Equity, access, and carbon cost-effectiveness of bilateral cataract surgery

Cataract surgery is one of the most widely done surgeries worldwide.1Cicinelli MV Buchan JC Nicholson M Varadaraj V Khanna RC Cataracts.Lancet. 2023; 401: 377-389Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar The growing and ageing global population is expected to cause a rising mismatch between available resources and demand for cataract surgery, placing increasing burden on health-care systems, society, and the environment.1Cicinelli MV Buchan JC Nicholson M Varadaraj V Khanna RC Cataracts.Lancet. 2023; 401: 377-389Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar The 2023 BICAT-NL study2Spekreijse L Simons R Winkens B et al.Safety, effectiveness, and cost-effectiveness of immediate versus delayed sequential bilateral cataract surgery in the Netherlands (BICAT-NL study): a multicentre, non-inferiority, randomised controlled trial.Lancet. 2023; 401: 1951-1962Summary Full Text Full Text PDF PubMed Google Scholar is a timely and invaluable addition to the literature that supports the effectiveness, safety, and superior cost-effectiveness of immediate sequential bilateral cataract surgery (ISBCS) compared with the conventional model of delayed sequential bilateral cataract surgery (DSBCS). WHO defined the seven domains of quality that should be embraced by health services (appendix). Nevertheless, health-care systems and interventions that score highly on all seven domains but have a high carbon footprint can no longer be deemed sustainable or acceptable. Health-care systems are responsible for producing approximately 2 gigatonnes of carbon dioxide equivalent (2 × 1012 kgCO2e) annually, accounting for 4–5% of global greenhouse gas emissions.3Watts N Amann M Arnell N et al.The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (848) Google Scholar In view of this substantial climate impact, we advocate the inclusion of carbon cost-effectiveness as an eighth domain of quality in health-care services.3Watts N Amann M Arnell N et al.The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (848) Google Scholar, 4Buchan JC Thiel CL Steyn A et al.Addressing the environmental sustainability of eye health-care delivery: a scoping review.Lancet Planet Health. 2022; 6: e524-e534Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar For instance, carbon cost-effectiveness or carbon cost-utility can be measured by calculating the quality adjusted life-year per kgCO2e. This proposition resonates with the 2022 advocacy by McAlister and colleagues5McAlister S Morton RL Barratt A Incorporating carbon into health care: adding carbon emissions to health technology assessments.Lancet Planet Health. 2022; 6: e993-e999Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar on incorporating carbon footprint into health technology assessments. We would encourage all randomised controlled trials to consider comparing the carbon cost-effectiveness or cost-utility of each group to avoid adopting interventions that are effective, but ultimately unsustainable. For BICAT-NL, however, inclusion of this outcome could be expected to show superior carbon cost-effectiveness with ISBCS over DSBCS and strengthen the evidence for its adoption. We declare no competing interests. DSJT acknowledges support from the Medical Research Council/Fight for Sight Clinical Research Fellowship (MR/T001674/1) and the Fight for Sight/John Lee Royal College of Ophthalmologists Primer Fellowship (24CO4). Download .pdf (.11 MB) Help with pdf files Supplementary appendix Safety, effectiveness, and cost-effectiveness of immediate versus delayed sequential bilateral cataract surgery in the Netherlands (BICAT-NL study): a multicentre, non-inferiority, randomised controlled trialOur results showed non-inferiority of ISBCS versus DSBCS regarding effectiveness outcomes, comparable safety, and superior cost-effectiveness of ISBCS. National cost savings could amount to €27·4 million (US$34·5 million) annually, advocating for ISBCS if strict inclusion criteria are applied. Full-Text PDF Equity, access, and carbon cost-effectiveness of bilateral cataract surgeryWe read the study by Spekreijse and colleagues1 with interest. By use of a randomised controlled trial design, the authors report that immediate sequential bilateral cataract surgery (ISBCS) had similar refractive outcomes and complications and superior cost-effectiveness compared with delayed sequential bilateral cataract surgery (DSBCS) at ten Dutch hospitals.1 Data from the Intelligent Research in Sight registry in the USA also showed comparable refractive outcomes and complication rates for ISBCS and DSBCS. Full-Text PDF Equity, access, and carbon cost-effectiveness of bilateral cataract surgery – Authors' replyWe thank both John C Lin and Paul B Greenberg, and Darren S J Ting and John C Buchan for their interest in our Article regarding the BICAT-NL study1. As reported by Lin and Greenberg, the Intelligent Research in Sight registry study2 reported large-scale outcome data on refractive results of immediate sequential bilateral cataract surgery (ISBCS). This registry study found slightly worse refractive outcomes after ISBCS compared with delayed sequential bilateral cataract surgery (DSBCS). However, multiple factors, including allocation to surgery group, missing data (ie, more than 50% of surgeries were excluded due to missing data on visual outcomes), confounding factors, and very large sample sizes can explain these small differences found. Full-Text PDF