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Distribution gaps in cataract surgery care and impact on seniors across Ontario

  • Author Footnotes
    a These two authors contributed equally to this work.
    Shicheng Jin
    Footnotes
    a These two authors contributed equally to this work.
    Affiliations
    Keenan Research Centre for Biomedical Sciences, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.
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  • Author Footnotes
    a These two authors contributed equally to this work.
    Sze Wah Samuel Chan
    Footnotes
    a These two authors contributed equally to this work.
    Affiliations
    Keenan Research Centre for Biomedical Sciences, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.
    Search for articles by this author
  • Neeru Gupta
    Correspondence
    Correspondence to Neeru Gupta, MD, St. Michael's Hospital, 30 Bond Street, Cardinal Carter Wing, 8-072, Toronto, Ont. M5B 1W8.
    Affiliations
    Keenan Research Centre for Biomedical Sciences, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.

    Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ont.

    Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont.

    Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.
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  • Author Footnotes
    a These two authors contributed equally to this work.
Open AccessPublished:January 16, 2019DOI:https://doi.org/10.1016/j.jcjo.2018.10.022

      Abstract

      Objective

      To assess recent cataract service delivery across communities of all sizes in Ontario.

      Design

      Retrospective analysis of health records.

      Participants

      All Ontario Health Insurance Plan users.

      Methods

      Raw physician Ontario Health Insurance Plan claims data for cataract surgery (E140A, E214A) from April 1, 2009, to March 31, 2014, were extracted from the Ontario Ministry of Health and Long-Term Care (MOHLTC) IntelliHealth database. Cataract surgery claims data were sorted by sex, by age, and by Ontario's 444 municipalities based on patient residence. Cataract surgery distribution was examined by population centre: Large Urban (≥100 000 persons), Medium (30 000–99 999 persons), Small (1000–29 999 persons), and Rural (<1000 persons) as defined by Statistics Canada. Wait times were extracted from the MOHLTC wait times database. Cataract surgery rate (CSR), defined as the number of cataract surgeries performed per million, was calculated.

      Results

      Cataract surgery volumes remained unchanged from 2010 to 2014. Mean patient age was 71.6 ± 10 years. Patients lived in large urban (63%), medium (15%), small (21%), and rural (0.6%) communities. Mean wait times increased by 28% to 68.5 days, and 90th percentile wait times increased by 44% to 154.3 days. A reduction in CSR was observed among seniors aged 65–74 years (−10%) and 75+ years (−16%). Rural communities showed the largest decline (−19%). Among seniors aged ≥75 years, CSR declined the most for those living in rural communities (−25%).

      Conclusions

      Adjusting the current government policy of zero-growth in cataract surgery volumes will support growing demands for cataract care in our aging population.

      Résumé

      Objectif

      Évaluer la prestation récente de services en matière de cataractes dans des collectivités de toutes tailles en Ontario.

      Nature

      Analyse rétrospective de dossiers médicaux.

      Méthodes

      À partir de la base de données savoirSANTÉ du ministère de la Santé et des Soins de longue durée (MSSLD) de l'Ontario, on a procédé à l'extraction des données brutes issues des réclamations soumises à l'Assurance-santé de l'Ontario pour des chirurgies de la cataracte (E140A, E214A) entre le 1er avril 2009 et le 31 mars 2014. Les données sur les réclamations pour des chirurgies de la cataracte ont été triées en fonction du sexe, de l’âge et des 444 municipalités de l'Ontario, d'après le lieu de résidence du patient. La distribution des chirurgies de la cataracte a été répartie selon la classification des centres de population définis par Statistique Canada: grands centres de population urbains (≥ 100 000 habitants), moyens centres de population (30 000 à 99 999 habitants), petits centres (1000 à 29 999 habitants) et régions rurales (< 1000 habitants). Les délais d'attente ont été extraits de la base de données du MSSLD correspondante. On a pu alors calculer le taux de chirurgie de la cataracte (TCC), qui se définissait comme le nombre de chirurgies de la cataracte réalisées par million de personnes.

      Résultats

      Le volume de chirurgies de la cataracte est demeuré le même entre 2010 et 2014. L’âge moyen des patients était de 71,6 ± 10 ans. La répartition des patients en fonction de leur lieu de résidence se détaillait comme suit : grands centres (63 %), moyens centres (15 %), petits centres (21 %) et régions rurales (0,6 %). Le délai d'attente moyen a augmenté de 28 %, pour atteindre 68,5 jours, et le 90e percentile de délai d'attente a crû de 44 % pour atteindre 154,3 jours. On a enregistré une réduction du TCC chez les sujets âgés de 65 à 74 ans (–10 %) et chez ceux de ≥ 75 ans (–16 %). La baisse la plus importante s'est produite en région rurale (–19 %). Enfin, le TCC chez les personnes de ≥ 75 ans a accusé la dégression la plus prononcée en région rurale (–25 %).

      Conclusions

      On note depuis quelques années une baisse du taux de chirurgie de la cataracte chez les personnes âgées en Ontario, tous lieux de résidence confondus. L'ajustement des politiques gouvernementales actuelles qui prônent une hausse nulle du volume de chirurgies de la cataracte pourrait compenser les besoins croissants en matière de soins des cataractes au sein de notre population vieillissante.
      Cataract is a “disease of aging” and the leading cause of reversible visual impairment worldwide, affecting 95 million people globally and 2.5 million Canadians.
      • Liu Y-C
      • Wilkins M
      • Kim T
      • Malyugin B
      • Mehta JS
      Cataracts.

      Canadian National Institute for the Blind. CNIB—Cataracts. 2015. [cited 2017 Jun 15]. Available from: http://www.cnib.ca/en/your-eyes/eye-conditions/cataracts/pages/default.aspx.

      This number is expected to increase as Canada's population continues to grow and age.

      Canadian National Institute for the Blind. CNIB—Cataracts. 2015. [cited 2017 Jun 15]. Available from: http://www.cnib.ca/en/your-eyes/eye-conditions/cataracts/pages/default.aspx.

      • Hatch WV
      • Campbell E
      • de L
      • Bell CM
      • El-Defrawy SR
      • Campbell RJ
      Projecting the growth of cataract surgery during the next 25 years.
      However, with advancements in safe and reliable cataract surgical techniques, visual impairment from cataracts has become treatable.
      • Liu Y-C
      • Wilkins M
      • Kim T
      • Malyugin B
      • Mehta JS
      Cataracts.
      To tackle this growing problem, in 2013, Canada was among the WHO member states at the World Health Assembly that unanimously endorsed the Global Action Plan for Universal Eye Health (GAP) 2014 to 2019.
      WHO
      Universal Eye Health: A Global Action Plan 2014–2019.
      • Gupta N
      • Kocur I
      Chronic eye disease and the WHO Universal Eye Health Global Action Plan 2014–2019.
      The GAP aims to reduce avoidable blindness and visual impairment by 25% by 2019.
      WHO
      Universal Eye Health: A Global Action Plan 2014–2019.
      The GAP uses the term “cataract surgery rate” (CSR), which is defined as the number of cataract operations performed per year per million population. CSR is important because the GAP plan recommends using “cataract surgery delivery” as the primary indicator to assess progress for eye care service provision at a population level.
      WHO
      Universal Eye Health: A Global Action Plan 2014–2019.
      Ontario is Canada's most populous province with a total population of 13.6 million among urban and rural settings. In Ontario, 2.3 million individuals are over the age of 65 years; by 2041 this number is projected to double to 4.6 million.
      Association of Municipalities Ontario
      Ontario Municipalities.
      Ontario Ministry of Finance
      Ontario Population Projections Update.
      The Ontario Ministry of Health and Long-Term Care (MOHLTC) has prioritized improving “access” to medical services for all Ontarians in rural and urban areas as a part of its Patient's First mandate.
      Ministry of Health and Long-Term Care
      Patients First: Action Plan for Health Care.
      In addition, the Ontario MOHLTC Wait Time Strategy has identified improving access to cataract surgery as a key priority area.
      Ministry of Health and Long-Term Care
      Ontario Wait Times Strategy.
      The key metric used is mean and 90th percentile wait times (days).
      Ministry of Health and Long-Term Care
      Ontario Wait Times Strategy.
      While wait times provides a measure from the perspective of the patient in terms of the time they wait for cataract surgery, CSR provides a population-adjusted metric for the provision of cataract surgery at a regional level. However, cataract surgery volume in Ontario has entered a period of government-mandated zero growth and the impact of this on Ontario's cataract service delivery is unknown.
      • Campbell RJ
      • El-Defrawy SR
      • Bell CM
      • et al.
      Effect of cataract surgery volume constraints on recently graduated ophthalmologists: a population-based cohort study.
      Previous studies have reported declines in cataract surgery volumes in Ontario over the past decade and a 136% projected increase in cataract surgery volume as needed to meet the demands of Ontario's aging and growing population.
      • Hatch WV
      • Campbell E
      • de L
      • Bell CM
      • El-Defrawy SR
      • Campbell RJ
      Projecting the growth of cataract surgery during the next 25 years.
      Canada has a “universal health care system,” which aims to provide the same high quality of care regardless of location. To date, there is a lack of data regarding the distribution and trends in cataract care by community sizes in Ontario. The MOHLTC collects Ontario Health Insurance Plan (OHIP) claims data and this repository provides an opportunity to gain insights into CSRs and care. This study aims to assess cataract service delivery in Ontario with particular attention to differences across rural, small, medium, and urban communities using the most recently available population data.

      Methods

      This study is a retrospective population-level analysis of cataract surgery health records in Ontario from April 1, 2009, to March 31, 2014 (fiscal years 2010 to 2014). Raw OHIP physician claims data for cataract surgery were extracted from the Ontario MOHLTC IntelliHealth database that captures all billing codes and claims for OHIP card users (last accessed February 30, 2018).
      Ministry of Health and Long-Term Care
      IntelliHealth Ontario.
      Cataract surgery was coded using the OHIP Schedule of Benefits and Fees: E140A (cataract surgery including insertion of an intraocular lens) and E214A (cataract surgery with glaucoma filtration surgery). Procedures performed in combination with cataract surgery were extracted as follows: E121A (penetrating corneal transplant), E122A (lamellar corneal transplant), E148A (posterior vitrectomy), and E940A (anterior vitrectomy). Any procedure performed in combination with cataract surgery on the same day was captured and analyzed as a combination procedure. Each cataract surgery on a single eye was treated as a single distinct event as recommended by the WHO. Raw demographic information at the time of surgery and the municipality of patient residence was extracted across all of Ontario's 444 municipalities. CSR, defined as the number of cataract surgeries performed per million, was calculated by sex, age, and municipality. Data were extracted and categorized by population centre as defined by Statistics Canada: Large Urban (≥100 000 persons), Medium (between 30 000 and 99 999 persons), Small (between 1000 and 29 999 persons), and Rural (<1000 persons).
      Statistics Canada
      Dictionary, Census of Population, 2016 Population centre (POPCTR).
      Additional subanalysis was performed for seniors by community size to understand age group trends within communities in Ontario. Demographic data for the study period for Ontario and by age, sex, and municipality were extracted from IntelliHealth, sourced from Statistics Canada. Population projection data for all of Ontario and by age group were used to calculate CSR projections to 2025; this population data were sourced from age and sex standardized projection models from the Ontario Ministry of Finance (last accessed September 30, 2017). Wait times were extracted from the MOHLTC public wait times database and compared with CSR.

      Statistical analysis

      Raw cataract surgery data were obtained from the MOHLTC IntelliHealth database, which contains all of the health system data for valid OHIP card users from Ontario. Statistical hypothesis testing was not necessary, as all differences in this study represent true differences in the population.

      Results

      Demographics

      Over the 5-year period, 726 049 total cataract surgeries were performed in Ontario, and 98.9% ± 0.2% of cataract surgeries were performed as a solo procedure. Mean patient age was 71.6 ± 10 years, with a female-to-male ratio of 1.3:1.0. Most cataract surgeries were performed in the age groups of 75+ years (41.7% ± 1.1%), 65–74 years (36.7% ± 1.3%), and 45–64 years (20.5% ± 0.3%) (Table 1). Ontario's population increased by 4.1% during this period. By age group, population increased for the 65–74-year (+21.8%), 75+-year (+11.1%), 45–64-year (+4.3%), 20–44-year (+3%), and 0–19-year (+1.8%) age groups.
      Table 1Ontario cataract surgery patients demographics
      20102011201220132014Mean (SD)
      Cataract surgery volume145 302147 550143 617144 341145 239−0.04%
      Mean age (y)71.7 ± 1071.6 ± 1071.5 ± 1071.5 ± 9.971.5 ± 9.971.6 ± 10
      Sex (female %:male %)57:4358:4257:4357:4357:4357 ± 0.3:43 ± 0.1
      Age, y (%)
       0–190.10.10.10.10.10.1 ± 0.01
       20–441.01.01.00.90.91.0  ±  0.05
       45–6420.420.821.020.420.020.5 ± 0.34
       65–7435.035.636.437.938.536.7 ± 1.3
       75+43.442.541.540.740.441.7 ± 1.1

      Ontario cataract surgery trends

      Ontario's cataract surgery volumes stayed relatively stable from 2010 to 2014 (Table 1). When adjusted for population, CSR decreased from 2011 to 2014 (Fig. 1). CSR was lower in males than in females across all years (Table 2 and Fig. 2). By age group, those aged ≥75 years showed the largest reduction in CSR of 16.2% (Table 2).
      Fig. 1.
      Fig. 1Ontario cataract surgery rate versus population.
      Table 2Ontario cataract surgery rates
      20102011201220132014% Change
      Ontario11 06211 12410 71010 65210 619−4.0
      Sex
       Female12 48712 59511 99011 89311 837−5.2
       Male95879600938493659356−2.4
      Age (y)
       0–196163605554−11.6
       20–44327322306285274−16.2
       45–6480258150796776947552−5.9
       65–7452 21851 90448 62348 24447 151−9.7
       75+73 77871 69466 32963 51761 837−16.2
      Fig. 2.
      Fig. 2Ontario 5-year cataract surgery rates by sex.
      Mean wait times for cataract surgery increased from 53.5 to 68.5 days (+43.5%, Table 3), and 90th percentile wait times increased from 107.5 to 154.3 days (+28%, Table 3). We assumed zero growth in cataract surgery volumes from 2014 levels as per the government-mandated policy and used population projection data to 2025 from Statistics Canada to project future CSR. We found that Ontario's overall CSR will decrease by 12.6% by 2025 (Fig. 3A) and CSR will fall by 31.9% and 34.9% for the age groups of 65–74 years and 75+ years, respectively (Fig. 3B).
      Table 3Ontario cataract surgery wait times
      20102011201220132014% Change
      90th percentile wait times (days)107.5123.5122.8134.0154.3+43.5
      Mean wait times (days)53.558.857.862.068.5+28.0
      Fig. 3.
      Fig. 3A, Ten-year projected Ontario cataract surgery rates assuming unchanged 2014 cataract surgery volumes. B, Ten-year projected 65–74-year and 75+-year cataract surgery rates assuming unchanged 2014 cataract surgery volumes.

      Distribution of cataract surgery care

      Patients who underwent cataract surgery resided in 25 large urban, 33 medium, 292 small, and 104 rural population centres (Table 4). In descending order, most lived in large urban (63.4%) followed by medium (14.9%), small (20.9%), and rural (0.6%) centres. From 2010 to 2014, CSR showed small declines among large urban (−3.4), medium (−6.4%), and small (−3.9%) communities, with the largest decline seen in rural communities of almost 19% (Table 4). Additional subanalysis by age group living within each of the communities revealed that, regardless of community size, the 75+-year age group showed the largest absolute reduction in CSR, with seniors above the age of 75 years living in rural communities most affected (−24.7%) (Table 5).
      Table 4Cataract surgery rate by patient population centres in Ontario from 2010 to 2014
      Population CentreNo. of MunicipalitiesCataract Surgery %20102014% ChangeAbsolute ChangeCSR Standard Deviation
      Large Urban
      Large urban population centre (≥100 000 persons).
      2563.410 3159968−3.4−347±2420
      Medium
      Medium population centre (30 000–99 999 persons).
      3314.911 98511 219−6.4−766±3493
      Small
      Small population centre (1000–29 999 persons).
      29220.913 13212 614−3.9−518±8529
      Rural
      Rural population centre (<1000 persons).
      1040.617 03213 852−18.7−3181±17695
      Population centre groupings based on 2014 populations and use formal population centre definitions from Statistics Canada.
      low asterisk Large urban population centre (≥100 000 persons).
      Medium population centre (30 000–99 999 persons).
      Small population centre (1000–29 999 persons).
      § Rural population centre (<1000 persons).
      Table 5Ontario population centres cataract surgery rate by municipalities for patients over 45 years of age (2010–2014)
      Population CentreAge Group, y20102014% ChangeAbsolute CSR Change
      Large Urban
      Large Urban Population Centre (≥100 000 persons).
      45–6480567637−5.2−419
      65–7453 19148 284−9.2−4907
      75+71 72660 890−15.1−10836
      Medium
      Medium Population Centre (30 000–99 999 persons).
      45–6476467066−7.6−580
      65–7449 26644 765−9.1−4501
      75+78 52164 783−17.5−13738
      Small
      Small Population Centre (1000–29 999 persons).
      45–6484117762−7.7−649
      65–7452 65246 217−12.2−6435
      75+75 35760 495−19.7−14862
      Rural
      Rural Population Centre (<1000 persons).
      45–6413 63510 129−25.7−3506
      65–7484 24256 067−33.4−28175
      75+123 36992 868−24.7−30501
      Population centre groupings based on 2014 populations and use formal population centre definitions from Statistics Canada.
      low asterisk Large Urban Population Centre (≥100 000 persons).
      Medium Population Centre (30 000–99 999 persons).
      Small Population Centre (1000–29 999 persons).
      § Rural Population Centre (<1000 persons).

      Discussion

      The assessment of vision health service provision is a key objective of the WHO: A Global Action Plan for Universal Eye Health 2014–2019 (GAP).
      WHO
      Universal Eye Health: A Global Action Plan 2014–2019.
      This study assesses the most recent data regarding cataract care distribution and trends using the CSR framework as recommended by the WHO with particular attention to seniors living in urban and rural communities in Ontario. We found that from 2010 to 2014, Ontario saw a decline in CSR and increases in wait times, with large variations in cataract care across communities in Ontario impacting seniors and rural communities the most.
      As cataracts are primarily a disease of aging,
      • Liu Y-C
      • Wilkins M
      • Kim T
      • Malyugin B
      • Mehta JS
      Cataracts.
      it is not surprising that nearly 80% of cataract surgery patients in Ontario were found to be over 65 years. A history of performing more cataract surgeries in the older population is well established.
      • Hatch WV
      • Cernat G
      • Singer S
      • Bell CM
      A 10-year population-based cohort analysis of cataract surgery rates in Ontario.
      The mean age of 71.5 years is consistent with reports from the USA,
      • Gollogly HE
      • Hodge DO
      • St Sauver JL
      • Erie JC
      Increasing incidence of cataract surgery: population-based study.
      UK,
      • Courtney P
      The National Cataract Surgery Survey: I. Method and descriptive features.
      Sweden,
      • Behndig A
      • Montan P
      • Stenevi U
      • Kugelberg M
      • Lundstrom M
      One million cataract surgeries: Swedish National Cataract Register 1992–2009.
      and the Netherlands.
      • Lundstrom M
      • Goh P-P
      • Henry Y
      • et al.
      The changing pattern of cataract surgery indications: a 5-year study of 2 cataract surgery databases.
      We found that more females had cataract surgery than males (57F:43M) similar to a 2001–2004 Ontario study.
      • Bell CM
      • Hatch WV
      • Cernat G
      • Urbach DR
      Surgeon volumes and selected patient outcomes in cataract surgery: a population-based analysis.
      Over 5 years, sex proportions remained consistent, and thus the increased number of females may be explained by the higher number of females in the senior age group due to higher life expectancy. A higher female cataract patient proportion was also observed in the USA,
      • Gollogly HE
      • Hodge DO
      • St Sauver JL
      • Erie JC
      Increasing incidence of cataract surgery: population-based study.
      • Schein OD
      • Cassard SD
      • Tielsch JM
      • Gower EW
      Cataract surgery among Medicare beneficiaries.
      UK,
      • Courtney P
      The National Cataract Surgery Survey: I. Method and descriptive features.
      Sweden,
      • Behndig A
      • Montan P
      • Stenevi U
      • Kugelberg M
      • Lundstrom M
      One million cataract surgeries: Swedish National Cataract Register 1992–2009.
      and China.
      • Li EY
      • Liu Y
      • Zhan X
      • et al.
      Prevalence of blindness and outcomes of cataract surgery in Hainan Province in South China.
      There is evidence that females have an increased risk of cataracts relative to males as they age, which have been linked to changing estrogen levels postmenopause.
      • Zetterberg M
      • Celojevic D
      Gender and cataract—the role of estrogen.
      We found minimal changes to cataract surgery volume from 2010 to 2014, approximately levelling at 145 000 cataract surgeries per year. This is in keeping with the Ontario government's mandated zero-growth policy, limiting the number of cataract operations per year.
      • Campbell RJ
      • El-Defrawy SR
      • Bell CM
      • et al.
      Effect of cataract surgery volume constraints on recently graduated ophthalmologists: a population-based cohort study.
      With this governmental cap in cataract surgeries, coupled with a growing and aging population as demonstrated by this work, we believe the cataract surgery cap to be the primary factor contributing to the decline in CSR in Ontario. Assuming unchanged cataract surgery volume as per the government-mandated zero growth policy
      • Campbell RJ
      • El-Defrawy SR
      • Bell CM
      • et al.
      Effect of cataract surgery volume constraints on recently graduated ophthalmologists: a population-based cohort study.
      and a growth in population over the next 5 years, we project a decline in Ontario's overall CSR by nearly 13% by 2025 (Fig. 3A).
      • Szigiato A-A
      • Trope GE
      • Jin Y
      • Buys YM
      Wait times and volume of cataract surgery in Ontario: 2000–2012.
      If cataract surgery volumes remain consistent, the 65–74-year and over 75-year age groups’ CSRs will drop by approximately one-third by 2025, which may be inadequate to meet the demands for cataract surgery care in Ontario (Fig. 3B).
      • Hatch WV
      • Campbell E
      • de L
      • Bell CM
      • El-Defrawy SR
      • Campbell RJ
      Projecting the growth of cataract surgery during the next 25 years.
      • Szigiato A-A
      • Trope GE
      • Jin Y
      • Buys YM
      Wait times and volume of cataract surgery in Ontario: 2000–2012.
      ,
      • Rachmiel R
      • Trope GE
      • Chipman ML
      • Buys YM
      Cataract surgery rates in Ontario, Canada, from 1992 to 2004: more surgeries with fewer ophthalmologists.
      From 2000 to 2012, Ontario saw a decline in cataract surgeons per capita by 5.9%, which may be contributing to on-going strains for the delivery of cataract care in the population. Additional research is needed to understand the distribution of these cataract surgeons in urban and rural communities to shed additional insights into the provision of care at the community level. However, we expect more surgeons to practice in urban versus rural settings, which may further increase difficulties for patients accessing cataract care in rural communities.
      • Szigiato A-A
      • Trope GE
      • Jin Y
      • Buys YM
      Wait times and volume of cataract surgery in Ontario: 2000–2012.
      In our study, mean wait times for cataract surgery increased by 44%, whereas 90th percentile wait times increased by 28% to 154 days. Current national surgery wait times specify that the 90th percentile wait time should be 112 days.
      Canadian Institute for Health Information
      Cataract—Wait Times.
      Although Ontario had 88% of surgeries meet this benchmark in 2010, a drop to 80% by 2014 suggests a possible mismatch in supply and demand for cataract surgery.
      Canadian Institute for Health Information
      Cataract—Wait Times.
      Furthermore, we found that CSR declined across urban and rural communities, with a greater decline seen in rural communities. According to Statistics Canada, more seniors live in rural areas than in urban areas.
      • Dandy K
      • Bollman RD
      Rural and Small Town Canada.
      As seniors showed the largest decline in CSR, this may help explain in part the decline in CSR in rural areas. In addition, the shift in population from rural to urban centres may account for additional pressures for cataract surgery in the large urban centres.
      Statistics Canada
      Population, urban and rural, by province and territory (Ontario).
      Difficulty accessing vision care is reflected by our finding of increased wait times for cataract surgery and differences in urban versus rural patients’ cataract surgery trends, which point to a need for changes in resources and policies to address the cataract care challenges seniors and rural Ontarians face.
      Ontario is Canada's most populous province, with a population of 13.6 million. By 2040, nearly 1 in 4 Ontarians will be over 65 years of age.
      Ontario Ministry of Finance
      Ontario Population Projections Update.
      Cataract is a disease primarily of aging,
      • Liu Y-C
      • Wilkins M
      • Kim T
      • Malyugin B
      • Mehta JS
      Cataracts.
      and as Ontarians continue to age, more will require cataract surgery.
      • Hatch WV
      • Campbell E
      • de L
      • Bell CM
      • El-Defrawy SR
      • Campbell RJ
      Projecting the growth of cataract surgery during the next 25 years.
      Cataract surgery is one of the most frequently performed surgical procedures in the developed world, providing significant improvements to vision and quality of life at low cost.
      • Lansingh VC
      • Carter MJ
      • Martens M
      Global cost-effectiveness of cataract surgery.
      • Desai P
      • Reidy A
      • Minassian DC
      • Vafidis G
      • Bolger J
      Gains from cataract surgery: visual function and quality of life.
      Over 13 years ago, the MOHLTC launched the Ontario Wait Time Strategy,
      Office of the Premier
      Ontario's Wait Time Strategy.
      which focused on improving wait times for Ontarians across 5 priority areas: cancer surgery, select cardiac procedures, hip and knee joint replacements, MRI and CT scans, and cataract surgery.
      Ministry of Health and Long-Term Care
      Ontario Wait Times Strategy.
      With this plan, the Ontario government pledged to fund 14 000 additional cataract surgeries, which was an increase of 13% over 2004/2005 levels.
      Ministry of Health and Long-Term Care
      Ontario Wait Times Strategy.
      Office of the Premier
      Ontario's Wait Time Strategy.
      Over a decade later, our research shows that this previous increase in funded surgeries has not been enough as wait times for cataract surgery have increased and patients in communities across Ontario have experienced increased difficulty accessing cataract care. Poor access to timely cataract care has been linked to reduced quality of life, vision loss, and increased falls and motor vehicle accidents.
      • Hodge W
      • Horsley T
      • Albiani D
      • et al.
      The consequences of waiting for cataract surgery: a systematic review.
      • Conner-Spady B
      • Sanmartin C
      • Sanmugasunderam S
      • et al.
      A systematic literature review of the evidence on benchmarks for cataract surgery waiting time.
      Therefore, we believe that policymakers address the need to increase the volume of cataract surgeries. Furthermore, there is work needed to optimize infrastructure and human capital across all communities to provide patients who need cataract surgery timely and high quality care.
      Medically necessary procedures such as cataract surgery are covered by Ontario's health care system and should capture all cataract surgeries performed by physicians billing in Ontario. While IntelliHealth's population level data provide information assessing Ontario's CSR situation over the 5-year study period, these data do not take into account who will become a cataract surgery patient, which does have variability. A limitation of this work is that information about surgical outcomes and long-term quality of life outcomes is not available from IntelliHealth, which may be useful in assessing the impact of cataract surgery across communities. In addition, the WHO does not define an “appropriate” CSR for a region such as Ontario, by urban or rural communities or for specific age groups, and therefore this study can comment only on the relative changes in CSR and distribution of cataract care over the 5-year study period. In addition, decreases in CSR do not necessarily translate to poorer cataract care, and so additional research is necessary to understand long-term quality of life indicators for cataract patients. Another important indicator for delivery of cataract service is the cataract surgical coverage (CSC), which compares the number of people with operated cataracts, surgery outcomes, and those who need it. Based on age group and geographical distribution, we expect to see similar CSR trends pointing to deficiencies in senior and rural care. In addition, CSR treats each surgery as an individual event as we did in this study, but further research may aim to understand cataract care at the individual eye level, which currently IntelliHealth does not provide. Furthermore, our study examines one province in Canada and these findings may not be generalizable to other provinces or other international jurisdictions.
      CSR data were used to assess the adequacy of cataract care and point to a need to pay attention to distribution of cataract care in Ontario and the function and quality of vision care of our more vulnerable senior and rural population. Further research and evidence-based government advocacy are necessary to advocate for changes in resource planning that can help prevent avoidable sight loss for seniors in Ontario.

      Footnotes and Disclosure

      The authors have no proprietary or commercial interest in any materials discussed in this article.

      Acknowledgement:

      Dorothy Pitts Chair in Ophthalmology and Vision Science (NG).

      References

        • Liu Y-C
        • Wilkins M
        • Kim T
        • Malyugin B
        • Mehta JS
        Cataracts.
        Lancet. 2017; 90: 600-612
      1. Canadian National Institute for the Blind. CNIB—Cataracts. 2015. [cited 2017 Jun 15]. Available from: http://www.cnib.ca/en/your-eyes/eye-conditions/cataracts/pages/default.aspx.

        • Hatch WV
        • Campbell E
        • de L
        • Bell CM
        • El-Defrawy SR
        • Campbell RJ
        Projecting the growth of cataract surgery during the next 25 years.
        Arch Ophthalmol. 2012; 130: 1479
        • WHO
        Universal Eye Health: A Global Action Plan 2014–2019.
        ([cited 2017 Jun 14]. Available from:)
        • Gupta N
        • Kocur I
        Chronic eye disease and the WHO Universal Eye Health Global Action Plan 2014–2019.
        Can J Ophthalmol. 2014; 49: 403-405
        • Association of Municipalities Ontario
        Ontario Municipalities.
        ([cited 2017 Jul 3]. Available from:)
        • Ontario Ministry of Finance
        Ontario Population Projections Update.
        ([cited 2017 Jun 14]. Available from:)
        • Ministry of Health and Long-Term Care
        Patients First: Action Plan for Health Care.
        MOHLTC, Toronto, Ont.2015
        • Ministry of Health and Long-Term Care
        Ontario Wait Times Strategy.
        ([cited 2017 Jun 15]. Available from:)
        • Campbell RJ
        • El-Defrawy SR
        • Bell CM
        • et al.
        Effect of cataract surgery volume constraints on recently graduated ophthalmologists: a population-based cohort study.
        CMAJ. 2017; 189: E424-E430
        • Ministry of Health and Long-Term Care
        IntelliHealth Ontario.
        ([cited 2017 Jun 15]. Available from:)
        • Statistics Canada
        Dictionary, Census of Population, 2016 Population centre (POPCTR).
        Government of Canada, 2017 ([cited 2018 May 1]. Available from:)
        • Hatch WV
        • Cernat G
        • Singer S
        • Bell CM
        A 10-year population-based cohort analysis of cataract surgery rates in Ontario.
        Can J Ophthalmol. 2007; 42: 552-556
        • Gollogly HE
        • Hodge DO
        • St Sauver JL
        • Erie JC
        Increasing incidence of cataract surgery: population-based study.
        J Cataract Refract Surg. 2013; 39: 1383-1389
        • Courtney P
        The National Cataract Surgery Survey: I. Method and descriptive features.
        Eye (Lond). 1992; 6: 487-492
        • Behndig A
        • Montan P
        • Stenevi U
        • Kugelberg M
        • Lundstrom M
        One million cataract surgeries: Swedish National Cataract Register 1992–2009.
        J Cataract Refract Surg. 2011; 37: 1539-1545
        • Lundstrom M
        • Goh P-P
        • Henry Y
        • et al.
        The changing pattern of cataract surgery indications: a 5-year study of 2 cataract surgery databases.
        Ophthalmology. 2015; 122: 31-38
        • Bell CM
        • Hatch WV
        • Cernat G
        • Urbach DR
        Surgeon volumes and selected patient outcomes in cataract surgery: a population-based analysis.
        Ophthalmology. 2007; 114: 405-410
        • Schein OD
        • Cassard SD
        • Tielsch JM
        • Gower EW
        Cataract surgery among Medicare beneficiaries.
        Ophthalmic Epidemiol. 2012; 19: 257-264
        • Li EY
        • Liu Y
        • Zhan X
        • et al.
        Prevalence of blindness and outcomes of cataract surgery in Hainan Province in South China.
        Ophthalmology. 2013; 120: 2176-2183
        • Zetterberg M
        • Celojevic D
        Gender and cataract—the role of estrogen.
        Curr Eye Res. 2015; 40: 176-190
        • Szigiato A-A
        • Trope GE
        • Jin Y
        • Buys YM
        Wait times and volume of cataract surgery in Ontario: 2000–2012.
        Can J Ophthalmol. 2016; 51: 7-13
        • Rachmiel R
        • Trope GE
        • Chipman ML
        • Buys YM
        Cataract surgery rates in Ontario, Canada, from 1992 to 2004: more surgeries with fewer ophthalmologists.
        Can J Ophthalmol. 2007; 42: 539-542
        • Canadian Institute for Health Information
        Cataract—Wait Times.
        ([cited 2017 Jun 15]. Available from:)
        • Dandy K
        • Bollman RD
        Rural and Small Town Canada.
        Analysis Bulletin Catalogue No. 21-006X. 2008; 7: 1-56
        • Statistics Canada
        Population, urban and rural, by province and territory (Ontario).
        ([cited 2017 Jul 23]. Available from:)
        • Lansingh VC
        • Carter MJ
        • Martens M
        Global cost-effectiveness of cataract surgery.
        Ophthalmology. 2007; 114: 1670-1678
        • Desai P
        • Reidy A
        • Minassian DC
        • Vafidis G
        • Bolger J
        Gains from cataract surgery: visual function and quality of life.
        Br J Ophthalmol. 1996; 80: 868-873
        • Office of the Premier
        Ontario's Wait Time Strategy.
        Queens Printer for Ontario, 2005 ([cited 2018 Aug 5]. Available from:)
        • Hodge W
        • Horsley T
        • Albiani D
        • et al.
        The consequences of waiting for cataract surgery: a systematic review.
        CMAJ. 2007; 176: 1285-1290
        • Conner-Spady B
        • Sanmartin C
        • Sanmugasunderam S
        • et al.
        A systematic literature review of the evidence on benchmarks for cataract surgery waiting time.
        Can J Ophthalmol. 2007; 42: 543-551