Cataract Blindness and Simulation-Based Training for Cataract Surgeons

An Assessment of the HelpMeSee Approach

by James R. Broyles, Peter Glick, Jianhui Hu, Yee-Wei Lim

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Research Questions

  1. What are the projections for cataract cases and surgery backlog?
  2. What are some existing models for cataract surgery training and delivery?
  3. What is the projected impact of the HelpMeSee approach?
  4. What are some potential challenges to the HelpMeSee approach?

Abstract

Cataracts account for about half of all cases of blindness worldwide, with the vast majority in developing countries, where blindness and visual impairment can reduce life expectancy and economic productivity. Most of these cases can be cured by quick, inexpensive surgical procedures, but a shortage of trained surgeons makes it unlikely that the need for such surgeries — estimated to reach 32 million cases globally by 2020 — can be met under current practices. HelpMeSee Inc. (HMS) is developing an approach to surgery training and delivery that includes use of high-fidelity simulator technology and associated curricula for high-volume training, development of a system of independent private practitioners, and training where necessary of individuals without medical degrees. RAND researchers determined that the program has the potential to scale up surgical capacity rapidly and that under optimistic assumptions, the HMS program could largely close the backlog of surgical cases in the four major regions studied, resulting in 21 million cases of cataract-caused visual impairment in 2030, compared with 134 million cases under the status quo. The program also promises to have large impacts on health and productivity, and the estimated costs per year of disability averted suggest that the intervention would be highly cost-effective in each of the regions researched. However, a number of significant challenges need to be met, particularly in the areas of outreach, remote monitoring of independent practitioners (especially non-doctors), and public and legal acceptance of non-doctors as surgeons. It is important to carefully pilot and monitor the approach before fully scaling up.

Key Findings

Cataracts Are a Growing Problem Worldwide

  • Cataracts account for about half of all cases of blindness worldwide, with the majority in developing countries. A shortage of trained surgeons makes it unlikely that the need for such surgeries—estimated to reach 32 million cases globally by 2020—can be met under current practices.

Cataract Treatment Improves Economic Output for Developing Countries

  • By reducing cataract cases, the program potentially will have significant impacts on future economic output. This reflects the large expected losses to national income due to cataract-caused visual impairment under the status quo.

HelpMeSee Approach Expedites Training Process

  • HelpMeSee Inc. (HMS) will have the capacity to scale up surgical capacity rapidly, reflecting the speed with which new simulator training produces surgeons.
  • Once surgeons are in place, effects on the number of cataract cases will be determined mainly by the level of demand or uptake.

Challenges to the HMS Approach

  • There appears to be a potential for a significant surplus of surgical capacity (and surgeons) once the cataract surgery backlog is eliminated or reduced as much as it can be given uptake rates.
  • Arranging for the screening will be the responsibility of the practitioner. This and other aspects of managing a practice may impose a significant burden on practitioners who are expected to perform high-volume surgery.
  • Monitoring of performance is a particular concern due to geography and the number of HMS surgeons who will not be trained doctors or even medical professionals. HMS is developing a technology-driven approach to this issue.

Recommendations

The HMS model should be carefully piloted and assessed before fully scaling up the approach. HMS recognizes this and is planning a pilot study that would involve assessments by external experts. The objective of the pilot is to assess the effectiveness of the simulator and courseware training approach. In addition to its own evaluation, HMS plans to have external evaluators measure these outcomes.

The sophisticated remote monitoring of outcomes, the reliance on independent practitioners, and a supply chain system to serve myriad dispersed practitioners should either be evaluated in a pilot study, or with careful ongoing monitoring and adjustments. A judicious approach would be to set up one full-fledged training center in one region, and allow several years to assess how the various components of the complete model perform.

It would be advisable to follow the initial pilot with a similar size cohort of nondoctors and nonmedical professionals, to establish the effectiveness of the training approach for this group, or point to areas for improvement. This should be done before considering going to scale in the training of nondoctors. Subsequent monitoring of quality outcomes and the effectiveness of remote monitoring systems for this group of specialists will be essential.

The simulator may have significant benefits as a training tool for other cataract systems. If the HMS pilot study demonstrates the pedagogical effectiveness of the simulator, it would be worth exploring whether the simulator technology can increase training output and efficacy in more standard cataract surgery systems as well.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Global Cataract Problem and Cataract Surgery Backlog

  • Chapter Three

    Existing Models of Cataract Surgery Training and Delivery

  • Chapter Four

    The HelpMeSee Approach

  • Chapter Five

    Forecasting the Burden of Cataract

  • Chapter Six

    Modeling the Impacts of HelpMeSee

  • Chapter Seven

    Analysis of Costs and Cost-Effectiveness

  • Chapter Eight

    Potential Challenges to the HelpMeSee Approach

  • Chapter Nine

    Summary of Findings and Conclusions

  • Appendix A

    Modeling Approach, Methodology, and Data Sources

  • Appendix B

    Sensitivity Analysis — Practitioner Attrition and Trainee Intake

  • Appendix C

    Detailed Input Costs and Methodology

Research conducted by

The research described in this report was sponsored by HelpMeSee, Inc. and was conducted within RAND Health, a unit of the RAND Corporation.

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