Appropriateness of phacoemulsification in Spain
To evaluate the appropriateness of phacoemulsification procedures performed in four Spanish regions, applying criteria developed by means of RAND/UCLA methodology. Prospective observational study. Seventeen public teaching hospitals in four regions of Spain. Patients on waiting list to undergo cataract extraction by phacoemulsification. Cataract surgery by phacoemulsification. Level of appropriateness of each intervention, according to criteria developed by means of the RAND/UCLA appropriateness methodology. Among the 5442 analysed patients the indication of phacoemulsification was appropriate in 69.6%, inappropriate in 7.3% and uncertain in 23.0%. Presence of ocular comorbidity, lack of cataract-induced visual function limitation, anticipated postoperative visual acuity of <0.5, preoperative visual acuity of >0.1 and high surgical complexity were associated with inappropriateness. Some clinical characteristics, when present, make it especially important to obtain a careful assessment of the risks and benefits of surgery. Consideration of these characteristics may improve the appropriateness of phacoemulsification.
Appropriateness of phacoemulsiﬁcation
´NDEZ DE LARREA1, JUAN ANTONIO BLASCO1, URKO AGUIRRE2, SUSANA GARCI
´N ELIZALDE3, GEMMA NAVARRO4AND SABINA PE
´REZ5, THE IRYSS CATARACT GROUP
Unidad de Evaluacio´n de Tecnologı
´as Sanitarias, Agencia Laı
´n Entralgo, Madrid, Spain,
Unidad de Investigacio´n, Hospital Galdakao-
Usansolo, Galdakao, Vizcaya, Spain,
Servicio de Planiﬁcacio´ n Investigacio´n y Evaluacio´ n Sanitaria, Direccion Territorial de Sanidad, San
Unidad de Epidemiologı
´nica, Corporacio´Sa`nitaria Parc Taulı
´, Barcelona, Spain, and
Apoyo a la Investigacio´n, Fundacio´n para la Investigacio´n Biosanitaria Andalucı
´a Oriental, Granada, Spain
Address reprint requests to: Nerea Ferna´ndez de Larrea, Unidad de Evaluacio´ n de Tecnologı
´as Sanitarias, Agencia Laı
´n Entralgo, C/Gran
´a 27, 28013 Madrid, Spain. Tel: 34-9-13-08-94-00; Fax: þ34- 9-13-08-95-33; E-mail: email@example.com
Accepted for publication 4 November 2009
Objective. To evaluate the appropriateness of phacoemulsiﬁcation procedures performed in four Spanish regions, applying
criteria developed by means of RAND/UCLA methodology.
Design. Prospective observational study.
Setting. Seventeen public teaching hospitals in four regions of Spain.
Participants. Patients on waiting list to undergo cataract extraction by phacoemulsiﬁcation.
Intervention. Cataract surgery by phacoemulsiﬁcation.
Main Outcome Measure. Level of appropriateness of each intervention, according to criteria developed by means of the
RAND/UCLA appropriateness methodology.
Results. Among the 5442 analysed patients the indication of phacoemulsiﬁcation was appropriate in 69.6%, inappropriate in
7.3% and uncertain in 23.0%. Presence of ocular comorbidity, lack of cataract-induced visual function limitation, anticipated
postoperative visual acuity of ,0.5, preoperative visual acuity of .0.1 and high surgical complexity were associated with
Conclusions. Some clinical characteristics, when present, make it especially important to obtain a careful assessment of the
risks and beneﬁts of surgery. Consideration of these characteristics may improve the appropriateness of phacoemulsiﬁcation.
Keywords: appropriateness, phacoemulsiﬁcation, cataract surgery, RAND/UCLA appropriateness methodology
The appropriateness of medical procedures is important at
every level of the health-care system, from policy-makers 
to clinicians deciding whether to perform a procedure.
Identifying and avoiding inappropriate procedures may
reduce the number of adverse events for the patient and may
slow the increase in costs. In the mid-1980s, RAND
Corporation and the University of California at Los Angeles
(UCLA) developed the RAND/UCLA appropriateness
methodology  as an instrument to evaluate the appropri-
ateness of medical and surgical procedures. The rationale
supporting this methodology is that physicians and surgeons
must make decisions about when to apply medical and surgi-
cal procedures, even though robust scientiﬁc evidence about
risks and beneﬁts is frequently incomplete [3–5]. The
RAND/UCLA appropriateness methodology combines the
best available scientiﬁc evidence with the collective judge-
ment of experts to yield explicit criteria regarding the appro-
priateness of medical or surgical procedures. According to
the RAND/UCLA deﬁnition, a procedure is appropriate
when ‘the expected health beneﬁt exceeds the expected nega-
tive consequences by a sufﬁciently wide margin that the pro-
cedure is worth doing, excluding monetary cost’.
Cataracts are a frequent ocular pathology, with a preva-
lence that reaches some 15–30% in developed countries
The co-investigators of the IRYSS Cataract Group are listed in Appendix.
International Journal for Quality in Health Care vol. 22 no. 1
#The Author 2009. Published by Oxford University Press in association with the International Society for Quality in Health Care;
all rights reserved 31
International Journal for Quality in Health Care 2010; Volume 22, Number 1: pp. 31 –38 10.1093/intqhc/mzp052
Advance Access Publication: 6 December 2009
[6–9]. Phacoemulsiﬁcation is the surgical technique of
choice in most cases for cataract correction [10 – 12]. It has
been shown to provide clear beneﬁts in terms of patient
quality of life and in the prevention of some of the more
common problems of old age, such as falls [7, 8, 10, 13 –
15]. As a result, cataract surgery is the most frequently per-
formed of all surgical interventions in the industrialized
world [6, 7, 13]. In the Spanish National Health System this
type of surgery is usually performed as ‘major ambulatory
surgery’, and represents the most frequent surgical procedure
in this category (about 31% of all interventions) .
Using the RAND/UCLA appropriateness methodology,
in 2005 our group established a set of appropriateness cri-
teria for phacoemulsiﬁcation . These explicit criteria were
applied in the present work to assess the appropriateness of
phacoemulsiﬁcation procedures performed in four regions of
Spain with the goal of identifying characteristics associated
with overuse of phacoemulsiﬁcation.
Development of appropriateness criteria
This study made use of previously established criteria regard-
ing the appropriateness of phacoemulsiﬁcation. These criteria
were developed by means of the RAND/UCLA method-
ology, as has been described previously . Brieﬂy, a review
was made of the literature and 765 clinical scenarios ident-
iﬁed representing the majority of settings in which phacoe-
mulsiﬁcation is considered. A panel of experts comprising 12
ophthalmologists (including a mix of those who perform cat-
aract extraction and those who do not) rated the appropriate-
ness of this technique in each of these clinical scenarios
using a scale ranging from 1 (least appropriate) to 9 (most
appropriate). The 765 scenarios were classiﬁed into ‘appro-
priate’, ‘uncertain’ or ‘inappropriate’ [2, 17]. An additional
round of analysis was performed for the scenarios in which
phacoemulsiﬁcation was deemed ‘appropriate’ in order to
identify the scenarios under which the intervention would
also be considered necessary. ‘Necessity’ means that the
intervention is not only appropriate but crucial and that it
would be improper care not to recommend it in the given
clinical situation [18, 19]. Each scenario was rated for neces-
sity using a 9 point scale. Scenarios considered appropriate
that also had a median necessity rating between 7 and 9 and
without disagreement among the panellists were considered
‘necessary’. Otherwise, they were classiﬁed as ‘appropriate’.
A complete description of these deﬁnitions can be found in
a previous publication .
Measuring the degree of appropriateness of
performed phacoemulsiﬁcation procedures
A prospective observational study was conducted between
October 2004 and July 2005. Patients became eligible for the
study at the time of their inclusion in waiting list for cataract
Data were collected on the cataract extractions performed
by phacoemulsiﬁcation at 17 public hospitals in four regions
of Spain (Andalusia, Catalonia, Madrid and the Basque
Country). The sample size was estimated in order to detect
differences of between 1 and 5% in the rate of inappropriate-
ness of phacoemulsiﬁcation (
value of 0.05 and 1 2
0.80). Within each centre 350 operations were included in the
Patients aged between 18 and 90 years were enrolled. All
gave their consent to be included. Patients were excluded for
the following reasons: presence of corneal dystrophy, cataract
surgery associated with some other type of ophthalmic
surgery, bilateral cataracts when the second intervention was
performed within 3 months of the ﬁrst, patients who could
not collaborate because of organic pathologies or serious
psychiatric disorders or who were illiterate, and those who
could not speak Spanish or who had some problem that pre-
vented the questionnaires from being completed. Patients
who died or changed address before the intervention, for
whom clinical data were lost, or for whom data for over 50%
of the variables considered important were not available,
were deemed lost.
The patients’ clinical data were collected by ophthalmolo-
gists or other health-care professionals trained in the extrac-
tion of data from clinical records and blinded to the study
goals. A form was designed for the collection of data, which
included sex, age and the seven clinical variables necessary
for each intervention to be assigned to one of the 765 clini-
cal scenarios for which appropriateness criteria had been pre-
viously established: ocular comorbidity, visual acuity of the
eye with the cataract and the contralateral eye, visual func-
tion, anticipated surgical complexity of the procedure, lateral-
ity of the cataract and anticipated postoperative visual acuity
. A data collection manual was elaborated providing clear
deﬁnitions of each variable. The data collection form and
abstraction manual were reﬁned during a pilot study prior to
the beginning of the study.
Sociodemographic data (educational status, work status,
civil status and living condition) were retrieved from the
questionnaire completed by patients prior to the surgery.
The main study outcome was the proportion of surgical
interventions in each of the four appropriateness categories
(necessary, appropriate, uncertain and inappropriate). The
secondary outcome was the prevalence of clinical scenarios
encountered in clinical practice, among all of the scenarios
developed and rated by the panel of experts.
This study was approved by the ethics committees of the
participating centres. The conﬁdentiality of data was main-
tained in compliance with the Spanish Law of Data
Protection (O.L. 15/1999).
The unit of analysis was the patient. When two operations
had been performed in the same patient during the study
period, only the ﬁrst operation was included in the analysis.
Descriptive analysis was performed and categorical vari-
ables were summarized as frequencies and percentages and
de Larrea et al.
continuous variables as means and standard deviations (SD).
95% conﬁdence intervals (CI) were calculated for the appro-
We compared the characteristics of included patients and
those that were excluded because they did not match any of
the scenarios or because of lack of the necessary information
to assign them to a clinical scenario. The relationship
between appropriateness and clinical variables was analysed.
Continuous variables were compared by means of the analy-
sis of variance and categorical variables with the chi-square
test. P-values ,0.05 were considered statistically signiﬁcant.
Finally, frequencies of the most frequent scenarios in each
level of appropriateness were calculated. All computations
were developed using the SAS statistical software for
Windows v. 9.1.
During the observation period a total of 6112 patients who
met the inclusion criteria underwent phacoemulsiﬁcation. Of
these patients, 215 were classiﬁed into 100 clinical scenarios
that were excluded from our study. Most of the excluded
scenarios were deemed to be rare or very infrequent in clini-
cal practice, such as patients with bilateral cataracts having a
higher visual acuity in the eye to be operated than in the con-
tralateral eye and patients with a visual acuity of 0.1 in
both eyes and no difﬁculties in their daily living activities
(ADL). There were 455 patients excluded because they
lacked information on a variable required to assign them to a
clinical scenario. Patients that did not match any of the clini-
cal scenarios had a higher mean age than those included in
the study, but there were no other statistically signiﬁcant
differences in the comparison of sociodemographic charac-
teristics (Table 1). The ﬁnal study sample was composed of
5442 patients. 58.5% of them were women and mean age
73.2 years (SD 8.9).
The majority of the patients (77.0%) had simple cataracts
(Table 2). In 60% of all patients the visual acuity of the catar-
act involved eye was 0.2 to 0.4, and in 70% of those with a
non-simple cataract a post-surgery visual acuity of 0.5 was
anticipated. In 81% of cases the anticipated surgical com-
plexity was low. Of the 5442 ﬁrst surgeries performed, the
use of phacoemulsiﬁcation was classiﬁed as necessary in
39.9% [95% CI: 38.5–41.2], appropriate in 29.8% [95% CI:
28.5–31.0], inappropriate in 7.3% [95% CI: 6.7–8.1] and
uncertain in 23.0% [95% CI: 21.9 – 24.2].
Table 2 shows the degree of appropriateness of the inter-
ventions with respect to the patients’ clinical variables. The
largest difference in the proportion of patients with an inap-
propriate surgery was seen in the following comparisons: a)
between simple cataracts and cataracts associated with other
ocular disease; b) between patients with preoperative visual
acuity of the cataract involved eye ,0.5 and those with
visual acuity 0.5; c) between patients with anticipated post-
operative visual acuity of .0.1 and those with anticipated
visual acuity of 0.1; d) between low and high anticipated
surgical complexity, and; e) between cataracts causing no
functional impairment and cataracts causing glare or difﬁcul-
ties with recreational or daily living activities (ADL).
Table 1 Sociodemographic characteristics of the patients
Patients with insufﬁcient
Patients no matching
any of the scenarios
Age x(SD) 73.2 (8.9) 73.2 (9.6) 75.4 (8.1) 0.003
Sex (%) Women 58.5 59.6 54.4 0.43
Education (%) Secondary/university 15.4 12.3 18.1 0.33
None/primary 84.6 87.7 81.9
Civil status (%) Married/living with partner 61.9 61.1 58.0 0.61
Single/separated 8.2 8.3 11.7
Widowed 29.9 30.6 30.3
Work status (%) Active worker 5.3 4.5 5 0.41
Transitory inability to work 1.1 1.7 0
Work in the household 26.9 30.9 22.8
Retired 64.6 61.2 68.3
Others 2.2 1.7 3.9
Living condition (%) Living alone 18.2 18.9 25.9 0.06
Living with partner 79.5 80.6 71.3
In a retirement home 1.2 0.6 2.2
Others 1.1 0 0.6
The number of patients (n) may be lower in some variables due to missing values.
‘Patients with insufﬁcient information’ refers to those
which could not be included in the ﬁnal analysis because of the gathering of insufﬁcient information for a clinical scenario to be
Appropriateness of phacoemulsiﬁcation
Differences in the proportion rated inappropriate were lower
in comparisons between unilateral and bilateral cataracts or
among the degrees of contralateral visual acuity.
In all, 400 interventions were classiﬁed as inappropriate
with 62.0% involving cataracts associated with other ocular
disease, 61.3% unilateral and 15.5% involving highly
complex surgery. With respect to visual acuity, it was 0.5 in
the cataract-involved eye in 51.8% of patients and 0.5 in
the contralateral eye in 76.3% of patients. In 59.8% there was
no limitation of visual function. Among those inappropriate
interventions involving cataracts associated with other ocular
disease, the anticipated postoperative visual acuity was 0.1
in 15.7% of cases, between 0.2 and 0.4 in 27.0% and 0.5
in 57.3%. In contrast, the 2169 interventions classiﬁed as
necessary involved cataracts associated with other ocular
disease in 5.4% of cases. The visual acuity was 0.5 in the
operated eye in no case and in the contralateral in 43.4%,
and the anticipated postoperative visual acuity in those with
cataracts associated with other ocular disease was always
.0.1. With respect to visual function, 62.8% of necessary
interventions were done in patients with difﬁculties in ADL
and none in patients with no impairment. In the case of
interventions classiﬁed as appropriate, in 31.8% of them
patient had difﬁculties in ADL and the percentage with no
impairment was 2.3%. Characteristics of interventions classi-
ﬁed as uncertain were intermediate between those of appro-
priate and those of inappropriate interventions.
Of the 765 clinical scenarios for which the appropriate-
ness of phacoemulsiﬁcation had been established a priori, 429
(56.1%) were encountered in our study. Table 3 shows the
most common scenarios at each level of appropriateness
(necessary, appropriate, uncertain and inappropriate). In the
most common scenarios the degree to which visual function
was limited was the variable most closely associated with the
appropriateness of the procedure. In general, phacoemulsiﬁ-
cation was necessary in cases in which visual function was
Table 2 Distribution of interventions by level of appropriateness according to preoperative characteristics
Type of cataract
Simple 4191 (77.0) 48.9 25.7 21.7 3.6
Associated with diabetic
192 (3.5) 10.4 42.2 29.7 17.7
Associated with some other
1059 (19.5) 9.3 43.5 27.0 20.2
Unilateral 2608 (47.9) 34.8 30.8 25.0 9.4
Bilateral 2834 (52.1) 44.5 28.8 21.2 5.5
Preoperative visual acuity of the cataractous eye
0.5 814 (15.0) 0 22.6 52.0 25.4
0.2–0.4 3268 (60.0) 40.1 33.6 21.8 4.5
0.1 1360 (25.0) 63.0 24.9 8.6 3.5
Anticipated postoperative visual acuity
0.5 876 (70.0) 0 61.2 22.6 16.2
0.2–0.4 298 (23.8) 39.6 2.0 35.9 22.5
0.1 77 (6.2) 0 0 50.7 49.3
Preoperative visual acuity of the contralateral eye
0.5 3289 (60.4) 28.6 32.0 30.1 9.3
0.2–0.4 1948 (35.8) 56.4 27.5 11.8 4.3
0.1 205 (3.8) 62.9 14.6 17.1 5.4
Anticipated surgical complexity
Low/no complexity 4396 (80.8) 40.9 30.1 22.6 6.4
Medium 545 (10.0) 35.4 31.2 23.3 10.1
High 501 (9.2) 35.1 25.8 26.7 12.4
No impairment 589 (10.8) 0 6.5 52.9 40.6
Glare 1249 (23.0) 6.7 46.4 41.1 5.8
Recreational difﬁculties 1584 (29.1) 45.7 30.7 18.8 4.7
Difﬁculties with activities of
2020 (37.1) 67.4 25.5 6.4 0.6
Only for patients with diabetic retinopathy or some other associated ocular disease (n¼1243). All P-values are ,0.001.
de Larrea et al.
Table 3 Description of the three most common scenarios per level of appropriateness
n% Preoperative visual acuity
of the contralateral eye
Preoperative visual acuity
of the cataractous eye
Type of cataract Laterality Anticipated surgical
1 277 12.8 0.2 – 0.4 0.2 – 0.4 Simple Bilateral Low/no complexity Difﬁculties with
activities of daily living
2 231 10.7 0.2 – 0.4 0.2 – 0.4 Simple Bilateral Low/no complexity Recreational difﬁculties
3 218 10.1 0.5 0.2–0.4 Simple Unilateral Low/no complexity Recreational difﬁculties
1 266 16.4 0.5 0.2–0.4 Simple Unilateral Low/no complexity Glare
2 171 10.6 0.5 0.2–0.4 Simple Bilateral Low/no complexity Recreational difﬁculties
3 115 7.1 0.2 – 0.4 0.2 – 0.4 Simple Bilateral Low/no complexity Glare
1 151 12.1 0.5 0.2–0.4 Simple Unilateral Low/no complexity No impairment
2 114 9.1 0.5 0.5 Simple Unilateral Low/no complexity Glare
3 106 8.5 0.5 0.2–0.4 Simple Bilateral Low/no complexity Glare
16416 0.5 0.5 Simple Unilateral Low/no complexity No impairment
2 27 6.3 0.5 0.5 Simple Bilateral Low/no complexity No impairment
3164 0.5 0.2– 0.4 Associated with some
other ocular disease
Unilateral Low/no complexity No impairment
n, number of interventions assigned to each clinical scenario; %, percentage of interventions of the total at each level of appropriateness.
The ‘anticipated postoperative visual acuity’ in this scenario was 0.5.
Appropriateness of phacoemulsiﬁcation
most affected; the patients involved experienced difﬁculties
with ADL as well as recreational difﬁculties (e.g. reading or
watching television). In those scenarios in which the pro-
cedure was deemed appropriate, the patients suffered less
impairment of visual function (two of the most common of
these scenarios involved glare as the only limitation).
Interventions deemed uncertain involved even less loss of
visual function or visual acuity, while those deemed inap-
propriate involved patients whose visual function was not
affected and in whom visual acuity in the cataract involved
eye was 0.5 or they had some other ocular disease associ-
ated with the cataract that limited the visual prognosis.
The high prevalence of cataracts, their impact on the quality
of life, and the frequency with which cataract surgery is per-
formed, highlight the need to assess the degree to which the
use of phacoemulsiﬁcation is appropriate. Given the impor-
tant beneﬁts that can be obtained from cataract surgery it
should be performed in nearly all cases that meet clinical cri-
teria for necessity, and in the majority of those cases in
which it would be considered appropriate. However, despite
the relatively low risk of complications with phacoemulsiﬁca-
tion, it should not be offered to patients who are unlikely to
gain sufﬁcient beneﬁt to outweigh the risk involved.
At 7.3%, the percentage of patients in which phacoemulsi-
ﬁcation was deemed inappropriate was low compared with
that recorded for some procedures investigated using this
same methodology (e.g. percutaneous transluminal coronary
angioplasty) , and similar to that recorded for yet others
(e.g. hip arthroplasty) . Although this percentage is rela-
tively small compared with the percentage reported for some
other conditions, the absolute number of phacoemulsiﬁca-
tions performed annually is large, making it important to use
strategies to reduce this ﬁgure. The scenarios in which pha-
coemulsiﬁcation was deemed inappropriate usually involved
patients whose visual function was not impaired (239 of the
400 inappropriate cases), who showed only a slight reduction
in visual acuity (91 cases), or in whom the expected visual
improvement was limited due to the presence of ocular
comorbidity (38 cases). Especially careful assessment of
patients with these characteristics should be performed in
order to avoid futile or harmful interventions.
Surgeon enthusiasm for a technique and patient prefer-
ences have been proposed to explain the overuse of surgery
in general. These factors might also be applicable to
phacoemulsiﬁcation. Some inappropriate surgeries may be
performed because some specialists judge that phacoemulsi-
ﬁcation carries such a low risk that it can be justiﬁed even
when the loss of visual acuity is small and the potential
beneﬁt is limited. For 74 patients with anticipated postopera-
tive visual acuity higher than the preintervention visual
acuity, in which surgery was deemed inappropriate, phacoe-
mulsiﬁcation may have been selected solely on criteria related
to visual acuity, without taking accounting for visual
In some cases, such as in populations with a high socio-
cultural level, patient pressure could lead to the inappropriate
use of a procedure.
The literature contains few studies of the appropriateness
of phacoemulsiﬁcation using criteria developed by the
RAND/UCLA methodology. However, the overall results
obtained—69.6% appropriate and 7.3% inappropriate—are
very similar to those reported by Choi et al.  (77% appro-
priate and 7.7% inappropriate) for South Korea, but quite
different from the 91 and 2%, respectively reported by
Tobacman et al.  for the US. These discrepancies might
be explained by the surgical technique employed. Tobacman
et al. describe the situation in 1990, before the use of phacoe-
mulsiﬁcation became widespread. In contrast, in the work of
Choi et al., performed in 1997, phacoemulsiﬁcation was used
in 88% of the interventions and the present study included
only phacoemulsiﬁcation procedures. The smaller risk associ-
ated with phacoemulsiﬁcation compared with extracapsular
cataract extraction (the most common technique used at the
time of the Tobacman study) may have lead some specialists
to expand the range of patients they consider to have an indi-
cation; they may therefore have used the technique to treat
patients for whom the anticipated beneﬁts were small and
Some 96.5% of the interventions encountered in our
study had been contemplated in the original list of 765 clini-
cal scenarios. This ﬁnding reﬂects the exhaustive nature of
the scenarios assessed by the panel of experts for the deﬁ-
nition of the appropriateness criteria. In addition, the speci-
ﬁcity of our list of scenarios was also high. Among the 765
scenarios, 56% were encountered between the recorded inter-
ventions, compared with the 11% of the list of scenarios in
the study by Tobacman .
Our study has some limitations. The appropriateness of
phacoemulsiﬁcation for cataract treatment was assessed using
reference criteria developed by a panel of ophthalmologists
with recognized expertise in the ﬁeld, following the RAND/
UCLA methodology . The validity of this methodology
for the development of appropriateness criteria for medical
and surgical procedures has been reported for several inter-
ventions [24– 26], including cataract surgery [27, 28]. Still,
the percentages of appropriateness should be interpreted in
the context of this methodology. Some of the interventions
classiﬁed as inappropriate could have been appropriately indi-
cated because of the presence of other individual factors not
taken into account in our appropriateness criteria. Data col-
lection was carried out by a variety of personnel and in some
cases extracted from clinical records so the quality of data
may have been inﬂuenced by the experience or motivation of
those involved. To try to minimize these problems, however,
the persons who collected data were trained and had clear
operating guidelines. In addition, the percentage of cases in
which sufﬁcient information was available for a clinical scen-
ario to be assigned was high at 93%, indeed much higher
than in other studies (43  and 33% ). With respect to
the external validity of the results, extrapolating them to
other regions of Spain or other countries should be under-
taken with caution as there may be differences in the services
de Larrea et al.
offered that have an effect on the degree of inappropriate-
ness of procedures.
Even though it was not the aim of this study, measuring
the underuse of procedures is an important issue related to
the appropriateness of health interventions. We have not
found studies addressing underuse in cataract surgery, prob-
ably due to difﬁculties related to the identiﬁcation of patients
with undiagnosed cataract that need surgery. This would
require the implementation of a study to diagnose cataract at
the population level, which would probably be unfeasible. An
indirect way to address the underuse of cataract surgery
could be to measure the proportion of patients that have
been operated in an advanced stage, when suffering an
extremely low visual acuity with important limitations in
In conclusion, the appropriateness of cataract extrac-
tions performed by phacoemulsiﬁcation in the studied
setting is high, although there is an opportunity to further
reduce the percentage of cataract procedures rated inap-
propriate. A reasonable goal would be to reduce the per-
centage of inappropriate procedures to ,5% without
underusing the technique. The adaptation of appropriate-
ness criteria to clinical practice guidelines and the pro-
duction of electronic aids to decision-making could assist
in reaching this goal.
We are grateful for the support of the staff members of the
different services, research and quality units, as well as the
medical records sections of the participating hospitals and
the professionals who participated in the data collection.
This study supported in part by grants from the Fondo de
Investigacio´n Sanitaria (PI03/0550, PI03/0724, PI03/0471,
PI03/0828, PI04/1577), the Department of Health of the
Basque Country and the thematic networks—Red IRYSS—of
the Instituto de Salud Carlos III (G03/220). SP is supported
by a research contract from the Instituto de Salud Carlos III.
The IRYSS Cataract Group included the following co-investi-
gators: Dr. Jesu
´nez-Tapias, Dr. Eduardo Aguayo
(Hospital Universitario Virgen de las Nieves, Granada); Dr.
Emilio Perea-Milla (Hospital Costa del Sol-CIBER
´a y Salud Pu
´blica (CIBERESP), Ma´laga); Dr.
Eduardo Briones (Hospital Universitario Virgen de Valme,
Sevilla); Dr. Juan R. Lacalle (Facultad de Medicina,
Universidad de Sevilla); Dr. Marisa Bare´, (Corporacio´
Sanitaria Parc Taulı
´, Sabadell); Dr. Elena Andradas (Agencia
´n Entralgo, Madrid); Dr. Inmaculada Aro´stegui
(Departamento de Matema´tica Aplicada, UPV-CIBER
´a y Salud Pu
´blica (CIBERESP)); Amaia Bilbao,
Berta Iba´n˜ez (Fundacio´n Vasca de Innovacio´n e
Investigacio´n Sanitarias-(BIOEF)-CIBER Epidemiologı
´blica (CIBERESP), Bizkaia); Dr. Txomin Alberdi
(Servicio de Oftalmologı
´a, Hospital de Galdakao, Bizkaia);
Dr. Sandra de Fernando (Servicio de Oftalmologı
de Cruces, Bizkaia); Dr. Javier Mendicute (Servicio de
´a, Hospital de Donostia, Gipuzkoa); Dr. Jose M.
Begiristain (Direccio´n Territorial de Gipuzkoa); Dr. Idoia
Garai (Direccio´n Territorial de Bizkaia); Dr. Josefa Pe´rez de
Arriba (Direccio´ n Territorial de Araba); Dr. Felipe Aizpuru
(Unidad de Investigacio´n del Hospital de Txagorritxu-
´a y Salud Pu
´blica (CIBERESP), Araba);
Dr. Jose´ Ignacio Pijoan (Unidad de Investigacio´n, Hospital
de Cruces-CIBER Epidemiologı
´a y Salud Pu
(CIBERESP), Bizkaia); Dr. Antonio Escobar. (Unidad de
Investigacio´n, Hospital de Basurto-CIBER Epidemiologı
´blica (CIBERESP), Bizkaia); Dr. Jose M. Quintana,
Nerea Gonza´lez, Iratxe Lafuente (Unidad de Investigacio´n
del Hospital Galdakao-Usansolo-CIBER Epidemiologı
´blica (CIBERESP), Bizkaia).
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