Practical use of indicators:
CSR, CSC & outcomes
Susan Lewallen, MD
A place to start
• CSC would probably be the most
important indicator to tell us how well
we’re serving people
• Ideally we’d have a CSC of 100% in
every “district” and country (assuming
all surgeries had a good outcome!)
Inconvenient reality…
• Measuring CSC requires a population
based survey
– Expensive
– Difficult
• Most “VISION 2020 Districts” will never
have such a survey
CSR is more practical to measure
• Limitations:
– requires proper record keeping to know where
patient resides
– requires cooperation and reporting from all
providers
– still not measured properly in most districts
– country level CSR hides inequalities among
districts
– does not consider outcomes
• But it’s still the best we’ve got for planning
and monitoring
So what CSR over time would lead to a
100% CSC?
How many surgeries required to do all the
cataracts?
Incident
cataracts
People (eyes)
who die
unoperated
Eyes with unop’d
cataract
Operated
eyes
Target CSR should equal
annual incidence of cataract.
How can we get incidence
data in developing countries?
It can be modeled from age
specific prevalence data obtained
in population based surveys, such
as RAABs
ung
4500
4000
3500
3000
2500
2000
1500
1000
500
0
Rwa
nda
K en
yaN ak
K en
ur u
yaSN
yan
za
T an
zani
a-Ki
li
Gha
na
Z am
bia
Mal
awi
K en
ya K
er ic
Mad
ho
aga
scar
-Ats
in
Libe
r ia
Moz
amb
i que
Sier
ra L
eon
S en
e
ega
l-Fa
tick
S en
ega
l-Ka
olac
k
K en
yaKwa
T an
le
zani
a- Z
anz
ibar
Eritr
S ud
ea
anNor
th S
tate
Guin
ea B
isau
S ud
an S en
nar
S ud
anK as
S ud
sala
anNK
ordo
S ud
rfan
anWhi
te N
ile
Mal
i 20
11
ape
am o
st C
- Nt
- Ea
nda
RSA
Uga
AFRICA
Variation in target CSR needed for 100%
CSC (eyes at <6/18)
Hypothesis: variation due to genetic differences?
Other factors that determine what
target CSR should be
Population structure
LATIN AMERICA
Variation in target CSR needed for 100%
CSC (eyes at <6/18)
Cub
a
ado
r
Ecu
il
Bra
z
u
Per
Chi
le
ntin
a
Arg
e
tem
al
Gua
la
ezu
e
Ven
Dom
Rep
Mex
ico
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Much of the variation due to age structure
differences
Other factors that determine what
target CSR should be
VA at which
cataracts are
operated
Better pre op VA requires
higher CSR
Target CSR varies with VA
7000
6000
5000
4000
3000
2000
1000
0
Kili
Eritrea
Mali
Moz
Argent
Ecuador
6/18
6/60
3/60
Another inconvenient reality…
Not all surgeries
result in sight
restoration.
Some bad
outcomes occur
ya (
S
ya (
N
ak)
70
60
50
40
30
20
10
0
Ny a
n)
TZ
(Kil
Uga
i)
nda
(Ntu
ng)
Mal
awi
RSA
(E C
ape
Mad
)
aga
s (A
t sin
Rw
)
and
a (W
est)
Bur
und
i (N
orth
)
Erit
rea
Sud
an (
Nor
th)
TZ
(Za
nz)
Ken
ya (
Kw
al e)
Ken
Ken
Outcomes (RAAB)
good
poor
Monitoring outcomes
• Some hospitals/programmes do it
• Most do not. Why?
– Extra work for someone
– Culture not established
– Donors not demanding it
– WHO guidelines designed for use at 6
weeks
• But it could be done at discharge, at
the hospital. Much better than nothing.
Summary- use of indicators
• CSC meaningful but not practical to
measure
• Target CSR to achieve 100% CSC can be
modeled from RAAB data. Useful planning
tool
• Actual CSR can be monitored annually
– Requires reasonable records
– Requires cooperation among all eye care
providers
– Can be monitored by District or by country
• Outcomes -just as important as CSC
– Most practical is to measure at hospital level
Thank you