OBJECTIVES: To compare the cost of cataract surgery in patients with and without astigmatism, as reported in the French national Diagnosis Related Group (DRG) database (PMSI: Programme de Médicalisation des Systèmes d’Information). METHODS: The 2007 DRG database was used. Patients with cataract surgery were identified by the surgery procedure codes (BFGA001-BFGA010; BFLA001-BFLA004). Patients with declared astigmatism had a H522 ICD10 code. DRG standard cost was adjusted according to the number of procedures. Surgery and anaesthesia costs estimated from the Echelle National des Coûts were adjusted with the same method. Average costs were calculated in both groups. Student t-test and chi-square were used to compare the two groups. RESULTS: A total of 475 declared astigmatic and 579,778 without declared astigmatism patients were extracted (age: 73.6 years, 2 males: 3 females). Astigmatic patients were more often operated on in a private hospital. Astigmatic patients showed a trend towards a longer length of stay (2.41 versus 2.17 days; p=0.12, ambulatory patients excluded), more co-morbidity (2.38 versus 1.03; P<0.001) and more procedures (3.03 versus 2.43; P<0.001). The cost of procedures was higher for astigmatic patient (€580 versus €464) leading to a higher total hospital cost (€1488 versus €1372). CONCLUSIONS: Astigmatism is dramatically under-reported in the PMSI database in comparison to nationwide prevalence rate estimates. Astigmatic patients required more procedures, partially due to increased co-morbidity. An astigmatic patient costs more and this is not taken into account by today’s V11 clustering cost algorithm. Time and motion analysis should be conducted to better understand astigmatism management during cataract surgery.