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  • Measure Summary
  • NQMC:010052
  • Oct 2015

Ambulatory surgery: percentage of cataract surgery patients who have an unplanned anterior vitrectomy.

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

Primary Measure Domain

Related Health Care Delivery Measures: Use of Services

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy.

Rationale

The need for unplanned anterior vitrectomy is an unanticipated event that can decrease the probability of good postoperative visual acuity, and generally result in worse long-term outcome after cataract surgery. Because cataract surgery is the most common surgery performed in Ambulatory Surgery Centers (ASCs), with millions being performed every year, even low unplanned anterior vitrectomy rates translate to relatively high total numbers of affected patients. ASCs can help keep rates low by tracking and comparing rates to established benchmarks, and facilitating mentoring as needed.

Clinical Practice Guidelines
No clinical practice guidelines addressing unplanned anterior vitrectomy in cataract surgery are available at this time. However, rates of unplanned anterior vitrectomy have been published in the clinical literature, and can serve as comparative benchmarks of performance.

Evidence for Rationale

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

Primary Health Components

Ambulatory Surgery Center (ASC); cataract surgery; anterior vitrectomy

Denominator Description

All cataract surgery patients (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

All cataract surgery patients who had an unplanned anterior vitrectomy (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

The measures included in this implementation guide have been developed using a multi-step process. Each has been vetted with both an internal panel of technical experts and an external panel of individuals and/or organizations with relevant expertise. All of the measures have been pilot tested in Ambulatory Surgery Centers (ASCs) and assessed for validity, feasibility and reliability.

Evidence for Extent of Measure Testing

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

State of Use

Current routine use

Current Use

Monitoring and planning

Public reporting

Measurement Setting

Ambulatory Procedure/Imaging Center

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

All ages

Target Population Gender

Either male or female

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All cataract surgery* patients

*Refer to the original measure documentation for specific Current Procedural Terminology (CPT) codes for cataract surgery.

Exclusions
None

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
All cataract surgery patients who had an unplanned anterior vitrectomy*

*Unplanned anterior vitrectomy: An anterior vitrectomy that was not scheduled at the time of the patient's admission to the Ambulatory Surgery Center (ASC).

Exclusions
None

Numerator Search Strategy

Encounter

Data Source

Administrative clinical data

Paper medical record

Other

Type of Health State

Proxy for Health State

Instruments Used and/or Associated with the Measure

Sample Data Collection Sheet: Unplanned Anterior Vitrectomy

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Does not apply to this measure (i.e., there is no pre-defined preference for the measure score)

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Unplanned anterior vitrectomy.

Measure Collection Name

Ambulatory Surgery Center (ASC) Quality Measures

Submitter

Ambulatory Surgery Center (ASC) Quality Collaboration - Health Care Quality Collaboration

Developer

Ambulatory Surgery Center (ASC) Quality Collaboration - Health Care Quality Collaboration

Funding Source(s)

Ambulatory Surgery Center (ASC) providers; nursing, physician, and provider associations

Composition of the Group that Developed the Measure

Ambulatory Surgery Center (ASC) providers; nursing, physician, and provider associations; provider accrediting organizations

Financial Disclosures/Other Potential Conflicts of Interest

None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

Source(s)

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

Measure Availability

Source available from the Ambulatory Surgery Center (ASC) Quality Collaboration Web site External Web Site Policy.

For more information, contact the ASC Quality Collaboration's Executive Director, Donna Slosburg, at E-mail: donnaslosburg@ascquality.org; Web site: ascquality.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on August 3, 2015. The information was verified by the measure developer on September 11, 2015.

Copyright Statement

No copyright restrictions apply.

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