Lorne Bellan and Mathen Mathen have presented data on the first attempt to institute standard prioritization criteria in a Canadian context for cataract surgery.1 Although this is a worthwhile effort to manage waiting lists, we have a few concerns regarding the scoring system used for prioritization.
The 14-item Visual Functioning Index (VF-14 questionnaire) is already heavily biased toward working and driving. The program developers' addition of 60 extra points for work and driving impairment alters the point scoring system significantly and has not been validated in outcome studies. The fact that a correlation developed between VF-14 scores and difficulty with work or driving following institution of the system proves that surgeons used the system to prioritize their patients. However, unless objective patient-derived outcome measures are used to show that patients with high-priority scores also have better visual function outcomes or less morbidity while waiting for surgery, it does not prove that patients have been prioritized correctly for surgery. The reason for prioritizing waiting lists (rather than simply using a first-come, first-served system) is to reduce morbidity and mortality of patients waiting for surgery. Until this is achieved, the Manitoba Cataract Waiting List Program is just a consensus model to which this group of surgeons has agreed
The use of an open-ended priority score with points given for waiting also defeats the objective of equitable treatment and encourages surgeons to manipulate the system. In many parts of Canada where 12- to 18-month waits for surgery are common, the mere act of waiting for 18 months would give a patient a higher priority score than someone who had much more severe visual morbidity who had not been waiting as long. The act of waiting should only increase priority if the patient's clinical condition worsens or the wait produces clearly proven morbidity. Otherwise, if a patient waits for surgery without deterioration of his or her condition, it is a success of medical therapy rather than a failure of surgical therapy.
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