# Financial vulnerability of the elderly population undergoing cataract surgery within a distributed eye care delivery system in India (2011–2022): a multicentre, retrospective cohort study

## TL;DR

This study examines how insurance coverage affects cataract surgery outcomes for elderly patients in India, finding that lower insurance rates correlate with worse visual results.

## Contribution

The study provides novel evidence on the relationship between insurance uptake and visual outcomes in elderly cataract patients in Southeast Asia.

## Key findings

- Insurance uptake declines with age, dropping below 10% for those over 85 years.
- Elderly patients without insurance had worse surgical outcomes compared to those with insurance.
- Insurance uptake increased from 10.65% (2011–2017) to 20.61% (2018–2022).

## Abstract

The health burden of geriatric eye care is expected to rise, yet medical insurance uptake among the elderly population remains low. There is minimal evidence regarding insurance uptake for eye care among the elderly population in the Southeast Asia region. We explored insurance uptake and its impact on visual outcomes among the elderly population who visited an eye care system distributed across four Indian states.

In this retrospective cohort study, we used a browser-based proprietary, Hospital Information Management System (HIMSS) stage six, electronic medical record (EMR) system. Datasets were collected from new patients who visited the four tertiary centres with linked primary and secondary centres of our pyramidal health system (L V Prasad Eye Institute [India]) distributed in four Indian states, Andhra Pradesh, Odisha, Telangana, and Karnataka, between August 2011 and December 2022. The electronic medical records of 38,387 patients aged >70 years who underwent cataract surgery were included (45.5% were females [17,471]). Individuals treated with fully subsidised care were excluded. Data on age, health insurance uptake, type of health insurance (government or private), and mode of payment for cataract surgery were collected. Factors impacting insurance uptake and visual outcomes were studied using logistic regression analysis.

Insurance uptake declined from 17.5% among people aged 70 years to less than 10% among those aged >85 years. Private insurance uptake declined from 13.3% among people aged 70 years to 4.7% among those aged 90 years, while publicly funded insurance remained between 3.3% and 4.2%. Insurance uptake increased during 2018–2022 compared to 2011–2017 (20.61% vs. 10.65%; p < 0.001). A higher proportion of males had insurance uptake compared to females. Median waiting times for surgery among patients with government versus private insurance were 18 and 11 days, respectively. Among patients aged >80 years, surgical outcomes for those without insurance were worse than for those with insurance.

Insurance uptake declined dramatically in patients aged above 80 years and was associated with poorer visual outcomes following cataract surgery, as the insurance uptake may impact the quality of eye care received. Policy changes are needed to increase insurance uptake for eye care in this population.

10.13039/501100009053DBT Wellcome Trust India Alliance, Clinical Research Centre Grant IA/CRC/19/1/610010; 10.13039/501100005809Hyderabad Eye Research Foundation (HERF).