Quando l’analisi economica ha un punto di vista societario e non si esaurisce in una valutazione d’impatto sul budget di un singolo ospedale!
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.
Fractures secondary to falls are a significant cause of morbidity and mortality in the elderly population,1 accounting for more than 60% of expenses resulting from fall-related injuries and costing the United States more than $10 billion in the year 2000.2 Visual impairment has been found to be strongly associated with an increased risk of fractures,3 – 5 with reports of increased fracture incidence in patients with poor visual acuity,4 depth perception,6 contrast sensitivity,6 and visual field loss.7
Specifically, vision plays an important role in providing a reference frame for postural balance and stability, and cataract-induced changes in vision have been found to be associated with postural instability.8 A systematic review found that patients who wait more than 6 months for cataract surgery had an increased rate of falls.9 Furthermore, cataracts have been found to be the most common cause of fracture-related visual impairment,10 with untreated cataract causing up to 49% of visual impairment in patients with femoral neck fractures related to decreased vision.10
Despite the association of poor vision and cataracts with increased fall and fracture risk, only a limited number of studies11 – 15 have examined the influence of cataract surgery on fall incidence in visually impaired adults, and only 2 of these studies11 – 12 examined the incidence of fractures secondary to falls. These 2 studies examined the relationship of first and second eye cataract surgery with fall and fracture risk in the same population of women in the United Kingdom older than 70 years, with sample sizes of fewer than 350 patients in each study. To our knowledge, no other studies have examined the association of cataract surgery and fracture incidence in visually impaired adults. This study examined the association between cataract surgery and fracture incidence in a cohort of US Medicare beneficiaries.