Preoperative Vision and Surgeon Volume as Predictors of Visual Outcomes after Cataract Surgery.

PURPOSE: To evaluate the relationship between preoperative vision and surgeon volume with visual outcomes after cataract surgery. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients aged ≥18 years old enrolled in the Kaiser Permanente Southern California Health Plan who underwent cataract surgery by nontrainee surgeons. METHODS: Patients who underwent cataract surgery between January 1, 2013 and December 31, 2015, were included. A multivariate analysis using Generalized Additive Mixed Models was performed to determine the relationship between surgeon volume and postoperative visual acuity after controlling for patient age, preoperative visual acuity, history of diabetes, and history of diabetic retinopathy. Modeling was done for the relationship between preoperative vision and visual outcomes while controlling for surgeon volume, patient age, history of diabetes, and history of diabetic retinopathy. MAIN OUTCOME MEASURE: Absolute letter change and percentage of patients to achieve ≥5 Early Treatment Diabetic Retinopathy Study (ETDRS) letter gain postoperatively. RESULTS: There were 103 920 cataract surgeries performed by 136 surgeons included in this analysis. Patients whose surgeons performed <91.0 surgeries/year (95% confidence interval [CI], 61.1-139; P < 0.05) gained fewer letters postoperatively than the overall average, whereas those whose surgeons performed >91 but <227 surgeries/year (95% CI, 169-∞; P < 0.05) gained more letters than average. Although statistically significant, the difference between the lowest and highest performing surgeons was approximately 1.25 letters. Surgeons who performed <110 surgeries/year (95% CI, 81.7-149; P < 0.05) had fewer patients who gained ≥5 letters. Surgeons who performed >110 but <293 surgeries/year (95% CI, 232-∞; P < 0.05) were approximately 15% more likely to have patients who gained ≥5 letters. Patients with preoperative vision <74.7 letters (95% CI, 74.7-74.8; P < 0.05) and <75.8 letters (95% CI, 75.8-75.9; P < 0.05) gained more letters and were more likely to gain ≥5 letters postoperatively, respectively. CONCLUSIONS: Patients whose vision is approximately 20/32 or worse are more likely to have significant visual gains after cataract surgery. Although statistically significant differences exist in postoperative vision based on surgeon volume, these do not appear to be clinically meaningful. Overall, visual outcomes are functionally comparable across a wide range of surgeon volumes.

Centralized Reading Center Improves Quality in a Real-World Setting.

BACKGROUND AND OBJECTIVE: Diabetic retinopathy (DR) screening is standard of care, but its utility diminishes unless high quality is maintained. This project describes the improvement in diagnostic accuracy achieved at a large health maintenance organization by implementing a centralized reading center. PATIENTS AND METHODS: Data were extracted from the electronic health records of patients with diabetes who underwent DR screening between January 1, 2009, and December 31, 2013, at 13 medical centers. Certified ophthalmic assistants and technicians were trained to read DR images under the supervision of a retinal specialist. This program was pilot-tested prior to full implementation. RESULTS: DR prevalence among the 13 centers in 2009 was 10.1%, far below the national average. After implementation, prevalence increased to 22.1%. The program also resulted in improved access to follow-up. CONCLUSION: The results demonstrate the value of a reading center in decreasing diagnostic error and achieving other improvements in a real-world setting.