Patient-reported outcome measuring tools in cataract surgery: Clinical comparison at a tertiary hospital

The implementation, use and impact of patient reported outcome measures in value-based healthcare programmes: A scoping review

BACKGROUND

Value-Based Healthcare (VBHC) focuses on the value of patient outcomes and is achieved by ensuring resources already available are managed to realise the best possible individual and population health outcomes. Patient reported outcome measures (PROMs) measure the impact of illnesses from the patient perspective. We conducted a scoping review to understand how PROMs were implemented and used, and their impact in the context of VBHC.

METHODS

Arksey and O'Malley's overarching framework supplemented by principles from mixed-methods Framework Synthesis were used. CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, Web of Science, Google Scholar and reference lists were searched. An a priori data extraction framework was created using the review question and objectives as key domains against which to extract data. Mixed-methods data were organised, integrated and preserved in original format and reported for each domain.

RESULTS

Forty-three studies were included with 60,200 participants. Few studies reported a well-developed programme theory and we found little robust evidence of effect. PROMs were universally considered to have the potential to increase patient satisfaction with treatment and services, enhance patient awareness of symptoms and self-management, and improve health outcomes such as quality of life and global health status. Evidence is currently limited on how PROMs work and how best to optimally implement PROMs to achieve the target outcome. Implementation challenges commonly prevented the realisation of optimal outcomes and patients generally needed better and clearer communication about why PROMs were being given and how they could optimally be used to support their own self-management.

CONCLUSION

PROMSs have yet to demonstrate their full potential in a VBHC context. Optimal PROMs implementation is poorly understood by clinicians and patients. Future studies should explore different models of PROM implementation and use within VBHC programmes to understand what works best and why for each specific context, condition, and population.

Should We Perform Early Cataract Surgery? A Patient Reported Outcome Study

Purpose

Current guidance states that access to cataract surgery should not be restricted by visual acuity (VA); nevertheless, 6/12 is used as a cut-off criterion in some health institutions. This study aims to determine the benefits of performing cataract surgery in patients with VA of 6/9 or better in both eyes; determine whether these benefits change over time; and compare the benefit observed between early first eye and second eye surgery.

Patients and Methods

Fifty adults with VA at least 6/9 in the worst eye and no ocular comorbidity were recruited. The Visual Function Index (VF-14) and Impact of Visual Impairment (IVI) questionnaires were conducted pre-operatively, 4 months post-operatively, and 12 months post-operatively. The t-test or a non-parametric equivalent was used to compare averages between groups.

Results

The mean change in VF-14 from baseline to 4 months was 16.43 (95% CI 12.49–20.50, p < 0.001) and the median change in IVI was 6.5 (IQR 9.75, p < 0.001). There was no significant difference between 4-month and 12-month follow-up (p > 0.05). There was no significant difference in the change in visual function between the first and second eye surgery (p > 0.05).

Conclusion

This study provides evidence that visual function improves after cataract surgery in patients with pre-operative VA of 6/9 or better. The improvement observed was clinically significant and unchanged a year after surgery. Visual function improved after second eye as much as after first eye surgery. Assessing patient reported visual function may give a more realistic indication of the benefit of early cataract surgery than relying on VA alone.

Validation and comparison of the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) and the Visual Function Index-14 (VF-14) in patients with cataracts: a multicentre study

PURPOSE

The present study aimed to investigate and compare the psychometric properties of the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) and the Visual Function Index-14 (VF-14) in a large sample of patients with cataracts.

METHODS

A total of 1052 patients with bilateral age-related cataracts were recruited in the study. Patients with other comorbidities that severely impacted vision were excluded. Participants completed the two questionnaires in random order. Classical test theory and Rasch analyses were used to assess the psychometric properties of the questionnaires.

RESULTS

Complete data were obtained from 899 patients. The mean overall index score on the NEI VFQ-25 was 76.1 ± 19.0, while that on the VF-14 was 46.5 ± 15.0. Cronbach's α-values for the NEI VFQ-25 and VF-14 were 0.89 and 0.95, respectively. Ceiling effects were observed on nine of the 12 subscales in the NEI VFQ-25. The correlation between total scores on the NEI VFQ-25 and VF-14 was moderate (r = 0.600; p < 0.001), and subscales of the NEI VFQ-25 were weakly or moderately correlated with the similar domains on the VF-14. Rasch analysis revealed ordered category thresholds and sufficient person separation for both instruments, while the two questionnaires had critical deficiencies in unidimensionality, targeting and differential item functioning.

CONCLUSION

Neither the NEI VFQ-25 nor VF-14 is optimal for the assessment of vision-related quality of life in typical Chinese patients with cataracts. The potential deficiencies of the questionnaires should be taken into consideration prior to application of the instruments or interpretation of the results.

Cataract standard set for outcome measures: An Italian tertiary referral centre experience

PURPOSE

Implementation of the International Consortium for Health Outcomes Measurements (ICHOM) standard for cataract surgery into clinical practice at an Italian tertiary referral centre.

METHODS

Prospective, observational, descriptive study consisting of the registry and analysis of cataract surgeries performed during a 6-month enrolment period at the University Eye Clinic of Trieste, Trieste, Italy. Outcomes were recorded and analysed according to the ICHOM Cataract Standard Set version 2.0.1. Records included clinician-reported outcome measures (CROMs) - visual outcome and complications - and patient-reported outcome measures (PROMs) - self-assessed vision with the Catquest-9SF questionnaire. Correlations between PROMs and CROMs were evaluated. A multiple linear regression was used for predicting the change in PROMs with surgery.

RESULTS

A total of 218 eyes (of 218 patients) were analysed. Postoperative corrected distance visual acuity (CDVA) was ⩾0.3 in 89.0% (194/218) of eyes. There was a statistically significant improvement of the post-operative Catquest-9SF global average score. (p < 0.001). The change in the Catquest-9SF score significantly correlated with the change in Item 2 score (related to intermediate vision) (r = 0.634, p < 0.001). A predictive model of the change in the Catquest-9SF score was found (p < 0.001, R2: 0.527) based on preoperative Catquest-9SF total score, presence or not of macular degeneration, presence or not of intraoperative complications, age >75 years old, and preoperative CDVA.

CONCLUSIONS

Cataract surgery improves the functional vision, with some factors limiting the outcomes such as comorbidities. Self-perceived improvement in intermediate vision significantly influenced the improvement in self-assessed vision.

Global multi-site, prospective analysis of cataract surgery outcomes following ICHOM standards: the European CAT-Community

PURPOSE

To evaluate in a large sample of patients from 10 different European centers the results of cataract surgery, characterizing the relationship between patient-reported outcomes (PROMs) and clinician-reported outcome measures (CROMs).

METHODS

Prospective non-interventional multicenter observational descriptive study analyzing the clinical outcomes of a total of 3799 cases undergoing cataract surgery (mean age: 72.7 years). In all cases, the cataract surgery standard developed by the International Consortium for Health Outcomes Measurements (ICHOM) was used to register the clinical data. Three-month postoperative visual acuity and refraction data were considered CROMs, whereas Rasch-calibrated item 2 (RCCQ2) and total Catquest-9SF score (CQ) were considered PROMs.

RESULTS

Postoperative corrected distance visual acuity (CDVA) was 0.3 logMAR or better in 88.7% (2505/2823) of eyes. Mean differences between preoperative and postoperative RCCQ2 and CQ scores were -3.09 and -2.39, respectively. Visual function improvement with surgery was reported by 91.5% (2163/2364) of patients. Statistically significant, although weak, correlations of postoperative CDVA with postoperative refraction, PROMs, and complications were found (0.133 ≤ r ≤0.289, p < 0.001). A predictive model (R²: 0.254) of postoperative CDVA considering 10 variables was obtained, including preoperative CDVA, different ocular comorbidities, age, gender and intraoperative complications. Likewise, another predictive model (R²: 0.148) of postoperative CQ considering a total of 14 variables was obtained, including additionally preoperative CQ, target refraction and previous surgeries.

CONCLUSIONS

Cataract surgery provides an improved functional vision in most of patients although this improvement can be limited by ocular comorbidities and complications. The relationship between PROMs and CROMs is multifactorial and complex.

A very short version of the Visual Function Questionnaire (VFQ-3oo7) for use as a routinely applied Patient-Reported Outcome Measure

BACKGROUND

Patient-reported outcome measures (PROMs) are valuable supplements in regular care to facilitate routine monitoring of quality of life from the patient's perspective. The 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) is a widely used PROM in ophthalmology. However, the NEI-VFQ-25 is too time-consuming and cumbersome for routine evaluations in regular care. The aim of this study is to construct a 7-item questionnaire of which only 3 items are presented to the patient, by means of routing. This VFQ 3 out of 7 (VFQ-3oo7) should have a minimal loss of information compared with the NEI-VFQ-25.

METHODS

An historical database including 3293 administrations of the NEI-VFQ-25 was constructed involving patients with retinal detachment, cataract, corneal diseases, glaucoma, macular degeneration, uveal melanoma and a normal population sample. The data were subjected to Rasch analyses, in particular a generalized partial credit model. Items were sorted on the latent trait and divided into seven categories. From each category, the item with the highest discriminative value was selected. Through routing, only three out of the seven remaining questions are used, where the answers navigate patients to a fitting trait level.

RESULTS

A one-dimensional structure was considered fitting. The VFQ-3oo7 showed a small loss of information compared with the total score of the NEI-VFQ-25: correlation 0.927 and a relative precision of 0.868.

CONCLUSION

The very short, but valid, VFQ-3oo7 can be applied to evaluate the patient's perceived vision-related health status in routine evaluations of treatments in regular care, with a small burden for patients.

Evaluation of eye movements and visual performance in patients with cataract

Eye movement is an essential component of visual perception. Eye movement disorders have been observed in many eye disease, and are thought to affect various visual performance in daily life. However, eye movement behaviors of the elderly with cataract are poorly understood, and the impact of cataract surgery on eye movements has not been investigated. In this study, we observed the eye movement behaviors in thirty patients with bilateral age-related cataract while performing three performance-based tasks (visual search, face recognition and reading). Eye movements were automatically recorded by an eye tracker during task performance. We found an overall improved visual performance postoperatively, presented as elevated percentage of correctly identified objects and faces, reduced search time and increased reading speed. Eye movement parameters were found significantly altered after cataract surgery. Fixation count, total fixation duration and total visit duration were markedly increased in the visual search task and face recognition task. The proportion of regressive saccades was obviously decreased in the reading task. These eye movement parameters were found to be correlated with the measures of visual performance. Our findings suggested a potential association between the eye movement disturbance and impaired visual performance, and provided a new insight on the potential usefulness of eye movement as an objective and valid tool to understand visual impairments caused by cataract, as well as evaluate practical outcomes of cataract surgery.

A matched case-control study of the clinical, economic, and patient-reported outcomes of cystoid macular edema complicating phacoemulsification surgery

PURPOSE

To assess the visual outcomes of pseudophakic cystoid macular edema (CME) as compared with age- and copathology-matched control subjects, the costs of treatment and follow-up, and the patient-reported outcomes using the new Cat-patient-reported outcome measures (PROM) 5 questionnaire.

SETTING

West Suffolk Hospital NHS Foundation Trust, United Kingdom.

DESIGN

Matched case-control study.

METHODS

Fifty-two eyes of 49 patients developed CME over an 18-month period. Age- and copathology-matched patients were identified from clinical records over the same time period in a 2:1 ratio (90 eyes). Postoperative clinical outcomes were recorded including treatments received, costs of treatments, and patient-reported outcome measures using the Cat-PROM5.

RESULTS

Patients with CME reported a significantly worse outcome from surgery than control subjects. Furthermore, patients with CME had significantly worse visual acuity postoperatively than control subjects (CME: logarithm of the minimum angle of resolution 0.40 ± 0.33, n = 37; control subjects: 0.30 ± 0.33; P < .05) despite there being no difference in preoperative visual acuity. In patients with epiretinal membrane (ERM), notably those with CME had worse patient-reported outcomes than control subjects with ERM, and only 18% received prophylactic corticosteroid injection at surgery compared with 63.6% of control subjects. CME resulted in an excess of 266 outpatient appointments, with 388 weeks of topical therapy, 18 orbital floor injections, 6 intravitreal steroid injections, 5 intravitreal antivascular endothelial growth factor injections, and 1 intravitreal dexamethasone implant with an excess expenditure of £216.81 per case.

CONCLUSIONS

Patients developing CME after cataract surgery had reduced visual acuity at 4 to 6 weeks, patient-reported visual outcomes, and increased number of hospital appointments, treatments, and costs.

EQ-5D-5L is More Responsive than EQ-5D-3L to Treatment Benefit of Cataract Surgery

BACKGROUND

It is not clear whether 5-level EQ-5D (EQ-5D-5L) utilities based on recently developed value sets are more responsive than 3-level EQ-5D (EQ-5D-3L) utilities.

OBJECTIVES

The study aims were to compare (1) the responsiveness of EQ-5D-5L and EQ-5D-3L utilities and (2) the responsiveness of these utilities with the Short Form-6 Dimension (SF-6D) and Health Utilities Index Mark 3 (HUI3) utilities to the treatment benefit of cataract surgery.

METHODS

A total of 148 patients were interviewed before and after their cataract surgery using EQ-5D-3L, EQ-5D-5L, SF-6D, and HUI3. Responsiveness was assessed for all measures using the mean change (post-treatment-pre-treatment), standardized effect size (SES), standardized response mean (SRM), and F-statistic.

RESULTS

Using the Singapore value sets, mean change for EQ-5D-3L and EQ-5D-5L utilities was 0.016 and 0.028, SES was 0.097 and 0.199; SRM was 0.091 and 0.196; and F-statistic was 1.2 and 5.7, respectively. Similar trends were observed using the UK/England EQ-5D value sets, although the magnitude was slightly smaller. The mean change, SES, SRM and F-statistics for SF-6D (UK value set) were 0.020, 0.234, 0.249, and 9.2, respectively. The values of mean change, SES, SRM and F-statistics for HUI3 (Canada value set) were 0.080, 0.472, 0.474, and 33.3, respectively.

CONCLUSIONS

The EQ-5D-5L utilities tend to be more responsive than the EQ-5D-3L utilities to treatment benefits of cataract surgery. The HUI3 utilities are more responsive than both the EQ-5D-5L and SF-6D, and SF-6D utilities may be slightly more responsive than the EQ-5D-5L for assessing patients undergoing cataract surgery.

Assessing the construct validity and responsiveness of Preference-Based Measures (PBMs) in cataract surgery patients

PURPOSE

The validity and responsiveness of the EQ-5D-3L in visual conditions has been questioned, inspiring development of a vision 'bolt-on' domain (EQ-5D-3L + VIS). Developments in preference-based measures (PBM) also includes the EQ-5D-5L and the ICECAP-O capability wellbeing measure. This study aimed to examine the construct validity and responsiveness of the EQ-5D-3L, EQ-5D-5L, EQ-5D-3L + VIS and ICECAP-O in cataract surgery patients for the first time, to inform choice of PBM for economic evaluation in this population.

METHODS

The analyses used data from the UK Predict-CAT cataract surgery cohort study. PBMs and the Cat-PROM5 [a validated measure of cataract quality of life (QOL)] were completed before surgery and 4-8 weeks after. Construct validity was assessed using correlations and known-group differences evaluated using regression. Responsiveness was evaluated using effect sizes and analysis of variance to compare change scores between groups, defined by patient-reported and clinical outcomes.

RESULTS

The sample comprised 1315 patients at baseline. No PBMs were associated with visual acuity and only the ICECAP-O (Spearman's rs =  - 0.35), EQ-5D-3L + VIS (rs =  - 0.42) and EQ-5D-5L (Value Set for England rs =  - 0.31) correlated at least moderately with the Cat-PROM5. Effect sizes of change were consistently largest for the EQ-5D-3L + VIS (range 0.34-0.41), followed by the ICECAP-O (range 0.20-0.34). Results indicated no improvement in responsiveness using the EQ-5D-5L (range 0.13-0.16) compared to the EQ-5D-3L (range 0.17-0.20).

CONCLUSIONS

Whilst no PBMs comprehensively demonstrated evidence of construct validity and responsiveness in cataract surgery patients, the ICECAP-O was the most responsive generic PBM to improvements in QOL. Surprisingly the EQ-5D-5L was not more responsive than the EQ-5D-3L in this setting.

Effects of clinical parameters on patient-reported outcome in cataract patients: a multicentre study

PURPOSE

Ophthalmologists tend to evaluate the results of cataract surgery by focusing on the clinical visual and refractive outcomes and the incidence of complications, where patients' main interest might be their ability to perform daily activities. Therefore, there appears to be a need for optimizing effective communication between patients and ophthalmologist about the outcome of cataract surgery. The aim of this multicentre study was to determine the effects of whether the surgery was performed in one or two eyes, ocular comorbidity and per- and postoperative complications on visual function experienced by patients measured with the Catquest-9SF.

METHODS

To measure patient-reported outcomes, Catquest-9SF data were collected between 2014 and 2015 in five Dutch hospitals. Data from 870 pairs of questionnaires - completed before and after cataract surgery - were compared with clinical data. Clinical data, retrieved from patients' medical files, consisted of one or two eye surgery, ocular comorbidity and per- and postoperative complications.

RESULTS

Quality of vision improved more in patients who had surgery in both eyes and had fewer postoperative complications (both p < 0.001). We found a nonsignificant trend that quality of vision was worse when ocular comorbidity was present. No significant effect of peroperative complications was observed.

CONCLUSION

Our results emphasize the added value of the Catquest-9SF as a tool for visual function experienced by patients; the additional information can complement clinical parameters to improve patient-centred approaches in clinical practice.

Mapping standard ophthalmic outcome sets to metrics currently reported in eight eye hospitals

BACKGROUND

To determine alignment of proposed international standard outcomes sets for ophthalmic conditions to metrics currently reported by eye hospitals.

METHODS

Mixed methods comparative benchmark study, including eight eye hospitals in Australia, India, Singapore, Sweden, U.K., and U.S. All are major international tertiary care and training centers in ophthalmology. Main outcome measure is consistency of ophthalmic outcomes measures reported.

RESULTS

International agreed standard outcomes (ICHOM) sets are available for cataract surgery (10 metrics) and macular degeneration (7 metrics). The eight hospitals reported 22 different metrics for cataract surgery and 2 for macular degeneration, which showed only limited overlap with the proposed ICHOM metrics. None of the hospitals reported patient reported visual functioning or vision-related quality of life outcomes measures (PROMs). Three hospitals (38%) reported rates for uncomplicated cataract surgeries only. There was marked variation in how and at what point postoperatively visual outcomes following cataract, cornea, glaucoma, strabismus and oculoplastics procedures were reported. Seven (87.5%) measured post-operative infections and four (50%) measured 30 day unplanned reoperation rates.

CONCLUSIONS

Outcomes reporting for ophthalmic conditions currently widely varies across hospitals internationally and does not include patient-reported outcomes. Reaching consensus on measures and consistency in data collection will allow meaningful comparisons and provide an evidence base enabling improved sharing of "best practices" to improve eye care globally. Implementation of international standards is still a major challenge and practice-based knowledge on measures should be one of the inputs of the international standardization process.