title: Cost and Expected Visual Effect of Interventions to Improve Follow-up After Cataract Surgery: Prospective Review of Early Cataract Outcomes and Grading (PRECOG) Study.
abstract: OBJECTIVE
  Some experts recommend increasing low rates of follow-up after cataract surgery in low- and middle-income countries using various interventions. However, little is known about the cost and effect of such interventions.
  
  
  OBJECTIVE
  To examine whether promoting follow-up after cataract surgery creates economic value.
  
  
  METHODS
  The Prospective Review of Early Cataract Outcomes and Grading (PRECOG) is a cohort study with data from patients undergoing cataract surgery from January 19, 2010, to April 18, 2012. Final follow-up was completed on August 10, 2012. Data were collected before surgery, at discharge, and at follow-up at least 40 days after surgery from 27 centers in 8 countries in Asia, Africa, and Latin America. Each center enrolled 40 to 120 consecutive patients undergoing cataract surgery. If patients did not return to the hospital for the follow-up visit, hospitals could use telephone calls or transportation subsidies to increase follow-up rate. Data were analyzed from December 2013 to January 2016.
  
  
  METHODS
  Cost of interventions (telephone calls and transportation subsidies) to increase follow-up at least 40 days after surgery, visual acuity (VA) in the eye undergoing cataract surgery, presence of complications, patient and facility costs per visit, and willingness to pay for treatment or glasses if needed. The maximum incremental cost of improving VA in 1 patient (incremental cost-effect ratio [ICER]) was calculated for spontaneous follow-up (compared with no follow-up) and follow-up with the telephone and transportation interventions. Expected ICERs were estimated including only those patients willing to pay.
  
  
  RESULTS
  Among 2487 patients (1068 men [42.9%]; 1405 women [56.5%]; 14 missing [0.6%]; mean [SD] age, 68.4 [11.3] years), 2316 (93.1%) received follow-up, of whom 369 (16.0%) were seen in an outside facility or home and were in the cost-effectiveness analysis as unable to follow up. A grand mean (a mean of means of the different countries) of 56.3% of patients needed glasses, of whom 56.9% were willing to pay, and 1.6% had treatable complications, of whom 39.4% were willing to pay. Maximum proportions with improved VA (and corresponding ICERs) were 0.08 for no follow-up, 0.45 ($151.56) for spontaneous follow-up, 0.53 ($164.46) for a telephone intervention, and 0.53 ($133.07) for a transportation intervention. These results were most sensitive to the cost of follow-up. Expected proportions (ICERs) were 0.08, 0.27 ($232.69), 0.30 ($456.22), and 0.30 ($206.47), respectively.
  
  
  CONCLUSIONS
  Most patients benefiting from follow-up after cataract surgery returned spontaneously when requested at discharge. Use of telephone calls or transportation subsidies to increase follow-up in low- and middle-income countries may not be cost-effective.
authors.affiliation: Division of Preventive Ophthalmology, Zhongshan Ophthalmic Center, State Key Laboratory, Sun Yat-Sen University, Guangzhou, China.
authors.forename: Mirjam E
authors.initials: ME
authors.lastname: Meltzer
authors.affiliation: Division of Preventive Ophthalmology, Zhongshan Ophthalmic Center, State Key Laboratory, Sun Yat-Sen University, Guangzhou, China2Orbis International, New York, New York3Center for Public Health, Queen's University Belfast, Belfast, Northern Ireland.
authors.forename: Nathan
authors.initials: N
authors.lastname: Congdon
authors.affiliation: Medwin Group, St Louis, Missouri.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Kymes
authors.affiliation: Division of Preventive Ophthalmology, Zhongshan Ophthalmic Center, State Key Laboratory, Sun Yat-Sen University, Guangzhou, China.
authors.forename: Xixi
authors.initials: X
authors.lastname: Yan
authors.affiliation: Help Me See, New York, New York6Instituto Mexicano de Oftalmologia, Querétaro, Mexico.
authors.forename: Van C
authors.initials: VC
authors.lastname: Lansingh
authors.affiliation: Orbis International, New York, New York.
authors.forename: Alemayehu
authors.initials: A
authors.lastname: Sisay
authors.affiliation: The Fred Hollows Foundation, Sydney, Australia8Regional Office in the Western Pacific, World Health Organization, Manila, Philippines.
authors.forename: Andreas
authors.initials: A
authors.lastname: Müller
authors.affiliation: The Brien Holden Vision Institute, Durban, South Africa.
authors.forename: Ving Fai
authors.initials: VF
authors.lastname: Chan
authors.affiliation: Division of Preventive Ophthalmology, Zhongshan Ophthalmic Center, State Key Laboratory, Sun Yat-Sen University, Guangzhou, China.
authors.forename: Ling
authors.initials: L
authors.lastname: Jin
authors.affiliation: Lions Aravind Institute of Community Ophthalmology, Madurai, India.
authors.forename: Sasipriya M
authors.initials: SM
authors.lastname: Karumanchi
authors.affiliation: Orbis International, New York, New York7The Fred Hollows Foundation, Sydney, Australia.
authors.forename: Chunhong
authors.initials: C
authors.lastname: Guan
authors.affiliation: Orbis International, New York, New York.
authors.forename: Quy
authors.initials: Q
authors.lastname: Vuong
authors.affiliation: Latin America Regional Office, VISION 2020, International Agency for the Prevention of Blindness, Miami, Florida.
authors.forename: Nelson
authors.initials: N
authors.lastname: Rivera
authors.affiliation: Orbis International, New York, New York.
authors.forename: Joan
authors.initials: J
authors.lastname: McCleod-Omawale
authors.affiliation: Division of Preventive Ophthalmology, Zhongshan Ophthalmic Center, State Key Laboratory, Sun Yat-Sen University, Guangzhou, China12Centre for Eye Research Australia, Melbourne, Australia.
authors.forename: Mingguang
authors.initials: M
authors.lastname: He