General practitioners' awareness of different techniques of cataract surgery: implications for quality of care

BMJ 1994;308:1334-35 (21 May)

Papers

General practitioners' awareness of different techniques of cataract surgery: implications for quality of care

T Potamitis, M Foulaid, R K Aggarwal, H S Jones, A R Fielder

Birmingham and Midland Eye Hospital, Birmingham B3 2NS Correspondence to: Mr Potamitis.

With the introduction of fundholding, general practitionerscan now purchase treatment from the provider of their choice.To obtain the best treatment for their patients they need tokeep abreast of new developments in a large range of specialties.The past decade has seen profound changes in ophthalmology,particularly in cataract surgery. Extracapsular cataract extractionand phacoemulsification have largely superseded intracapsularcataract extraction, mainly because of the higher risk of sightthreatening complications with intracapsular extraction.^1,2Although extracapsular surgery is now the most commonly usedmethod in the United Kingdom, 2%-4% of ophthalmologists routinelyperform intracapsular surgery^3,4 and 1% do not routinely useintraocular lens implants.⁴ The quality of cataract treatmentavailable therefore varies greatly between units. We examinedgeneral practitioners' familiarity with different types of cataractsurgery and their ability to evaluate the clinical merits ofthese methods.

Methods

and results

As the quality of cataract surgery varies mainly because ofthe difference between intracapsular and extracapsular cataractextraction, we identified ophthalmic units where both techniqueswere performed routinely and surveyed 593 general practitionerswithin the catchment areas of these units. A total of 367 (62%)completed questionnaires were received. Intracapsular extractionwas the best known method of cataract surgery (309 general practitioners),followed by extracapsular extraction (301). Forty seven generalpractitioners were familiar with phacoemulsification, 26 wereunaware of any of the methods used, and 43 were familiar withall three methods. Only 69 general practitioners expressed apreference for which method was used. The intracapsular techniquewas often preferred, and few of those expressing a preferencechose phacoemulsification (table). When referring patients withcataracts, only 32 general practitioners said that their choiceof consultant was influenced by the surgical method they used.

Methods of cataract surgery preferred by general practitioners
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                                                No of
                                                general practitioners
Preferred method                                (n=367)
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None                                               298
Intracapsular extraction                            29
Extracapsular extraction                            27
Phacoemulsification                                 10
Phacoemulsification or extracapsular extraction      3

Comment

As general practitioners can now choose their provider, qualityof outcome assumes a greater importance. Many who respondedto our questionnaire commented that they did not consider itnecessary to have such detailed knowledge of specialised surgery.This would be so if all types of cataract extraction were equal,but we know this not to be true. We found that intracapsularcataract extraction was best known, not surprisingly as it hasbeen available the longest. Although general practitioners wereequally aware of extracapsular surgery, however, few expresseda preference for which method was used, which suggests insufficientknowledge to distinguish between the two. This is further reinforcedby the high proportion who preferred intracapsular surgery,implying an inadequate appreciation of the advantages of modernmethods.

We used cataract surgery as an example of a commonly performedspecialist procedure (seventh most frequently performed operationin 1989-90).⁵ However, all specialties are undergoing change,and hopefully these changes will have distinct advantages andbenefits for the patient. Furthermore, a new variable has nowbeen introduced into the decision making process: that of cost.Hospital referral patterns are influenced by waiting times,which may well be influenced by cost. In the internal marketin health care purchasers must understand the clinical advantagesand disadvantages of various procedures when choosing treatmentfor their patients;if they do not the quality of patient carewill not even enter the equation.