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Intervenciones para mejorar el acceso a los servicios de cirugía de cataratas y la repercusión sobre la igualdad de condiciones en países de ingresos bajos y medios

Information

DOI:
https://doi.org/10.1002/14651858.CD011307.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 09 November 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Eyes and Vision Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Jacqueline Ramke

    Correspondence to: School of Population Health, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand

    [email protected]

  • Jennifer Petkovic

    Bruyère Research Institute, University of Ottawa, Ottawa, Canada

  • Vivian Welch

    Methods Centre, Bruyère Research Institute, Ottawa, Canada

  • Ilse Blignault

    School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia

  • Clare Gilbert

    Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK

  • Karl Blanchet

    Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK

  • Robin Christensen

    Musculoskeletal Statistics Unit, The Parker Institute, Copenhagen University Hospital, Bispebjerg og Frederiksberg, Copenhagen, Denmark

  • Anthony B Zwi

    School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia

  • Peter Tugwell

    Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada

Contributions of authors

JR assessed studies for inclusion and exclusion, assessed risk of bias, extracted data, entered data and authored the first draft of the review.

JP assessed studies for inclusion and exclusion, assessed risk of bias, extracted data, entered data and commented on the text of the review.

VW, IB, CG, KB, RC, AZ, and PT extensively reviewed the protocol and commented on the text of the review.

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • National Institute for Health Research (NIHR), UK.

    • Richard Wormald, Co‐ordinating Editor for Cochrane Eyes and Vision (CEV) acknowledges financial support for his CEV research sessions from the Department of Health through the award made by the National Institute for Health Research to Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology for a Specialist Biomedical Research Centre for Ophthalmology.

    • This review was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to the CEV UK editorial base.

    The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

Declarations of interest

JR, VW, IB, CG, JP, KB, RC, AZ, and PT have no known conflicts of interest. PT and VW are co‐convenors and JP is Co‐ordinator of the Campbell and Cochrane Equity Methods Group.

Acknowledgements

We thank:

  • Iris Gordon (Cochrane Eyes and Vision (CEV)) who created and executed the electronic searches, Jennifer Evans (CEV) for support with subgroup analysis and completing the review and Anupa Shah (CEV) for her assistance throughout the review process

  • GVS Murthy, Elena Schmidt, Andy Oxman and Nkengafac Villyen Motaze for comments on the protocol or review or both

Version history

Published

Title

Stage

Authors

Version

2017 Nov 09

Interventions to improve access to cataract surgical services and their impact on equity in low‐ and middle‐income countries

Review

Jacqueline Ramke, Jennifer Petkovic, Vivian Welch, Ilse Blignault, Clare Gilbert, Karl Blanchet, Robin Christensen, Anthony B Zwi, Peter Tugwell

https://doi.org/10.1002/14651858.CD011307.pub2

2014 Sep 20

Interventions to improve access to cataract surgical services and their impact on equity in low‐ and middle‐income countries

Protocol

Jacqueline Ramke, Vivian Welch, Ilse Blignault, Clare Gilbert, Jennifer Petkovic, Karl Blanchet, Robin Christensen, Anthony B Zwi, Peter Tugwell

https://doi.org/10.1002/14651858.CD011307

Differences between protocol and review

There are four differences between the protocol and review.

1. In the Types of outcome measures section we modified the text from:

Data will be extracted for any of these outcomes reported for any PROGRESS‐Plus groups if an assessment of the effect the intervention had on equity can be made.

to

Data will be extracted for any of these outcomes disaggregated by PROGRESS‐Plus groups if available.

2. In the Selection of studies section we made the underlined addition to the review:

This includes all studies that did not report outcome data in a usable way, or only reported overall effects, without reporting according to any of the PROGRESS‐Plus categories or without focusing on a disadvantaged population.

3. In the Assessment of risk of bias section we added the underlined text:

For RCTs, we assessed risk of bias using Cochrane’s ‘Risk of bias’ tool as described in Chapter 8 (Higgins 2011a) and Chapter 16 (Higgins 2011b) of the Cochrane Handbook for Systematic Reviews of Interventions . We also assessed recruitment bias, baseline imbalance, and loss of clusters for cluster RCTs.

4. In the Subgroup analysis section we separated the text into investigation of heterogeneity (type of investigation) and investigation of impact on equity (PROGRESS‐Plus). Hypotheses in Table 2 remained the same.

In addition, we made minor changes to phrasing and terminology between the protocol and review in response to reviewer comments.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Examples of interventions to improve access to cataract surgical services against Levesque and colleague’s1 conceptual framework of access to health care (Levesque 2013)
Figures and Tables -
Figure 1

Examples of interventions to improve access to cataract surgical services against Levesque and colleague’s1 conceptual framework of access to health care (Levesque 2013)

Logic model
Figures and Tables -
Figure 2

Logic model

Study flow diagram
Figures and Tables -
Figure 3

Study flow diagram

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
Figures and Tables -
Figure 4

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

Risk of bias summary: review authors' judgements about each risk of bias item for each included study
Figures and Tables -
Figure 5

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

Summary of findings for the main comparison. Information video and counselling to improve access to cataract surgical services compared with standard care for cataract

Information video and counselling to improve access to cataract surgical services compared with standard care for cataract

Patient or population: people with vision impairment caused by cataract

Settings: low‐ and middle‐income settings

Intervention: information video and counselling*

Comparison: standard care

Outcomes

Illustrative comparative risks** (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Standard care

Intervention to improve access to cataract surgical services

Change in the prevalence of cataract blindness

Not reported

Prevalence of visual impairment due to cataract

Not reported

Service utilisation: uptake of referral

400 per 1000

407 per 1000 (296 to 527)

OR 1.03 (0.63 to 1.67

434

(1)

⊕⊕⊝⊝

Low1

Service utilisation: uptake of surgery

340 per 1000

364 per 1000 (257 to 487)

OR 1.11 (0.67 to 1.84

434

(1)

⊕⊕⊝⊝

Low1

Cataract Surgical Coverage

Not reported

Surgical outcome (visual acuity in the operated eye)

Not reported

Adverse events

Not reported

*In this study, the intervention group (n = 212) watched a five‐minute informational video on cataract and cataract surgery then received a five‐minute counselling session (based on a script) from a trained nurse in groups of two to three, with family members. The control group (n = 222) were given standard care: they were advised they had decreased vision due to cataract and it could be treated, without being shown the video or receiving counselling.

**The assumed risk was the risk observed in the control group of this study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio

GRADE Working Group grades of evidence
High‐certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate‐certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low‐certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very low‐certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

1We downgraded by one level for imprecision (wide confidence intervals) and one level for indirectness (study was conducted in rural China and may not be applicable to other settings).

Figures and Tables -
Summary of findings for the main comparison. Information video and counselling to improve access to cataract surgical services compared with standard care for cataract
Summary of findings 2. Surgery fee waiver with/without transport provision or reimbursement to improve access to cataract surgical services compared with standard care for cataract

Surgery fee waiver with/without transport provision or reimbursement to improve access to cataract surgical services compared with standard care for cataract

Patient or population: people with vision impairment caused by cataract

Settings: low‐ and middle‐income settings

Intervention: financial incentives and/or reimbursement*

Comparison: standard care

Outcomes

Illustrative comparative risks** (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Standard care

Intervention to improve access to cataract surgical services

Change in the prevalence of cataract blindness

Not reported

Prevalence of visual impairment due to cataract

Not reported

Service utilisation: uptake of referral

Not reported

Service utilisation: uptake of surgery

150 per 1000

291 per 1000 (171 to 497)

RR 1.94 (1.14 to 3.31)

355

(1)

⊕⊕⊝⊝

Low1

Cataract Surgical Coverage

Not reported

Surgical outcome (visual acuity in the operated eye)

Not reported

Adverse events

* In this study, there were three intervention arms and a comparator arm: we have combined the intervention arms to display the results as there were no differences between them.

  • Intervention 1: reminded to use the low‐cost cataract surgery programme at the local hospital and offered free cataract surgery at local hospital (n = 86)

  • Intervention 2: reminded to use the low‐cost cataract surgery programme at the local hospital and offered free cataract surgery at local hospital plus offered reimbursement of transport costs (n = 90)

  • Intervention 3: reminded to use the low‐cost cataract surgery programme at the local hospital and offered free cataract surgery at local hospital plus offered free transport to and from the hospital (n = 93)

  • Comparator: reminded to use the low‐cost cataract surgery programme at the local hospital (n = 86)

**The assumed risk was the risk observed in the control group of this study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High‐certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate‐certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low‐certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very low‐certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

1We downgraded by one level for imprecision (wide confidence intervals and statistical analysis not adjusted for cluster randomised design) and one level for indirectness (study was conducted in rural China and may not be applicable to other settings).

Figures and Tables -
Summary of findings 2. Surgery fee waiver with/without transport provision or reimbursement to improve access to cataract surgical services compared with standard care for cataract
Table 1. Visual impairment categories (International Classification of Diseases ICD‐10)

Category

Presenting distance visual acuity

Worse than:

Equal to or better than:

0 Mild or no visual impairment

6/18

1 Moderate visual impairment

6/18

6/60

2 Severe visual impairment

6/60

3/60

3 Blindness

3/60

1/60*

4 Blindness

1/60*

light perception

5 Blindness

No light perception

9

Undetermined or unspecified

*or counts fingers (CF) at 1 metre

The term visual impairment comprises categories 1 to 5; blindness comprises categories 3 to 5 (Pascolini 2012).

Figures and Tables -
Table 1. Visual impairment categories (International Classification of Diseases ICD‐10)
Table 2. Subgroup analysis hypotheses

Explanatory factors

In which subgroup is the effect hypothesised to be larger

Type of intervention

Uni‐faceted versus multi‐faceted

It is hypothesised that multi‐faceted interventions will have a larger effect than uni‐faceted intentions (Chang 2008).

Targeted versus universal

It is hypothesised that targeted interventions will produce a larger effect for socially disadvantaged groups than universal interventions; universal interventions may benefit socially advantaged groups more than socially disadvantaged groups, and thereby increase inequity (Lorenc 2013).

Supply‐side versus demand‐side

Demand‐side interventions are unlikely to be effective if surgery is not accessible and affordable.

Supply‐side interventions might not be effective if there are unaddressed problems with demand.

Population characteristics

Gender/sex:
female versus male

Women have more barriers and less access to cataract surgical services than men (Lewallen 2009). Lack of social support to seek care is a major barrier for women. It is hypothesised that interventions that aim to modify women’s ability to perceive, to seek or to reach care (Figure 1) will produce larger effects for women than men, while universal interventions may produce larger effects for men.

SES/education/occupation:
low SES/ education/occupation versus higher

People with low SES/education have more barriers and less access to cataract surgical services than people with higher SES/education (Abubakar 2012; Jadoon 2007; Kuper 2008). It is hypothesised that interventions targeted to low‐SES people (especially in relation to ability to pay in Figure 1) would produce larger effects than for high‐SES people, while universal interventions may produce larger effects for high‐SES.

Place of residence:
urban versus rural

As services tend to be located in urban areas, rural dwellers tend to have less access to cataract surgical services than urban dwellers (Abubakar 2012; Jadoon 2007). It is hypothesised that interventions that address barriers faced by rural dwellers (such as those relating to availability and accommodation/ability to reach in Figure 1) would produce larger effects for rural dwellers, while other types of interventions may not produce a difference between urban and rural dwellers.

SES: socioeconomic status

Figures and Tables -
Table 2. Subgroup analysis hypotheses
Table 3. Subgroup analyses

Number of people

Odds ratio (95% CI)

Test for interaction (P value)

Outcome: uptake of referral

Place of residence

< 1 hour from hospital

225

0.86 (0.50 to 1.48)

0.49

≥ 1 hour from hospital

209

1.13 (0.65 to 1.95)

Gender

Men

185

0.77 (0.42 to 1.38)

0.35

Women

249

1.11 (0.67 to 1.85)

Education

Received some formal education

196

1.40 (0.80 to 2.47)

0.09

Received no formal education

238

0.71 (0.42 to 1.21)

Socioeconomic status

Patient will self‐pay for surgery

78

1.05 (0.42 to 2.62)

0.81

Patient will not self‐pay for surgery

356

0.93 (0.61 to 1.42)

Higher anticipated loss of income

246

0.89 (0.54 to 1.48)

0.63

Lower anticipated loss of income

167

1.10 (0.57 to 2.13)

More floor space/resident

222

0.78 (0.45 to 1.33)

0.28

Less floor space/resident

212

1.19 (0.69 to 2.05)

Social capital

Family member can accompany to hospital for surgery

369

0.98 (0.65 to 1.49)

0.66

Family member can not accompany to hospital for surgery

65

0.77 (0.29 to 2.09)

Family member accompanied patient to screening

188

0.95 (0.53 to 1.70)

0.77

Family member did not accompany patient to screening

246

1.07 (0.63 to 1.82)

Outcome: uptake of surgery

Place of residence

< 1 hour from hospital

225

0.63 (0.36 to 1.13)

0.10

≥ 1 hour from hospital

209

1.26 (0.71 to 2.22)

Gender

Men

185

0.88 (0.48 to 1.64)

0.94

Women

249

0.85 (0.50 to 1.45)

Education

Received some formal education

196

1.20 (0.67 to 2.15)

0.17

Received no formal education

238

0.68 (0.39 to 1.19)

Socioeconomic status

Patient will self‐pay for surgery

78

0.98 (0.37 to 2.59)

0.80

Patient will not self‐pay for surgery

356

0.85 (0.55 to 1.33)

Higher anticipated loss of income

246

0.85 (0.51 to 1.43)

0.58

Lower anticipated loss of income

167

1.09 (0.54 to 2.23)

More floor space/resident

222

0.79 (0.44 to 1.40)

0.57

Less floor space/resident

212

1.00 (0.57 to 1.75)

Social capital

Family member can accompany to hospital for surgery

369

0.88 (0.57 to 1.36)

0.86

Family member can not accompany to hospital for surgery

65

0.80 (0.28 to 2.30)

Family member accompanied patient to screening

188

1.05 (0.58 to 1.88)

0.64

Family member did not accompany patient to screening

246

0.86 (0.48 to 1.53)

Effect measure: odds ratio; analysis model: fixed effects.

Figures and Tables -
Table 3. Subgroup analyses