Purpose
To characterize patient-surgeon sex concordance and evaluate sex-based trends in cataract surgical volume over a 14-year period.
Design
Retrospective cohort and trend study.
Subjects
All cataract surgeries performed and all surgeons performing cataract surgery at the Bascom Palmer Eye Institute between January 1, 2011, and November 7, 2024.
Methods
Cataract surgery counts were aggregated by surgeon sex, patient sex, and calendar year to assess patient-surgeon sex concordance and longitudinal trends in surgical volume. Surgeon workforce composition and annual surgical productivity were evaluated using procedure counts. Associations between surgeon sex, sex distribution of operated eyes, and changes in surgical volume over time were examined.
Main Outcome Measures
Primary outcomes were patient-surgeon sex concordance at the cataract surgery level and surgeon-level cataract surgery volume. Secondary outcomes included temporal trends in surgeon workforce composition and sex-stratified distributions of cataract surgeries.
Results
Among 88,420 cataract surgeries (mean age of 68.2 ± 11.1 years; 55.9% female patients; 122 surgeons), women comprised approximately one-third of active surgeons, a proportion that remained stable over time. Patient-surgeon sex concordance was modest (OR, 1.06; 95% CI, 1.03-1.09), indicating limited deviation from equal odds of same-sex pairing. Despite stable workforce representation, female surgeons’ share of institutional cataract volume increased from 37.8% in 2011 to 52.8% in 2024 (β = 10.8 cases/year; P <.001), with higher mean annual productivity per surgeon in 2023-2024 compared with male surgeons (249.2 vs 122.7 cases; P =.03). Female surgeon productivity was strongly correlated with patient-surgeon sex concordance over time (ρ=0.83; P <.001).
Conclusions
In this large longitudinal cohort, patient-surgeon sex concordance was modest and closely aligned with changes in surgeon productivity and workforce output. These findings suggest that sex-based productivity disparities are modifiable and that institutional factors related to surgical volume distribution may influence gender equity in ophthalmic surgical practice.
Cataract surgery is the most frequently performed outpatient elective surgery in the United States, with millions of operations performed annually and demand projected to increase as the population ages. , Women account for a greater proportion of patients undergoing cataract surgery than men, representing approximately 55.1% to 58.2% of cases nationally. ,, This sex difference reflects the longer life expectancy of women and a higher prevalence of visually significant cataract at older ages, positioning cataract surgery as a uniquely sex-stratified and demographically relevant surgical domain within ophthalmology.
A growing body of literature across medical and surgical specialties suggests that health care delivery is influenced by patient and physician sex and is therefore not sex-neutral. ,, Prior studies have demonstrated that physician sex may influence communication style, patient satisfaction, clinical decision-making, and health outcomes. ,, Additionally, patient preferences for physician sex have been reported to vary by patient sex and clinical context, particularly in fields involving elective procedures. ,, This consideration can be especially relevant in ophthalmology, as cataract surgery is almost exclusively performed as an elective outpatient procedure, affording patients substantial opportunity to select their surgeon. However, the extent to which such preferences translate into observable patient-surgeon sex concordance may be limited by workforce structure and surgical volume distribution.
Existing ophthalmic literature has focused on the supply side, examining sex-based differences in workforce composition, surgical productivity, training exposure, income, and academic and leadership representation. ,,,,, Large database studies have consistently shown a male-dominant workforce with higher surgical volumes than female ophthalmologists, including in cataract surgery. ,,, These findings persist across diverse practice settings and geographic regions, raising concerns regarding equity in operative opportunities, referral patterns, and career advancement. , Concurrently, the proportion of women entering ophthalmology has steadily increased over the past two decades, resulting in a progressively more gender-diverse workforce. ,
Whether this demographic shift has translated into changes in patient-surgeon sex concordance or into narrowing of sex-based differences in surgical productivity remains unclear. The primary objective of this study was to evaluate the presence and magnitude of patient-surgeon sex concordance in cataract surgery over a 14-year period at a large tertiary referral center. Secondary objectives were to characterize temporal trends in workforce gender composition and to determine whether gender-based disparities in surgical volume have persisted or narrowed within a high-volume academic environment.
METHODS
Study Design
This retrospective cohort and trend study included all cataract surgical encounters performed across all clinical services at the Bascom Palmer Eye Institute between January 1, 2011, and November 7, 2024. The unit of analysis was the eye-level cataract surgical encounter. The study protocol was approved by the University of Miami Institutional Review Board (IRB Reference: 20200357) and was granted a waiver of informed consent owing to its retrospective design. The study adhered to the principles of the Declaration of Helsinki and complied with the Health Insurance Portability and Accountability Act.
Data Sources and Study Population
Patients were identified through the Epic electronic medical record (EMR) system (Epic Systems Corporation, Verona, WI, USA). Cataract surgeries were identified using Current Procedural Terminology (CPT) codes 66982 (complex), 66983 (intracapsular), and 66984 (standard phacoemulsification). The operating surgeon was identified by cross-referencing billing and service provider data; discrepancies were resolved by manual chart review of operative notes and clinical documentation to confirm the primary surgeon.
Analyses at the surgeon level included attending surgeons only, with a minimum of 10 cataract surgeries performed during the study period. Eligible encounters included patients aged 18 years or older at the time of surgery. Cases were excluded if patient sex was missing or recorded as unknown.
Variables and Measurements
Patient demographic variables included biological sex (male or female), age at surgery, race, and ethnicity as recorded in the EMR at the time of care. Surgical complexity was classified using CPT codes. Surgeon sex was obtained from institutional administrative records. Surgeon Spanish fluency was defined based on documentation indicating that a medical interpreter was not required for the informed consent discussion. Annual workforce composition was characterized by the proportion of active cataract surgeons by sex and by each sex’s share of total institutional cataract surgical volume. Clinical productivity was defined as cataract surgical volume. Annual cataract surgery volume by surgeon sex was assessed longitudinally to characterize temporal differences in surgical output between female and male surgeons. Patient-surgeon sex concordance was quantified using the following index:
Statistical Analysis
Continuous variables were summarized as mean ± SD and range, while categorical variables were reported as frequencies with percentages. Patient demographics (race, ethnicity) and CPT-coded surgical complexity were compared between surgeon sexes using Pearson chi-square tests. The overall association between patient and surgeon sex was evaluated using odds ratios (ORs) with 95% CIs.
Continuous variables were evaluated using independent t-tests, and categorical variables were assessed with Pearson chi-square tests when comparing patient demographic characteristics between female and male surgeons. Since patient-surgeon sex concordance is related to the relative distribution of surgical volume across the workforce, surgeon productivity was analyzed longitudinally to contextualize concordance trends. Linear mixed-effects models were used to cf average annual surgical volumes between female and male surgeons. For point-in-time comparisons, independent-sample t-tests were used to cf mean surgical volume between sexes during the most recent years (2023-2024). Spearman’s rank correlation was used to analyze temporal trends between female surgeon volume and patient-surgeon sex concordance.
All tests were two-sided, and P <.05 was considered statistically significant. Statistical analyses were performed using SPSS Statistics Software version 29.0.2.0 (IBM Corp.) and Microsoft Excel version 16.101 (Microsoft Corporation).
RESULTS
A total of 88,420 cataract surgeries performed by 122 surgeons were included over the 14-year study period. The mean patient age was 68.2 ± 11.1 years (median: 69 years, range: 18-102 years) ( Table 1 ). Female patients accounted for 55.9% ( n = 49,467) of surgeries, while male patients accounted for 44.1% ( n = 38,953). The study population was 78.0% White and 14.6% Black or African American. Ethnicity was 51.3% non-Hispanic or Latino, 46.0% Hispanic or Latino, and 3.1% unknown. There were significant differences in the patient demographics served by surgeon sex; female surgeons operated on a lower proportion of Hispanic or Latino patients (39.6%) compared to male surgeons (51.3%, P <.001).
Table 1
Demographic Characteristics of Patients Undergoing Cataract Surgery Stratified By Surgeon Sex From 2011 Through 2024
| Overall ( N = 88,420) | Female Surgeon ( N = 40,134) | Male Surgeon ( N = 48,286) | P -Value | |
|---|---|---|---|---|
| Age (Years) | 68.2 ± 11.1 | 68.6 ± 10.7 | 67.9 ± 11.3 | <.001 |
| Patient Sex, n (%) | <.001 | |||
| Female | 49,467 (55.9) | 22,780 (56.8) | 26,587 (55.3) | |
| Male | 38,953 (44.1) | 17,354 (43.2) | 21,599 (44.7) | |
| Race, n (%) | <.001 | |||
| White | 68,934 (77.9) | 31,669 (78.9) | 37,265 (77.1) | |
| Black or African American | 12,953 (14.6) | 5,527 (13.8) | 7,426 (15.4) | |
| Asian | 1,296 (1.5) | 680 (1.7) | 616 (1.3) | |
| American Indian or Alaska Native | 140 (0.2) | 63 (0.2) | 77 (0.2) | |
| Native Hawaiian or Other Pacific Islander | 98 (0.1) | 48 (0.1) | 50 (0.1) | |
| More Than One Race | 2,262 (2.6) | 846 (2.1) | 1,416 (2.9) | |
| Unknown | 2,737 (3.1) | 1,301 (3.2) | 1,436 (3.0) | |
| Ethnicity, n (%) | <.001 | |||
| Hispanic or Latino | 40,700 (46.0) | 15,913 (39.6) | 24,787 (51.3) | |
| Non-Hispanic or Latino | 45,350 (51.3) | 22,980 (57.3) | 22,370 (46.3) | |
| Unknown | 2,370 (2.7) | 1,241 (3.1) | 1,129 (2.3) |
There was no significant difference in surgical complexity between female and male surgeons based on CPT codes ( P =.82). Complex cataract surgery (CPT 66982) accounted for 15.3% of cases for female surgeons and 15.4% for male surgeons, while standard phacoemulsification (CPT 66984) comprised approximately 84.7% of cases for female surgeons and 84.6% for male surgeons.
The proportion of active cataract surgeons who were female remained relatively stable, starting at 34.8% in 2011 and ending at 35.6% in 2024 (mean: 36.2%, range: 32.6-43.5%) ( Figure 1 ). Despite this stable workforce ratio, the distribution of total institutional surgical volume shifted significantly. The proportion of all surgeries performed by female surgeons increased from 37.8% in 2011 to 52.8% in 2024, while the volume share for male surgeons decreased from 62.2% to 47.2% over the same period ( Figure 2 ). The transition to a female-majority volume occurred in 2019; while it briefly dipped during 2020 to 2021, female surgeons have performed the majority of institutional cataract procedures in the most recent 3 years (2022-2024).
Annual proportion of active surgeons by sex from 2011 through 2024.
Annual distribution of cataract surgery volume by surgeon sex from 2011 through 2024.
Average annual surgical volume per surgeon increased more rapidly over time among female surgeons than among male surgeons. In 2011, female and male surgeons performed a similar number of cases (118.8 vs. 104.4 cases/year, respectively). By 2024, the mean annual productivity for female surgeons had risen to 249.2 cases (range: 2-754 cases), whereas male surgeons averaged 122.7 cases (range: 1-548 cases). Linear mixed-effects model analysis confirmed a significant annual growth in productivity for female surgeons (β = 10.8 cases/year, P <.001), which was significantly greater than the trend for male surgeons ( P interaction =.002). For the most recent two-year period (2023-2024), female surgeons demonstrated significantly higher mean clinical productivity than their male counterparts (252.3 vs. 132.8 cases; P =.028) ( Figure 3 ). Surgical volume was highly concentrated; the top 10 highest-volume surgeons (5 female and 5 male surgeons) accounted for 60.6% of the total 88,420 procedures performed during the study period.
