People of lower socioeconomic status less likely to receive cataract surgery in private clinics, study finds

Following an infusion of public funding to for-profit surgical centres in Ontario, the cataract surgery rate fell by nine per cent for people in the lowest socioeconomic group in those centres, according to new research from ICES, Queen’s University and the University of Toronto.

In contrast, researchers found that the rate of cataract surgery for patients in the highest socioeconomic status group rose by 22 per cent at private for-profit centres. Cataract surgery rates fell equally for all patient groups in publicly funded hospitals over the six-year study period.

The COVID-19 pandemic led to large shortfalls in cataract surgery rates worldwide. To meet the growing need in Ontario, public funding was funneled into private, for-profit surgical centres to offset the need to charge patients for extra services.

“It is important to be innovative and open-minded in searching for the best approach to health care,” said lead author Robert Campbell, a clinician-scientist in the department of ophthalmology at Queen's University and a senior adjunct scientist at ICES.

“However, despite an infusion of public funding into private for-profit surgical centres that was designed to cover facility overhead costs and enable access to care regardless of ability to pay, rates of cataract surgery at private for-profit centres have improved mainly for those with the highest socioeconomic status.”

The study was published in CMAJ, and in collaboration with several researchers at U of T’s Temerty Faculty of Medicine including Professors Sherif El-Defrawy, Chaim Bell, David Urbach, Therese Stukel, Jonathan Irish, Nancy Baxter and David Gomez.

The researchers analyzed all cataract surgeries (935,729) in Ontario between 2017 and 2022, and explored the effect of socioeconomic status on access to surgery at public hospitals versus private for-profit surgical centres. They looked at two time periods: the pre-funding change period up to February 2020, and the post-funding period from March 2020 to March 2022.

Key findings include:

• 81 per cent of cataract operations were performed in public hospitals, versus 19 per cent performed in private for-profit surgical centres.
• Patients in the highest socioeconomic category made up 23 per cent of private surgical cases, whereas those in the lower category made up just 14 per cent.
• Cataract operations performed in private for-profit centres increased from 16 per cent in the pre-COVID period to 23 per cent in the post-funding change period.
• The private centre surgical rate rose 22 per cent for patients in the highest socioeconomic status group, whereas the rate fell by 9 per cent for patients in the lowest socioeconomic status group.

“If public funding is going to continue to be used to buy services at private for-profit centres, important issues will need to be addressed,” said Campbell. “Patients need to be assured that their interests are the only ones considered in decision making, and that the private centres and the surgeons working there don't have financial conflicts of interest that could influence the approach to surgery.”

The researchers note that important questions remain unanswered, and that future studies should explore whether patients of lower socioeconomic status decline surgery at for-profit centres because of financial barriers and whether the existence of separate waitlists for those willing to pay plays a role in the disparities.

“Unifying surgical waitlists such that wait times are the same whether a patient pays extra or not would go a long way toward building a fair system,” said Campbell.

Learn more about this study on the ICES and Queen’s University websites.