Cataract Blindness and Simulation-Based Training for Cataract Surgeons

137 Pages·2012·1.99 MB·English

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TECHNICAL REPORT
Cataract Blindness and
Simulation-Based Training
for Cataract Surgeons
An Assessment of the HelpMeSee Approach

James R. Broyles, Peter Glick, Jianhui Hu, Yee-Wei Lim
Sponsored by HelpMeSee, Inc.
HEALTH
The research described in this report was sponsored by HelpMeSee, Inc. and was conducted
within RAND Health, a unit of the RAND Corporation.
The RAND Corporation is a nonprofit institution that helps improve policy and
decisionmaking through research and analysis. RAND’s publications do not necessarily
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Preface
An estimated 20 million people around the world are blind from cataracts, mostly in devel-
oping countries, where blindness and visual impairment can have enormous negative impacts
on the quality of life, in addition to reducing life expectancy and economic productivity. The
great majority of cataract cases can be cured by quick and inexpensive surgical procedures that
have been shown to have very high success rates in developing country contexts. However, a
shortage of trained cataract surgeons makes it unlikely that the need for such surgeries can be
met under current practices.
To address this problem, HelpMeSee, Inc. (HMS) is developing an innovative approach
to cataract surgery training and delivery. The HMS approach includes: use of high-fidelity sim-
ulator technology for high-volume training in cataract surgery; an HMS-supported system of
independent private surgery practitioners (a contrast to traditional highly centralized, hospital-
based systems); and the training of significant numbers of nondoctors in cataract surgery, with
the expectation that such individuals will be willing to live and work in underserved areas.
HMS approached RAND to undertake an assessment of its approach, with the objective
of learning whether it could significantly reduce the problem of cataract-caused blindness and
low vision in the developing world, and whether it would be a cost-effective means of doing so.
The analysis in this report develops a model to forecast the prevalence of cataract-caused visual
impairment in Africa, Asia, and Latin America under the “status quo” as well as several HMS
scenarios. The model estimates the potential effects of HMS on the prevalence of cataract-
caused visual impairment, Disability Adjusted Life Years (DALYs), and economic losses from
blindness and visual impairment. We also assess the potential cost-effectiveness of the HMS
model. Finally, we consider a range of potential challenges to the success of the approach, and
discuss how a pilot study can assess some of these factors.
This research should be of interest to researchers, practitioners, and policymakers involved
in vision care and eye health in developing countries, as well as those with a more general inter-
est in the use of technology for training health care workers and those interested in different
approaches to health service delivery in developing countries.
The report was funded by HelpMeSee, Inc. under contract No. HELPMESEE_09.16.10.
The research was conducted as part of the Global Health Initiative in RAND Health, a
division of the RAND Corporation. A profile of RAND Health, abstracts of its publications,
and ordering information can be found at www.rand.org/health.
Comments or questions on this report should be addressed to the project leader, Peter
Glick. He can be reached by email at [email protected].
iii

Contents
Preface ........................................................................................................... iii
Figures ........................................................................................................... ix
Tables ............................................................................................................ xi
Summary ......................................................................................................xiii
Acknowledgments ............................................................................................ xxi
Abbreviations ................................................................................................ xxiii
ChAPTer One
Introduction ..................................................................................................... 1
Objectives of the Study .......................................................................................... 2
Outline of the Report ............................................................................................ 3
ChAPTer TwO
Global Cataract Problem and Cataract Surgery Backlog ............................................... 5
Cataract Burden in the Developing World ................................................................... 5
Defining Blindness, Low Vision, and Visual Impairment .................................................. 5
Cataracts .......................................................................................................... 6
Cataract Surgery Techniques ................................................................................... 7
Types of Cataract Surgery and Relative Costs/Benefits ..................................................... 7
Cataract Surgery Shortfall ...................................................................................... 9
Constraints to Expanding Cataract Surgery Coverage ....................................................10
ChAPTer Three
existing Models of Cataract Surgery Training and Delivery .........................................11
Aravind (India) ..................................................................................................11
Tilganga (Nepal) ...............................................................................................13
Project Vision (China) ..........................................................................................14
He Eye Care System (China) ..................................................................................14
Experiences in Africa ...........................................................................................15
Summary: Common Characteristics of Approaches .......................................................16
ChAPTer FOur
The helpMeSee Approach ....................................................................................19
Simulator Training ..............................................................................................19
HelpMeSee Learning Centers .................................................................................21
Composition of Surgical Trainees ........................................................................... 22
v
vi Cataract Blindness and Simulation-Based Training for Cataract Surgeons
Service Delivery Model ....................................................................................... 23
Private Practices .............................................................................................. 24
Financing System ............................................................................................ 24
Quality Assurance and Monitoring .......................................................................... 24
ChAPTer FIve
Forecasting the Burden of Cataract ....................................................................... 27
Introduction .................................................................................................... 27
Regional Breakdown for the Analysis ..................................................................... 27
Forecasts of Prevalence of Cataract-Caused Visual Impairment ..........................................29
Methodological Approach ...................................................................................29
Forecasts of Prevalence by Region ..........................................................................31
Disease Burden—Disability Adjusted Life Years ............................................................33
Forecasts of Productivity Loss Due to Cataracts ............................................................35
Methodology ..................................................................................................35
Results ........................................................................................................ 36
Summary .........................................................................................................37
ChAPTer SIx
Modeling the Impacts of helpMeSee ......................................................................39
Assumptions of the Model .....................................................................................39
Uptake .........................................................................................................41
Impacts on Number of Surgeons and Surgical Capacity .................................................. 42
Impacts on Prevalence of Cataract-Caused Visual Impairment ......................................... 44
Sensitivity Analysis ...........................................................................................47
Impacts on Disease Burden and Economic Productivity ...................................................49
Implications for the Viability of Individual Practices ...................................................... 54
Summary ........................................................................................................57
ChAPTer Seven
Analysis of Costs and Cost-effectiveness .................................................................59
Costs ..............................................................................................................59
Cost-Effectiveness Analysis ....................................................................................63
Impact of HelpMeSee on Disability Adjusted Life Years and Productivity Loss ......................63
Cost-Effectiveness of the HelpMeSee Intervention .......................................................65
Summary ....................................................................................................... 66
ChAPTer eIGhT
Potential Challenges to the helpMeSee Approach .....................................................69
Mobilization and Screening ....................................................................................69
Quality and Supervision .......................................................................................71
Ability of the Simulator Approach to Produce Skilled Surgeons ........................................71
Nondoctors as Cataract Surgeons ...........................................................................71
Monitoring Performance ....................................................................................72
The Surgeon-Entrepreneur Model ............................................................................73
Cataracts-Only Practices .......................................................................................74
Contents vii
Long-Term Viability of Surgical Practices ...................................................................75
Legal and Regulatory Environment ......................................................................... 77
ChAPTer nIne
Summary of Findings and Conclusions ...................................................................79
Learning from a Pilot Study ...................................................................................82
APPenDIxeS
A. Modeling Approach, Methodology, and Data Sources ..............................................85
B. Sensitivity Analysis—Practitioner Attrition and Trainee Intake ................................ 97
C. Detailed Input Costs and Methodology .............................................................. 99
references ..................................................................................................... 107