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Stagg BC, Ehrlich JR, Choi H, Levine DA. Association of Cognitive Impairment and Dementia With Receipt of Cataract Surgery Among Community-Dwelling Medicare Beneficiaries. JAMA Ophthalmol. 2019;137(1):114–117. doi:10.1001/jamaophthalmol.2018.5138
Correcting visual impairment may optimize functioning and reduce the risk of further cognitive decline for people with cognitive impairment and dementia (CID).1,2 Cataracts cause visual impairment in more than 20% of older adults and are effectively treated with low-risk surgery.3 Clinical guidelines state that older adults with CID, except those with limited life expectancy or advanced dementia, should be offered effective treatments, including cataract surgery.4 It is not known whether older adults with CID in the United States receive cataract surgery at the same rate as those with normal cognition. We tested the hypothesis that community-dwelling Medicare beneficiaries with CID are less likely to receive cataract surgery than those with normal cognition.
We used data from the National Health and Aging Trends Study (NHATS), a longitudinal survey annually administered to a nationally representative cohort of US Medicare beneficiaries 65 years and older (January 2011 to December 2016). We excluded participants who reported cataract surgery before enrollment. We censored participants after they reported receiving cataract surgery. In an effort to exclude those with advanced dementia, we excluded participants who required a proxy respondent or resided in nursing homes. The University of Michigan Institutional Review Board approved this study, and informed consent was waived because deidentified, publicly available survey data were used.
The outcome was self-reported receipt of cataract surgery measured annually. The predictor was CID using the NHATS system, which classifies participants as having probable CID (ie, report of physician diagnosis of dementia or Alzheimer disease or scores 1.5 SDs below the mean or lower on 2 or more cognitive tests of memory, orientation, and executive function), possible CID (a score 1.5 SDs below the mean or lower on 1 cognitive test), or no CID.5
Based on the NHATS survey design, we calculated the weighted proportions of participants for each sociodemographic group stratified by classification of CID. We performed multivariable logistic regression to examine the effect of an individual’s CID classification on receipt of cataract surgery in the subsequent year while adjusting for patient-related factors, including age, sex, race/ethnicity, education, annual income, survey year, self-reported distance and near visual impairment, smoking status, depressive symptoms, social isolation, self-care and activity limitations, and comorbidity (ie, self-reported diagnosis of heart disease, hypertension, diabetes, lung disease, stroke, and cancer). We calculated adjusted predicted proportions of the outcome. All analyses accounted for the complex design of NHATS, including sampling weights, units, and strata, and were conducted using Stata version 14 (StataCorp).
Table 1 presents participant characteristics. Participants with possible and probable CID were significantly less likely to receive cataract surgery than those with normal cognition after adjustment for patient factors (possible CID: adjusted odds ratio, 0.73; 95% CI, 0.56-0.95; P = .02; probable CID: adjusted odds ratio, 0.59; 95% CI, 0.36-0.96; P = .03). The adjusted predicted proportion receiving cataract surgery was 8.1% for those with normal cognition, 6.2% for those with possible CID, and 5.1% for those with probable CID (Table 2).
In this large, nationally representative study, community-dwelling Medicare beneficiaries with CID were less likely to receive cataract surgery than those with normal cognition. It is possible that CID is a proxy for other correlated factors (eg, older age, nonwhite race, lower educational attainment, lower income, depression, activity of daily living deficits, and history of stroke), which are also barriers to cataract extraction. Although we adjusted for many of these potential confounders, residual confounding could be present. Our study relies on self-reported data. Older adults are able to accurately report receipt of cataract surgery,6 although the accuracy of self-reported cataract surgery in those with CID is unreported.
We found that Medicare beneficiaries with CID were less likely to receive cataract surgery than those with normal cognition. Given that cataract surgery may help optimize functioning in persons with and without CID, it is important for primary care physicians, geriatricians, and ophthalmologists to be aware of the potential underuse of this effective, low-risk treatment in patients with CID.
Accepted for Publication: September 8, 2018.
Corresponding Author: Brian C. Stagg, MD, National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, 1000 Wall St, Ann Arbor, MI 48105 (firstname.lastname@example.org).
Published Online: October 25, 2018. doi:10.1001/jamaophthalmol.2018.5138
Author Contributions: Dr Stagg had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Stagg, Ehrlich, Choi.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Stagg.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Stagg, Choi.
Obtained funding: Ehrlich.
Administrative, technical, or material support: Levine.
Study supervision: Ehrlich, Choi, Levine.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Ehrlich has received grants from the National Eye Institute, National Institute on Aging, and Research to Prevent Blindness. Dr Levine has received grants from the National Institute on Aging and the National Institute of Neurological Disorders and Stroke. No other disclosures were reported.
Funding/Support: This research was supported by grant K23 EY027848 from the National Eye Institute (Dr Ehrlich); the American Society of Cataract and Refractive Surgery (Dr Ehrlich); grant P30 AG012846 from the National Institute on Aging to the Institute for Social Research at the University of Michigan; and an unrestricted grant from Research to Prevent Blindness to the Department of Ophthalmology and Visual Sciences at the University of Michigan.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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