Day care versus in-patient surgery for age-related cataract

 

Abstract

Background

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract found in the developing world. With the increased number of people with cataract there is an urgent need for cataract surgery to be made available as a day care procedure.

Objectives

To provide reliable evidence for the safety, feasibility, effectiveness and cost-effectiveness of cataract extraction performed as day care versus in-patient procedure.

Search methods

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 5), MEDLINE (January 1950 to May 2011), EMBASE (January 1980 to May 2011), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to May 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 23 May 2011.

Selection criteria

We included randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation.

Data collection and analysis

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Adverse effects information was collected from the trials.

Main results

We included two trials (conducted in Spain and USA), involving 1284 people. One trial reported statistically significant differences in early postoperative complication rates in the day care group, with an increased risk of increased intraocular pressure, which had no clinical relevance to visual outcomes four months postoperatively. The mean change in visual acuity (Snellen lines) of the operated eye four months postoperatively was 4.1 (standard deviation (SD) 2.3) for the day care group and 4.1 (SD 2.2) for the in-patient group and not statistically significant. The four-month postoperative mean change in quality of life score measured using the VF14 showed minimal differences between the two groups. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay. One study only reported hotel costs for the non-hospitalised participants making aggregation of data on costs impossible.

Authors' conclusions

This review provides some evidence that there is a cost saving but no significant difference in outcome or risk of postoperative complications between day care and in-patient cataract surgery. This is based on one detailed and methodologically sound trial conducted in the developed world. The success, safety and cost-effectiveness of cataract surgery as a day care procedure appear to be acceptable. Future research may well focus on evidence provided by high quality clinical databases and registers which would enable clinicians and healthcare planners to agree clinical and social indications for in-patient care and so make better use of resources, by selecting day case surgery unless these criteria are met.

 

Plain language summary

Same day surgery compared to overnight stay for treatment of cataract caused by old age

The lens in eyes can become cloudy with age, leading to blurry vision or total vision loss. Cataracts can be surgically removed using a process called phacoemulsification, followed by implantation of an artificial lens to restore vision. This method of surgery is quicker and together with a shorter recovery period has made the possibility of day surgery a reality. Two trials conducted in Spain and USA, involving a total of 1284 people, were included. The small number of trials in this review found that in developed countries at least, there is some evidence that day surgery for this type of cataract extraction may not only be cheaper but just as effective as hospitalisation and overnight stay for cataract extraction.

 

摘要

背景

老年性白內障門診手術與住院手術間的比較

開發中國家失明的主要原因是白內障，老年性白內障佔了超過全球失明人口的40%。隨著白內障患者日益增加，以門診手術方式進行白內障手術是迫切需要的。

目標

在安全性、可行性、效果與成本效益各方面，進行白內障門診手術與住院手術的比較，以提供可靠的證據。

搜尋策略

搜尋的來源包括下列各臨床實證醫學資料庫：Cochrane Central Register of Controlled Trials、Cochrane Eyes and Vision Group Trials Register (2006年)、MEDLINE (1996年∼2006年9月)、EMBASE (1980年∼2006年9月)、LILACS (2006年9月)。

選擇標準

對於老年性白內障進行門診手術與住院手術，由隨機對照試驗的方式，以手術六個星期後的視力滿意度作為初步結果進行比較。

資料收集與分析

由兩位作者獨立地評估試驗的品質與數據，連絡原研究的作者以取得更多的資訊，並收集關於試驗中副作用的資訊。

主要結論

在進行的兩個試驗中，總共收入了1284位患者。第一個試驗中，門診手術病患組在早期手術後併發症發生率上有顯著差異，包括增加眼壓升高的機率；不過在手術後四個月的視力上則沒有顯著差異。手術後四個月後的手術眼平均視力變化上，門診手術組為4.1 (2.3個標準差)；而住院手術組為4.1 (2.2個標準差)，兩者無統計上差異。 手術後四個月以視覺功能指數(VF14)量表衡量平均生活品質變化上，兩組僅有極小的差異。花費上，住院手術成本較門診手術高20%，主要原因為手術前一晚的住院費用。有一篇研究則只算入了非住院病患的旅館費用，使得成本計算上數據難以收集。

作者結論

這篇論文回顧提供了一些證據，關於門診手術與住院手術相比較，成本較為低廉而手術的結果與術後併發症無顯著的差異。這是根據在已發開國家所進行詳細而研究方法嚴謹的試驗。結果顯示，白內障門診手術是安全、成功、具成本效益，而可接受的。不過還需要更多設計良好的試驗來確認這些觀念。

翻譯人

本摘要由高雄榮民總醫院畢勇賢翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

比較老年性白內障門診手術與過夜住院手術的差異。眼睛內的水晶體隨著年紀會變得混濁，導致視力模糊甚而視力喪失。白內障可以經由超音波乳化手術移除混濁水晶體，再植入人工水晶體以恢復視力。手術過程時間的減少與恢復期的縮短使得白內障門診手術得以實現。兩項試驗，包含了1284位病患。在其中較小型的試驗發現，已開發國家日間白內障手術不但在成本上較為低廉，在手術的成果上與過夜住院白內障手術一樣地有效。