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    Waiting for surgery

    Medical systems and national wealth: What's wrong with this picture?


    Peter J. McDonnell, MD
    A recent trip provided the opportunity to visit two countries on two different continents and learn a little about their health-care systems and, more specifically, how they care for patients with cataracts. Both were English-speaking countries, and although my visit was brief, I think it was possible to get the lay of the land.

    In the first country, patients who have visual complaints are routinely seen the same day or whenever they want to come to the clinic. If the evaluation reveals that they have cataracts, they are measured for their IOLs, cleared medically for surgery, and typically have surgery performed within 1 week.

    In the second country, patients are not supposed to wait longer than 18 weeks for an appointment to see the ophthalmologist. In some cases, they are being required to wait at least 15 weeks.1 Once they see the ophthalmologist and a decision is made to perform surgery for cataracts, they will wait an average of about 6 months before the procedure is performed.2

    Which country is which?

    Based upon published data, the results (e.g., endophthalmitis rates) of cataract surgery in these two countries are roughly comparable.

    One country is within the so-called "developing world," with a gross domestic product (GDP) per capita (according to the International Monetary Fund)3 of $1,371, and a very modest degree of governmental financial support for health care. In the clinic I visited, much of the funding came from philanthropic support, and many patients paid nothing for their care because they are very poor.

    The other country is a developed economic power squarely within the "first world." GDP per capita is $36,164, and the government provides massive funding to support its health-care system.

    Now here's the question: Which is the country with the prompt availability of appointments and surgery? The answer (and I know you brilliant Ophthalmology Times readers have already guessed the punchline here) is that the "poor" nation, not the rich one, provided the exemplary prompt service to its patients.

    Pondering this observation during the long flight home to Baltimore, I struggled to understand how this makes sense. Without oversimplifying things too much, wouldn't it be natural to expect that citizens of wealthy countries with health-care systems that enjoy large cash infusions from the government would receive more timely service, especially with something like cataract surgery, which has been shown to be so cost-effective at improving quality of life?

    To be fair, although the language spoken in these two countries is the same, there are many cultural and political differences. So all other things are not equal, except for the amount of funding and the sources of that funding, for the respective health-care systems.

    Does it matter if some people wait a long time to have surgery? In Canada (a third English-speaking country with a GDP per capita of $46,303), cataract surgery outcomes were better in patients with waits of 6 weeks or less than in patients who waited 6 months or more. Patients who waited longer experienced more vision loss, a reduced quality of life, and an increased rate of falls (a major cause of death in the elderly).4

    Shouldn't rich countries do a better job of timely care and surgery for patients with eye disease?

    By Peter J. McDonnell, MD director of the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times.

    He can be reached at 727 Maumenee Building 600 N. Wolfe St. Baltimore, MD 21287-9278 Phone: 443/287-1511 Fax: 443/287-1514 E-mail:

    References

    1. Lansley hits back in NHS 'rationing' row. Financial Times. Monday Nov. 14, 2011.

    2. Royal College of Ophthalmologists. http://www.rcophth.ac.uk/page.asp?section=369&sectionTitle=Specific+Questions+Related+to+Cataract+Surgery

    3. Data refer to the year 2010. World Economic Outlook Database-September 2011, International Monetary Fund. Accessed Sept. 26, 2011.

    4. Hodge W, et al. The consequences of waiting for cataract surgery: A systematic review. CMAJ. April 24, 2007;176.

    Peter J. McDonnell, MD
    He is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of ...

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