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Cataract surgery is cost effective and should not be rationed, says NICE

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3588 (Published 25 July 2017) Cite this as: BMJ 2017;358:j3588
  1. Gareth Iacobucci
  1. The BMJ

New evidence that cataract surgery is cost effective will make it harder for service commissioners in England to ration treatment, experts have told The BMJ.

Draft guidelines1 from the National Institute for Health and Care Excellence for managing cataracts in adults contain new economic modelling that shows that cataract surgery for first or second eye is cost effective compared with no or delayed surgery.

The guidelines, which are out to consultation and will be published in October 2017, also make clear that restricting access to cataract surgery on the basis of visual acuity thresholds is inappropriate.

Experts said that the guidelines will make it tougher for clinical commissioning groups (CCGs) to justify controversial cost saving measures which have seen restrictions imposed in some areas on the basis of patients’ visual acuity or their ability to see clearly from one eye.23

A recent investigation by The BMJ4 found that exceptional patient funding requests for cataract removal in England soared from 359 in 2013-14 to 1034 in 2016-17, showing the difficulties that some patients are having in getting referred for surgery.

The draft guidelines make clear that cataract surgery for first or second eye is cost effective because it can avoid costs in the future— from falls and broken hips, for example.

“Visual acuity thresholds, or limits on second eye surgery, were likely to incur avoidable quality adjusted life year losses in most cases, and could be shown to increase longer term costs by raising the demand for low vision services,” it said.

“Visual acuity thresholds should not be used to restrict access to cataract surgery,” it added.

Janet Marsden, professor of ophthalmology and emergency care at Manchester Metropolitan University, and a member of the guideline committee, said that she hoped the guidelines would end the postcode lottery and the “outrageous” restrictions imposed by some CCGs.

Marsden said, “If commissioners take notice of the guidelines and take away that visual acuity bar, then it will get rid of the postcode lottery. The second eye recommendations will also help. For some CCGs only to offer the surgery on one eye is effectively to say to people, ‘it doesn’t really matter if you go blind in one eye’.”

Nick Wilson Holt, consultant ophthalmologist at Royal Cornwall Hospitals NHS Trust and a member of the guideline committee, said that while guidelines were not mandatory they would “add some muscle to the view that patients should be offered cataract surgery if they’ve got a disabling cataract.”

“It will be less easy for CCGs to arbitrarily make up thresholds as they go along,” he said.

Mike Burdon, chairman of the guideline committee and president of the Royal College of Ophthalmologists, said, “The economic model says that cataract surgery is justified for both eyes, almost irrespective of the starting criteria of the patient. I’m hoping that message gets across and that the rationing will disappear.”

Helen Lee, eye health policy manager at the Royal National Institute for the Blind, said the charity welcomed the draft guidelines and “would urge providers to fully implement them.”

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