Victoria L. Tseng

Risk of Fractures Following Cataract Surgery in Medicare Beneficiaries

CONTEXT Visual impairment is a known risk factor for fractures. Little is known about the association of cataract surgery with fracture risk. OBJECTIVE To determine the association of cataract surgery with subsequent fracture risk in US Medicare beneficiaries with a diagnosis of cataract. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of 1-year fracture incidence in a 5% random sample of Medicare Part B beneficiaries with cataract who received and did not receive cataract surgery from 2002 through 2009. MAIN OUTCOME MEASURES One-year incidence of hip fractures. Analyses were adjusted for age; sex; race/ethnicity; US region of residence; systemic comorbidities, including Charlson Comorbidity Index (CCI) score; ocular comorbidities; cataract severity; and presence of physically limiting conditions. Adjusted odds ratios (ORs) of hip fractures were calculated using logistic regression modeling. RESULTS There were 1,113,640 US Medicare beneficiaries 65 years and older with a diagnosis of cataract between 2002 and 2009 in the 5% random sample; of these patients, 410,809 (36.9%) received cataract surgery during the study period. There were 13,976 patients (1.3%) who sustained a hip fracture during the study period. The most common fracture-related comorbidity was osteoporosis (n = 134,335; 12.1%). The most common ocular comorbidity was glaucoma (n = 212,382; 19.1%). Compared with 1-year hip fracture incidence in patients with cataract who did not have cataract surgery, adjusted OR of hip fracture within 1 year after cataract surgery was 0.84 (95% CI, 0.81-0.87) with an absolute risk difference of 0.20%. Compared with matched subgroups of patients who did not receive cataract surgery, patient subgroups that experienced lower odds of hip fracture after cataract surgery included patients with severe cataract, patients most likely to receive cataract surgery based on propensity score, patients 75 years and older, and patients with a CCI score of 3 or greater. CONCLUSION In a cohort of US Medicare beneficiaries aged 65 years and older with a diagnosis of cataract, patients who had cataract surgery had lower odds of hip fracture within 1 year after surgery compared with patients who had not undergone cataract surgery.

Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans.

PURPOSE To investigate the prevalence and predictors of intraoperative and 90-day postoperative ocular complications associated with cataract surgery performed in the United States Veterans Health Administration (VHA) system. DESIGN Retrospective cohort study. PARTICIPANTS Forty-five thousand eighty-two veterans who underwent cataract surgery in the VHA. METHODS The National Patient Care Database was used to identify all VHA patients who underwent outpatient extracapsular cataract surgery and who underwent only 1 cataract surgery within 90 days of the index surgery between October 1, 2005, and September 30, 2007. Data collected include demographics, preoperative systemic and ocular comorbidities, intraoperative complications, and 90-day postoperative complications. Adjusted odds ratios (ORs) of factors predictive of complications were calculated using logistic regression modeling. MAIN OUTCOME MEASURES Intraoperative and postoperative ocular complications within 90 days of cataract surgery. RESULTS During the study period, 53786 veterans underwent cataract surgery; 45082 met inclusion criteria. Common preoperative systemic and ocular comorbidities included diabetes mellitus (40.6%), chronic pulmonary disease (21.2%), age-related macular degeneration (14.4%), and diabetes with ophthalmic manifestations (14.0%). The most common ocular complications were posterior capsular tear, anterior vitrectomy, or both during surgery (3.5%) and posterior capsular opacification after surgery (4.2%). Predictors of complications included: black race (OR, 1.38; 95% confidence interval [CI], 1.28-1.50), divorced status (OR, 1.10; 95% CI, 1.03-1.18), never married (OR, 1.26; 95% CI, 1.14-1.38), diabetes with ophthalmic manifestations (OR, 1.33; 95% CI, 1.23-1.43), traumatic cataract (OR, 1.80; 95% CI, 1.40-2.31), previous ocular surgery (OR, 1.29; 95% CI, 1.02-1.63), and older age. CONCLUSIONS In a cohort of United States veterans with a high preoperative disease burden, selected demographic factors and ocular comorbidities were associated with greater risks of cataract surgery complications. Further large-scale studies are warranted to investigate cataract surgery outcomes for non-VHA United States patient populations.

Predictors of mortality within 90 days of cataract surgery.

PURPOSE To identify predictors of mortality within 90 days of cataract surgery. DESIGN A retrospective cohort study. PARTICIPANTS A total of 45,082 patients who underwent cataract surgery in the Veterans Health Administration (VHA) between October 1, 2005 and September 30, 2007. METHODS The National Patient (US) Care Database (NPCD) was used to identify all patients who underwent outpatient extracapsular cataract surgery performed in the VHA and who had only 1 cataract surgery within 90 days of the index surgery. Data collected includes demographics, number of hospitalizations within 1 year before surgery, postoperative mortality, and systemic comorbidities using the Charlson Comorbidity Index (CCI), which predicts the 1-year mortality for a patient based on a range of co-morbid conditions scored 1, 2, 3 or 6 depending on the risk of dying associated with the condition. Adjusted odds ratios (OR) of factors predictive of 90-day mortality were calculated using logistical regression modeling. MAIN OUTCOME MEASURES Mortality within 90 days of cataract surgery. RESULTS Of the 53,786 patients who underwent cataract surgery during the study period, 45,082 met inclusion criteria. Mean age was 71.8 years; 97.6% were men; 5.0% had complex cataract surgery. The most frequent systemic comorbidities in the CCI were diabetes mellitus (40.6%), chronic pulmonary disease (21.2%), malignant neoplasms (12.5%) and congestive heart failure (CHF; 9.5%). Patients had a median CCI score of 1; 43.7% had a score ≥ 2. Mortality rate within 90 days after cataract surgery was 7.1 per 1000 patients. Independent predictors of 90-day postoperative mortality were [adjusted OR, (95% confidence interval; CI)]: age 80 or greater [2.54 (1.62, 3.98)], CCI ≥ 2 [2.06 (1.58, 2.70)], ≥ 1 hospitalizations in the past year [1.85 (1.45, 2.36)], chronic pulmonary disease (CPD) [1.69 (1.34, 2.14)], CHF [1.71 (1.29, 2.14)], cirrhosis [2.60 (1.31, 5.15)], multiple myeloma or leukemia [2.20 (1.07, 4.53)], and metastatic solid tumor [4.17 (1.80, 9.66)]. CONCLUSIONS The risk of 90-day mortality after cataract surgery is low, even for patients at higher risk for mortality such as the elderly and those with a high preoperative disease burden.

Compliance with the American Academy of Ophthalmology Preferred Practice Pattern for Diabetic Retinopathy in a resident ophthalmology clinic.

Purpose: The purpose of this study was to evaluate compliance with the American Academy of Ophthalmology Diabetic Retinopathy (DR) Preferred Practice Pattern for an initial DR examination in a resident ophthalmology clinic. Methods: Adult patients with diabetes were included if seen in the resident ophthalmology clinic at a Veterans Affairs Medical Center for an initial DR examination between July 2006 and June 2007. Medical records were reviewed for compliance with the 29 applicable elements from the American Academy of Ophthalmology DR Preferred Practice Pattern. Results: Of 451 diabetic patient visits in the ophthalmology clinic in the study period, 70 met inclusion criteria. The overall mean compliance rate was 52%. Compliance was best in the categories of examination (mean = 87%), diagnosis (mean = 82%), and treatment (mean = 74%). Compliance was lowest in the categories of medical history (mean = 11%) and counseling/referral (mean = 34%). Conclusion: Compliance with both practice and documentation of American Academy of Ophthalmology DR Preferred Practice Pattern guidelines at a resident ophthalmology clinic should be monitored, especially in the areas of medical history, patient education, and referrals. A target level of compliance should be set and maintained in all the DR Preferred Practice Pattern categories, especially in a teaching hospital where residents are developing their approach to quality care.

A survey of the current role of manual extracapsular cataract extraction

a mean ultrasound power of 27%. The next day, phacoemulsification with implantation of a 22.0 D IOL was performed uneventfully under topical anesthesia in the second (right) eye. The EPTwas 1minute 51 seconds with a mean ultrasound power of 39%. On the first postoperative day, the UCDAwas 0.2 in both eyes. At 6 months, it had improved to 0.6 and the corneas were clear. The patient is still alive.

Cataract Surgery and Mortality in the United States Medicare Population

PURPOSE To determine the association between cataract surgery and all-cause mortality in United States Medicare patients with cataract. DESIGN Retrospective cohort study. PARTICIPANTS A 5% random sample of United States Medicare beneficiaries with a diagnosis of cataract from the 2002 through 2012 Denominator and Physician/Supplier Part B files. METHODS The exposure of interest was cataract surgery and the outcome of interest was all-cause mortality. Baseline characteristics that were examined included demographics, systemic comorbidities, and ocular comorbidities. Cox proportional hazards regression modeling was used to assess the association between cataract surgery and mortality. Additional subgroup analyses were performed in propensity score deciles and within strata of age, gender, region, systemic disease burden, and in patients with versus without severe cataract subtypes. MAIN OUTCOME MEASURES All-cause mortality. RESULTS The 5% Medicare sample included 1 501 420 patients with cataract, of whom 544 984 (36.3%) underwent cataract surgery. Patients with cataract surgery were followed up for a mean of 11.4 quarters (standard deviation [SD], 10.8 quarters; range, 0.0-44.0 quarters), whereas patients without cataract surgery were followed up for a mean of 12.9 quarters (SD, 12.2 quarters; range, 0.0-44.0 quarters). Mortality incidence was 2.78 deaths per 100 person-years in patients with cataract surgery and 2.98 deaths per 100 person-years in patients without surgery (P < 0.0001). Overall, patients with cataract surgery had a lower adjusted hazard of mortality compared with patients without surgery (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.72-0.74). The strongest associations were observed in patients with a high propensity score decile (HR, 0.52; 95% CI, 0.50-0.54), patients 80 to 84 years of age (HR, 0.63; 95% CI, 0.62-0.65), women (HR, 0.69; 95% CI, 0.68-0.70), patients in the western United States (HR, 0.52; 95% CI, 0.32-0.86), patients with a moderate systemic disease burden (HR, 0.71; 95% CI, 0.69-0.72), and patients with severe cataract (HR, 0.68; 95% CI, 0.66-0.70). CONCLUSIONS In a national cohort of United States Medicare beneficiaries with cataract, cataract surgery was associated with decreased all-cause mortality. Further studies are needed to examine mechanisms surrounding the association between cataract surgery and mortality.

Cataract Surgery Complications in Nonagenarians

PURPOSE To investigate whether nonagenarians relative to octogenarians are at increased risk of ocular complications from cataract surgery in the US Veterans Health Administration (VHA). DESIGN A retrospective cohort study. PARTICIPANTS A total of 554 nonagenarians and 11 407 octogenarians who received cataract surgery in the VHA. METHODS Nonagenarians and octogenarians who received 1 cataract surgery without a second surgery within 90 days between October 1, 2005, and September 30, 2007, were identified using the National Patient Care Database (NPCD). Data collected include demographics, preoperative systemic and ocular comorbidities, intraoperative complications, and 90-day postoperative complications. The adjusted odds ratio (OR) of complications in nonagenarians using octogenarians as a reference group was calculated using logistic regression modeling. MAIN OUTCOME MEASURES Intraoperative and postoperative ocular complications within 90 days of cataract surgery in nonagenarians versus octogenarians. RESULTS The most common systemic comorbidity for both age groups was diabetes mellitus (DM), and the most common ocular comorbidity for both age groups was age-related macular degeneration (AMD). Octogenarians had a higher prevalence of most systemic comorbidities, and nonagenarians had a higher prevalence of most ocular comorbidities. The most common intraoperative and postoperative complications for both age groups were vitreous loss or posterior capsular tear and posterior capsular opacification. The risk of having any intraoperative or postoperative complication was 13.5% for octogenarians and 13.4% for nonagenarians (P = 0.9001). The OR of having any intraoperative or postoperative complication in nonagenarians with octogenarians as a reference group was 0.94 (95% confidence interval, 0.73-1.22). CONCLUSIONS Nonagenarians relative to octogenarians are not at increased risk of ocular complications from cataract surgery in the VHA. Further studies are needed to evaluate other outcome parameters, such as visual function and quality of life, in nonagenarians undergoing cataract surgery.

Association of cataract surgery with mortality in older women: Findings from the women's health initiative

Importance Previous studies have suggested an association between cataract surgery and decreased risk for all-cause mortality potentially through a mechanism of improved health status and functional independence, but the association between cataract surgery and cause-specific mortality has not been previously studied and is not well understood. Objective To examine the association between cataract surgery and total and cause-specific mortality in older women with cataract. Design, Setting, and Participants This prospective cohort study included nationwide data collected from the Women’s Health Initiative (WHI) clinical trial and observational study linked with the Medicare claims database. Participants in the present study were 65 years or older with a diagnosis of cataract in the linked Medicare claims database. The WHI data were collected from January 1, 1993, through December 31, 2015. Data were analyzed for the present study from July 1, 2014, through September 1, 2017. Exposures Cataract surgery as determined by Medicare claims codes. Main Outcomes and Measures The outcomes of interest included all-cause mortality and mortality attributed to vascular, cancer, accidental, neurologic, pulmonary, and infectious causes. Mortality rates were compared by cataract surgery status using the log-rank test and Cox proportional hazards regression models adjusting for demographics, systemic and ocular comorbidities, smoking, alcohol use, body mass index, and physical activity. Results A total of 74 044 women with cataract in the WHI included 41 735 who underwent cataract surgery. Mean (SD) age was 70.5 (4.6) years; the most common ethnicity was white (64 430 [87.0%]), followed by black (5293 [7.1%]) and Hispanic (1723 [2.3%]). The mortality rate was 2.56 per 100 person-years in both groups. In covariate-adjusted Cox models, cataract surgery was associated with lower all-cause mortality (adjusted hazards ratio [AHR], 0.40; 95% CI, 0.39-0.42) as well as lower mortality specific to vascular (AHR, 0.42; 95% CI, 0.39-0.46), cancer (AHR, 0.31; 95% CI, 0.29-0.34), accidental (AHR, 0.44; 95% CI, 0.33-0.58), neurologic (AHR, 0.43; 95% CI, 0.36-0.53), pulmonary (AHR, 0.63; 95% CI, 0.52-0.78), and infectious (AHR, 0.44; 95% CI, 0.36-0.54) diseases. Conclusions and Relevance In older women with cataract in the WHI, cataract surgery is associated with lower risk for total and cause-specific mortality, although whether this association is explained by the intervention of cataract surgery is unclear. Further study of the interplay of cataract surgery, systemic disease, and disease-related mortality would be informative for improved patient care.

Association of Dietary Fatty Acid Intake With Glaucoma in the United States

Importance Identifying whether an association exists between daily dietary polyunsaturated fatty acid (PUFA) consumption and the prevalence of glaucoma in the United States may provide modifiable dietary risk factors for the development of glaucoma. Objective To analyze the association between glaucoma and daily dietary intake of PUFAs, including &ohgr;-3 fatty acids, in the US population. Design, Setting, and Participants Data from 3865 participants in the National Health and Nutrition Examination Survey (NHANES) 2005-2008 database who were 40 years or older, had participated in the vision health and dietary intake questionnaires, and had available results from laboratory tests and eye examinations that included frequency-doubling technology visual field loss detection tests and optic disc photographs were included. Data collection was performed by NHANES from 2005 to 2006. Data for the present study were downloaded from their database May 1 to 30, 2017. Data analyses were performed from June 1 to October 1, 2017. Exposures Daily dietary intake of PUFAs, including &ohgr;-3 fatty acids. Main Outcomes and Measures Prevalence of glaucoma in the United States as defined using the Rotterdam criteria, which included a combination of optic cupping or asymmetry and visual field defect results. Results Of the 83 643 392 weighted survey participants included in this cross-sectional study, 43 660 327 (52.2%) were women and 3 076 410 (3.7%) met our criteria for having glaucoma. Compared with participants without glaucoma, those with glaucoma were older (mean [SE] age, 61.4 [0.8] vs 53.7 [0.4] years; P < .001). Increased levels of daily dietary intake of eicosapentaenoic acid (odds ratio [OR], 0.06; 95% CI, 0.00-0.73) and docosahexaenoic acid (OR, 0.06; 95% CI, 0.01-0.87) were associated with significantly lower odds of having glaucoma. However, participants with daily total dietary PUFA intake levels in the second (OR, 2.84; 95% CI, 1.39-5.79) and third (OR, 2.97; 95% CI, 1.08-8.15) quartiles showed significantly increased odds of meeting our criteria for a diagnosis of glaucoma. Conclusions and Relevance Increased daily dietary consumption levels of eicosapentaenoic acid and docosahexaenoic acid were associated with lower likelihood of glaucomatous optic neuropathy. However, consumption levels of total PUFAs in the higher quartiles were associated with a higher risk of glaucoma, which may have resulted from the relative intakes of &ohgr;-6 and &ohgr;-3 fatty acids and other confounding comorbidities. This study also hypothesizes that increasing the proportion of dietary &ohgr;-3 consumption levels while controlling overall daily PUFA intake may be protective against glaucoma. However, longitudinal studies or randomized clinical trials are needed to assess these hypotheses.

Characteristics Associated With Receiving Cataract Surgery in the US Medicare and Veterans Health Administration Populations

Importance Considerable variation exists with respect to the profiles of patients who receive cataract surgery in the United States. Objective To identify patient characteristics associated with receiving cataract surgery within the US Medicare and Veterans Health Administration (VHA) populations. Design, Setting, and Participants In this population-based retrospective cohort study of 3 073 465 patients, Medicare and VHA patients with a cataract diagnosis between January 1, 2002, and January 1, 2012, were identified from the 2002-2012 Medicare Part B files (5% sample) and the VHA National Patient Care Database. Patient age, sex, race/ethnicity, region of residence, Charlson Comorbidity Index (CCI) scores, and comorbidities were recorded. Cataract surgery at 1 and 5 years after diagnosis was identified. Data analysis was performed from July 1, 2016, to July 1, 2017. Main Outcomes and Measures Odds ratios (ORs) of cataract surgery for selected patient characteristics. Results The study sample included 1 156 211 Medicare patients (mean [SD] age, 73.7 [7.0] years) and 1 917 254 VHA patients (mean [SD] age, 66.8 [10.2] years) with a cataract diagnosis. Of the 1 156 211 Medicare patients, 407 103 (35.2%) were 65 to 69 years old, 683 036 (59.1%) were female, and 1 012 670 (87.6%) were white. Of the 1 917 254 VHA patients, 905 455 (47.2%) were younger than 65 years, 1 852 158 (96.6%) were male, and 539 569 (28.1%) were white. A greater proportion of Medicare patients underwent cataract surgery at 1 year (Medicare: 213 589 [18.5%]; VHA: 120 196 [6.3%]) and 5 years (Medicare: 414 586 [35.9%]; VHA: 240 884 [12.6%]) after diagnosis. Factors associated with the greatest odds of surgery at 5 years were older age per 5-year increase (Medicare: OR, 1.24 [95% CI, 1.23-1.24]; VHA: OR, 1.18 [95% CI, 1.17-1.18]), residence in the southern United States vs eastern United States (Medicare: OR, 1.38 [95% CI, 1.36-1.40]; VHA: OR, 1.40 [95% CI, 1.38-1.41]), and presence of chronic pulmonary disease (Medicare: OR, 1.26 [95% CI, 1.24-1.27]; VHA: OR, 1.40 [95% CI, 1.38-1.41]). Within Medicare, female sex was associated with greater odds of surgery at 5 years (OR, 1.14; 95% CI, 1.13-1.15). Higher CCI scores (CCI score ≥3 vs 0-2) were associated with increased odds of surgery among VHA but not Medicare patients at 5 years (Medicare: OR, 0.94 [95% CI, 0.92-0.95]; VHA: OR, 1.24 [95% CI, 1.23-1.36]). Black race vs white race was associated with decreased odds of cataract surgery 5 years after diagnosis (Medicare: OR, 0.79 [95% CI, 0.78-0.81]; VHA: OR, 0.75 [95% CI, 0.73-0.76]). Conclusions and Relevance Within both groups, older age, residence in the southern United States, and presence of chronic pulmonary disease were associated with increased odds of cataract surgery. Findings from this study suggest that few disparities exist between the types of patients receiving cataract surgery who are in Medicare vs the VHA, although it is possible that a smaller proportion of VHA patients receive surgery compared with Medicare patients.