Eyeworld

EW CATARACT 38 July 2016 by Matt Young and Gloria Gamat EyeWorld Contributing Writers Timing from diagnosis to surgery Of all the factors analyzed, differ- ences in timing from diagnosis to surgery may be the least well under- stood. "More work is required to understand the factors contributing to the large differences in timing observed," Dr. Kauh and colleagues reported. "Communities differ with respect to the characteristics of the patients residing in them, eyecare professional availability, how assertive the ophthalmologists are at recommending surgery, and different environmental and lifestyle factors that can affect the timing of surgery. Visual demands may also vary among persons residing in one community vs. another. For example, some communities have better public transportation systems, so there may be less of a need to see well enough to operate a motor vehicle to drive to work." Another view While scientific analysis has been pursued in analyzing such broad trends, 1 skeptic is John Sheppard, MD, professor of ophthalmology, microbiology and molecular biology, and clinical director, Thomas R. Lee Center for Ocular Pharmacology, Eastern Virginia Medical School, Norfolk, Virginia. "There are too many variables here [for a meaningful analysis]," Dr. Sheppard said. "Latitude [for example] may be too general to draw conclusions." The researchers acknowledged study limitations, suggesting that "some community-level variation in median age and rate of surgery could be due to chance alone." EW References 1. Kauh CY, et al. Geographic variation in the rate and timing of cataract surgery among US communities. JAMA Ophthalmol. 2016;134:267–76. 2. Javitt JC, et al. Geographic variation in utilization of cataract surgery. Med Care. 1995;33:90–105. Editors' note: The physicians have no financial interests related to their comments. Contact information Kauh: webmaster@ophth.wisc.edu Sheppard: jsheppard@vec2020.com despite the studies' use of different data … and an approximately 20- year difference in observation peri- ods," Dr. Kauh reported. "Although it is unclear why this particular com- munity has such high surgery rates, possible reasons include patient-re- lated factors (e.g., increased patient motivation for surgery), health care professional-related factors (e.g., differences in health care profession- als' aggressiveness in recommending surgery), or factors specific to that particular community (e.g., envi- ronmental exposures). Lake Charles is a major center for petrochemical refining, and chronic exposure to naphthalene and other pollutants involved in the refinery process increase the risk for cataracts." Meanwhile, focus groups found that older black patients named lack of transportation and ability to reach an ophthalmologist's office as a hurdle to achieving appropriate eyecare, the authors noted. Trust, communication, social support, and cost may be additional factors at play, the researchers reported. "Given that cataracts are a lead- ing cause of blindness among black people, and yet racial disparities in receipt of cataract surgery persist, additional work is needed to better identify and to eliminate black pa- tients' barriers to surgery," Dr. Kauh reported. In another line of inquiry, Dr. Kauh and colleagues suggested that surgical differences related to latitude may, in fact, be linked to UV light. "The hazard of surgery was re- duced for persons living in commu- nities farther away from the equator (higher latitude)," they wrote. "This highlights the importance that UV light exposure can have on the development and progression of cataracts." Further, the authors theorized that there is an impact of optom- etrists on cataract surgery rates for good reason. "It may be easier for patients who are struggling with their eyesight to access eyecare services in communities with more optom- etrists. With increased access, more patients are receiving cataract diag- noses and referrals for surgery," they reported. 15% decreased hazard of surgery compared to white patients (the term "hazard" here is derived from "hazard ratios" and does not refer to cataract surgery complications). Latino and Asian patients, mean- while, had an increased hazard of surgery compared to whites. In this study, multivariable regression modeling generated hazard ratios (HRs) "with 95% CIs identifying factors associated with patients' likelihood of undergoing cataract surgery." • For every 1 degree higher latitude, the hazard of surgery decreased by 1%. • For every additional optometrist per 100,000 patients, the hazard of surgery increased 0.1%. • The lowest age-standardized cataract surgery rate was 7.5%, in Honolulu, Hawaii, and the highest was 37.3% in Lake Charles, Louisiana. The study obtained records from beneficiaries of a nationwide managed care network, accessing all eyecare recipients from 2001 to 2011. Researchers identified patients older than 40 who had at least 1 cataract. Of note Lake Charles, Louisiana came up as particularly noteworthy in this study. It "had the country's highest cataract surgery rate in both [the Kauh and earlier Javitt 2 ] studies What new research means for how cataract surgery may be carried out in your town I n a report about geographic variation of cataract surgery in the United States, published in JAMA Ophthalmology, Courtney Kauh, MD, Madison, Wis- consin, and colleagues noted how different cataract surgery practices are between the north and south regions, and also compared the prac- tices to 30 years ago. 1 "Previous studies using data from the 1980s found relatively little geographic variation in cataract sur- gery rates across the United States," Dr. Kauh reported. Things have changed, to say the least. Major findings The report had diverse findings, including: • Median patient age was 59.9–60.1 years old in Lansing, Michigan as well as in Aurora, Illinois. But it was 77.0–79.6 years old in Mar- quette, Michigan; Rochester, New York; and Binghamton, New York. • The median time from diagnosis to surgery was 17 days in Victoria, Texas, while it was 367 days in Yakima, Washington. • There were significant racial differences. Black patients had a Cataract surgery varies by race, state, even latitude

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