RESEARCH Investigation of attributes which guide choice in cataract surgery services in urban Sydney, Australia Clin Exp Optom 2018; 101: 363–371 DOI:10.1111/cxo.12653 Celeste Gilbert* MIPH Lisa Keay* PhD Anna Palagyi* PhD Vu Quang Do* † PhD MOrth Peter McCluskey ‡ FRANZCO Andrew White ‡§¶ FRANZCO PhD Nicole Carnt ‡ PhD Fiona Stapleton † PhD Tracey-Lea Laba* k PhD *The George Institute for Global Health, The University of New South Wales, Newtown, New South Wales, Australia † School of Optometry and Vision Science, The University of New South Wales, Sydney, New South Wales, Australia ‡ Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia § Westmead Institute for Medical Research, Sydney, New South Wales, Australia ¶ Department of Ophthalmology, Westmead Hospital, Sydney, New South Wales, Australia k Menzies Centre for Health Policy, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia Email: lkeay@georgeinstitute.org.au Submitted: 24 August 2017 Revised: 28 November 2017 Accepted for publication: 29 November 2017 Background: It is critical to consult patients to develop patient-centred cataract surgery care. We aimed to identify attributes patients consider when making decisions about cataract sur- gery in an Australian context, where both publicly and privately funded surgery are available. This is the first step in investigating how decisions are made about cataract surgery services. Methods: This observational qualitative study was undertaken in two public hospitals and one private practice in Sydney, Australia. The study involved 19 women and men with age-related cataracts and no previous cataract surgery, aged > 18 years, able to speak con- versational English or Mandarin. A multi-stage attribute development process was fol- lowed, including: literature review, semi-structured interviews with surgery candidates in three eye clinics, and review by an expert panel. The main outcome measures were pri- mary attributes for making choices about cataract surgery. Results: Wait time, cost, institutional reputation, surgeon experience and travel time were identified as principal attributes; lower value was placed on consultation length and acces- sibility. Non-English speaking participants indicated greater interest in pre-operative infor- mation than English speakers, but expressed trust in the Australian healthcare system. Conclusions: Findings suggest individuals prioritise attributes which consume time or incur costs when accessing care (wait time, cost and travel time). They also consider factors associ- ated with the outcome of their cataract surgery (surgeon experience and institutional repu- tation). Similar to other decision-making processes, patients are likely to trade between these different attributes depending on their personal preferences and circumstances. Key words: cataract, discrete choice experiment, patient preferences, patient-centred care In Australia, almost 70 per cent of men and women will have developed some degree of cataract by 80 years of age. 1 Cataract places the greatest direct economic burden on the Australian ophthalmology health system, comprising 18 per cent of all eye care expenditure. 2 Between 2009 and 2014, cata- ract extraction was the most commonly per- formed elective procedure in Australia, with 8.9 surgeries occurring per 1,000 popula- tion. 3 The Australian health system offers a unique dual model of care, whereby citizens can access surgical services through private and public hospitals and clinics. The direct medical costs of cataract sur- gery for an individual admitted as a public patient in a public hospital are covered entirely by Australia’s federally funded uni- versal health insurance scheme, Medicare. This is available to all Australian residents. Those who access cataract surgery within a private setting cover the direct medical costs of surgery with a Medicare rebate and an out-of-pocket payment. Those who have private health insurance may be eligible to receive an additional rebate from their fund which contributes to reducing the out-of-pocket expense. With both pathways, costs such as transportation and other indi- rect costs are out-of-pocket expenses. Cataract surgery in the private setting typi- cally involves a significantly shorter wait time, enables the patient a choice of surgeon and hospital, and affords the option of having bilateral cataracts operated within one month of each other. In contrast, public sec- tor cataract surgery can involve an extended waiting period: in 2015–2016, 50 per cent of patients nationally waited 93 days to receive first eye surgery, a four per cent increase since 2011–2012. 3 New South Wales has the second longest surgical waiting period of Australian states and territories, with 50 per cent of patients waiting 240 days during 2015–2016. 3 Consequently, most (70 per cent) cataract surgery is performed in private hospitals and day surgeries. 4 Although long- term policy reform is required to improve © 2018 Optometry Australia Clinical and Experimental Optometry 101.3 May 2018 363 CLINICAL AND EXPERIMENTAL