Anesthesia Care for Cataract Surgery in Medicare Beneficiaries

Abstract

ImportanceCataract surgery in the US is routinely performed with anesthesia care, whereas anesthesia care for other elective, low-risk, outpatient procedures is applied more selectively.ObjectiveTo identify predictors of anesthesia care in Medicare beneficiaries undergoing cataract surgery and evaluate anesthesia care for cataract surgery compared with other elective, low-risk, outpatient procedures.Design, Setting, and ParticipantsThis population-based, retrospective observational cohort study included Medicare beneficiaries 66 years or older who underwent cataract surgery in 2017. The data were analyzed from August 2020 through May 2021.Interventions (for clinical trials) or Exposures (for observational studies)Anesthesia care during elective, low-risk, outpatient procedures.Main Outcomes and MeasuresPrevalence of anesthesia care during cataract surgery compared with other low-risk procedures; association of anesthesia care with patient, clinician, and health system characteristics; and proportion of patients experiencing a systemic complication within 7 days of cataract surgery compared with patients undergoing other low-risk procedures.ResultsAmong 36 652 cataract surgery patients, the mean (SD) age was 74.7 (6.1) years; 21 690 (59.2%) were female; 2200 (6.6%) were Black and 32 049 (87.4%) were White. Anesthesia care was more common among patients undergoing cataract surgery compared with patients undergoing other low-risk procedures (89.8% vs range of <1% to 70.2%). Neither the patient’s age (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; P = .01) nor Charlson Comorbidity Index (CCI) score (CCI of ≥3: adjusted odds ratio, 1.06; 95% CI, 0.95-1.18; P = .28; reference, CCI score of 0-1) was strongly associated with anesthesia care for cataract surgery, but a model comprising a single variable identifying the ophthalmologist predicted anesthesia care with a C statistic of 0.96. Approximately 6.0% of ophthalmologists never used anesthesia care, 76.6% always used anesthesia care, and 17.4% used it for only a subset of patients. Fewer cataract surgery patients experienced systemic complications within 7 days (2833 [7.7%]), even when limited to patients of ophthalmologists who never used anesthesia care (108 [7.4%]), than patients undergoing other low-risk procedures (range, 13.2%-52.2%).Conclusions and RelevanceThe results of this cohort study suggest that systemic complications occurred less frequently after cataract surgery compared with other elective, low-risk, outpatient procedures during which anesthesia care was less commonly used. Anesthesia care was not associated with patient characteristics, such as older age or worse health status, but with the ophthalmologists’ usual approach to cataract surgery sedation. The study findings suggest an opportunity to use anesthesia care more selectively in patients undergoing cataract surgery.

Perioperative Risk Assessment and Avoiding Overuse of Anesthesia Care for Routine Cataract Surgery

“…In Reply We thank Drs Nemet and Tuuminen and Dr Dalia and colleagues for their interest in our article. 1 Drs Nemet and Tuuminen's experiences in Finland add to the growing body of literature suggesting that complications after cataract surgery are exceedingly rare, even though anesthesia care for cataract surgery is used much more selectively at their institution than it is in the US. This approach to cataract surgery sedation is also the prevailing practice throughout the UK, 2 as well as at other dedicated eye care centers, 3,4 and has been shown to be safe and acceptable to patients in these settings.…”

“…Lastly, Dr Dalia and colleagues assert that the model results we shared in the online supplement 1 cannot account for all factors that affect the assignment of anesthesia care and/or the risk of developing perioperative complications. We agree that observational studies can only account for measured con- founders.…”

“…Simply conditioning the estimates on procedure type and the presence or absence of anesthesia personnel may produce estimates that are difficult to interpret because they are prone to selection bias. Accordingly, the data presented by Dr Perumal and colleagues neither support nor refute the value of anesthesia care because of the failure to consider the interplay of risk and nonrandom assignment of anesthesia care. Furthermore, it is not clear whether the models properly considered the many sources of confounding or bias inherent in this setting.…”

“…To the Editor The retrospective observational cohort study by Dr Perumal and colleagues evaluated a 5% sample of Medicare beneficiaries undergoing cataract surgery; the authors defined anesthesia care as the presence or absence of anesthesia personnel. These authors concluded that anesthesia care was not associated with lower perioperative complication rates among patients undergoing cataract surgery, and that the rate of complications after cataract surgery was less than for other procedures with lower rates of anesthesia care.…”

Perioperative Risk Assessment and Avoiding Overuse of Anesthesia Care for Routine Cataract Surgery

“…To the Editor In a recent cohort study by Dr Perumal and colleagues including 36 652 patients who had undergone cataract surgery, the authors observed that despite nearly 90% of the surgical procedures being performed under anesthesia care, systemic perioperative complications were infrequent. Moreover, using anesthesia care was not associated with the complication rate.…”