Abstract
Importance
Cataract-related vision impairment is an important public health issue that tends to affect older adults. Little is known about the association between older adults' social support networks and their likelihood of receiving cataract surgery.Objective
To determine if older adults with smaller social support networks are less likely to receive cataract surgery.Design, setting, and participants
Retrospective cohort study. The National Health and Aging Trends Study, a nationally representative US survey, administered annually from 2011 to 2015 to a cohort of Medicare beneficiaries 65 years and older with no cataract surgery prior to the start of the study.Main outcomes and measures
Multivariable logistic regression was performed to evaluate if the number of persons in an individual's social support network influenced whether that individual received cataract surgery during a given year of the study.Results
Overall, 3448 participants were interviewed from 2011 to 2015 for a total of 9760 observations. Of these observations, 3084 (weighted, 38.81%; 95% CI, 37.28-40.35) were aged 70 to 74 years, 5211 (weighted, 52.32%; 95% CI, 50.19-54.44) were women; 5899 (weighted, 78.53%; 95% CI, 76.29-80.61) were white, 2249 (weighted, 9.55%; 95% CI, 8.45-10.78) were black, 537 (weighted, 7.18%; 95% CI, 5.88-8.73) were Hispanic, and 303 (weighted, 4.74%; 95% CI, 3.56-62.9) reported other races. Medicare beneficiaries with smaller social support networks (0-2 individuals) were less likely to receive cataract surgery in a given year (adjusted odds ratio, 0.60; 95% CI, 0.37-0.96) than those with larger support networks (≥3 individuals). The adjusted predicted proportion of Medicare beneficiaries undergoing cataract surgery was 4.7% (95% CI, 2.7%-6.7%) and 7.5% (95% CI, 6.9%-8.1%) for those with small and large social support networks, respectively. Having fewer non-spouse/partner family members in the support network was associated with decreased odds of receiving cataract surgery (adjusted odds ratio, 0.60; 95% CI, 0.43-0.85), but having spouses/partners (adjusted odds ratio, 0.97; 95% CI, 0.77-1.22) and nonfamily members (adjusted odds ratio, 0.90; 95% CI, 0.72-1.11) did not have a significant association.Conclusions and relevance
Medicare beneficiaries with fewer non-spouse/partner family members in their social support networks were less likely to receive cataract surgery. These findings suggest that attention should be given to patients with smaller support networks to ensure that they receive cataract surgery when it is indicated.Free full text
Association of Social Support Network Size With Receipt of Cataract Surgery in Older Adults
1,4,5Associated Data
Key Points
Question
Are older adults who have fewer people in their social support networks less likely to undergo cataract surgery?
Findings
In this cohort study using nationally representative survey data, older adults with fewer family members in their social support network were less likely to receive cataract surgery.
Meaning
Smaller social support networks may represent a barrier to receiving cataract surgery among older adults in the United States.
Abstract
Importance
Cataract-related vision impairment is an important public health issue that tends to affect older adults. Little is known about the association between older adults’ social support networks and their likelihood of receiving cataract surgery.
Objective
To determine if older adults with smaller social support networks are less likely to receive cataract surgery.
Design, Setting, and Participants
Retrospective cohort study. The National Health and Aging Trends Study, a nationally representative US survey, administered annually from 2011 to 2015 to a cohort of Medicare beneficiaries 65 years and older with no cataract surgery prior to the start of the study.
Main Outcomes and Measures
Multivariable logistic regression was performed to evaluate if the number of persons in an individual’s social support network influenced whether that individual received cataract surgery during a given year of the study.
Results
Overall, 3448 participants were interviewed from 2011 to 2015 for a total of 9760 observations. Of these observations, 3084 (weighted, 38.81%; 95% CI, 37.28-40.35) were aged 70 to 74 years, 5211 (weighted, 52.32%; 95% CI, 50.19-54.44) were women; 5899 (weighted, 78.53%; 95% CI, 76.29-80.61) were white, 2249 (weighted, 9.55%; 95% CI, 8.45-10.78) were black, 537 (weighted, 7.18%; 95% CI, 5.88-8.73) were Hispanic, and 303 (weighted, 4.74%; 95% CI, 3.56-62.9) reported other races. Medicare beneficiaries with smaller social support networks (0-2 individuals) were less likely to receive cataract surgery in a given year (adjusted odds ratio, 0.60; 95% CI, 0.37-0.96) than those with larger support networks (≥3 individuals). The adjusted predicted proportion of Medicare beneficiaries undergoing cataract surgery was 4.7% (95% CI, 2.7%-6.7%) and 7.5% (95% CI, 6.9%-8.1%) for those with small and large social support networks, respectively. Having fewer non–spouse/partner family members in the support network was associated with decreased odds of receiving cataract surgery (adjusted odds ratio, 0.60; 95% CI, 0.43-0.85), but having spouses/partners (adjusted odds ratio, 0.97; 95% CI, 0.77-1.22) and nonfamily members (adjusted odds ratio, 0.90; 95% CI, 0.72-1.11) did not have a significant association.
Conclusions and Relevance
Medicare beneficiaries with fewer non–spouse/partner family members in their social support networks were less likely to receive cataract surgery. These findings suggest that attention should be given to patients with smaller support networks to ensure that they receive cataract surgery when it is indicated.
Introduction
Cataract is the most common treatable cause of vision impairment among older adults in the United States. Patients who receive cataract surgery have improved cognition and quality of life and have fewer falls. Nonetheless, in the United States cataract-related vision impairment remains a considerable public health problem, especially in underserved populations. Barriers such as cost, access, language, poor healthy literacy, and fear may keep some from receiving treatment.
In other medical specialties, smaller social support networks have been associated with decreased access to care, worse outcomes, and mortality. In qualitative studies from China, Kenya, and the Netherlands, patients cited inadequate social support as a barrier to cataract surgery uptake, possibly because older patients deciding whether to pursue a procedure that is elective (eg, cataract surgery) may experience difficulty with this choice. However, to our knowledge, the association of social support networks with receipt of cataract surgery has not been studied in a large cohort in the United States.
We hypothesized that older adults were less likely to undergo cataract surgery if they lacked a large social support network to help them navigate this decision. To test this, we analyzed nationally representative survey data from the National Health and Aging Trends Study (NHATS), which includes information about health care, including cataract surgery, and about social determinants of health, including social support networks. We investigated associations between the size of social support networks and the likelihood of receiving cataract surgery for adults 65 years and older.
Methods
Data and Analysis Sample
NHATS is a survey annually administered to a nationally representative cohort of Medicare beneficiaries 65 years and older, with data available from 2011 to 2015. NHATS includes data on demographics, socioeconomic status, social support, health, and health care use. We excluded all participants who reported having cataract surgery before enrollment. We began our analysis with data from 2012 to ascertain social support network status in the year before cataract surgery. Accordingly, our baseline sample included 3448 participants (eFigure in the Supplement) who contributed a total of 9760 participant observations. The University of Michigan institutional review board deemed this study exempt because it was a secondary data analysis. The original NHATS investigators obtained informed consent from study participants.
Variable Definitions
The predictor variable of interest was the number of individuals in a participant’s social support network. NHATS identifies individuals who have social contact with participants, including spouses, cohabiting partners, children, other relatives, friends, neighbors, coworkers, or others. We defined persons in a participant’s social support network from 3 sets of questions: the first asked participants if they had a spouse, cohabitating partner, and/or living children; the second enumerated anyone who helps with daily activities; and the third listed up to 5 people who participants talked to about important things. We created a variable that counted the number of unique individuals named in these questions to measure social support network size. The number of individuals in a social support network was treated as a time-varying covariate; if a child or spouse died, they were excluded from the count variable in subsequent years. We dichotomized the social support network variable for those with smaller (0-2 individuals) or larger (≥3 individuals) social support networks based on the distribution of study participants and exploratory analysis. We also created dichotomized variables for those with or without a spouse/partner, those with fewer (0-1 individuals) or more (≥2 individuals) non–spouse/partner family members, and those with fewer or more nonfamily members. Our outcome variable was self-reported receipt of cataract surgery during the prior 12 months.
Statistical Analyses
Based on the NHATS survey design, we calculated the weighted proportions of participants for each sociodemographic group stratified by social support network size. We report unadjusted P values from Pearson χ2 tests.
We used multivariable logistic regression to evaluate the association between the number of persons in a participant’s social support network and whether that participant reported receiving cataract surgery during the subsequent 12 months. In a second model, we examined whether the association of social support network members differed between spouses/partners, non–spouse/partner family members, and nonfamily members. In this model, predictor variables were: (1) having a spouse/partner, (2) number of non–spouse/partner family members, and (3) number of nonfamily members in the social support network. Regression models were adjusted for age, sex, education level, race/ethnicity, income, proxy respondent, and survey round. Because of considerable missing income data, multiple imputation income values provided by NHATS were used. Analyses were conducted using Stata version 14 (StataCorp). All analyses accounted for the complex design of NHATS, including sampling weights, units, and strata. Adjusted predicted proportions were calculated using the “margins” command in Stata.
Results
Characteristics of the study sample are reported in Table 1. The total weighted proportion of participants who underwent cataract surgery was 6.52% (unweighted number of patients, 667; 95% CI, 5.93-7.15). Table 2 presents the odds ratios from bivariate and multivariable logistic regressions of receiving cataract surgery as a function of social support network size. For those with smaller social support networks (0-2 individuals), the adjusted predicted proportion undergoing cataract surgery was 4.7% (95% CI, 2.7%-6.7%), and for those with larger networks (≥3 individuals), it was 7.5% (95% CI, 6.9%-8.1%). Participants with fewer non–spouse/partner family members had decreased odds of undergoing cataract surgery (adjusted odds ratio, 0.60; 95% CI, 0.43-0.85); however, the number of nonfamily members (adjusted odds ratio, 0.90; 95% CI, 0.72-1.11) or having a spouse/partner (adjusted odds ratio, 0.97; 95% CI, 0.77-1.22) in the social support network was not associated with receipt of cataract surgery (Table 2). The predicted proportion undergoing a cataract surgical procedure for each of these groups is depicted in the Figure. The Hosmer-Lemeshow P value for our model was .82.
Table 1.
| Characteristic | Participants With Smaller Social Networks, Observations (n =772)b | Participants With Larger Social Networks, Observations (n=8988)c | P Valued | ||
|---|---|---|---|---|---|
| Unweighted No. (Weighted %) | 95% CI | Unweighted No. (Weighted %) | 95% CI | ||
| Total | 772 (8.04) | 6.91-9.32 | 8988 (91.96) | 90.68-93.09 | NA |
| Age, y | |||||
| 65-69 | 129 (24.43) | 20.55-28.77 | 1193 (18.63) | 17.11-20.25 | .02 |
| 70-74 | 193 (32.54) | 27.69-37.80 | 2891 (39.35) | 37.66-41.07 | |
| 75-79 | 164 (20.32) | 15.48-26.19 | 2029 (21.39) | 19.95-22.91 | |
| 80-84 | 123 (11.12) | 8.52-14.38 | 1519 (11.94) | 11.09-12.85 | |
| 85-89 | 93 (7.69) | 5.52-10.64 | 862 (5.91) | 5.14-6.78 | |
| ≥90 | 70 (3.90) | 2.51-6.00 | 494 (2.78) | 2.30-3.36 | |
| Sex | |||||
| Male | 402 (56.29) | 49.63-62.73 | 4147 (46.93) | 44.79-49.08 | .007 |
| Female | 370 (43.71) | 37.27-50.37 | 4841 (53.07) | 50.92-55.21 | |
| Race/ethnicity | |||||
| White | 517 (79.45) | 73.03-84.66 | 5899 (78.45) | 76.12-80.61 | .64 |
| Black | 184 (9.02) | 6.66-12.11 | 2249 (9.60) | 8.48-10.84 | |
| Hispanic | 39 (5.69) | 3.15-10.06 | 537 (7.31) | 5.95-8.94 | |
| Other | 32 (5.84) | 3.05-10.89 | 303 (4.65) | 3.47-6.21 | |
| Education | |||||
| Less than high school degree | 183 (17.96) | 14.18-22.48 | 2113 (18.98) | 17.17-20.92 | .84 |
| High school degree | 202 (27.62) | 22.86-32.95 | 2305 (26.47) | 24.53-28.50 | |
| More than high school degree | 370 (54.42) | 48.35-60.37 | 4484 (54.55) | 52.10-56.99 | |
| Proxy respondent | |||||
| Not a proxy respondent | 717 (94.45) | 90.35-96.87 | 8350 (94.83) | 93.96-95.58 | .80 |
| Proxy respondent | 55 (5.55) | 3.13-9.65 | 638 (5.17) | 4.42-6.04 | |
| Income, mean (SE), $e | |||||
| 1st Quartile | 112 (23.18) | 17.20-30.48 | 1270 (19.24) | 17.18-21.48 | .04 |
| 2nd Quartile | 119 (26.52) | 20.06-34.18 | 1214 (20.00) | 18.17-21.96 | |
| 3rd Quartile | 84 (21.01) | 16.04-27.02 | 1453 (26.67) | 24.60-28.85 | |
| 4th Quartile | 98 (29.29) | 23.26-36.14 | 1526 (34.09) | 31.22-37.07 | |
Abbreviation: NA, not applicable.
65 years and older, accounting for the study design of the National Health and Aging Trends Study.Table 2.
| Models | UOR (95% CI) | P Value | AOR (95% CI)a | P Value |
|---|---|---|---|---|
| Model 1 | ||||
| Size of social support network | ||||
| Larger networkb | 1 [Reference] | .02 | 1 [Reference] | .03 |
| Smaller networkc | 0.58 (0.37-0.92) | 0.60 (0.37-0.96) | ||
| Model 2 | ||||
| Spouse | ||||
| Has spouse | 1 [Reference] | .24 | 1 [Reference] | .78 |
| No spouse | 1.14 (0.91-1.42) | 0.97 (0.77-1.22) | ||
| No. of non–spouse/partner family members in support network | ||||
| ≥2 Persons | 1 [Reference] | .001 | 1 [Reference] | .005 |
| 0-1 Persons | 0.56 (0.39-0.79) | 0.60 (0.43-0.85) | ||
| No. of nonfamily members in support network | ||||
| ≥2 Persons | 1 [Reference] | .48 | 1 [Reference] | .32 |
| 0-1 Persons | 0.93 (0.76-1.14) | 0.90 (0.72-1.11) |
Abbreviations: AOR, adjusted odds ratio; UOR, unadjusted odds ratio.
Proportion of individuals receiving cataract surgery adjusted for age, sex, education level, race/ethnicity, income, proxy respondent, and survey round. Error bars show 95% CIs.
Discussion
This study, using data from the nationally representative NHATS, describes an association between smaller social support networks and a lower likelihood of receiving cataract surgery among Medicare beneficiaries in the United States. Medicare beneficiaries who had fewer family members in their social support network had 40% lower odds of receiving cataract surgery compared with those with more family members, even after accounting for factors like age, race/ethnicity, education, and income. However, the number of nonfamily members and having a spouse/partner in an individual’s social support network did not influence the receipt of cataract surgery. Thus, non–spouse/partner family members likely play a critical role in older persons in the United States obtaining cataract surgery.
Our results suggest that patients without family support may need additional attention to improve access to cataract surgery and thereby decrease cataract-related vision impairment. It is possible that family members, but not nonfamily members, improve engagement with the health care system, increase self-efficacy or health literacy, and provide transportation and/or perioperative support. These factors may have led to receipt of surgery. In other medical specialties, support of both family and nonfamily members had a positive association with access to care and health outcomes. Although our analysis does not directly assess the quality of social support, it is possible that this is more important than who provides that support.
Future work could determine whether equal quality support by family members, nonfamily members, and spouses have similar associations. A nuanced understanding of the impact of social support networks is important to develop and implement strategies to improve access to cataract surgery for a rapidly growing older population.
Limitations
There were limitations to our study. NHATS relies on self-report, which can be subject to recall bias. Data do not allow us to distinguish between need and access to cataract surgery. There were considerable missing income data, although we used multiple imputation to reduce its effect. Finally, we cannot determine a causative association between social support networks and receipt of cataract surgery.
Conclusions
This study demonstrates that Medicare beneficiaries with smaller social support networks are less likely to undergo cataract surgery. These findings suggest that future interventions recognize the importance of social support networks when addressing the burden of cataract-related vision impairment among older adults in the United States.
Notes
Supplement.
eFigure. Flowchart showing sample selection
References
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Funding
Funders who supported this work.
NEI NIH HHS (2)
Grant ID: K23 EY023596
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NIA NIH HHS (1)
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