eMeasure Title

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

eMeasure Identifier (Measure Authoring Tool) 133 eMeasure Version number 5.2.000
NQF Number 0565 GUID 39e0424a-1727-4629-89e2-c46c2fbb3f5f
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward PCPI(R) Foundation (PCPI[R])
Measure Developer American Medical Association (AMA)
Measure Developer PCPI(R) Foundation (PCPI[R])
Endorsed By National Quality Forum
Description
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery
Copyright
Copyright 2015 PCPI(R) Foundation and American Medical Association.  All Rights Reserved.
Disclaimer
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Measure Scoring Proportion
Measure Type Outcome
Measure Item Count
Procedure, Performed: Cataract Surgery
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
1. Scientific basis for measuring visual acuity outcomes after cataract surgery
The only reason to perform cataract surgery (other than for a limited set of medical indications) is to improve a patient's vision and associated functioning. The use of a 20/40 visual acuity threshold is based on several considerations. First, it is the level for unrestricted operation of a motor vehicle in the US. Second, it has been consistently used by the FDA in its assessment for approval of intraocular lens (IOL) and other vision devices. Third, it is the literature standard to denote success in cataract surgery. Fourth, work by West et al in the Salisbury Eye Study suggests that 20/40 is a useful threshold for 50th percentile functioning for several vision-related tasks.

Most patients achieve excellent visual acuity after cataract surgery (20/40 or better). This outcome is achieved consistently through careful attention through the accurate measurement of axial length and corneal power and the appropriate selection of an IOL power calculation formula. As such, it reflects the care and diligence with which the surgery is assessed, planned and executed. Failure to achieve this after surgery in eyes without comorbid ocular conditions that would impact the success of the surgery would reflect care that should be assessed for opportunities for improvement.

The exclusion of patients with other ocular and systemic conditions known to increase the risk of an adverse outcome reflects the findings of the two published prediction rule papers for cataract surgery outcomes, by Mangione et al and Steinberg et al. In both papers, the presence of comorbid glaucoma and macular degeneration negatively impacted the likelihood of successful outcomes of surgery. Further, as noted in the prior indicator, exclusion of eyes with ocular conditions that could impact the success of the surgery would NOT eliminate the large majority of eyes undergoing surgery while also minimizing the potential adverse selection that might otherwise occur relative to those patients with the most complex situations who might benefit the most from having surgery to maximize their remaining vision. 

2. Evidence of a gap in care
This is an outcome of surgery indicator of direct relevance to patients and referring providers. Cataract surgery successfully restores vision in the majority of people who have the procedure. Because of the exclusion of comorbid ocular conditions, one would expect performance on this indicator to be as high as possible, with significantly lower rates suggestive of a gap in care.

The ASCRS National Cataract Database reported that at 3 months postoperatively, 85.5% of all patients had a 20/40 or better best-corrected visual acuity, 57.2% of patients had 20/25 or better postoperative best-corrected visual acuity, and 74.6% of patients were within +/- 1.0 D of target spherical equivalent. Based on 5,788 responses, the mean visual function index score at 3 months postoperatively was 70.3% compared with 55.0% preoperatively (AAO, 2011). 

Additionally, data from a UK multi-center Cataract National Dataset found a postoperative visual acuity of 6/12 (20/40) or better was achieved for 94.7% of eyes with no co-pathologies and in 79.9% of eyes with one or more co-pathologies (Jaycock, 2009). 
A rate of 85.5-94.7% of patients achieving a 20/40 or better visual acuity in the context of approximately 3 million cataract surgeries in the US annually would mean that between 160,000 to 435,000 individuals would not achieve a 20/40 or better visual acuity which suggests an opportunity for improvement.
Clinical Recommendation Statement
This is an outcome measure. As such, there is no statement in the guideline specific to this measurement topic.
Improvement Notation
Higher score indicates better quality
Reference
Mangione CM, Orav J, Lawrence MG, Phillips RS, Seddon JM, Goldman L. Prediction of visual function after cataract surgery: a prospectively validated model. Arch Ophthalmol. 1195;113:1305-11.
Reference
Steinberg EP, Tielsch JM, Schein OD, et al. National study of cataract surgery outcomes: variation in 4-month postoperative outcomes as reflected in multiple outcome measures. Ophthalmology. 1994;101:1131-41.
Reference
American Academy of Ophthalmology. Preferred practice pattern guidelines: cataract in the adult eye. San Francisco, CA: American Academy of Ophthalmology; 2011.
Reference
Jaycock P, Johnston RL, Taylor M, et al. The Cataract National Dataset electronic multi-centre audit of 55567 operations: updating benchmark standards of care in the United Kingdom and internationally. Eye. 2009;23:38-49
Definition
None
Guidance
This is an episode-based measure, meaning there may be more than one reportable event for a given patient during the measurement period. The level of analysis for this measure is each cataract surgery during the measurement period, including instances where more than one cataract procedure was performed during the measurement period. Every cataract surgery during the measurement period should be counted as a measurable denominator event for the measure calculation.
 
Only procedures performed during January 1 - September 30 of the reporting period will be considered for this measure, in order to determine if 20/40 or better visual acuity has been achieved within the 90 days following the cataract procedure. Cataract procedures performed during October 1 - December 31 are excluded from the initial population.

The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but ICD-9-CM and SNOMED-CT do not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible professional will record laterality in the patient medical record, as quality care and clinical documentation should include laterality.

This measure is to be reported by the clinician performing the cataract surgery procedure. Clinicians who provide only preoperative or postoperative management of cataract patients are not eligible for this measure.
Transmission Format
TBD
Initial Population
All patients aged 18 years and older who had cataract surgery
Denominator
Equals Initial Population
Denominator Exclusions
Patients with significant ocular conditions impacting the visual outcome of surgery
Numerator
Patients who had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following cataract surgery
Numerator Exclusions
Not Applicable
Denominator Exceptions
None
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents


Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
None