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

BMJ 1994; 308 doi: (Published 21 May 1994) Cite this as: BMJ 1994;308:1334
  1. T Potamitis,
  2. y Foulaid,
  3. R K Aggarwal,
  4. H S Jones,
  5. A R Fielder
  1. Birmingham and Midland Eye Hospital, Birmingham B3 2NS
  1. Correspondence to: Mr Potamitis.

    With the introduction of fundholding, general practitioners can now purchase treatment from theprovider of their choice. To obtain the best treatment for their patients they need to keep 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 Extracapsular cataract extraction and phacoemulsification have largely superseded intracapsular cataract extraction, mainly because of the higher risk of sight threatening complications with intracapsular extraction.1,2 Although extracapsular surgery is now the most commonly used method in the United Kingdom, 2%-4% of ophthalmologists routinely perform intracapsular surgery3,4 and 1% do not routinely use intraocular lens implants.4 The quality of cataract treatment available therefore varies greatly between units. We examined general practitioners' familiarity with different types of cataract surgery and their ability to evaluate the clinical merits of these methods.

    Methods and results

    As the quality of cataract surgery varies mainly because of the difference between intracapsular and extracapsular cataract extraction, we identified ophthalmic units where both techniques wereperformed routinely and surveyed 593 general practitioners within the catchment areas of these units. A total of 367 (62%) completed questionnaires were received. Intracapsular extraction was the best known method of cataract surgery (309 general practitioners), followed by extracapsular extraction (301). Forty seven general practitioners were familiar with phacoemulsification, 26 were unaware of any of the methods used, and 43 were familiar with all three methods. Only 69 general practitioners expressed a preference for which method was used. The intracapsular technique was often preferred, and few of those expressing a preference chose phacoemulsification (table). When referring patients with cataracts, only 32 general practitioners said that their choice of consultant was influenced by the surgical method they used.

    Methods of cataract surgery preferred by general practitioners

    View this table:


    As general practitioners can now choose their provider, quality of outcome assumes a greater importance. Many who responded to our questionnaire commented that they did not consider it necessary 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 intracapsular cataract extraction was best known, not surprisingly as it has been available the longest. Although general practitioners were equally aware of extracapsular surgery, however, few expressed a preference for which method was used, which suggests insufficient knowledge to distinguish between the two. This is further reinforced by the high proportion who preferred intracapsular surgery, implying an inadequate appreciation of the advantages of modern methods.

    We used cataract surgery as an example of a commonly performed specialist procedure (seventh most frequently performed operation in 1989-90).5 However, allspecialties are undergoing change, and hopefully these changes will have distinct advantages and benefits for the patient. Furthermore, a new variable has now been 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 market in health care purchasers must understand the clinical advantages and disadvantages of various procedures when choosing treatment for their patients;if they do not the quality of patient care will not even enter the equation.


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