Cut useless medical treatments, says Audit Commission
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2438 (Published 13 April 2011) Cite this as: BMJ 2011;342:d2438
All rapid responses
Cataract extraction is one of the commonest surgical procedures
worldwide, providing tremendous improvements in quality of life. NHS
waiting lists have come down significantly over the last decade. More
recently, with the drive for "efficiency savings", cataract surgery is in
some cases being designated a low priority procedure1,2 and will not be
funded above a specified level of visual acuity. Whilst exceptions are
acknowledged, for example when a patient experiences significant glare
limiting their driving, despite apparently good vision, the general thrust
has been to avoid operating at certain levels of acuity. This is logical
as the risk-benefit ratio is indeed close when the level of vision is
good, and surgery is usually not indicated if the patient is not
experiencing visual problems.
However, two important considerations are not usually factored into
cost-saving calculations. Firstly, delaying surgery in a patient with
significant cataract and subjective visual impairment until it has
progressed sufficiently so that their acuity falls below a certain level
can mean operating on a denser cataract, with a higher risk of
complications, potentially necessitating multiple procedures, and
therefore higher overall cost. Secondly, the risk of phacomorphic angle
closure glaucoma (where the increasing size of the lens blocks aqueous
drainage) is also higher, and this too has associated costs. Rates of
primary angle closure glaucoma have fallen in England as rates of cataract
surgery have risen,3 and, although this does not necessarily indicate a
causal relationship, it is possible that if cataract extraction rates are
to fall, the incidence of angle closure may rise again. Whilst it is
difficult to quantify such factors when costing, neglecting them could
mean that delaying cataract surgery proves a false economy in some cases.
1. BMJ 2011; 342:d2438
2. BMJ 2011; 342:d2380
3. Keenan TD, Salmon JF, Yeates D, Goldacre M. Trends in rates of
primary angle closure glaucoma and cataract surgery in England from 1968
to 2004. J Glaucoma. 2009 Mar;18(3):201-5.
Competing interests: No competing interests
Delivering less for less
Mooney reports on the Audit Commission Health Briefing, "Reducing
spending on low clinical value treatments".1 Your news report and the full
Audit Commission report raise several questions.2
Firstly, there is variability in the phraseology used to describe
"clinically ineffective" and "not cost-effective" treatments. The terms
used include: low clinical value, limited clinical value, inefficient,
ineffective and relatively ineffective. Who defines these terms and
ensures that standardisation of terminology is applied?
Secondly, this report is based on data from the southern half of
England and half of the Primary Care Trusts (PCTs) who took part are in
London or the South East. Can the Audit Commission say that the findings
gleaned from these areas are transferable to other parts of England?
Thirdly, a number of procedures are considered "potentially cosmetic"
and therefore of low clinical value. These include varicose veins (which
can be painful) and hernias (which can obstruct). I am concerned that
these procedures, amongst others, should not be labelled as cosmetic as
their rationing may lead to suffering and complications.
The Audit Commission has identified potential savings of 500 million
pounds a year if all PCTs cut low clinical value treatments. Not so much
"Delivering more for less" as delivering less for less.
1. Mooney H. Cut useless medical treatments, says Audit Commission.
BMJ 2011; 342: d2438
2. www.audit-
commission.gov.uk/sitecollectiondocuments/downloads/20110414reducingexpenditure.pdf
(Accessed 24 April 2011)
Competing interests: No competing interests