Variation in cataract surgical outcomes by facility type: evidence from 168 population-based surveys in 61 countries

Background/aims To compare visual outcomes after cataract surgery between outreach camps and fixed facilities, and among government, non-governmental organisation (NGO) and private providers within fixed facilities. Methods Pooled cross-sectional analysis of 41 881 cataract-operated eyes from adults aged 50 years and older in 168 population-based Rapid Assessment of Avoidable Blindness surveys across 61 countries. Analyses were restricted to surgeries performed between 2000 and 2020. Multilevel logistic regression with random intercepts for country, survey, cluster and individual was used to estimate the association between surgical setting and achieving presenting visual acuity of 6/18 or better, adjusting for age at surgery, sex, year of surgery and Global Burden of Disease super-region. Results Outreach camps accounted for 9.7% of surgeries and had a lower adjusted probability of achieving presenting visual acuity of 6/18 or better than fixed facilities (60.6% vs 66.6%; OR 0.59 (95% CI 0.50 to 0.70)). Within fixed facilities, probabilities were 64.8% in government hospitals, 66.8% in NGO hospitals and 69.5% in private hospitals. Compared with government hospitals, outcomes were similar in NGO hospitals (OR 1.21 (95% CI 0.95 to 1.53)) and better in private hospitals (OR 1.56 (95% CI 1.25 to 1.94)). Outcomes improved across all delivery models over time, but differences between settings remained unchanged. Conclusions In settings where outreach services account for a substantial proportion of surgical volume, persistently poorer outcomes may constrain gains in effective cataract surgical coverage. These findings highlight the importance of improving the organisation and quality of outreach surgery and strengthening public cataract surgical services.