Frailty and Monitored Anesthesia Care for Cataract Surgery in Older Adults

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Project Summary The vast majority of older adults undergo cataract surgery with 1-to-1 intraoperative monitoring and sedation administered by an anesthesiologist or nurse anesthetist (a.k.a., “monitored anesthesia care” or “MAC”). Proponents of MAC believe that cataract patients—many of whom are frail due to a combination of advanced age, multimorbidity and underlying visual impairment—generally benefit from close intraoperative monitoring by an anesthesia professional. However, given the procedure’s overall safety profile and the projected increase in cataract surgery demand as the US population ages, policymakers, clinicians, and payers have questioned whether the routine use of MAC for cataract surgery should continue in the US. Currently, there is inadequate evidence to predict which patients would be at highest risk for harm if MAC were to be removed as a component of routine cataract surgery. The rationale underlying the proposed research is that identifying the characteristics of patients at highest risk of harm could help facilitate a careful transition to non-MAC cataract surgery for the majority of patients who would be safe to proceed (and would not be harmed) without MAC. The central hypothesis is that the provision of MAC is only necessary for a relatively small subset of high-risk older adults undergoing cataract surgery. To test this hypothesis, the proposed research plan will investigate three aims. Aim 1 will examine the relationship between frailty, MAC, and the incidence of adverse events after cataract surgery through retrospective analysis of Medicare claims. Aim 2 will shed light on the facilitators and barriers for performing cataract surgery without MAC using semi-structured interviews of ophthalmologists whose practices represent a range of MAC utilization. Aim 3 will carry out a pilot study of low-risk older adults undergoing cataract surgery to determine feasibility and acceptability of non-MAC sedation for cataract surgery. These aims will create foundational knowledge to support future studies that can determine whether MAC can safely be removed as a component of routine cataract surgery in low-risk older adults. The Candidate is an anesthesiologist and health services researcher at UCSF. The Candidate, her mentors and her scientific advisors have developed a comprehensive career development plan that aligns well with the Aims of the proposed research. The key elements of this plan include training and didactics to obtain specialty knowledge in the following areas: 1) Principles of geriatrics and gerontology, 2) Biostatistical methods for advanced causal inference; 3) Introduction to qualitative research methodologies; 4) Implementation science and feasibility pilot studies, and 5) Structured career development with exposure to thought leaders in geriatrics, health services research, ophthalmology, and anesthesiology. This career development award will help the Candidate achieve her goal of becoming a national leader in geriatric perioperative health services research at the forefront of promoting evidence-based, high-value surgical and anesthetic care in older adults. With strong institutional commitment, the Candidate is well-positioned to attain research independence.