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

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

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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. The available evidence suggests that cataract surgery achieves this in between 86 and 98% of surgeries in eyes without comorbid ocular conditions (this indicator). While small, the volume of cataract surgery in the US of over 2.8 million surgeries suggests that the impact could affect more than 100,000 patients per year. 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 opportunities for improvement.
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. (The score is based on a scale of 0 to 100, with 0 indicating an inability to perform any of the activities.) The European Cataract Outcome Study reported for 1999 that 89% of patients achieved a postoperative visual acuity of 0.5 or more (20/40 or better), the average induced astigmatism was 0.59 D, and 86% of patients had an induced astigmatism within +/- 1.0 D.
The AAO National Eyecare Outcomes Network (NEON) database also found similar rates of success, with an improvement in visual acuity in 92.2% of patients and improvement in VF-14 in over 90% of patients. Best-corrected visual acuity (BCVA) of 20/40 was achieved by 89% of all NEON patients and 96% of NEON patients without preoperative ocular comorbid conditions. Seventy-eight percent of patients were within +/-1.0 D of target spherical equivalent. Ninety-five percent of patients reported being satisfied with the results of their surgery. Patients who were dissatisfied with the results of their surgery were slightly older and more likely to have ocular comorbidity.
In studies of phacoemulsification cataract surgery performed by ophthalmology residents, the reported range of patients with postoperative BCVA of 20/40 or better is 80% to 91%. If eyes with ocular comorbidities are excluded, the reported range of patients with postoperative BCVA of 20/40 or better is 86% to 98%. (AAO, 2011)

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

Higher score indicates better quality.

Albanis CV, Dwyer MA, Ernest JT. Outcomes of extracapsular cataract extraction and phacoemulsification performed in a university training program. Ophthalmic Surg Lasers 1998;29:643-8.

Blomquist PH, Rugwani RM. Visual outcomes after vitreous loss during cataract surgery performed by residents. J Cataract Refract Surg 2002;28:847-52.

Corey RP, Olson RJ. Surgical outcomes of cataract extractions performed by residents using phacoemulsification. J Cataract Refract Surg 1998;24:66-72.

Karp KO, Albanis CV, Pearlman JB, Goins KM. Outcomes of temporal clear cornea versus superior scleral tunnel phacoemulsification incisions in a university training program. Ophthalmic Surg Lasers. 2001;32:228-232.

Randleman JB, Srivastava SK, Aaron MM. Phacoemulsification with topical anesthesia performed by resident surgeons. J Cataract Refract Surg. 2004;30:149-154.

Tarbet KJ, et al. Complications and results of phacoemulsification performed by residents. J Cataract Refract Surg. 1995;21:661-665.

Quillen DA, Phipps SJ. Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience. Am J Ophthalmol. 2003;135:732-733.

American Academy of Ophthalmology. Preferred Practice Pattern: Cataract In the Adult Eye. 2011.

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 patient 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.

All patients aged 18 years and older who had cataract surgery

Equals Initial Patient Population

Patients with significant ocular conditions impacting the visual outcome of surgery

Patients who had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following cataract surgery

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

Initial Patient Population =
- AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Measurement Period"
- AND: "Occurrence A of Procedure, Performed: Cataract Surgery" during "Measurement Period"
- AND: "Occurrence A of Procedure, Performed: Cataract Surgery" > 92 day(s) starts before start of "Measurement End Date"
Denominator =
- AND: "Initial Patient Population"
Denominator Exclusions =
- AND:
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Acute and Subacute Iridocyclitis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Acute and Subacute Iridocyclitis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Pathologic Myopia" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Pathologic Myopia" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Retinal Detachment with Retinal Defect" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Retinal Detachment with Retinal Defect" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Retinal Vascular Occlusion" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Retinal Vascular Occlusion" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Purulent Endophthalmitis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Purulent Endophthalmitis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Certain Types of Iridocyclitis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Certain Types of Iridocyclitis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Glaucoma Associated with Congenital Anomalies, Dystrophies, and Systemic Syndromes" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Glaucoma Associated with Congenital Anomalies, Dystrophies, and Systemic Syndromes" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Chronic Iridocyclitis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Chronic Iridocyclitis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Choroidal Degenerations" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Choroidal Degenerations" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Optic Neuritis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Optic Neuritis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Other Background Retinopathy and Retinal Vascular Changes" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Other Background Retinopathy and Retinal Vascular Changes" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Other Corneal Deformities" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Other Corneal Deformities" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Cloudy Cornea" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Cloudy Cornea" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Other Retinal Disorders" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Other Retinal Disorders" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Prior Penetrating Keratoplasty" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Prior Penetrating Keratoplasty" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Other and Unspecified Forms of Chorioretinitis and Retinochoroiditis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Other and Unspecified Forms of Chorioretinitis and Retinochoroiditis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Amblyopia" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Amblyopia" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Corneal Edema" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Corneal Edema" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Nystagmus and Other Irregular Eye Movements" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Nystagmus and Other Irregular Eye Movements" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Moderate or Severe Impairment, Better Eye, Profound Impairment Lesser Eye" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Moderate or Severe Impairment, Better Eye, Profound Impairment Lesser Eye" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Hereditary Choroidal Dystrophies" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Hereditary Choroidal Dystrophies" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Hereditary Retinal Dystrophies" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Hereditary Retinal Dystrophies" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Burn Confined to Eye and Adnexa" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Burn Confined to Eye and Adnexa" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Scleritis and Episcleritis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Scleritis and Episcleritis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Other Disorders of Sclera" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Other Disorders of Sclera" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Focal Chorioretinitis and Focal Retinochoroiditis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Focal Chorioretinitis and Focal Retinochoroiditis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Degenerative Disorders of Globe" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Degenerative Disorders of Globe" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Degeneration of Macula and Posterior Pole" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Degeneration of Macula and Posterior Pole" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Disseminated Chorioretinitis and Disseminated Retinochoroiditis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Disseminated Chorioretinitis and Disseminated Retinochoroiditis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Diabetic Macular Edema" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Diabetic Macular Edema" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Uveitis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Uveitis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Profound Impairment, Both Eyes" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Profound Impairment, Both Eyes" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Other Proliferative Retinopathy" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Other Proliferative Retinopathy" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Cataract Secondary to Ocular Disorders" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Cataract Secondary to Ocular Disorders" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Disorders of Visual Cortex" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Disorders of Visual Cortex" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Choroidal Detachment" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Choroidal Detachment" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Disorders of Optic Chiasm" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Disorders of Optic Chiasm" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Injury to Optic Nerve and Pathways" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Injury to Optic Nerve and Pathways" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Choroidal Hemorrhage and Rupture" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Choroidal Hemorrhage and Rupture" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Other Disorders of Optic Nerve" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Other Disorders of Optic Nerve" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Glaucoma" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Glaucoma" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Chorioretinal Scars" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Chorioretinal Scars" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Hereditary Corneal Dystrophies" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Hereditary Corneal Dystrophies" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Central Corneal Ulcer" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Central Corneal Ulcer" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Corneal Opacity and Other Disorders of Cornea" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Corneal Opacity and Other Disorders of Cornea" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Optic Atrophy" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Optic Atrophy" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Open Wound of Eyeball" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Open Wound of Eyeball" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Other Endophthalmitis" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Other Endophthalmitis" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Separation of Retinal Layers" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Separation of Retinal Layers" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
  - OR:
    - AND: "Occurrence A of Diagnosis, Active: Visual Field Defects" starts before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
    - AND NOT: "Occurrence A of Diagnosis, Active: Visual Field Defects" ends before start of "Occurrence A of Procedure, Performed: Cataract Surgery"
Numerator =
- AND: "Physical Exam, Finding: Best Corrected Visual Acuity (result: 'Visual Acuity 20/40 or Better')" <= 90 day(s) starts after end of "Occurrence A of Procedure, Performed: Cataract Surgery"
Denominator Exceptions =
- None

"Diagnosis, Active: Acute and Subacute Iridocyclitis" using "Acute and Subacute Iridocyclitis Grouping Value Set (2.16.840.1.113883.3.526.3.1241)"
"Diagnosis, Active: Amblyopia" using "Amblyopia Grouping Value Set (2.16.840.1.113883.3.526.3.1448)"
"Diagnosis, Active: Burn Confined to Eye and Adnexa" using "Burn Confined to Eye and Adnexa Grouping Value Set (2.16.840.1.113883.3.526.3.1409)"
"Diagnosis, Active: Cataract Secondary to Ocular Disorders" using "Cataract Secondary to Ocular Disorders Grouping Value Set (2.16.840.1.113883.3.526.3.1410)"
"Diagnosis, Active: Central Corneal Ulcer" using "Central Corneal Ulcer Grouping Value Set (2.16.840.1.113883.3.526.3.1428)"
"Diagnosis, Active: Certain Types of Iridocyclitis" using "Certain Types of Iridocyclitis Grouping Value Set (2.16.840.1.113883.3.526.3.1415)"
"Diagnosis, Active: Chorioretinal Scars" using "Chorioretinal Scars Grouping Value Set (2.16.840.1.113883.3.526.3.1449)"
"Diagnosis, Active: Choroidal Degenerations" using "Choroidal Degenerations Grouping Value Set (2.16.840.1.113883.3.526.3.1450)"
"Diagnosis, Active: Choroidal Detachment" using "Choroidal Detachment Grouping Value Set (2.16.840.1.113883.3.526.3.1451)"
"Diagnosis, Active: Choroidal Hemorrhage and Rupture" using "Choroidal Hemorrhage and Rupture Grouping Value Set (2.16.840.1.113883.3.526.3.1452)"
"Diagnosis, Active: Chronic Iridocyclitis" using "Chronic Iridocyclitis Grouping Value Set (2.16.840.1.113883.3.526.3.1416)"
"Diagnosis, Active: Cloudy Cornea" using "Cloudy Cornea Grouping Value Set (2.16.840.1.113883.3.526.3.1417)"
"Diagnosis, Active: Corneal Edema" using "Corneal Edema Grouping Value Set (2.16.840.1.113883.3.526.3.1418)"
"Diagnosis, Active: Corneal Opacity and Other Disorders of Cornea" using "Corneal Opacity and Other Disorders of Cornea Grouping Value Set (2.16.840.1.113883.3.526.3.1419)"
"Diagnosis, Active: Degeneration of Macula and Posterior Pole" using "Degeneration of Macula and Posterior Pole Grouping Value Set (2.16.840.1.113883.3.526.3.1453)"
"Diagnosis, Active: Degenerative Disorders of Globe" using "Degenerative Disorders of Globe Grouping Value Set (2.16.840.1.113883.3.526.3.1454)"
"Diagnosis, Active: Diabetic Macular Edema" using "Diabetic Macular Edema Grouping Value Set (2.16.840.1.113883.3.526.3.1455)"
"Diagnosis, Active: Diabetic Retinopathy" using "Diabetic Retinopathy Grouping Value Set (2.16.840.1.113883.3.526.3.327)"
"Diagnosis, Active: Disorders of Optic Chiasm" using "Disorders of Optic Chiasm Grouping Value Set (2.16.840.1.113883.3.526.3.1457)"
"Diagnosis, Active: Disorders of Visual Cortex" using "Disorders of Visual Cortex Grouping Value Set (2.16.840.1.113883.3.526.3.1458)"
"Diagnosis, Active: Disseminated Chorioretinitis and Disseminated Retinochoroiditis" using "Disseminated Chorioretinitis and Disseminated Retinochoroiditis Grouping Value Set (2.16.840.1.113883.3.526.3.1459)"
"Diagnosis, Active: Focal Chorioretinitis and Focal Retinochoroiditis" using "Focal Chorioretinitis and Focal Retinochoroiditis Grouping Value Set (2.16.840.1.113883.3.526.3.1460)"
"Diagnosis, Active: Glaucoma" using "Glaucoma Grouping Value Set (2.16.840.1.113883.3.526.3.1423)"
"Diagnosis, Active: Glaucoma Associated with Congenital Anomalies, Dystrophies, and Systemic Syndromes" using "Glaucoma Associated with Congenital Anomalies, Dystrophies, and Systemic Syndromes Grouping Value Set (2.16.840.1.113883.3.526.3.1461)"
"Diagnosis, Active: Hereditary Choroidal Dystrophies" using "Hereditary Choroidal Dystrophies Grouping Value Set (2.16.840.1.113883.3.526.3.1462)"
"Diagnosis, Active: Hereditary Corneal Dystrophies" using "Hereditary Corneal Dystrophies Grouping Value Set (2.16.840.1.113883.3.526.3.1424)"
"Diagnosis, Active: Hereditary Retinal Dystrophies" using "Hereditary Retinal Dystrophies Grouping Value Set (2.16.840.1.113883.3.526.3.1463)"
"Diagnosis, Active: Injury to Optic Nerve and Pathways" using "Injury to Optic Nerve and Pathways Grouping Value Set (2.16.840.1.113883.3.526.3.1427)"
"Diagnosis, Active: Moderate or Severe Impairment, Better Eye, Profound Impairment Lesser Eye" using "Moderate or Severe Impairment, Better Eye, Profound Impairment Lesser Eye Grouping Value Set (2.16.840.1.113883.3.526.3.1464)"
"Diagnosis, Active: Nystagmus and Other Irregular Eye Movements" using "Nystagmus and Other Irregular Eye Movements Grouping Value Set (2.16.840.1.113883.3.526.3.1465)"
"Diagnosis, Active: Open Wound of Eyeball" using "Open Wound of Eyeball Grouping Value Set (2.16.840.1.113883.3.526.3.1430)"
"Diagnosis, Active: Optic Atrophy" using "Optic Atrophy Grouping Value Set (2.16.840.1.113883.3.526.3.1466)"
"Diagnosis, Active: Optic Neuritis" using "Optic Neuritis Grouping Value Set (2.16.840.1.113883.3.526.3.1467)"
"Diagnosis, Active: Other Background Retinopathy and Retinal Vascular Changes" using "Other Background Retinopathy and Retinal Vascular Changes Grouping Value Set (2.16.840.1.113883.3.526.3.1469)"
"Diagnosis, Active: Other Corneal Deformities" using "Other Corneal Deformities Grouping Value Set (2.16.840.1.113883.3.526.3.1470)"
"Diagnosis, Active: Other Disorders of Optic Nerve" using "Other Disorders of Optic Nerve Grouping Value Set (2.16.840.1.113883.3.526.3.1471)"
"Diagnosis, Active: Other Disorders of Sclera" using "Other Disorders of Sclera Grouping Value Set (2.16.840.1.113883.3.526.3.1472)"
"Diagnosis, Active: Other Endophthalmitis" using "Other Endophthalmitis Grouping Value Set (2.16.840.1.113883.3.526.3.1473)"
"Diagnosis, Active: Other Proliferative Retinopathy" using "Other Proliferative Retinopathy Grouping Value Set (2.16.840.1.113883.3.526.3.1480)"
"Diagnosis, Active: Other Retinal Disorders" using "Other Retinal Disorders Grouping Value Set (2.16.840.1.113883.3.526.3.1474)"
"Diagnosis, Active: Other and Unspecified Forms of Chorioretinitis and Retinochoroiditis" using "Other and Unspecified Forms of Chorioretinitis and Retinochoroiditis Grouping Value Set (2.16.840.1.113883.3.526.3.1468)"
"Diagnosis, Active: Pathologic Myopia" using "Pathologic Myopia Grouping Value Set (2.16.840.1.113883.3.526.3.1432)"
"Diagnosis, Active: Prior Penetrating Keratoplasty" using "Prior Penetrating Keratoplasty Grouping Value Set (2.16.840.1.113883.3.526.3.1475)"
"Diagnosis, Active: Profound Impairment, Both Eyes" using "Profound Impairment, Both Eyes Grouping Value Set (2.16.840.1.113883.3.526.3.1476)"
"Diagnosis, Active: Purulent Endophthalmitis" using "Purulent Endophthalmitis Grouping Value Set (2.16.840.1.113883.3.526.3.1477)"
"Diagnosis, Active: Retinal Detachment with Retinal Defect" using "Retinal Detachment with Retinal Defect Grouping Value Set (2.16.840.1.113883.3.526.3.1478)"
"Diagnosis, Active: Retinal Vascular Occlusion" using "Retinal Vascular Occlusion Grouping Value Set (2.16.840.1.113883.3.526.3.1479)"
"Diagnosis, Active: Scleritis and Episcleritis" using "Scleritis and Episcleritis Grouping Value Set (2.16.840.1.113883.3.526.3.1481)"
"Diagnosis, Active: Separation of Retinal Layers" using "Separation of Retinal Layers Grouping Value Set (2.16.840.1.113883.3.526.3.1482)"
"Diagnosis, Active: Uveitis" using "Uveitis Grouping Value Set (2.16.840.1.113883.3.526.3.1444)"
"Diagnosis, Active: Visual Field Defects" using "Visual Field Defects Grouping Value Set (2.16.840.1.113883.3.526.3.1446)"
"Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set (2.16.840.1.113883.3.560.100.4)"
"Physical Exam, Finding: Best Corrected Visual Acuity" using "Best Corrected Visual Acuity Grouping Value Set (2.16.840.1.113883.3.526.3.1488)"
"Procedure, Performed: Cataract Surgery" using "Cataract Surgery Grouping Value Set (2.16.840.1.113883.3.526.3.1411)"
Attribute: "Result: Visual Acuity 20/40 or Better" using "Visual Acuity 20/40 or Better Grouping Value Set (2.16.840.1.113883.3.526.3.1483)"

"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeSex Value Set (2.16.840.1.113762.1.4.1)"

eMeasure Title	Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
eMeasure Identifier (Measure Authoring Tool)	133	eMeasure Version number	3
NQF Number	0565	GUID	39e0424a-1727-4629-89e2-c46c2fbb3f5f
Measurement Period	January 1, 20xx through December 31, 20xx
Measure Steward	American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Measure Developer	American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Measure Developer	National Committee for Quality Assurance
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 2013 National Committee for Quality Assurance (NCQA) and American Medical Association. All Rights Reserved.
Disclaimer	Physician Performance Measures (Measures) and related data specifications have been developed by the American Medical Association (AMA) - convened Physician Consortium for Performance Improvement(R) (PCPI[R]) and the National Committee for Quality Assurance (NCQA). These Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA, (on behalf of the PCPI) or NCQA. Neither the AMA, PCPI, NCQA nor its members shall be responsible for any use of the Measures. THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, PCPI, NCQA and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring	Proportion
Measure Type	Outcome
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. The available evidence suggests that cataract surgery achieves this in between 86 and 98% of surgeries in eyes without comorbid ocular conditions (this indicator). While small, the volume of cataract surgery in the US of over 2.8 million surgeries suggests that the impact could affect more than 100,000 patients per year. 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 opportunities for improvement. 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. (The score is based on a scale of 0 to 100, with 0 indicating an inability to perform any of the activities.) The European Cataract Outcome Study reported for 1999 that 89% of patients achieved a postoperative visual acuity of 0.5 or more (20/40 or better), the average induced astigmatism was 0.59 D, and 86% of patients had an induced astigmatism within +/- 1.0 D. The AAO National Eyecare Outcomes Network (NEON) database also found similar rates of success, with an improvement in visual acuity in 92.2% of patients and improvement in VF-14 in over 90% of patients. Best-corrected visual acuity (BCVA) of 20/40 was achieved by 89% of all NEON patients and 96% of NEON patients without preoperative ocular comorbid conditions. Seventy-eight percent of patients were within +/-1.0 D of target spherical equivalent. Ninety-five percent of patients reported being satisfied with the results of their surgery. Patients who were dissatisfied with the results of their surgery were slightly older and more likely to have ocular comorbidity. In studies of phacoemulsification cataract surgery performed by ophthalmology residents, the reported range of patients with postoperative BCVA of 20/40 or better is 80% to 91%. If eyes with ocular comorbidities are excluded, the reported range of patients with postoperative BCVA of 20/40 or better is 86% to 98%. (AAO, 2011)
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	Albanis CV, Dwyer MA, Ernest JT. Outcomes of extracapsular cataract extraction and phacoemulsification performed in a university training program. Ophthalmic Surg Lasers 1998;29:643-8.
Reference	Blomquist PH, Rugwani RM. Visual outcomes after vitreous loss during cataract surgery performed by residents. J Cataract Refract Surg 2002;28:847-52.
Reference	Corey RP, Olson RJ. Surgical outcomes of cataract extractions performed by residents using phacoemulsification. J Cataract Refract Surg 1998;24:66-72.
Reference	Karp KO, Albanis CV, Pearlman JB, Goins KM. Outcomes of temporal clear cornea versus superior scleral tunnel phacoemulsification incisions in a university training program. Ophthalmic Surg Lasers. 2001;32:228-232.
Reference	Randleman JB, Srivastava SK, Aaron MM. Phacoemulsification with topical anesthesia performed by resident surgeons. J Cataract Refract Surg. 2004;30:149-154.
Reference	Tarbet KJ, et al. Complications and results of phacoemulsification performed by residents. J Cataract Refract Surg. 1995;21:661-665.
Reference	Quillen DA, Phipps SJ. Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience. Am J Ophthalmol. 2003;135:732-733.
Reference	American Academy of Ophthalmology. Preferred Practice Pattern: Cataract In the Adult Eye. 2011.
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 patient 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.
Transmission Format	TBD
Initial Patient Population	All patients aged 18 years and older who had cataract surgery
Denominator	Equals Initial Patient 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
Measure Population	Not Applicable
Measure Observations	Not Applicable
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 Data Elements)

Reporting Stratification

Supplemental Data Elements