Support System Helps Overcome Barriers for Nursing Home Residents in Need of Cataract Surgery
Although nursing home residents with vision-impairing cataract face significant obstacles to obtaining surgical services, a support system that facilitates scheduling surgery and getting the patient to and from the hospital increases cataract surgery rates, according to a study in the November issue of the Archives of Ophthalmology, one of the JAMA/Archives journals.
Cataract removal is the most commonly performed operation among the Medicare population. More than 1.5 million procedures were performed in 1998. Surgery is highly successful in restoring good vision, and more than 95 percent of patients achieve 20/40 or better vision, according to background information in the article.
David S. Friedman, M.D., M.P.H., and colleagues at The Johns Hopkins University, Baltimore, conducted a study to determine whether individuals receiving assistance in scheduling cataract evaluation and attending cataract surgery were more likely to undergo cataract surgery than those receiving routine care. The Salisbury Eye Evaluation in Nursing Home Groups (SEEING) project is a randomized clinical trial studying the effect of a comprehensive vision restoration-rehabilitation program-including the provision of cataract surgery services when needed. Twenty-eight nursing homes in the Eastern Shore area of Maryland and Delaware were matched in pairs by size and payment type. Nursing homes within each pair were randomized to usual care or targeted intervention. Eligible residents in both groups underwent visual acuity screening, and those with visual impairment underwent a full ophthalmologic examination. In the intervention group, the project staff facilitated access to new eyeglasses, cataract surgery, or low-vision care, if these services were indicated.
The authors report 31 percent of residents in intervention homes who needed cataract removal underwent surgery, compared with only two percent in usual-care facilities.
"Without a program to assist residents in identifying a surgeon, making it to the appointment, and getting to the hospital for surgery, only two (two percent) of 99 identified by an ophthalmologist as having decreased vision due to cataract received surgery," they write.
"In contrast, an intensive effort to support residents in the process led to one third (24 of 77 persons) being scheduled for surgery, all but two of whom had the surgery," they continue.
Residents with cataract-regardless of nursing home assignment-tended to be older, were more likely to be black, had lower scores on a test for cognitive impairment, and had longer length of stay in the nursing home.
The authors point out that this project highlights the many barriers to providing cataract surgery services to institutionalized, cognitively impaired elderly residents of nursing homes. "Not only is testing vision in these residents more difficult than in community-dwelling individuals, but once residents are identified as having a cataract as the primary cause of vision loss, multiple obstacles prevent them from undergoing cataract surgery," they write.
"If it is found that cataract surgery improves the quality of life of frail nursing home residents, then it will be essential to establish programs to remove barriers to access cataract surgery services," the authors conclude (Arch Ophthalmol. 2005;123:1581-1587).