Surgical follow-up in low-income and middle-income countries – Authors' reply
Authors: Nathan Congdon
Journal: The Lancet Global Health (2013)

We thank Rele Ologunde and Sohaib Rufai for their interest in our study.1Congdon N Yan X Lansingh V et al.Assessment of cataract surgical outcomes in settings where follow-up is poor: PRECOG, a multicentre observational study.Lancet Glob Health. 2013; 1: e37-e45Summary Full Text Full Text PDF Scopus (44) Google Scholar Their conclusions echo those of the Comment by Yuzhen Jiang and Paul Foster2Jiang Y Foster PJ Quality assessment of cataract surgery in regions with low follow-up rates.Lancet Glob Health. 2013; 1: e9-10Summary Full Text Full Text PDF Scopus (8) Google Scholar that accompanied our report, in accepting the usefulness of early assessment of cataract surgery, while also stressing that good follow-up is crucial to “detect and treat postoperative complications in a timely manner”.2Jiang Y Foster PJ Quality assessment of cataract surgery in regions with low follow-up rates.Lancet Glob Health. 2013; 1: e9-10Summary Full Text Full Text PDF Scopus (8) Google Scholar Ologunde and Rufai suggest that doctors should actively advise patients when to return in order to promote compliance.Although our study methods required all patients to be instructed to return for examination 40 days after surgery, only half returned to the clinic without additional prompting, and only a quarter did so from the 18 Chinese hospitals. Jiang and Foster2Jiang Y Foster PJ Quality assessment of cataract surgery in regions with low follow-up rates.Lancet Glob Health. 2013; 1: e9-10Summary Full Text Full Text PDF Scopus (8) Google Scholar cite evidence that failure to correct refractive error often leads to poor outcomes in low-resource settings, and recommend interventions to improve follow-up, as do Ologunde and Rufai.Despite the clinical benefits of postoperative care after cataract surgery, little evidence exists for its cost effectiveness in settings with poor follow-up. The cost of improving follow-up might be substantial for facilities, and present a financial burden to patients. Balanced against this issue could be a low acceptance and effectiveness of postoperative care: although 87% of patients in a Chinese study3Congdon NG Rao SK Zhao X Wang W Choi K Lam DS Visual function and postoperative care after cataract surgery in rural China: Study of Cataract Outcomes and Up-Take of Services (SCOUTS) in the Caring Is Hip Project, report 2.Arch Ophthalmol. 2007; 125: 1546-1552Crossref PubMed Scopus (22) Google Scholar could obtain improved vision with refraction after cataract surgery, only a third would accept prescriptions, the most common reason being a perceived lack of need. Although uptake of free yttrium aluminium garnet (YAG) capsulotomy in the same setting was substantially higher, such procedures improved visual acuity in less than 10% of patients from the surgical cohort who presented with poor postoperative vision.4Congdon N Fan H Choi K et al.Impact of posterior subcapsular opacification on vision and visual function among subjects undergoing cataract surgery in rural China: Study of Cataract Outcomes and Up-Take of Services (SCOUTS) in the Caring is Hip Project, report 5.Br J Ophthalmol. 2008; 92: 598-603Crossref PubMed Scopus (18) Google ScholarResearch is needed to establish the cost effectiveness of interventions to improve follow-up after cataract surgery before we can assert that such interventions are warranted. In PRECOG, we collected information about follow-up costs from both patients and facilities. We identified patients whose visual acuity could improve by two or more lines with refraction or other treatment, and the proportion who would accept and pay for glasses or treatment. We will soon report on the average cost of identifying a single patient whose vision could be improved by refraction or other treatment. We very much agree with the correspondents and the Comment authors2Jiang Y Foster PJ Quality assessment of cataract surgery in regions with low follow-up rates.Lancet Glob Health. 2013; 1: e9-10Summary Full Text Full Text PDF Scopus (8) Google Scholar that all patients deserve the best care that we as providers can give. However, in settings where postoperative compliance is challenging and acceptance and effectiveness of postoperative interventions can be low, we feel that cost-effectiveness data can be helpful for deciding how much we are prepared to ask patients and facilities to spend on additional follow-up.We declare that we have no conflicts of interest. We thank Rele Ologunde and Sohaib Rufai for their interest in our study.1Congdon N Yan X Lansingh V et al.Assessment of cataract surgical outcomes in settings where follow-up is poor: PRECOG, a multicentre observational study.Lancet Glob Health. 2013; 1: e37-e45Summary Full Text Full Text PDF Scopus (44) Google Scholar Their conclusions echo those of the Comment by Yuzhen Jiang and Paul Foster2Jiang Y Foster PJ Quality assessment of cataract surgery in regions with low follow-up rates.Lancet Glob Health. 2013; 1: e9-10Summary Full Text Full Text PDF Scopus (8) Google Scholar that accompanied our report, in accepting the usefulness of early assessment of cataract surgery, while also stressing that good follow-up is crucial to “detect and treat postoperative complications in a timely manner”.2Jiang Y Foster PJ Quality assessment of cataract surgery in regions with low follow-up rates.Lancet Glob Health. 2013; 1: e9-10Summary Full Text Full Text PDF Scopus (8) Google Scholar Ologunde and Rufai suggest that doctors should actively advise patients when to return in order to promote compliance. Although our study methods required all patients to be instructed to return for examination 40 days after surgery, only half returned to the clinic without additional prompting, and only a quarter did so from the 18 Chinese hospitals. Jiang and Foster2Jiang Y Foster PJ Quality assessment of cataract surgery in regions with low follow-up rates.Lancet Glob Health. 2013; 1: e9-10Summary Full Text Full Text PDF Scopus (8) Google Scholar cite evidence that failure to correct refractive error often leads to poor outcomes in low-resource settings, and recommend interventions to improve follow-up, as do Ologunde and Rufai. Despite the clinical benefits of postoperative care after cataract surgery, little evidence exists for its cost effectiveness in settings with poor follow-up. The cost of improving follow-up might be substantial for facilities, and present a financial burden to patients. Balanced against this issue could be a low acceptance and effectiveness of postoperative care: although 87% of patients in a Chinese study3Congdon NG Rao SK Zhao X Wang W Choi K Lam DS Visual function and postoperative care after cataract surgery in rural China: Study of Cataract Outcomes and Up-Take of Services (SCOUTS) in the Caring Is Hip Project, report 2.Arch Ophthalmol. 2007; 125: 1546-1552Crossref PubMed Scopus (22) Google Scholar could obtain improved vision with refraction after cataract surgery, only a third would accept prescriptions, the most common reason being a perceived lack of need. Although uptake of free yttrium aluminium garnet (YAG) capsulotomy in the same setting was substantially higher, such procedures improved visual acuity in less than 10% of patients from the surgical cohort who presented with poor postoperative vision.4Congdon N Fan H Choi K et al.Impact of posterior subcapsular opacification on vision and visual function among subjects undergoing cataract surgery in rural China: Study of Cataract Outcomes and Up-Take of Services (SCOUTS) in the Caring is Hip Project, report 5.Br J Ophthalmol. 2008; 92: 598-603Crossref PubMed Scopus (18) Google Scholar Research is needed to establish the cost effectiveness of interventions to improve follow-up after cataract surgery before we can assert that such interventions are warranted. In PRECOG, we collected information about follow-up costs from both patients and facilities. We identified patients whose visual acuity could improve by two or more lines with refraction or other treatment, and the proportion who would accept and pay for glasses or treatment. We will soon report on the average cost of identifying a single patient whose vision could be improved by refraction or other treatment. We very much agree with the correspondents and the Comment authors2Jiang Y Foster PJ Quality assessment of cataract surgery in regions with low follow-up rates.Lancet Glob Health. 2013; 1: e9-10Summary Full Text Full Text PDF Scopus (8) Google Scholar that all patients deserve the best care that we as providers can give. However, in settings where postoperative compliance is challenging and acceptance and effectiveness of postoperative interventions can be low, we feel that cost-effectiveness data can be helpful for deciding how much we are prepared to ask patients and facilities to spend on additional follow-up. We declare that we have no conflicts of interest. Surgical follow-up in low-income and middle-income countriesThe poorest third of the world's population is estimated to receive only 3·5% of the 234 million surgical procedures undertaken annually.1 Despite being a small proportion of global surgical output, such procedures represent a substantial challenge for health-care providers in low-resource settings. This challenge is compounded by the burden of managing postoperative complications (particularly delayed complications), which patients might not present with, as evidenced by the low rates of follow-up in many low-income and middle-income countries. Full-Text PDF Open Access