Fang et al. BMC Public Health 2010, 10:543 http://www.biomedcentral.com/1471-2458/10/543 [3]. To reduce the backlog, the number of cataract opera- tions performed each year must at least equal the inci- dence of operable cataract. A cataract screening program, including a total of 27 screening groups, was conducted in the rural Chaoshan area of eastern Guangdong pro- vince between March 2008 and March 2009. Among 24 screening group subjects refusing cataract surgery, the most common reasons were concern about costs (60.4%), and unwillingness to undergo surgery due to age (22.9%) [8]. Therefore, the cost of cataract surgery may be an important factor that influences the amount of cataract surgery[8-10]. Cataract is a common public health problem in patients above 50 years old in China. Although the mag- nitude of the problem is so large, little is known about the costs of cataract surgery or variation in costs among different providers in China. Moreover, the patterns of cataract surgery, economic status of population and reimbursement ratios have changed greatly in the past few years, but little is known about the relation between costs of surgery and disposable annual income of local residents. Average costs incurred by cataract surgery alone in the United Kingdom were about US$620 in 2004 dollars, but another research demonstrated that the cost is US$3461, approximately 5.6 times of the for- mer one. This is because of the difference between direct and indirect costs [11]. In 2005, the mean total costs per cataract intervention from nine European countries(Denmark, England, France, Germany, Hun- gary, Italy, the Netherlands, Poland, and Spain) were €714, ranging from €318 to €1087(€1 = US$1.18 for 2005)[12]. Cataract surgery is considerably less expen- sive in Europe than in the United States with the mean cost of surgery totaled US$2525[13,14]. In order to achieve a higher CSR, it is necessary to investigate the barriers that may be preventing patients from seeking surgery in China. The aim of this survey performed in four different graded providers of China was to collect information on costs of cataract surgery and to compare the overall cost of surgery with disposa- ble annual income of local residents. It is also hoped that the survey will provide a valuable source of data for developing new strategies for the prevention and treat- ment of blindness caused by cataract. Methods Subjects with age-related cataract for this study were recruited from four different graded providers in two provinces (Figure 1). Zhongshan Ophthalmic Center (ZOC) is the largest eye hospital in China, located in Guangdong province, one of the most economic devel- oped regions in China. The other three eye clinics from three general hospitals are located in Hubei province in central China. Union Hospital (UH) is located in Page 2 of 7 Wuhan, capital of Hubei province. First Hospital of Jingzhou (FHJ) is located in Jingzhou, one medium-sized city. Jingshan County Hospital (JCH) is located in Jian- shan County, which is a typical agricultural county with a total population of 640,000, 69% are farmers. These four eye clinics represent four different size and grade respectively in China. These clinics are described in details in Table 1. The average cost of a cataract extraction at each clinic during the month of November 2009 was studied. The cost of a cataract surgery episode including one pre- operative visit, the surgery itself and one post-operative visit was calculated in three sections as follows: cost of intraocular lens, cost of drugs and facility cost. Facility cost included laboratory test expenses, nursing expenses, check fees, costs of equipment depreciation, and the costs of one preoperative and one postoperative visit, etc. The check fees included the costs of ultrasonic examination, intraocular pressure measurement and slit lamp examination. Operating microscopes and phacoe- mulsifier were the main equipments used in cataract surgery. In the case of JCH, the cost of physician and his or her equipment charges went under facility costs. Costs such as travel costs and costs of complications of surgery were excluded. Costs were based on hospital finance department data. In addition to the costs for one episode of cataract surgery, each provider was asked to provide information on the reimbursement fees they received for performing the service. Disposable annual incomes of local urban and rural residents were acquired from the websites of National and Provincial Bureau of Statistics (Data from Guang- dong province available from http://www.gdstats.gov.cn/ tjgb/t20100225_74438.htm; Hubei province available from http://www.stats-hb.gov.cn/structure/xxgk/tjgb/ qstjgbzw_185369_1.htm; Jingzhou city available from http://www.stats-hb.gov.cn/structure/xxgk/tjgb/ sztjgbzw_187478_1.htm; Jingshan County available from http://www.jingshan.gov.cn/article/2010/0120/arti- cle_8100.html; Accessed on 5 July 2010). All costs were collected in Renminbi (RMB) and converted to US dol- lars (US$) from an exchange rate of US$ 1 = RMB 6.8. In the study, we used the principles outlined in the Helsinki declaration. The study was approved by the ethical committees of Yangtze University, Huazhong University of Science and Technology, Sun Yat-sen University and Jingshan County. Results A total of 1,189 patients were recruited by 4 eye clinics: 1,038 patients from ZOC, 78 patients from UH, 45 patients from FHJ and 28 patients from JCH. Some patients underwent bilateral surgeries, thus a total of 1,264 operations were performed in four clinics (Table 1). The