A sharper image: Doctor brings outcomes into sight

Cataract patients need realistic expectations

Patients are more likely to be satisfied with a procedure’s outcomes if they start out with realistic expectations. That’s why Kansas City, MO, ophthalmologist John Hunkeler, MD, uses a functional health questionnaire and patient counseling sessions before he performs cataract surgery.

He wants to know what activities patients engage in, such as knitting or driving. How important is it to them to drive at night? Do they expect to be able to see without glasses? Do they have other complications, such as retinal deterioration, that will affect their vision even after cataract surgery? (See sample patient questionnaire, inserted in this issue.)

Since the intraocular lens cannot change shape as patients shift from distance to close vision, the surgery adjusts for one or the other. "We [usually] try to make the patient best able to see at distance and educate them about this being an endpoint," says Hunkeler. "The feedback [from outcomes measurement] tells us this is what most patients are satisfied with."

But cataract patients have individual needs, and Hunkeler maintains that good outcomes rely on meeting them.

For example, some patients like the freedom from glasses that can come with "monovision," in which the implanted lens in the nondominant eye is adjusted for seeing up close, while the dominant eye is adjusted for distance. "It’s a functional advantage for patients and a lot of people really enjoy it," he says.

But some patients may need glasses for sustained close-up activity, such as reading. Others may wish for greater clarity that comes with both eyes adjusted for distance. So now Hunkeler advises patients, "for you to see the very sharpest, you’re going to need a pair of glasses."

In fact, Hunkeler and his staff spend a good bit of time toning down unrealistic expectations on the part of patients. For example, one patient thought cataract surgery would restore his complete vision — although he had suffered a retinal stroke that caused irreversible damage.

"I thought we had clearly explained to him that we could get rid of the blur due to the cataract formation but we were not going to be able to improve his peripheral vision," says Hunkeler. "He didn’t understand that. It’s not his job to understand it; it’s our job to explain it correctly."

Questionnaire tracks patient’s progress

Hunkeler’s patients fill out a questionnaire about their functional vision preoperatively and at each follow-up visit, which typically take place one day, one week, one month, and one year after surgery. Hunkeler also keeps track of visual acuity measures of distance vision, reading vision, corrected and uncorrected vision, and corneal readings.

The questionnaire may be used to rule out cataract surgery. "All of us develop cataract formation at some point," he says. "The question is, how much does it affect their vision and impact what they’re doing? Will removal of the cataract and placement of the implant improve the patient’s life? The majority of patients with cataracts do not need surgery because they are relatively asymptomatic."

By monitoring outcomes, Hunkeler also has been able to determine that 80% of his patients who have one eye corrected for distance vision can pass a driver’s test without glasses. That rises to more than 90% when both eyes are corrected for distance. "It indicates to me we’re selecting the right implant [one that provides good outcomes]," Hunkeler says.

Hunkeler also monitors his performance by comparing visual acuity outcomes against a national database developed by Data.Site of Kansas City, KS. Data.Site provides on-line outcomes information, including uncorrected vision, best-corrected vision, deviation from expected correction, and patient satisfaction. (See editor’s note for contact information on Data.Site.)

While the outcomes information helps Hunkeler shape his practice and improve patient education, so far he says it hasn’t had much impact on negotiation of contracts with managed care organizations. "Frankly, I don’t think the managed care people are tuned into that at this point," he says.

But good outcomes means happy patients, and those patients have fueled word-of-mouth referrals, Hunkeler says.

[Editor’s note: For more information about the on-line outcomes management system, contact Data.Site Medical Information Systems, 1212 Cambridge Circle Drive, Kansas City, KS 66103. Telephone: (800) 490-9093. Fax: (913) 281-4484. Internet: www.datasite1.com.]