Measuring surgical outcomes

guest editorial Measuring surgical outcomes

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ataract surgery volume is increasing in most parts of the world. At the same time, surgical technique is undergoing continuous development. For the surgeon, cataract surgery is exciting, and invariably the patients are both grateful and happy. They are grateful for being given the chance to have surgery as in many countries, patients have limited access to surgery. They are also grateful for their improved visual acuity and quality of vision in terms of contrast and color. The patient’s reactions may lead a surgeon to believe that the technical quality of his or her surgery is perfect. However, this is not always the case for the quality can be quite variable. How, then, can we monitor the quality of the surgery we deliver? The first thing to do is ensure proper followup. Failure to do this conveys the message to our patients—past, present, and future—that we do not really care. If we do not see our patients more than once immediately after surgery, we simply do not know the final outcome, which means we do not know whether target refraction has been reached, whether the difference in refraction achieved between eyes is acceptable, which postoperative astigmatism was achieved, and so forth. How can we improve a surgical technique if we do not know the outcomes of the present one? The need for follow-up must not be forgotten even if long waiting lists for cataract surgery force us to speed up the cataract surgery process. The second thing to do is to use a systematic followup protocol, observe our performance over time, and compare our results with those of others. By comparing our performance over time, we learn about changes, for better or for worse, in the quality of the cataract care delivered. By comparing our performance with that of others, we can learn what can be achieved. This in turn will trigger ideas to improve our own surgical technique. One way to achieve this quality control is to participate in multicenter outcome studies or in national cataract surgery databases. The European Cataract Outcome Study (ECOS)1 is an example of a multicenter outcome investigation that  2004 ASCRS and ESCRS Published by Elsevier Inc.

serves as a benchmark for participating units. The purpose of the study is to explore differences in techniques and outcomes of routine cataract surgery at these units. Data on every patient at participating units during a limited study period are analyzed. Each participant receives the outcomes of his or her patients and can compare them anonymously with those from other units. As many as 45 surgical units from 22 countries are participating in the current study (2003–2004). This year, the ECOS is turning into a web-based system for data collection and immediate online reporting for participating units through the ECOS web site (http://www.eurocat.net). The European Society of Cataract & Refractive Surgeons (ESCRS) supports the ECOS, which means participating units do not have to pay for data collection and analysis. Currently (ie, in 2004), a new outcomes study is being launched as a result of collaboration between ESCRS and the American Society of Cataract and Refractive Surgery. This study will recruit participating cataract surgeons from both sides of the Atlantic Ocean. Its purpose is similar to that of the ECOS, but the data collection will be more advanced. Another way for participating units to achieve outcomes data and to benchmark is to organize a national database on cataract surgery. Such a database exists in Sweden2 (http://www.cataractreg.com) and Denmark (http://www.katbase.dk) and is being constructed in the United Kingdom. The intention of these national databases is to achieve near 100% coverage to reflect the outcomes of routine cataract surgery at a national level. In addition to analyzing the outcomes and setting standards for participating surgeons, a large national database provides the possibility to study rare complications and perform risk analyses. The Swedish National Cataract Register (NCR) contains data on more than half a million cataract extractions performed nationwide since 1992. Rare complications that have been studied are postoperative endophthalmitis3 and unexpected postoperative aphakia. Interesting findings in outcomes studies can also initiate in-depth studies of data reported by 0886-3350/04/$–see front matter doi:10.1016/j.jcrs.2004.08.011

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the participating units or help set up randomized clinical trials. This issue of the journal contains 2 articles on unexpected postoperative aphakia based on data from the NCR. The first article (pages 2105–2110) reports results, including risk analyses, from the national database. The second (pages 2111–2115) is an in-depth study of cases from several participating surgical units. Although the primary goal of the NCR is not to serve as a source for research, the unique data collection makes such research possible. However, the most important contribution of the possibility of research based on these types of data is the sincere interest of all participating surgeons in improving the quality of cataract surgery care. Having a system for quality control, presenting the results, and continuously striving for quality improve-

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ment in cataract surgery should be the responsibility of every cataract surgeon. The resources needed for this should be part of the calculated costs of cataract surgery. Mats Lundstro¨m, MD, PhD

References 1. Lundstro¨m M, Barry P, Leite H, et al. 1998 European Cataract Outcome Study: report from the European Cataract Outcome Study Group. J Cataract Refract Surg 2001; 27:1176–1184 2. Lundstro¨m M, Stenevi U, Thorburn W. The Swedish National Cataract Register: a 9-year review. Acta Ophthalmol Scand 2002; 80:248–257 3. Montan P, Lundstro¨m M, Stenevi U, Thorburn W. Endophthalmitis following cataract surgery in Sweden; the 1998 national prospective survey. Acta Ophthalmol Scand 2002; 80:258–261

J CATARACT REFRACT SURG—VOL 30, OCTOBER 2004