International variation in ophthalmologic management of patients with cataracts: Results from the international cataract surgery outcomes study

Objectives: To describe international variation in the management of patients with cataracts in 4 health care systems and to discuss the potential implications for cost and utilization of services. Design: To characterize current clinical practice on patients with no coexisting medical or ocular conditions, a standardized questionnaire was sent to random samples of ophthalmologists in the United States (response rate, 82.5%), Canada (66.9%), and Barcelona, Spain (70.4%), and to all ophthalmologists in Denmark (80.1%). From the United States, 526 ophthalmologists who performed cataract surgery participated in the study; there were 276 from Canada, 89 from Barcelona, and 82 from Denmark. Results: Although in all 4 sites most surgeons reported that they performed A-scanning, fundus examination, and refraction routinely before surgery, significant cross-national variation was observed in preoperative ophthalmic and medical testing. While preoperative medical tests were virtually unused in Denmark, they were widely used in the other sites. A significantly higher proportion of the surgeons in the United States and Barcelona reported that they performed less than 100 extractions per year compared with surgeons in Canada and Denmark (P<.001). A significantly higher proportion of the surgeons in the United States and Canada were performing predominantly phacoextraction compared with surgeons in Denmark and Barcelona (P<.001). Both within and across sites, considerable variation in number of follow-up visits and postoperative tests was observed. Conclusions: Significant international variation in the management of healthy patients with cataracts has been observed. If less intensive care is not associated with poorer outcomes, there is the potential for less costly care of patients with cataracts. Further research identifying the most cost-effective practices is needed.