Module 4: Best Practices in Eye Care
Eye care programs must eliminate patient barriers to care by fully funding surgeries, bringing eye care services to the patients, providing transportation to the eye clinic for surgery as needed, and educating communities about blindness.
Bring Eye Care To The Patient
Outreach services must be brought to the patients in their villages, whether those remote areas are one hour from the local eye clinic, or seven hours away.
“Mobile screening programs (diagnostic eye camps and screening vans) that identify surgical candidates and arrange transport to central hospitals for IOL-surgery appear to be effective, and can target rural populations, though women and the illiterate may be less likely to attend. It is most efficient to staff screening programs with healthcare workers or volunteers with a small amount of extra training, given the shortage of ophthalmic surgeons in many areas. These ophthalmic assistants have been found to have good sensitivity and specificity for detecting cataract, compared to examinations performed by an ophthalmologist. A flashlight to detect the presence of a white pupil, and gross visual acuity measurement (ability to count fingers) is often sufficient to identify cases, which can then be more thoroughly evaluated to determine whether surgery is warranted.”(1)
The Unite For Sight eye care model incorporates community outreach in the form of local community health workers, local volunteers, and visiting volunteers. In addition to sending volunteers into impoverished communities to support and assist local eye care professionals, Unite For Sight hires, trains, and pays local community health workers to go door to door in their villages and provide educational information, screen for basic eye diseases, and act as case-finders and liaisons for Unite For Sight and its partners.(2) This model allows high quality eye care to reach patients who otherwise would not be seen.
Bring The Patient To The Eye Clinic
Patients living in extreme poverty cannot seek eye care from local clinic because costs are prohibitively high. Global eye care organizations should facilitate patient access to care by subsidizing surgeries to reduce or eliminate the cost to the patient. A secondary aim should be to provide supportive services for patients and their families, as the hidden costs of obtaining surgery are significant.
Unite For Sight supports eye clinics worldwide by investing human and financial resources in their social ventures to eliminate patient barriers to eye care.(3) Financial subsidies provided by Unite For Sight have proven to be highly successful in increasing local surgical capacity, affecting thousands of lives. For example, prior to working with Unite For Sight, one eye clinic in Accra, Ghana provided 600 surgeries per year. Today, the clinic provides close to 2,000 surgeries each year, 86% of which are provided to Unite For Sight-sponsored patients. This means that 86% of the patients receiving eye care from the clinic are patients living in extreme poverty who could not have afforded surgery on their own. Unite For Sight's partnership with an ophthalmologist in northern Ghana has been similarly successful. Prior to Unite For Sight's partnership in 2005, the local ophthalmologist in Tamale, Ghana was unable to provide a single cataract surgery because he lacked surgical supplies, and patients could not afford the cost of cataract surgery. In 2008, the local ophthalmologist provided 2,000 surgeries coordinated and sponsored by Unite For Sight.
High-Quality Care Is A Must
Eye care services must be comprehensive, including examinations by local eye doctors, diagnosis and care for all treatable conditions, promotion, and prevention. This full range of services must be delivered to the population year-round. Only skilled, local ophthalmologists may act as primary medical providers; qualified visiting doctors or volunteers can support and assist the local doctors.
One major barrier to patients’ acceptance of eye care is a fear of cataract surgery. These fears are not always unjustified, as low quality cataract surgeries can result in permanent blindness.(4) Just as surgeries in the developed world require follow-up care and careful monitoring, the outcome of surgeries must be monitored to ensure that patients have good results. Quality results can also be ensured by emphasizing to patients the importance of the postoperative medication (see Module 5), and providing surgeries at the eye clinic and not in makeshift field setups. It is imperative that patients receiving free or subsidized care are obtaining the same quality of surgery as paying patients at the same eye clinic.
Continuity of Care By Local Eye Doctors
Continuous healthcare provided by local medical providers “facilitate[s] long-term solutions for reducing blindness,” which is particularly important in developing countries “where the scanty infrastructure and human resources have led to piecemeal approaches to blindness control, and which more often than not have failed to produce substantial results.”(5) The hiring of local community health workers is an important step to ensure continued access to care, compliance with post-operative protocols, and effective long-term monitoring of eye health. Another important benefit of continuity of service is that it inspires confidence in the health care system. When ongoing care is provided to the same communities on a regular basis, trust develops between patients and local doctors, and fears of surgical procedures are allayed, leading more patients to seek medical treatment.
“Trust in a particular service provider, as generated by repeated outreach screening camps in the same vicinity and good outcomes reported by peers, has been found to be an important factor increasing uptake. Providing continuous services of good quality might be a way to considerably increase cataract surgery service uptake.”(6)
“A number of patients refused the offered services because of the unease they felt about trusting an unknown service provider to operate on their eyes. However, acceptance of offered surgery increased considerably if the service provider repeatedly facilitated outreach screening camps in the community or vicinity.”(7)
It is possible to lower the cost of surgery by increasing operating efficiency. Chang et al. suggest that the best way to streamline operations and boost productivity is through improved training, reimbursement incentives, and career opportunities for physicians.(8)
“Overhead costs associated with setting up the infrastructure to provide the surgical services, costs of perioperative visits, and the work lost by the patient during the perioperative period, also add to the expense of cataract surgery . The best way to improve cost-effectiveness is to increase the surgical rate per ophthalmic surgeon by improving the efficiency and throughput of surgical services, since the overhead and administrative costs associated with the surgery center are fixed. These fixed costs can decline per capita, as the number of operations performed increases… In order to optimize these services, the National Program for the Control of Blindness (NPCB) in India has set standards for the minimum number of cataract surgeries expected to be performed by each surgeon per year (currently 700 cases per year) and the expected number of operations per designated eye bed per year (currently 40 per year).”(9)
(1) Chang, M.A., Condon, N.G., Baker, S.K., Bloem, M.W., Savage, H. and Sommer, A. “The surgical management of cataract: barriers, best practices, and outcomes.” International Opthalmology. 28.4 (2008): 247-260. Accessed on 9 January 2009. <http://www.springerlink.com/content/2640634853477514/fulltext.pdf>
(2) “Unite For Sight Receives Grant from Starbucks.”(2008) Press release. Uniteforsight.org. Accessed on 9 January 2009. <http://www.uniteforsight.org/news/starbucks-innovation-fund>
(3) “What We Do: Best Practices.” Unite For Sight. www.uniteforsight.org. Accessed on 9 January 2009. <http://www.uniteforsight.org/what-we-do/best-practices>
(4) "Module 8: The Significant Harm of Worst Practices in Eye Care." Unite For Sight. www.uniteforsight.org. Accessed on 9 January 2009. < http://www.uniteforsight.org/community-eye-health-course/module8>
(5) Dandona, R., and Dandona, L. “Refractive Error Blindness.” Bulleting of the World Health Organization. 79.3 (2001): 237-243. Accessed on 12 January 2009. <http://www.who.int/ncd/vision2020_actionplan/documents/vol79.no.3.237-243.pdf>
(6) Dandona, L., Dandona, R., Naduvilath, T.J., McCarty, C.A., Mandal, P., Srinivas, M., Nanda, A., and Rao, G.N. “Population-based assessment of the outcome of cataract surgery in an urban population in southern India.” American Journal of Ophthalmology. 127.6 (1999): 650-658. Accessed on 12 January 2009. <http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VK5-3WM5B4N-3&_user=483692&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000022720&_version=1&_urlVersion=0&_userid=483692&md5=1182878b23769df5e307471a192127ee>
(8) Chang, M.A., Condon, N.G., Baker, S.K., Bloem, M.W., Savage, H. and Sommer, A. “The surgical management of cataract: barriers, best practices, and outcomes.” International Opthalmology. 28.4 (2008): 247-260. Accessed on 9 January 2009. <http://www.springerlink.com/content/2640634853477514/fulltext.pdf>