Residence and insurance inequities in the timeliness of access to first-eye cataract surgery in Eastern China

PURPOSE: To quantify residence and insurance inequities in the timeliness of access to first-eye cataract surgery in Eastern China, using better-eye best-corrected visual acuity (BCVA) at surgical-pathway entry as an electronic health record-derived indicator. METHODS: We conducted a retrospective cohort study of consecutive first-eye cataract surgeries at a tertiary hospital in Yangzhou, China (August 2024-July 2025). Analyses were restricted to local insured residents; non-local and self-pay patients were excluded. The primary outcome was better-eye BCVA (logMAR), defined as the better (lower logMAR) value between the two eyes measured at the admission-registration (pathway-entry) assessment. Adjusted differences were estimated using multivariable linear regression with surgeon fixed effects and heteroskedasticity-consistent (HC3) robust standard errors. Prespecified categorical analyses used multinomial logistic regression. RESULTS: Among 1438 eligible patients, bilateral BCVA was measured at pathway entry in 1437 (99.9%). Compared with Urban-Employee patients, adjusted better-eye BCVA was worse in Urban-Resident (0.09 logMAR; 95% CI 0.01-0.17), Rural-Employee (0.11; 0.01-0.21), and Rural-Resident patients (0.17; 0.11-0.24); adjusted marginal means were 0.32, 0.41, 0.43, and 0.49 logMAR, respectively. Rural-Resident patients were less likely to enter in the early category (RRR 0.52; 95% CI 0.39-0.69) and more likely to enter in the late category (RRR 1.76; 95% CI 1.15-2.69). CONCLUSION: Residence and insurance inequities in the timeliness of access to first-eye cataract surgery were evident. Better-eye BCVA at pathway entry is a low-cost, scalable metric that can complement coverage and postoperative outcomes to guide pathway and financing interventions.