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

Percentage of cataract surgeries for patients aged 18 and older with a diagnosis of uncomplicated cataract 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 in the operative eye within 90 days following the cataract surgery

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In the United States, cataracts affect more than 24 million adults over 40 years (National Eye Institute, 2016). According to the American Academy of Ophthalmology (2016), cataract surgery has a substantial beneficial impact on visual function and on quality of life. 

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. (1995) and Steinberg et al. (1994). 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
Cataract surgery successfully restores vision in the majority of people who have the procedure. 

Data from a study of 368,256 cataract surgeries show that corrected visual acuity (CDVA) of 0.5 (20/40) or better was achieved in 94.3% and CDVA of 1.0 (20/20) or better was achieved in 61.3% of cases (Lundstrom et al., 2013).

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 et al., 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.

This is an outcome measure. As such, there is no statement in the guideline specific to this measurement topic.

Higher score indicates better quality

American Academy of Ophthalmology. (2016). Cataract in the adult eye Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology. 

Jaycock, P., Johnston, R. L., Taylor, M., et al. (2009). The Cataract National Dataset electronic multi-centre audit of 55,567 operations: Updating benchmark standards of care in the United Kingdom and internationally. Eye, 23(1), 38-49.

Lundstrom, M., Barry, P., Henry, Y., et al. (2013, May). Visual outcome of cataract surgery; Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. Journal of Cataract & Refractive Surgery, 39(5), 673-679.

Mangione, C. M., Orav, J., Lawrence, M. G., et al. (1995). Prediction of visual function after cataract surgery: a prospectively validated model. Archives of Ophthalmology, 1195(113), 1305-1311.

National Eye Institute. (2016, April). Statistics and data: Cataract. Retrieved from https://nei.nih.gov/eyedata/cataract

Steinberg, E. P., Tielsch, J. M., Schein, O. D., et al. (1994). National study of cataract surgery outcomes: Variation in 4-month postoperative outcomes as reflected in multiple outcome measures. Ophthalmology, 101(6), 1131-1141.

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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 or eligible clinician 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.

TBD

All cataract surgeries for patients aged 18 years and older who did not meet any exclusion criteria

Equals Initial Population

Cataract surgeries in patients with significant ocular conditions impacting the visual outcome of surgery

Cataract surgeries with best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following cataract surgery

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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