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- Reduction of public waiting lists for cataract surgery
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A hypothetical intervention to reduce waiting time for cataract surgery by 1.5 months per patient on the current waiting list would result in:
- a population saving of 225 years spent living with cataracts;
- health care cost savings of €116,675, informal care cost savings of €108,176 and productivity cost savings of €52,670;
- a cost of €35,118 associated with bringing forward cataract surgeries; and
- 50 DALYs being averted as a result of the intervention.
Key intervention costs would be associated with:
- increasing the capacity of public hospitals to undertake more cataract surgeries;
- increasing the number of ophthalmic surgeons trained in cataract surgery; and
- investment in better technology to increase the efficiency of surgery.
Unfortunately, no data were identified to estimate these key intervention costs. Under a societal perspective, this intervention would be considered highly cost effective if the key intervention costs were less than €1.3 million, cost effective if the key intervention costs were between €1.3 million and €3.6 million, and cost saving if the key intervention costs were less than €141,647 (using WHO definitions of cost effectiveness).
Under a health care perspective, this intervention would be considered highly cost effective if the key intervention costs were less than €1.9 million, cost effective if the key intervention costs were between €1.9 million €5.5 million, and cost saving if the key intervention costs were less than €81,557 (using WHO definitions of cost effectiveness).
More research is required on the cost of reducing cataract surgery waiting times by 1.5 months for every patient on the waiting list, to determine whether this intervention is cost effective according to the results above and should therefore be funded.
The burden of waiting for cataract surgery encompasses physical and financial effects. A decline in vision over this waiting time may be associated with adverse events and co-morbidities, including falls, fractures, and depression (Gimbel and Dardzhikova, 2011). Another adverse effect may be disruption to ability to participate in the workforce (productivity loss). Lowering waiting times for cataract surgery has been found to lead to fewer reported accidents and falls from vision problems, and patients presenting with less severe cataract symptoms (Boisjoly et al, 2010; Freeman et al, 2009).
Possible methods for reducing the number of people on surgery waiting lists include:
- increased funding to the public sector;
- subsidising private sector care to encourage a shift to private care when public sector resources are constrained;
- innovations in cataract surgery procedures and technology that may improve surgeon productivity;
- funding that links provider payment and performance; and
- priority setting to determine patients with the greatest need – in the ROI, public hospital booking systems prioritise cataract surgeries according to clinical assessment criteria (DOHC, 2010).
A cataract surgery efficiency program implemented in Montreal, Canada, in 2003, involved performing surgery in ambulatory care centres, implementing new technology, training surgical technicians and increasing operating room time. This efficiency program doubled the number of cataract surgeries (Boisjoly et al, 2010). Another method to improve waiting times may be to increase the day case rate for cataract surgery (DOHC, 2010). In the ROI, the share of cataract surgeries carried out as day cases increased from 20.7% in 1997 to 60.9% in 2007 (OECD, 2009).
The hypothetical intervention evaluated in this section relates to government initiatives to improve the efficiency and capacity of cataract surgery services in public hospitals. The intervention is assumed to reduce the median waiting time for cataract surgery in the ROI by 50% in line with the impact of the Montreal program (Boisjoly et al, 2010). The national median waiting time for cataract extraction in the ROI is 3 months (NTPF, 2010). An improvement of 50% would reduce the median waiting time to 1.5 months.
Long and O’Brien (2001) analysed HIPE data and reported that in 2001, cataract surgery alone accounted for 82% of common ophthalmic procedures in the ROI (procedures for cataracts, glaucoma, retinal detachment, strabismus and repair of perforating injuries). In the absence of data on the precise number of people waiting for cataract surgery, this percentage was applied to the 2,192 people on the public hospital waiting list for ophthalmological surgical procedures at April 2010 (NTPF, 2010). Thus, it is estimated that 1,797 people were waiting for cataract surgery in public hospitals at April 2010. Throughout this section it is assumed that people on the waiting list for cataract surgery have moderate VI to severe VI (blindness).
7.3.2 Benefits from the intervention
As detailed in Section 7.3.1, the hypothetical intervention would aim to reduce waiting time for cataract surgery by 1.5 months per patient on the waiting list. Multiplying this by the 1,797 people on the cataract waiting list estimates the intervention to save 225 years living with cataracts.
It is assumed that patients on the waiting list would avoid the treatment costs, productivity losses and informal care costs that would have applied over the additional waiting period. These include:
- Annual health care cost per person with VI of €519.29 as estimated in Section 7.1.6.
- Total productivity costs from VI and blindness of €342.23 per person aged under 65 years, estimated as total productivity costs of €56.7 million in 2010 (Section 4.1) divided by total prevalence of moderate VI and blindness in those aged less than 65 years in 2010 (165,732)
- Total informal care costs of €481.47 per person, estimated as total informal care costs of €108.3 million in 2010 (Section 4.2) divided by the total prevalence of moderate VI and blindness (224,832).
Annual health care and informal care costs per person were multiplied by the saving of 225 years living cataract to estimate €116,675 health care cost savings and €108,176 informal care cost savings. The productivity cost per person was multiplied by 225 years and the 68% of total moderate VI and blindness from cataract that occurs in people aged less than 65 years in the ROI (Chapter 2). Savings of €52,670 in productivity costs were estimated to result from the intervention.
Stouthard et al (1997) estimated a disability weight 0.17 for moderate VI and 0.43 for blindness. The shares of moderate VI (80%) and blindness (20%) within the sum of moderate VI and blindness due to cataracts give a combined disability weight of 0.22. This disability weight was multiplied by 225 years to estimate 50 DALYs averted through the intervention.
7.3.3 Costs of the intervention
Public hospital costs per bed day for ‘glaucoma and complex cataract surgery procedures’ in the ROI were estimated in Section 3.1.1. These costs were multiplied by ALOS to estimate total costs per surgery.
The resulting costs of cataract surgery in the ROI are presented in Table 7.10. Because costs differ for same-day and overnight procedures, these costs were weighted by the 2007 share of cataract surgeries in the ROI being same-day procedures (60.9% from OECD, 2009). The estimated cost per cataract surgery in the ROI was €4,015.
Table 7.10: Costs of cataract surgery in the ROI
|Cost per bed day||ALOS (days)||Total Costs|
|Glaucoma & complex cataract procedures (39.1%)||€1,828||3.8||€6,945|
|Glaucoma & complex cataract procedures, same day (60.9%)||€2,133||1.0||€2,133|
|All glaucoma & complex cataract procedures (100%)||€4,015|
Source: Deloitte Access Economics cost calculations using DoHA (2009), AIHW (2009) and World Bank (2010). ALOS data from ESRI (2010).
Cataract surgery costs for people on the waiting list in 2010 would be incurred at some time regardless of whether the intervention to reduce waiting time was implemented or not. However, with the intervention, waiting time would be reduced by 1.5 months. The earlier surgery costs are incurred, the higher their present value. Using a discount rate of 4% (Department of Finance, 2010), the cost of bringing forward surgery costs for all people on the waiting list at April 2010 would be €35,118.
However, reducing waiting lists for cataract surgery would primarily include the following ‘key intervention costs’:
- increasing capacity in public hospitals to perform more cataract surgeries (e.g. additional beds and theatres);
- increasing the number of ophthalmic surgeons trained in cataract surgery (training and recruitment costs); and
- investing in better technology to undertake cataract surgery more efficiently.
A proportion of these costs would be upfront fixed capital costs. Unfortunately, no data were identified to estimate these costs.
7.3.4 Cost effectiveness results
Since the other costs of reducing waiting lists in the ROI are unknown, rather than estimating the cost effectiveness of such an intervention, the CEA estimated the highest key intervention cost for which the intervention would be cost effective. Health care, productivity and informal care cost offsets were deducted from total intervention costs under the societal perspective (key intervention costs plus €35,118 bring-forward surgery costs and DWL) to estimate the highest feasible net cost of the intervention. The DWL of raising tax revenue to fund government expenditure on the intervention (key intervention costs and bring-forward of surgery costs) was estimated using a MCPF of 57 cents for every euro raised from taxation (Kleven and Kreiner, 2003, see Section 4.3).
The health care perspective included health care costs as the only cost offset. The net costs under the societal and health care perspectives were divided by 50 DALYs averted by the intervention to estimate the ICERs.
Hypothetical intervention costs which would meet WHO cost effectiveness thresholds reported at the beginning of this chapter are presented in Table 7.11.
Table 7.11: Hypothetical intervention costs against WHO cost effectiveness thresholds
|Highly cost effective||Cost effective||Cost saving|
|ICER threshold criteria (Cost per DALY averted)||Less than €35,801||Between €35,801 and €107,403||Less than €0|
|Hypothetical key intervention costs (a) under scenarios:|
|- Societal offset||<€1,280,538||Between €1,280,538 and €3,558,320||Less than €141,647|
|- Health care only offset||<€1,869,816||Between €1,869,916 and €5,445,733||Less than €81,557|
Source: Deloitte Access Economics calculations using DoHA (2009), AIHW (2009), ESRI (2010), NTPF (2010), Stouthard et al (1997), WHO (2011) and World Bank (2010). (a) These costs would be in addition to bring-forward of surgical costs, estimated to be €35,118 and associated DWL under the ‘societal’ scenario. Cost effectiveness is assessed against total intervention costs, comprised of hypothetical intervention costs (presented in this table), bring-forward of surgical costs and DWL (in the societal scenario only).
Importantly, the intervention costs estimated here are annual costs. However, a proportion of the cost of interventions to reduce cataract surgery waiting lists is likely to be up front fixed capital costs such as investment in new infrastructure and equipment. Although these costs would be amortised over a period of time they may not be generalisable to all future years. Therefore, it should be considered that the intervention costs presented below include ongoing additional variable costs and amortised fixed costs of reducing waiting lists, rather than the total investment cost associated with the intervention.
Under the societal perspective, key intervention costs of less than €1,280,538 would allow the intervention to be considered highly cost effective. With intervention costs of between €1,280,538 and €3,558,320, the intervention would be considered cost effective. With intervention costs of less than €141,647, the intervention would be cost-saving.
Under the health care perspective, key intervention costs of less than €1,869,816 would allow the intervention to be considered highly cost effective. With intervention costs of between €1,869,816 and €5,445,733, the intervention would be considered cost effective. With intervention costs of less than €81,557, the intervention would be cost-saving.