a ee SECTION EDITOR: PAUL P. LEE, MD Longitudinal Rates of Cataract Surgery Adrienne Williams, MD; Frank A. Sloan, PhD; Paul P. Lee, MD, JD Objective: To determine the cumulative probability of cataract surgery and factors accounting for such surgery les Among the Oldest Old survey, a national longitudi- nal panel, were interviewed in 1998, 2000, and 2002 to determine whether they had undergone cataract extrac- tion since the previous interview (N=8363 in 1998). Mul- tivariate analysis was used to identify factors affecting eata- ct surgery rates. Results: The annual incidence of cataract surgery from January 1, 1995, to December 31, 2002, was 7.4%. The prevalence of unilateral pseudophala increased from 7.6% fn 1998 to 9.8% in 2002; the prevalence of bilateral pseu- dophakia increased from 10.5% i 1908 to 22.3% in 2002. surgery improved related to that of others (a difference of 04 on a 9-point scale; P<.001). Black individuals were less likely to undergo cataract surgery than white indi- viduals (P*<.01). The highest rates of surgery were for per- sons who were 65 years of alder in 1998. However, pe sons with Medicare parts A and B coverage underwent more procedures than those with primary private employer based coverage oF the uninsured. Conelusions: At 5.3%, the cataract surgery incidence is similar to that given in previous reports, Persons under- going cataract surgery more often had low self-reported Vision before surgery, and their vision improved on av- erage relative to others aller surgery The sell-repor vision of persons undergoing cataract Arch Ophthalmol, 2006:124:1308-1314 Author Affiliations: Departments of Ophthalmology (Drs Williams and Lee) and Economies (Dr Sloan), Duke University, Durham, GGE-RELATED CATARACT RE- ‘mains the leading cause of visual impairment among elderly persons, affecting more than 20.5 million, Americans.’ Americans 65 years or older ‘compose 13% of the population,* and the prevalence of age-related cataract is pro- jected to increase dramatically in the fu- ture.” Cataract extraction is the most fre- quently performed surgical procedure in the Medicare-insured population.*® An- ‘nual population rates in the United States vary between 2% and 6%, depending in parton the geographic region and whether the population is insured under fee-for- service ora health maintenance organiss- tion*®; incidence rates of 5.7% in popula tions 49 years or older (in 1997) and 9.1% in those 60 years or older (in 1998) have been reported in other countries.”® R cent improvements in surgical teeh- ‘niques and new intraocular lens technolo- es will continue to contribute to growth ‘in cataract surgical procedures.” ‘While several studies have generated es- Limates of cross-sectional or annual rales of cataract surgery, particularly in the Medicare-aged population,’ few data ex- NC. {stabout the cumulative longitudinal prob- ability of cataract surgery. This study uses ‘national longitudinal data on eataraet sur- gery use rates from January 1, 1095, 10 De- cember 31, 2002, to provide initial infor- ‘mation about this question. Furthermore, demographic factors related to variation {in the probability of undergoing cataract surgery ate examined in this nationally rep- resenlative data set ss DATA The Asset and Health Dynamics Among the Oldest Old (AHEAD) survey isa national panel survey of US households, drawn as an area probability sample with an oversampling of Facks, Latinos, and Floridians" When the frst wave of interviews was conducted in 1993, the survey sampled noninstitutionalized persons 70 years or older and theit spouses or par ners (who could be any age). Follow-up inter views of the same persons were conducted in 1095, 1998, 2000,and 2002. Persons were fol- lowed up irespective ofthe setting in which they resided: by 2002, 89% of respondents lived {in nursing homes. Spouses of partners re ceived identical interviews as sample persons, 4m 1998, AHEAD was merged withthe Health (©2006 American Medical Association. AI rights reserved,and Retirement Study (HRS), a panel survey of persons pri marily aged 51 to Ol years when first interviewed in 1992, ‘The AHEAD (and the AHEADVHRS merged sample) is unique in collecting comprehensive, longitudinal, and national infor- ‘mation on selt-reported health services use, including eataract surgery, self-reported health, visual status, functional and cog- nilive satus, demographic characteristics, and family strac- ture. At each wave, additional respondents are added periodi- cally to maintain sample size. Detailed and up-to-date information on survey design, sampling, data collection, and follow-up and institutional review board information are avail able from the AHEADVHRS Web site.” Data from the 1993 AHEAD interviews were not used inthis study because the survey only asked whether the person had ever undergone cataract surgery, but did not request informa- tion on the number of eyes undergoing such surgery. The eat act surgery question was aretrospective question covering the period since the last interview and was skipped for persons Younger than 65 years in the survey year. We only included persons who were 65 years or older in 1998 and who had re- ported no prior cataract surgery in 1993 or 1995. SAMPLE CONSTRUCTION We began with 8970 respondents, interviewed in 1998, who were years older and observed these persons through 2002 tnless respondents were aot eintcrviwed because of death or forother reasons (Figure 1). Allperonsin the analysis sample had not undergone eataract surgery on 2 eyes at the previous interview A tal of 8363 respondents were sll avalable in 1995, 3/2 1m 2000, and 5218 In 2002. lightly diferent fe- quencies were used in regression analysis because we eX claded an observation i there was missing information on any othe covariates. Deaths accounted forabout half of total losses ol the sample from 1995 to 2002. The dataset id not include tthe easons or nonresponse. Proxy responsesfor persons with Substantial physial oF cognitive smpaitments an those will ing to have someone else answer on theit behalf were in- eltided in the analysis and were denied by an indicator vat shen the regression analysis, Persons with missing data were tale from the repression analyses Persons entered the ssomple repeatedly until death or los to fllow-p. PERSONS UNDERGOING CATARACT SURGERY AND CATARACT SURGERY PROCEDURES The AHEAD shed apnea wheter hey had ever undergone cataract surgery. Those who gave aflmative responses were asked whether they had undergone sich sr gery since the previous Interview. Ifyes, the were asked how fhany eyes were operated on, To compute numberof cataract fuglel procedures since the previo interview, we tok the difference between the numberof eyes operated on athe cur tent and previous interviews: In all years combined (1998, $000, and 2002), here were discrepant values for the cataract surgery variable in 16% of eases, Because the rte is low, the cffecton our estimates of prevalence and incidence i minor. ANALYSIS OF FACTORS ASSOCIATED WITH CATARACT SURGERY We used fixed-effects regression analyses to assess the likelt- hood of having undergone cataract surgery between stccesive interviews and among individuals, The primary dependent vati- able was numberof eataract surgical procedares since the lst in- terview. Wealso assessed whether having undesgone cataract sti _gery improved self-reported visual functioning, aking advantage (Stearate |_~- [ram oT iT fons Lot Suis eas 7a Pens on an + [OF Pes TD Witbank wig rp NY i esas TE nat Figur. Sule atton From he ft etviw n 1988 rd Interv in 202A data are based on tho total (N=8570 persons) interoved 1088, ofa survey question that asked respondents to rate their eye sightas excellent, very good, good, ar, poor, o lgally blind In patculr transitions {rem vston ranging from legally blind o Isirto vision ranging from good o excellent were assessed Explanatory health vanables, defined forthe begining of the te interval (eg, for 1995, when the dependent varlable twas the number of eataract procedures the person underwent Between 1995 and 1998), inchided sell-reported measures of overall health a hearing impairment, and imental health, Sell- reported felt was measured by responses a question that ‘shed individual orate their health as excellent, very good, 00d, ar, or poor OF the 3 mutually exclusive groupe, we cre- Ned 1 indicator variable fair or poor health compared with ex- Cellet to good health, te omited reference group. Previous research” has indicated that this subjective measure of sell- reported health is systematically elated io objective measures of calth, including mortality. The mental health measure was ‘binary variable breed onthe following question, “Have you had or as doctor old you that you have any emotional, ner- ‘ous, of poychlatri problems? ‘Analyses were adjised for depression, using an abridged version ofthe 20stem Center for Epidemilogial studies De- pression Scale The abridged version asked whether, during the week belore the interview, the respondent (1) felt de presed, (2) felt everthing he or she did was an effort, (3) ex periencedrestlessleep, (4) could nt get going (5) fel lonely, {hfeend much othe time, enjoyed ie, and () was happy: Each affirmative response tothe frst and each negative re- sponse tothe lat 2 question received a score ofl The sum twas the depressive sympioms score used in our analysis, The ‘ality and reliably of the Centr for Epidemiologial Stud des Depresion Scale has been assessed. ‘The AHEAD survey seo included a battery of entcal ques- {ons in each wave tlic the cognitive functioning of respon dents" These questions included immediate snd delayed word recall serial 7s subtraction tet, counting backward, provid- ing the date, and naming objects, yielding a maximum score Of 5 points Questions were also included to measure know!- ge language, and orientation. Total cognitive scores per t= dividual ranged from zero (lowest functioning) to 35 (highest functioning) The validity and reliability of AHEAD’ cogni= tive text have been evaluated" ‘Cognitive tasks represented a range of dlficuly levels, with naming tasks being te easiest and the recall and the sei Ts tasks Being the most dificult” Most of the cognitive mea Sure were adapted from the Telephone Interview for Cogni- tive Stas." Follow-up surveys were conducted by telephone for individuals younger than 80 years and In peron fo oth ers, Herzogand Rodgers found nodifeence in measured per- formance depending on whether the cognitive test was con- (©2006 American Medical Association. AI rights reserved, ‘Downloaded From: https:/jamanetwork.com/ on 3001/2021Abbreviations: AHEAD Asst an Heath Dyrais rong the Ole ES Caro EpifemilgilStusssDeprer san Sa HA, Heth and Patrarent St. Daa are given as paceiage of ach rou unless thers indicat Thase dts a son or Bary vale Because the xan vars war all deed fr th ravous inary, th 1908 lea for 1085 the 2000 aes or 108, andthe 2002 vate for 200 ‘Dazaare hen a mean (0). These data ar town fr cominuus vale ‘The mean ($0) educational vel foal ie pois was 11.20 (3.57) years dducted over the telephone of in person, We defined a variable for whether the person had a total cognitive score of 10 oF less We included explanatory variables for sex, race/ethnicity (black, Latino, and other, with white being the omitted refer ence group), years of schooling, marital status, annual income, and age, We defined separate binary variables forage in 5-year intervals, but all persons older than 90 years were represented bya single binary variable, with those aged 62 to 64 years being, the omitted reference group. A binary variable was inclided for whether the survey respondent was a proxy forthe sample per- son. Finally, we included binary variables for the typeof insur- ance coverage that individuals had. Categories were as follows: (employer provided as the primary source of insurance, (2) Medicare pare A and B with other supplemental coverage (e, Medigap, Civilian Health and Medical Program of the Uni- formed Services, Civilian Health and Medical Program of the De- partment of Veterans Affairs, and health maintenance organiza- tion enrollment) (3) Medicare parts A and Bwith Medicaid, 4) Medicare part A but not part B, and (5) uninsured, The omitted reference group was Medicare parts A and B only ESTIMATION The primary dependent variable was the numberof eatarsct sur- gical procedures the person reported having bewveen 2 adja- cent interviews. We used linea fixed-effects regression with yearand individual fixed effects. The fixe-ellects approach uses ‘Table 1. characterises of Respondents Table 2. Inedonce of Cataract Surgery> (AHEAD/MRS Sample), From 1998 to 2002+ we ote e200 operai on since 1908, 200 0a Varabte (Pro) (e737) (N= 8198) hnetastntrtew —(W=8803) = 0572) (= 8718 Eeanatrt 0 wa wer ae Fare oe von ms mie 1 74 70 7 Pyetelgea rol i ua 2 56 40 48 Hsing pation me m0 at Faro poral 2 mses “Datars gen pangs of ach rp. The mab of Cagaton scr 10 mi a ine beatin nhs ferro thse ge ites and 3 because ceeDaroet oraz) 9548) 8004) Steates mh eatractprowcres ad ea) ben peared panei ‘temainn an era procsdue for om ine poe not sess 23 aa ks ac Back ma mata Lato st) tse 30 30 50 ‘ithinndividal changes versie to iden eflects of changes Warr ei 0 sa dn the explanatory variables on changes inthe outcome vat Progy 6 2960 she Therefore, im the estimation of each model, only sor tout 763180) 723160) e03(80) ‘mation on persons experiencing at last 1 change inthe d= Aonalicame sito} 252(037) 185(02H 1820029) | pendent varubletsused For comparison, we sed ordinary as sane ares regression. We sed Sala, version 8.2 software.” Employ o¢ 5748 *M'fhe fixed-effects methods exploit the repeated cross- er nsance sed GL Gt sectional nature of panel data using changes in explanatory art a ee sles fr each person overtime (each wave of the panel) 0 pre- MedcanputAandrotan® 18 4938 let changes tee dependent vanables. Variables hat dim changeover time foreach person (eg, race and schooling) had tobe exchided, Use ofthe fixed-efecte method eliminates the possibility of biased variable estimates resulting from a corre- [ition between covariates and time-invariant facors specific to the individual and not measured by the survey." Results from a fixed-effects specification show effects ofthe changes in the explanatory variables on the nsimber of eataract surgical pro- cedures between 2 adjacent interviews, EE SAMPLE CHARACTERISTICS. The prevalence of fair or poor self-reported vision i creased from 27% to 319% during the 7-year period over which sample persons were observed (Table 1). Per- sons were between the ages of 62 and 106 years, The mean age increased from 76.32 to 80.32 years. Household an- nual income decreased [rem $25.00 in 1098 to $18 000 in 2002 (to be expected, given retirement onset and pat- terns of spending relative to annual income after retire- ‘ment). Persons in the cohort whose primary coverage was ‘employer based declined from 9% to 5% from 1998 to 2000, The uninsured were 13% of the sample in 1998, but were 296 of the sample in 2000. INCIDENCE, Between January 1, 1995, and December 31, 1998, 7.1% of respondents underwent surgery on 1 eye and an ad- ditional 5.6% underwent surgery on 2 eyes (Table 2). Between January 1, 1998, and December 31, 2000, 7.0% underwent surgery on 1 eye and 4.9% underwent sur gery on 2 eyes. Between January 1, 2000, and December 51, 2002, the corresponding values were 7.4% and 4.8%, respectively, Taken together, these estimates imply an.an- nual rate of cataract surgery of 5.3%, (©2006 American Medical Association. AI rights reserved, jamanetwork.comy/ on 0301/2021PREVALENCE As of 1905, 88.4% of subjects had not undergone cata- ract surgery (able 3). Seven years later, 67.0% had not undergone such surgery. The prevalence of individuals who underwent unilateral cataract surgery was 7.0% by 1008, 8.79% by 2000, and 9.8% by 2002. The prevalence of 2 operated-on eyes increased from 5.5% t0 22.3% CATARACT EXTRACTION AND SELF-REPORTED VISION Persons who underwent surgery had lower self-reported vision before surgery than did the others (x}=357.5) (Figure 2). Persons who underwent surgery on average experienced 0.4 greater improvement in vision than those who did not (P*<.001). Of those persons who underwent surgery during the past 2 to 3 years and who reported hav- ing poor vision at the beginning of the period, 36.0% re- ported continued poor vision, with the remaining 64.0% Uuansitioning to vision that was excellent to fair. Among, those who did not undergo surgery and who reported poor Viston atthe beginning ofthe period, 64.2% still had poor Vision at the end of the period, with 35.8% having im- proved vision. Among those with excellent self-reported Vision in the prior period, 34.2% reported excellent vi- sion alter surgery. For those who did not undergo sur- gery, only 27.8% still had vision. REGRESSION ANALYSIS With individual and time fixed effects Table 4), per- sons with fairor poor self-reported vision were more likely to undergo surgery than those with excellent to good vi- sion at the beginning of the period. On average, the elfect of fair or poor visual status was to increase the number of eyes operated on by 0.11 within the 2- to 3-year interval Persons in the groups aged 65 to 69, 70 to 74, and 75 10 79 years at the beginning of the period had fewer proce- dures during the 2- to 3-year periods than did those in the omitted 62 to 64 years age group. Men were not as likely as women to undergo cataract surgery, but the difference was not statistically significant. Although the 1995 to 1998 period was 3 years, and subsequent periods were 2 years, individuals underwent more procedures in the latter 2 pe- rods, holding the other factors constant, ‘When we dropped time-invariant binary variables for interview year in the regression with individual fixed ef- fects, because they are perfectly correlated with the fixed elfects, married persons underwent fewer procedures and persons 70 years and older were more likely to have un- dergone surgery. Persons with private employer-based coverage underwent fewer procedures than those in the omitted reference group (persons with Medicare parts A and B coverage). The uninsured also underwent fewer procedures. In ordinary least squares regression, black individuals underwent fewer procedures than did white Individuals (the omitted reference group). ‘Nonsignficant factors pertaining tothe ikelihood ofeata- ract surgery were depression (determined by the Center {or Epidemiological Suidies Depression Scale score), over- all health, mental status, hearing problems, sex, years of Table 3. Prevalence of Persons Undergoing Cataract Surgery* tee 2000 28070) (w= 7807) (W= 0100) ae 42a 76 a7 08 Sa Data are given as percantage of ach group education, memory status, annual income, and Medicaid insurance (Table 4). Patients with supplemental insur- ance (629%) were more likely to undergo cataract surgery (mean probability, 0.27; P=.05) than the uninsured or per- sons with only Medicare parts A and B, Black individials| underwent slightly ewer cataract surgical procedures (-0.04 per 2 to 3 years; P<01) than did white individuals. Se By the end of the observational period, nearly a third of persons in the United States 69 years or older under- Went a cataract procedure in at least 1 eye, more than double the number of such persons in the cohort who hhad undergone such surgery 7 years previously. The in- idence of such surgery from 1995 to 2002 was 7.4%. This is slightly higher than previously reported. The regression analysis identified factors that lead to, such surgery and factors that do not, Important in the former group are race, age structure, and source of pay- ‘ment. Psychological problems, including depression, hear~ ingimpairments, low general health status, and poor cog- nition are not determinants of undergoing such surgery Other studies!” have reported changing trends in the frequency of cataract surgery, but have done this forlim- ited geographic populations, The prevalence of cataract extraction in 1 e} creased to 8.7% in 2000, and then to 9.8% by 2002. Yet, the overall probability of having I or 2 eyes operated on increased to 30% during the observational period, mostly attributable to cohort aging, These estimates are higher than the 5.1% previously reported; however, this di crepancy may be expected because the lower estimates, ‘were for persons 40 years or older.” Estimates in that study ‘were obtained by applying prevalence rates from several popullation-based studies’ and were cross-sectional. Equivalent estimates from our study were 11.6% in 1905 in the initial survey of those who had undergone cata- ract surgery. The difference most likely reflects the na- ture of the 2 studies and their populations, While indi viduals may overstate the rate at which they undergo cataract surgery by self-report, such bias may not be sul- ficiently high as to account for the differences noted. Fur thermore, 28% of the Medicare-insured population never sev an ee cteprovde na 5-year psviod, suggesting Sell-eported vision was elicited on a 5-point scale, rang- ing from poor to excellent. Individuals with sell-reported {air oF poor vision were more likely to undergo cataract (©2006 American Medical Association. AI rights reserved, jamanetwork.comy/ on 0301/2021a ‘a Those Who Dderwe Sugary a. ‘Eh ie Date Sa ©. w. . ea a. ‘weber w ot o. sas] o 6 Ww : f ‘wet Repondets ‘wet Reapndas ‘wet apne ae ‘uot Rents les a [an ros a z = 1 2 . t Changin Step Vin, Pav Cure Pai Figure 2. Change in veal st-separtad vision (na previous itera) apaad as excelent (A), very good (8), good (0), a (0), ar poor, fr persons who ior dd not undergo extract surgery. In A,n=76 to hse wh underwent surgry and n=1186 fo these wha dd no undergo surgery: B. n= 42 for hose ‘iho unérvent urgery and n= #504 fo thse who dd net undergo surgery Cn =B50 or ose whe undervent surgery and n= 6228 for hese wha dd not. Undego surgery 0. n= 619 for thas ho undervent surgery sd n=2682 for thaee vo 8 ot ergo utp and. n= 336 for thas who underwent surgery and n= 106 for tose who dl not undergo suger. Percentages may nt total 100 because of rounding (©2006 American Medical Assoc ijamanetwork.com/ on 0301/2021 om. A rights reserved,Table 4, Determinants of Cataract Surgery* cranary Least squarer aia! ane as (newsgator icuing neato sme Fides nae tec arabes or Yat arabe or Year Eplanstony aio poor vison 011 oot x2 (00124 013 01} 013 (0010 Pojcolgiea problem -n0014 (0.025) 013 0.025) 0085 0.012) ones (0.0%) cesD score ‘ots (0.029) 100042 (0.0020) 000077 (aan) 00050 (0.0024) Hearing problem 0085 (0.03) 024 0.03), 019 (0.0007) ‘1a (0.0007) Fair poor hath 0.00088 (0.02) 8.020 0.012) 1006200022) 1.0086 (0.0002) Cognition score <10 0082 (0.06) 0.0060 (0.016) =a. (0.018) -nonas (oats) Demographic aes Na NA 0013 (0.008) 2013 (0.080) Pace lack Na NA 0025 001 a5 (001 Latino NA NA 027 (0017), 0.026 0.017) Ober NA NA 0026 (0.022) a6 (0.022) Educa (measured in years) NA NA 200021 (0.013) 0008s (0.013) Nested 2131 (0.021) 0.1 (002t}4 ‘0.0022 (0.008) 0.00060 (0.0089) ‘Anna ncome 00075 (oot) 23 (0014)§ 10072 (00022) 0.0056 (0.0002) Proxy ‘0045 (0.051) 1050 (0.052) 1.083 (0.038) 060 (0.038) gay 60 2088 (0.015)4 0085 (0.015) ots 0018) 0.0086 0.018) mis 0.12 0.022} 011 (0.021) ag (0016) 0.079 ots 7570 2070 (0.025) 014 0.00 013 0.016} 012 (0015+ mas 0 (0.030) 024 0005)¢ 014 aint 013 0016 520 0076 (0.03) 028 (000+ 014 0.020 014 (coro 00 (0077 (0.031) 07 (00st 036 (0.021) 0.031 (0.020) Ineurance Enpioer -.00025 (0.028) 1050 (0.028)§ 0020 0.018), 0.021 (0.015) ther insurance 0028 (0.04) ato (0014) 026 (0.011)§, m2? arts Moscis 013 (0.028) 038 (0.028) 01028 (0.019) 215 (0.010) Micra part Aad nt part B 0045 (0.025) 0.0038 (0.025), 0.2 (0020), 023 (0.020) Uninsired -nonas (0.02) 0073 (0022}¢ “1010 0016), 20001 (0.016) ober Year 2000 0.12 0.00014 Na 0015 (0.00 Na 2002 20 (001 NA -n017 0010) NA Constant 013 (0004 011 (005 088 (0.036) 0.059 (0.086) ‘Abbrvations: CES, Caner for Epiderologcal Suds Dopression Scale A not applicable “Data ae qhuen a mean (SE). The number of ober atons for ech ragrsson elects pooling of obeeration among years. Fr india and tie had ates (tin) = 0.073, Fg = 945 for nal ned tet, (ota) = 8, and for rn lest squares, 0, “Sintean a P00 $Signfeantat Pat Sigteant at P05, 038, Fa surgery than others. Changes in vision were assigned nu- merical values from 4 to 4, depending on the number and direction of changes in responses between 2 adjacent in- terviews (Figure 2). By using the 9-point range as the de- nominator and changes on the scale as a measure of change In Vision, relative to those who did not undergo surgery those who underwent surgery experienced a nearly 4.5% improvement in sel-reported vision. This relauive change 1s probably a lower bound on the true estimate because we ‘measured changes in self-reported vision over a2- to 3-year Interval. In fact, vision may have declined after an inter- view but before surgery Prior studies have documented improvements in vie sual function following cataract surgery. Visual impair- ‘ment correlates with overall perception of well-being, Prior studies? have consistently shown a higher incidence of calaract surgery among women and with increasing age. 06 for orig net equates, f= 0.03 Fyn 205 In our study, women also had higher rates, but this re- sult was not statistically significant at conventional lev- cls. Also consistent with prior studies,” persons 70 years, or older in our study were more likely to undergo cata- ract surgery compared with persons younger than 70 years. This pattern is likely explained by the slowly pro- gressive and age-related nature of cataract. Itis possible that this trend does not continue into the 90 years and older demographic category because the individuals have already undergone prior eataract surgery. Also, other health concerns may cause individuals 90 years or older to be deemed poor surgical candidates." Not surprisingly, black individuals were less likely to undergo cataract surgery than white individuals in our study. An oversampling of black individuals was used to censure representative inclusion of such persons, Histori- cally, there has been underuse of many health eare se (©2006 American Medical Association. AI rights reserved, ‘Downloaded From: https:/jamanetwork.com/ on 3001/2021vices among the black population. 1tisunlikely that lower rates of cataract extraction could reflect lower rates of lens opacification among black individuals because it has been reported that unoperated-on cataract accounts for 27% of all blindness among black residents of Balti- more, Md; also, blindness from cataract is much more likely among black than among white individuals." More plausible explanations to understand the slightly lower rates ofealaract surgery among black persons include lack of access to cataract surgery, resignation to decreased Vi- sion with the aging process, and lack of understanding of the possible benelits of cataract surgery.” We acknowledge several study limitations. First, al- most 30% ofthe original sample was lost to follow-up. Al- though sample aurition may cause bias, it isnot clear what the direction of bias would be. Second, the self-report data relied on the respondent’ subjective assessment of his or her own visual acuity and the accuracy of reporting cata ract surgery. While this is likely to correlate with objec- tive clinical measures, there may be some variation due to subjective interpretation, lack of recall, or misunderstand- ing of a surgical procedure. Some respondents, for ex- ample, may confuse laser capsulotomy with posterior cap- sular opacification resulting from previous cataract surgery ashaving undergone anadditional cataract surgery. But par- ticular confusion is unlikely given that only 1.6% of re- spondents had discrepant results across interviews. Third, we did not have elinical information from the physician's perspective. Type of lens opacity present within the indi- Vidual was not assessed. The likelihood of undergoing eata- rat surgery has been linked to the presence of specific types of cataract; some studies” cite mixed opacities as more likely tobe associated with visual impairment, while others® cite nuclear sclerotic eataractsas the subtype present belorecata- rat surgery. Posterior subeapsular cataract has been linked to inereased odds of eataraet surgery in other studies ”"* Subtype of lens opacity isan important determinant of like- lihood of surgery.* Along with age-related cataract, age-related macular degeneration and glaucoma are the leading causes of Vi- sion loss in the United States, and advancing age is among the risk factors for the development of both. The AHEAD/HRS survey did not ask individuals about these conditions, and visual loss may have resulted from these entities rather than from age-related cataract. Indeed, the fact that the condition of many of those with fair or poor Vision did not improve after cataract surgery could be some evidence of the effect of these conditions. Understanding longitudinal cataract surgery pat- terns and factors influencing the likelihood of undergo- ing surgery ean have a significant effect on Medicare and hncalth eare delivery. tnformation from such analysis will better allow us to develop policies and procedures to en- sure access to appropriate care. Submitted for Publication: June 30, 2005; final revision received February 21, 2006; accepted February 23, 2006. Correspondence: Frank A. Sloan, PhD, Center for Health Policy, Law, and Management, Duke University, 114 Ru- benstein Hall, Campus Box 90253, Durham, NC 27708 (sloan@hpolicy.duke-edu) Financial Disclosure: None reported, Funding/Support: This study was supported in part by {grant ROL-AG-17473 from the National Institute on Ag- ingand by Research to Prevent Blindness. Dr Lee isa re- cipient of the Lou Wasserman Merit Award, Role of the Sponsor: The funding bodies had no role in data extraction and analyses, in the writing of the manu- script, or in the decision to submit the manuscript for publication. —_ EES} 1. Nato stat nse Aa, Vines aS po lonest adn parentage ad ee atae nes are eve prelniess.rpkatart pat Acese une 205, 2, PopltanDvsio, US Gna ras. Au ett te populton by dsl age rouge rh Une Se: pi 200 aly 2008 [databace] tips awa census gow popesvnauonaastWNC-E512003 MOS 2 yt Aeesed pe 5,208, Congeor i Vngting J KE, iat Ej Oseases Provence Research Gioup. Prolene of arc and paudopakisaphaca amare acs he Untee Ss Aen Optima 2004 e487 04, Ja ard, Tasch o.Gzoyaphie variation in ion tea act surgay Med ave 1050010, eae Would ebmnaig dren in physic race sya go- Eas can spy te Meet He ig: Miva Carle Varaons eta etacon ais ins AMA 1007277 15-17 fra ich, Tum k,ostchia. Foran Cumming a idence of cate Suge th lu Moura Eye Study. 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