Validity of Newly Developed Appropriateness Criteria for Cataract Surgery

Development and Validation of a Visual Symptom-Specific Patient-Reported Outcomes Instrument for Adults With Cataract Intraocular Lens Implants

PURPOSE

To develop a patient-reported outcome measure for capturing visual and ocular symptoms before and after implantation of intraocular lenses (IOLs) for treatment of cataracts.

DESIGN

Questionnaire development and validation study.

METHODS

The Questionnaire for Visual Disturbances (QUVID) was developed based on a literature and instrument review; 13 clinician interviews among ophthalmologists in the United States and Europe; and 67 hybrid qualitative patient interviews among adult patients in the United States and Australia before and/or after monofocal, traditional multifocal, or trifocal IOL implantation. Assessment of the QUVID's psychometric properties was conducted via a noninterventional cross-sectional study of previously treated cataract patients in the United States, Canada, and Australia (n = 150), and assessment of ability to detect meaningful change via 2 pivotal US clinical trials among patients with trifocal or extended vision IOL compared with monofocal IOL controls (n = 457).

RESULTS

The QUVID includes subitems about the bothersomeness of 7 visual symptoms: starburst, halo, glare, hazy vision, blurred vision, double vision, and dark areas. The postoperative version contains 1 item asking the respondents whether their symptoms bothered them enough to want another surgery, if the IOL was the cause.

CONCLUSIONS

The QUVID was reviewed by the US Food and Drug Administration and found appropriate as a fit-for-purpose measure, demonstrating requisite evidence for content validity, construct validity, reliability, and ability to detect change.

Beyond visual acuity: Patient-relevant assessment measures of visual function in retinal diseases

PURPOSE

To identify patient-reported outcomes (PROs) and other clinical outcome measures (contrast sensitivity (CS), low-luminance visual acuity (LLVA) and reading acuity or reading speed (RA-RS)), relevant to patients with age-related macular degeneration (AMD) or diabetic retinopathy (DR), which would be recommended for use in clinical practice.

METHODS

The RAND/UCLA Appropriateness Method, based on the synthesis of the scientific evidence and the collective judgment of an expert panel using the two-round Delphi method, was applied. The evidence synthesis was performed by searching for articles on outcome measures for AMD and/or DR published between 2005 and 2018 in English or Spanish. The expert panel consisted of 14 Spanish ophthalmologists, who rated the recommendation degree for each outcome measure on a scale of 1 (extremely irrelevant) to 9 (maximum relevance). The recommended outcome measures were established according to the panel median score and the level of the panelists' agreement.

RESULTS

Through the evidence search, 33 PRO-specific questionnaires (21 for visual function, six for AMD, three for DR, one for AMD and DR) and two treatment satisfaction questionnaires (one on AMD and one on DR) were identified. In addition, 21 methods were found for measuring CS, five for LLVA, and nine for RA-RS. According to the panel ratings, 11 of the 64 outcome measures evaluated for AMD, and seven of the 61 evaluated for DR were recommended.

CONCLUSION

The AMD and DR outcome measures recommended will help ophthalmologists choose the outcome measure most appropriate for their patients. Furthermore, the use of PROs will contribute to shifting clinical practice towards patient-centered medicine.

Rethinking Elective Cataract Surgery Diagnostics, Assessments, and Tools after the COVID-19 Pandemic Experience and Beyond: Insights from the EUROCOVCAT Group

The progressive deterioration of the visual function in patients on waiting lists for cataract surgery has a negative impact on their quality of life, especially in the elderly population. Patient waiting times for cataract surgeries in many healthcare settings have increased recently due to the prolonged stop or slowdown of elective cataract surgery as a result of coronavirus disease 19 (COVID-19). The aim of this review is to highlight the impact of such a "de-prioritization" of cataract surgery and to summarize some critical issues and useful hints on how to reorganize cataract pathways, with a special focus on perioperative diagnostic tools during the recovery phase and beyond. The experiences of a group of surgeons originating from nine different countries, named the European COVID-19 Cataract Group (EUROCOVCAT), have been combined with the literature and recommendations from scientific ophthalmic societies and healthcare institutions. Key considerations for elective cataract surgery should include the reduction of the number of unnecessary visits and examinations, adoption of precautionary measures, and implementation of telemedicine instruments. New strategies should be adopted to provide an adequate level of assistance and to guarantee safety conditions. Flexibility will be the watchword and regular updates would be necessary following scientific insights and the development of the pandemic.

Correlation among Lens Opacities Classification System III grading, the 25-item National Eye Institute Visual Functioning Questionnaire, and Visual Function Index-14 for age-related cataract assessment

Purpose

To evaluate the relationship between cataract types and subjective visual function among patients with age-related cataract.

Methods

This was a prospective, multicenter, 831 Chinese patient-based, cross-sectional study. Patients were administered the Visual Function Index-14 (VF-14) and the 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) to evaluate their subjective visual function. Lens Opacities Classification System III (LOCS III) was used to evaluate the type of cataract. Relationships among these parameters were analyzed.

Results

LOCS III cortical (C) and posterior subcapsular scores are negatively associated with VF-14 (r = − 0.188, P < 0.01; r = − 0.146, P < 0.01) and total score of NEI-VFQ-25 (r = − 0.223, P < 0.01; r = − 0.160, P < 0.01), respectively; LOCS III nuclear opalescence (NO) score is positively associated with VF-14 (r = 0.087, P < 0.05) and total score of NEI-VFQ-25 (r = 0.097, P < 0.05). In multiple linear regression, a decrease in the LOCS III C score is a significant predictor for improvement of the total score of NEI-VFQ-25 (β = − 1.286, P < 0.05). In contrast, an increase in LOCS III NO score is a significant predictor for improvement of VF-14 (β = 3.826, P < 0.01) and total score of NEI-VFQ-25 (β = 4.618, P < 0.01). Patients with LOCS III C score ≤ 2 have higher VF-14 (49.38 versus 43.74, P < 0.01), total (80.73 versus 71.58, P < 0.01) and subscale scores of NEI-VFQ-25 than patients with LOCS III C score > 2.

Conclusion

Cortical cataract has adverse effects on subjective visual function, while mild-to-moderate nuclear cataract has positive effects. Furthermore, “LOCS III C score > 2” can be a potential cutoff as a reference for cataract surgery without self-assessing questionnaires.

Electronic supplementary material

The online version of this article (10.1007/s10792-020-01353-0) contains supplementary material, which is available to authorized users.

Use of cataract surgery in urban Beijing: a post screening follow-up of the elderly with visual impairment due to age-related cataract

OBJECTIVE

To understand the perception for the use of cataract surgical services in a population of acceptors and non-acceptors of cataract surgery in urban Beijing.

METHODS

From a community-based screening program a total of 158 patients with presenting visual acuity of less than 6/18 on either eye due to age-related cataract were informed about the possibility of surgical treatment. These patients were interviewed and re-examined 36 to 46 months after initial screening. The main reasons for not accepting surgery were obtained using a questionnaire. Vision function and vision-related quality of life scores were assessed in those who received and did not receive surgery.

RESULTS

At the follow-up examination 116 of the 158 patients were available and 36 (31.0%) had undergone cataract surgery. Cases who chose surgery had higher education level than those who did not seek surgery (OR=2.64, 95% CI: 1.08-6.63, P=0.02). There were no significant differences in vision function (P=0.11) or quality of life scores (P=0.16) between the surgery group and the non-surgery group. Main reasons for not having surgery included no perceived need (50.0%), feeling of being "too old" (19.2%), and worry about the quality of surgery (9.6%). Cost was cited by 1 (1.9%) subject as the main reason for not seeking surgery.

CONCLUSIONS

The data suggest that in China's capital urban center for patients with moderate visual impairment there is a relative low acceptance rate of cataract surgery, mainly due to people's perception of marginal benefits of surgery. Cost is not a determining factor as barrier to undergo surgery and patients with poorer education are less likely to undertake surgery.

[Clinical practice variation in cataract surgery]

PURPOSE

Cataract surgery rates have dramatically increased in the last two decades. However, clinical practice variation in cataract surgery has not been thoroughly studied. The aim of this review is to analyze clinical practice variation, including the causes and consequences of this phenomenon. Then, its role in health care planning and health care quality is focused, emphasizing the importance of reducing it and providing several practical strategies to accomplish it.

RECENT FINDINGS

The latest researches are presented in this article. They identify the development and implementation of clinical practice guidelines as the best tool to standardize care processes.

CONCLUSION

Managing unwarranted or unwanted variation would improve quality of care and may lead to a significant saving in health care spending.

[Uncorrected visual function after cataract surgery]

PURPOSE

To study the relationship between refraction after cataract surgery and the use of spectacles in patients older than 65 years.

METHODS

Retrospective case control study. The study included 40 retired subjects older than 65 years-old who fulfilled our inclusion criteria. Clinical ophthalmic and optical information was collected, and patients were requested to complete a validated questionnaire of visual function (VF14) and a test of independence of spectacles. The difference between VF14 test results with and without glasses (difVF14) was calculated.

RESULTS

The study included 16 men and 24 women, with a mean age of 74 years. There was a significant correlation between difVF14 and postoperative refraction, with lower difVF14 values associated with postsurgical refraction in the range -0.50 to -1.00 D (OD 0.479 [95% CI; 0.286-0.804]). The questionnaire of independency of lenses did not show significant correlation with postoperative refraction.

CONCLUSIONS

Patients with postsurgical refraction between -0.50 and -1.00 diopters displayed better visual function without glasses than those with refraction out of that range. Neutral distant refraction and positive lenses for near vision might not be the ideal solution for every patient. Postsurgical refraction should be individualized for each patient according to their personal preferences, in order to achieve the best visual function and the best vision-related quality of life.

The Pyhäjärvi Cataract Study II. Criteria for cataract surgery

PURPOSE

It is necessary to develop tools for patient selection to target cataract surgery to patients with the best expected outcomes. We used visual acuity, visual functioning 14 (VF-14) test, the 15-dimension health-related quality-of-life questionnaire (15D) and the New Zealand priority criteria to evaluate the criteria for cataract surgery in a post hoc setting.

MATERIAL AND METHODS

Ninety-three consecutive patients living in a defined rural area in Finland had cataract surgery as a part of the Pyhäjärvi Cataract Study in 2003. Success of cataract surgery was defined as improvement of visual acuity by at least 2 lines and/or improvement of visual function measured by questionnaires.

RESULTS

The patients with a visual acuity of 0.30 logMAR (0.5 Snellen decimal) or worse in the better eye and/or 0.52 logMAR (0.3 Snellen decimal) in the worse eye had successful surgery in 59-83% of cases depending on the definition of success. When subjective judgement was added, the success rates varied between 63% and 91%.

CONCLUSION

Setting indication criteria, it seems sufficient to use two global questions in addition to visual acuity: one on the subjective view on disability, and one on a more neutral view on visual function, such as the 15D item on vision. The VF-14 did not perform any better than the single item counterparts.

Use of the patient acceptable symptom state and the minimal clinically important difference to evaluate the outcomes of cataract extraction

PURPOSE

To determine the minimal clinically important difference and the patient acceptable symptom state for visual acuity and visual function, 2 key visual outcomes for patients undergoing cataract extraction, as an aid for evaluating the outcome of cataract extraction.

DESIGN

Prospective cohort study.

METHODS

SETTING

Multicenter study of 17 hospitals.

PATIENTS

A total of 4335 consecutive patients advised to undergo cataract extraction.

MAIN OUTCOME MEASURES

Sociodemographic and clinical data, including visual acuity (VA), patient satisfaction, and responses to the Visual Function Index 14 (VF-14) and transitional questions were collected before and after cataract extraction. The patient acceptable symptom state and minimal clinically important difference were estimated for the entire sample and for subgroups by preintervention status and presence of ocular comorbidities.

RESULTS

Among patients with simple cataract, postintervention patient acceptable symptom state values for VA ranged from 0.67 to 0.80, depending on preintervention VA, while VF-14 scores ranged from 88 to 90. For patients with any additional ocular comorbidity, VA ranged from 0.63 to 0.75, depending on preintervention VA, while VF-14 scores ranged from 86 to 92. For the entire sample, postintervention patient acceptable symptom state values were 0.75 for VA and 86.1 for VF-14 scores. Minimal clinically important difference for patients who reported being a little better ranged from 0.17 to 0.5 in VA and 0.41 to 37.46 in VF-14 scores, depending on preintervention status and presence of ocular comorbidities.

CONCLUSION

The minimal clinically important difference and patient acceptable symptom state values are complementary parameters that may help in the clinical decision-making process by providing more meaningful estimates of the impact of cataract extraction on 2 important outcomes, visual acuity and visual function.

Interhospital variation in appropriateness of cataract surgery

OBJECTIVE

The aim of this study was to analyse the inter-hospital variation in the appropriateness of cataract phacoemulsification in Spain.

METHODS

This observational, multicentre, prospective study involved patients aged 18-90 years. Each phacoemulsification intervention was classified as 'necessary', 'appropriate', 'uncertain' or 'inappropriate' according to explicit appropriateness criteria previously established using the RAND/UCLA methodology. A descriptive statistical analysis was performed, followed by univariate and multivariate logistic regression analysis, in order to examine the differences between hospitals.

RESULTS

In total, 5063 patients from 15 hospitals were enrolled. The percentage of patients in each hospital who inappropriately underwent phacoemulsification varied from 1.2% to 24.0% (P < 0.0001). The most common inappropriate scenario was that of patients with a simple, unilateral cataract with no limitation of their visual function, with a pre-surgery visual acuity of ≥ 0.5 in both eyes, and for whom surgical correction would involve low technical complexity.

CONCLUSIONS

The variation in appropriateness of phacoemulsification cannot be attributed solely to the clinical differences between the hospitals' patients. There is room for improvement in the appropriate indication of phacoemulsification. Measures based on the dissemination of appropriateness criteria might improve quality of care.

Waiting time for cataract extraction: Predictive factors and influence on outcomes

PURPOSE

To identify variables related to time spent on a waiting list for cataract extraction and the effect of waiting time on some outcomes.

SETTING

Twelve ophthalmology units throughout Spain.

DESIGN

Cohort study.

METHODS

This study included consecutive patients scheduled to have cataract removal by phacoemulsification. Sociodemographic and clinical data, including visual acuity, and Visual Function Index 14 (VF-14) results were collected before and after cataract extraction. Univariate and multivariate linear regression was performed to identify variables related to time on the waiting list for cataract extraction and the influence of waiting time on postoperative visual acuity, visual function, and complications.

RESULTS

The study comprised 3787 patients. Patients with social support spent significantly more time (1.04 times) on the waiting list (P = .0188), while those with contralateral visual acuity better than 0.5 and those with vision-related daily living difficulties spent less time on the waiting list. Patients who waited longer than 5 months for cataract extraction had smaller gains in visual acuity than those who waited fewer than 3 months (P = .0348). Time on the waiting list did not significantly influence changes in the VF-14 results or complications from surgery.

CONCLUSIONS

The finding that some contradictory sociodemographic factors influence time spent on a waiting list for cataract extraction suggests that rational, explicit, and homogeneous appropriateness and priority criteria are not being applied to these patients. Use of such criteria could improve waiting times and order waiting lists so patients who need cataract extraction the most would receive it soonest.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Assessment of patient satisfaction with outcomes of and ophthalmic care for cataract surgery

PURPOSE

To assess patient satisfaction with cataract surgery care.

SETTING

Private and public health ophthalmic centers, France.

METHODS

This prospective longitudinal multicenter observational study enrolled patients attending consultation for a preoperative visit from September 2007 to February 2008. Patients were eligible if they had uncomplicated cataract and agreed to participate. At the preoperative visits, medical data and disease history were collected. At the first postoperative visit (at 1 to 7 days), the following data were collected: patient status, surgical procedure, and follow-up (patient management, complications, medications). Patients completed a questionnaire after each visit to assess satisfaction with their management and follow-up before, during, and after surgery (up to 30 days postoperatively).

RESULTS

Of the 781 patients enrolled by 91 ophthalmologists, 41 were excluded for not meeting eligibility criteria, leaving 740 patients in the statistical analysis. Cataract extraction was by phacoemulsification. The incision was 2.2 to 3.2 mm in 94.7% of cases, and the intraocular lens was acrylic in 96.3% of cases. Anesthesia was mainly topical (56.8%) or local (42.1%). The most frequent postoperative treatments were nonsteroidal antiinflammatory eyedrops and combined steroidal and antibacterial eyedrops (95.9% and 94.7%, respectively). Most patients (96.4%) said the surgery results met their expectations, and 67.2% reported being able to perform activities they could not do preoperatively. Overall, 98.2% of patients said they were satisfied with their management.

CONCLUSION

Assessment of the management and follow-up of patients having cataract surgery showed that the care provided was in accordance with the expectations of French patients.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Development and validation of clinical scores for visual outcomes after cataract surgery

PURPOSE

To develop and validate a clinical score to predict visual acuity (VA) and functional changes after phacoemulsification on the basis of readily obtainable preoperative history data and patient assessment.

DESIGN

Prospective follow-up study.

PARTICIPANTS

A sample of 5512 patients on waiting lists for phacoemulsification at 17 hospitals in Spain.

METHODS

Data were obtained at the baseline examination from the 5512 patients. The patients were divided randomly into 2 subgroups: derivation (n = 3285; 60%) and validation (n = 2227; 40%). The preoperative predictors of postoperative gains in VA and visual function index 14 (VF-14) were determined by multivariate logistic regression analysis and implemented using a prediction score.

MAIN OUTCOME MEASURES

Probability of postoperative improvement in VA and VF-14 scores. The cutoff points were established for each outcome on the basis of the minimal clinically important difference values.

RESULTS

The predictive variables for VA gain were the baseline VA, patient age, ocular comorbidity, and surgical complexity. Regarding the VF-14, the predictive factors were the preoperative VF-14, the eye with the better VA, and the surgical complexity. In the multivariate logistic model in the derivation sample, the final VA and VF-14 scores ranged from 0 to 44 and from 0 and 24, respectively. Receiver operating characteristic curves were developed in the derivation and validation samples, and no statistical significance was found when their areas under the curve were compared. Areas under the curve ranged from 65% to 80%. Both scores had a positive predictive value from 74% to 85%.

CONCLUSIONS

Newly developed and validated clinical prediction scores may assist physicians and patients in decision making about the expected outcomes and benefits of cataract surgery.

Potential for 2 priority systems to be used as appropriateness of indication tools for cataract surgery

OBJECTIVE

To test 2 systems developed to prioritize patients on waiting lists for cataract surgery, the Western Canadian Waiting List (WCWL), and the Catalan Agency for Health Technology Assessment and Research Cataract Priority System (CCPS), as tools for judging the appropriateness of the intervention.

DESIGN

Cross-sectional study with follow-up.

PARTICIPANTS

A total of 1723 prospective patients awaiting cataract extraction in 5 hospitals were included in the study.

METHODS

Priority scores using the WCWL and the CCPS systems were calculated and compared with visual acuity (VA) and visual function, measured by the Visual Function-14 index, before and after surgery. The sensitivity of each priority system to different groups was evaluated using a validated appropriateness of indications tool for cataract extraction. One-way analysis of variance and the Jonckheere-Terpstra test were used to detect differences in group scores. Spearman correlation coefficients were also examined.

RESULTS

The WCWL and CCPS systems produced different mean values according to the preoperative levels of VA and visual function (p < 0.0001). Neither system showed a significant difference in mean scores based on gains in VA and visual function. Both systems produced different mean scores according to the different groups of appropriateness set by the appropriateness of indications tool for cataract (p < 0.0001).

CONCLUSIONS

Given that appropriateness tools should correlate with outcomes, we recommend using neither the WCWL nor the CCPS for appropriateness purposes. Incorporating new criteria into these systems may improve the correlation with important outcomes and their adequacy for use as appropriateness tools.

Can an appropriateness evaluation tool be used to prioritize patients on a waiting list for cataract extraction?

OBJECTIVES

To determine whether a system originally developed to ascertain the appropriateness of cataract intervention may also be used to prioritize patients on cataract extraction waiting lists.

METHODS

The IRYSS-appropriateness of indication for cataract surgery tool and the IRYSS-Cataract Priority Score were applied to a sample of 5448 patients consecutively placed on waiting lists for cataract surgery. Clinical data were gathered by ophthalmologists, and patients self-completed the Visual Function Index-14. The general linear model (GLM) was used to assign scores to the categories of the appropriateness and priority criteria. The relationship between both systems was evaluated by correlating scores. To assess the validity of the new appropriateness and priority scores, correlations with visual acuity (VA) and visual function were calculated.

RESULTS

The GLM method generated highly similar scores for both appropriateness and prioritization systems. The correlation between scores was very strong (r=0.96). The appropriateness scoring system correlated 0.29 with VA and 0.21 with gain in visual function. The priority system correlated -0.54 with VA and -0.28 with preintervention visual function.

CONCLUSIONS

The new appropriateness scoring system strongly correlates with the priority scoring system. This easy-to-use appropriateness rating could serve as a tool for simultaneously assessing the appropriateness of cataract surgery and assigning priority.