1) in Sri Lanka. Women who are not married are a vulnerable group who experience poor access to cataract services and high cataract blindness. To “leave no one behind”, multi-faceted strategies are needed to address their needs.
Collapse
Affiliation(s)
- Jacqueline Ramke
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
- School of Optometry and Vision Science, University of Auckland, Auckland 1010, New Zealand.
| | - Fatima Kyari
- College of Health Sciences, Baze University, Abuja 900108, Nigeria.
| | - Nyawira Mwangi
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
- Department of Clinical Medicine, Kenya Medical Training College, Nairobi 00100, Kenya.
| | - Mmpn Piyasena
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
- Ministry of Health, Indigenous Medicine and Nutrition, Policy Analysis and Development Unit, Colombo 10, Sri Lanka.
| | - Gvs Murthy
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
- Public Health Foundation of India, Hyderabad, Telangana 122002, India.
| | - Clare E Gilbert
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
| |
Collapse
|
17
|
Wu X, Huang Y, Liu Z, Lai W, Long E, Zhang K, Jiang J, Lin D, Chen K, Yu T, Wu D, Li C, Chen Y, Zou M, Chen C, Zhu Y, Guo C, Zhang X, Wang R, Yang Y, Xiang Y, Chen L, Liu C, Xiong J, Ge Z, Wang D, Xu G, Du S, Xiao C, Wu J, Zhu K, Nie D, Xu F, Lv J, Chen W, Liu Y, Lin H. Universal artificial intelligence platform for collaborative management of cataracts. Br J Ophthalmol 2019; 103:1553-1560. [PMID: 31481392 PMCID: PMC6855787 DOI: 10.1136/bjophthalmol-2019-314729] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/21/2019] [Accepted: 08/07/2019] [Indexed: 11/24/2022]
Abstract
Purpose To establish and validate a universal artificial intelligence (AI) platform for collaborative management of cataracts involving multilevel clinical scenarios and explored an AI-based medical referral pattern to improve collaborative efficiency and resource coverage. Methods The training and validation datasets were derived from the Chinese Medical Alliance for Artificial Intelligence, covering multilevel healthcare facilities and capture modes. The datasets were labelled using a three-step strategy: (1) capture mode recognition; (2) cataract diagnosis as a normal lens, cataract or a postoperative eye and (3) detection of referable cataracts with respect to aetiology and severity. Moreover, we integrated the cataract AI agent with a real-world multilevel referral pattern involving self-monitoring at home, primary healthcare and specialised hospital services. Results The universal AI platform and multilevel collaborative pattern showed robust diagnostic performance in three-step tasks: (1) capture mode recognition (area under the curve (AUC) 99.28%–99.71%), (2) cataract diagnosis (normal lens, cataract or postoperative eye with AUCs of 99.82%, 99.96% and 99.93% for mydriatic-slit lamp mode and AUCs >99% for other capture modes) and (3) detection of referable cataracts (AUCs >91% in all tests). In the real-world tertiary referral pattern, the agent suggested 30.3% of people be ‘referred’, substantially increasing the ophthalmologist-to-population service ratio by 10.2-fold compared with the traditional pattern. Conclusions The universal AI platform and multilevel collaborative pattern showed robust diagnostic performance and effective service for cataracts. The context of our AI-based medical referral pattern will be extended to other common disease conditions and resource-intensive situations.
Collapse
Affiliation(s)
- Xiaohang Wu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yelin Huang
- Beijing Tulip Partners Technology Co., Ltd, Beijing, China
| | - Zhenzhen Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Weiyi Lai
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Erping Long
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Kai Zhang
- School of Computer Science and Technology, Xidian University, Xi'an, China
| | - Jiewei Jiang
- School of Computer Science and Technology, Xidian University, Xi'an, China
| | - Duoru Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Kexin Chen
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Tongyong Yu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Dongxuan Wu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Cong Li
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yanyi Chen
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Minjie Zou
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Chuan Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.,Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yi Zhu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.,Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chong Guo
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiayin Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Ruixin Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yahan Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yifan Xiang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Lijian Chen
- Beijing Tulip Partners Technology Co., Ltd, Beijing, China
| | - Congxin Liu
- Beijing Tulip Partners Technology Co., Ltd, Beijing, China
| | - Jianhao Xiong
- Beijing Tulip Partners Technology Co., Ltd, Beijing, China
| | - Zongyuan Ge
- Department of Electrical and Computer Systems Engineering, Faculty of Engineering, Monash University, Melbourne, Victoria, Australia
| | | | - Guihua Xu
- Huizhou Municipal Central Hospital, Huizhou, China
| | - Shaolin Du
- Tung Wah Hospital, Sun Yat-sen University, Dongguan, China
| | - Chi Xiao
- Dongguan Guangming Ophthalmic Hospital, Dongguan, China
| | - Jianghao Wu
- Dongguan Guangming Ophthalmic Hospital, Dongguan, China
| | - Ke Zhu
- Kaifeng Eye Hospital, Kaifeng, China
| | - Danyao Nie
- Shenzhen Eye Hospital, Shenzhen Key Laboratory of Ophthalmology, Shenzhen University School of Medicine, Shenzhen, China
| | - Fan Xu
- Department of Ophthalmology, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Jian Lv
- Department of Ophthalmology, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Weirong Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yizhi Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | | |
Collapse
|
18
|
Mörchen M, Zambrano O, Páez A, Salgado P, Penniecook J, Brandt von Lindau A, Lewis D. Disability-Disaggregated Data Collection: Hospital-Based Application of the Washington Group Questions in an Eye Hospital in Paraguay. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16173085. [PMID: 31450663 PMCID: PMC6747208 DOI: 10.3390/ijerph16173085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 08/16/2019] [Accepted: 08/23/2019] [Indexed: 11/16/2022]
Abstract
Disability-disaggregated data are increasingly considered important to monitor progress in Universal Eye Health Care. Hospital-based data are still elusive because of the cultural ambiguities of the term disability, especially in under-resourced Health Information Systems in low-and middle-income countries. The aim of this study was to estimate the hospital-based rate of disability in patients presenting at an eye department of a rural hospital in Paraguay and to discuss implications for the management of access barriers. Therefore, we introduced two standardized sets of the Washington Group (WG) Questions as a pilot project. In total, 999 patients answered the self-report WG short set (WG-SS) questionnaire with six functional domains, and 501 of these patients answered an extended set, which included additional domains for "anxiety" and "depression" (WG-ES3). Overall, 27.7% (95% Confidence Interval (CI) 24.9-30.3) were categorized as having a disability. A total of 9.6% (95% CI 7.9-11.6) were categorized as having a disability because of communication difficulties, which was second only to visual difficulties. The odds ratio for disability for patients aged 70 years and older was 8.5 (95% CI 5.0-14.4) and for male patients, it was 0.83 (95% CI 0.62-1.1). Of those patients who answered the WG-ES3, 3.4% were categorized as having a disability because of being worried, nervous or anxious and 1.4% because of feeling depressed. An analysis of the questions of the "depression" domain was impeded by a high rate of measurement errors. The results of the different domains can now be used to inform the identification and mitigation of potential access barriers to eye health services for different types of impairments.
Collapse
Affiliation(s)
- Manfred Mörchen
- Christoffel Blindenmission (CBM) International, Stubenwaldallee 5, 64625 Bensheim, Germany.
| | - Olmedo Zambrano
- Christoffel Blindenmission (CBM) International, Stubenwaldallee 5, 64625 Bensheim, Germany
| | - Alexander Páez
- Fundaciόn Visiόn, Ingavi, Fernando de la Mora 8000, Paraguay
| | - Paola Salgado
- Fundaciόn Visiόn, Ingavi, Fernando de la Mora 8000, Paraguay
| | | | | | - David Lewis
- CBM Australia, 56 Rutland Rd, Melbourne 3128, Australia
| |
Collapse
|
19
|
Prasad M, Malhotra S, Kalaivani M, Vashist P, Gupta SK. Gender differences in blindness, cataract blindness and cataract surgical coverage in India: a systematic review and meta-analysis. Br J Ophthalmol 2019; 104:220-224. [PMID: 31221669 DOI: 10.1136/bjophthalmol-2018-313562] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 02/12/2019] [Accepted: 04/02/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND The magnitude of blindness is unevenly distributed worldwide. This systematic review aimed to study gender differences in the prevalence of blindness, cataract blindness and cataract surgical coverage in India among persons aged 50 years and above. METHODS Literature search was carried out in the Medline, Web of Science, Google Scholar, EMBASE and Trip databases. Data were abstracted and risk of bias was assessed for the selected full-text articles. Pooled prevalence, ORs and risk differences were synthesised by meta-analyses. RESULTS 22 studies were included in the systematic review. The pooled prevalence of blindness obtained for men was 4.17% and that for women was 5.68%. Women had 35% higher odds of being blind (OR 1.35, 95% CI 1.08 to 1.62) and 69% higher odds of being cataract blind (OR 1.69, 95% CI 1.44 to 1.95). Women had a 27% lower odds of getting cataract surgery (OR 0.73, 95% CI 0.45 to 1.01). In women, around 35% of the prevalence of blindness and 33% of the prevalence of cataract blindness are attributable to their gender. CONCLUSION Marked gender differences in blindness, cataract blindness and cataract surgical coverage were seen in India, with the odds being unfavourable for women. Interventions implemented for reduction of blindness, including cataract blindness, need to consider these gender differentials in the Indian context. Further research is needed to ascertain the reasons for these differences and devise interventions to reduce these differences in order to tackle the magnitude of avoidable blindness in India.
Collapse
Affiliation(s)
- Manya Prasad
- Community Medicine, All India Institute of Medical Sciences, Delhi, India
| | - Sumit Malhotra
- Community Medicine, All India Institute of Medical Sciences, Delhi, India
| | - Mani Kalaivani
- Biostatistics, All India Institute of Medical Sciences, Delhi, India
| | - Praveen Vashist
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Delhi, India
| | - Sanjeev K Gupta
- Community Medicine, All India Institute of Medical Sciences, Delhi, India
| |
Collapse
|
20
|
Ramke J, Evans JR, Gilbert CE. Reducing inequity of cataract blindness and vision impairment is a global priority, but where is the evidence? Br J Ophthalmol 2018; 102:1179-1181. [PMID: 29844087 DOI: 10.1136/bjophthalmol-2018-311985] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/29/2018] [Indexed: 12/11/2022]
Abstract
Throughout the world, people who are socially or economically disadvantaged disproportionately experience blindness and vision impairment caused by cataract. Reducing vision loss from cataract and its unequal distribution must be a priority if the WHO's aim of 'universal eye health' is to be realised. To help achieve this, decision-makers and service planners need evidence on which strategies improve access to cataract services among disadvantaged populations, and under what circumstances. Unfortunately, despite many strategies to improve cataract services being implemented in recent decades, evidence of what works, for who and in what circumstances is not readily available. This paper summarises the extent of the evidence on interventions to reduce inequity of vision loss from cataract and makes suggestions for how the evidence base can be strengthened.
Collapse
Affiliation(s)
- Jacqueline Ramke
- Department of Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Auckland, New Zealand .,Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Jennifer R Evans
- Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Clare E Gilbert
- Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
21
|
Ramke J, Petkovic J, Welch V, Blignault I, Gilbert C, Blanchet K, Christensen R, Zwi AB, Tugwell P. Interventions to improve access to cataract surgical services and their impact on equity in low- and middle-income countries. Cochrane Database Syst Rev 2017; 11:CD011307. [PMID: 29119547 PMCID: PMC6486054 DOI: 10.1002/14651858.cd011307.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cataract is the leading cause of blindness in low- and middle-income countries (LMICs), and the prevalence is inequitably distributed between and within countries. Interventions have been undertaken to improve cataract surgical services, however, the effectiveness of these interventions on promoting equity is not known. OBJECTIVES To assess the effects on equity of interventions to improve access to cataract services for populations with cataract blindness (and visual impairment) in LMICs. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 3), MEDLINE Ovid (1946 to 12 April 2017), Embase Ovid (1980 to 12 April 2017), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 12 April 2017), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 12 April 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 12 April 2017 and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 12 April 2017. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA We included studies that reported on strategies to improve access to cataract services in LMICs using the following study designs: randomised and quasi-randomised controlled trials (RCTs), controlled before-and-after studies, and interrupted time series studies. Included studies were conducted in LMICs, and were targeted at disadvantaged populations, or disaggregated outcome data by 'PROGRESS-Plus' factors (Place of residence; Race/ethnicity/ culture/ language; Occupation; Gender/sex; Religion; Education; Socio-economic status; Social capital/networks. The 'Plus' component includes disability, sexual orientation and age). DATA COLLECTION AND ANALYSIS Two authors (JR and JP) independently selected studies, extracted data and assessed them for risk of bias. Meta-analysis was not possible, so included studies were synthesised in table and text. MAIN RESULTS From a total of 2865 studies identified in the search, two met our eligibility criteria, both of which were cluster-RCTs conducted in rural China. The way in which the trials were conducted means that the risk of bias is unclear. In both studies, villages were randomised to be either an intervention or control group. Adults identified with vision-impairing cataract, following village-based vision and eye health assessment, either received an intervention to increase uptake of cataract surgery (if their village was an intervention group), or to receive 'standard care' (if their village was a control group).One study (n = 434), randomly allocated 26 villages or townships to the intervention, which involved watching an informational video and receiving counselling about cataract and cataract surgery, while the control group were advised that they had decreased vision due to cataract and it could be treated, without being shown the video or receiving counselling. There was low-certainty evidence that providing information and counselling had no effect on uptake of referral to the hospital (OR 1.03, 95% CI 0.63 to 1.67, 1 RCT, 434 participants) and little or no effect on the uptake of surgery (OR 1.11, 95% CI 0.67 to 1.84, 1 RCT, 434 participants). We assessed the level of evidence to be of low-certainty for both outcomes, due to indirectness of evidence and imprecision of results.The other study (n = 355, 24 towns randomised) included three intervention arms: free surgery; free surgery plus reimbursement of transport costs; and free surgery plus free transport to and from the hospital. These were compared to the control group, which was reminded to use the "low-cost" (˜USD 38) surgical service. There was low-certainty evidence that surgical fee waiver with/without transport provision or reimbursement increased uptake of surgery (RR 1.94, 95% CI 1.14 to 3.31, 1 RCT, 355 participants). We assessed the level of evidence to be of low-certainty due to indirectness of evidence and imprecision of results.Neither of the studies reported our primary outcome of change in prevalence of cataract blindness, or other outcomes such as cataract surgical coverage, surgical outcome, or adverse effects. Neither study disaggregated outcomes by social subgroups to enable further assessment of equity effects. We sought data from both studies and obtained data from one; the information video and counselling intervention did not have a differential effect across the PROGRESS-Plus categories with available data (place of residence, gender, education level, socioeconomic status and social capital). AUTHORS' CONCLUSIONS Current evidence on the effect on equity of interventions to improve access to cataract services in LMICs is limited. We identified only two studies, both conducted in rural China. Assessment of equity effects will be improved if future studies disaggregate outcomes by relevant social subgroups. To assist with assessing generalisability of findings to other settings, robust data on contextual factors are also needed.
Collapse
Affiliation(s)
- Jacqueline Ramke
- University of AucklandSchool of Population Health, Faculty of Medicine and Health SciencesAucklandNew Zealand
| | - Jennifer Petkovic
- University of OttawaBruyère Research Institute43 Bruyère StAnnex E, room 312OttawaONCanadaK1N 5C8
| | - Vivian Welch
- Bruyère Research InstituteMethods Centre85 Primrose AvenueOttawaONCanada
| | - Ilse Blignault
- University of New South WalesSchool of Public Health and Community MedicineSydneyNew South WalesAustralia
| | - Clare Gilbert
- London School of Hygiene & Tropical MedicineDepartment of Clinical Research, Faculty of Infectious and Tropical DiseasesKeppel StreetLondonUKWC1E 7HT
| | - Karl Blanchet
- London School of Hygiene & Tropical MedicineDepartment of Global Health and Development15‐17 Tavistock PlaceLondonUKWC1H 9SH
| | - Robin Christensen
- Copenhagen University Hospital, Bispebjerg og FrederiksbergMusculoskeletal Statistics Unit, The Parker InstituteNordre Fasanvej 57CopenhagenDenmarkDK‐2000
| | - Anthony B Zwi
- University of New South WalesSchool of Social Sciences, Faculty of Arts and Social SciencesRoom G25, Ground Floor, Morven Brown BuildingSydneyNew South WalesAustralia2052
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
| | | |
Collapse
|