Cataract Surgery in Hospice Patients: Pros,Cons,and Cost-Effectiveness

Dear Editor:

In 2013, ∼1.54 million patients received hospice care in the United States; 84% were 65 years old or older. Likewise, nearly 80% of people with visually significant cataracts are over the age of 65. Although many patients who receive hospice care have cataracts, and cataract extraction can greatly improve quality of life, there is no published literature on cataract extraction in this population.

Many previous studies have used the cost of hemodialysis as the benchmark to define societal willingness to pay for a quality-adjusted life year (QALY), arguing that the federal entitlement to Medicare insurance coverage for patients with chronic renal failure implies the program's benefits are worth its cost. Thus, the cost per QALY for cataract surgery was calculated and compared with the cost per QALY for hemodialysis. Calculations for cost per QALY of cataract extraction versus hemodialysis are summarized in Table 1. The utility gain for cataract surgery in the first eye has been reported to be 0.148. ¹ The average cost of cataract extraction in 2013 was $650.40. ² The average duration hospice care was received was 72.6 days, giving initial cataract surgery in hospice patients a benefit of 0.0294 QALYs. In 2013, the total Medicare cost of hemodialysis per person per year was $84,550. ³ Previous work determined that hemodialysis confers patients a benefit of 0.055 QALY/month, or 0.66 QALY/year. ⁴

Based on the mentioned data, the average cost per QALY of performing cataract extraction in a hospice patient is $22,100/QALY and the average cost per QALY of hemodialysis is $128,000/QALY (Table 1).

Improved vision may permit hospice patients to see loved ones, increase independence, and allow for ambulation without navigational assistance. For those unable to ambulate due to other limitations, improved vision may allow patients to qualify for aid to purchase an automated scooter. Improved vision also allows patients to participate in sight-dependent leisure activities such as reading, watching television, playing card games, and using the computer.

Hospice patients are particularly susceptible to delirium due to their overall poor health and older age. Vision impairment is another risk factor for delirium. One study found that a visual acuity worse than 20/70 conferred an adjusted relative risk of 3.5 for developing delirium. ⁵ Although delirium in the immediate post-operative period is an established complication of cataract surgery, improved visual acuity may decrease the incidence of delirium in the long term.

Increased risk of surgical complications due to patient comorbidities is an obvious concern in this population. Patients with systemic comorbidities, especially those with congestive heart failure, hypertension, or history of cerebrovascular accident or transient ischemic attack, are at risk for developing intraoperative cardiovascular events and post-operative delirium, even with monitored anesthesia care. For this reason, hospice patients may particularly benefit from cataract surgery performed under local anesthesia, which is becoming more commonplace.

Our brief analysis suggests that cataract surgery may be a cost-effective intervention for some hospice patients. Surgeons should undergo detailed discussions with their palliative care patients about the potential visual gains and the risk of complications before pursuing cataract surgery.