There are over 50,000 cataract surgeries performed at Department of Veterans Affairs (VA) health facilities every year and more than 3 million throughout the country, but there has never been a system in place to collect detailed patient outcomes on a national level, in either the private or public sectors.
Dr. David Vollman, 34, an ophthalmologist in only his second year working at the St. Louis VA Medical Center, helped organize and implement a pilot project for tracking cataract surgery results that will lead to the creation of a national VA database. This information will help in the improvement and refinement of current medical practices, benefiting veterans and the general population.
“It is setting the standard for how surgical care and the patient’s experience will be documented from start to finish,” said Dr. Amy Chomsky, chief of ophthalmology at the VA Tennessee Valley Healthcare System Center. “Academic and private healthcare systems are starting to catch on, observing and learning from VA.”
A cataract is a clouding of the eye’s natural lens and is the leading cause of vision loss in adults 55 years and older. Cataract surgery is the most common ophthalmic surgical procedure performed by the VA and in the Medicare system.
Clinicians, however, have never had access to broad data on questions such as what medicines were used, if the patient’s quality of life improves or even if the expected outcome was achieved. The new VA database will include information on patient conditions and risk factors before and after the procedure, enabling ophthalmologists to make better recommendations about surgery, provide enhanced patient care and, ultimately improve the quality of the procedure’s results.
“We had nothing to measure outcomes and show what works and what is most cost-effective,” said Dr. James Shepherd, chief of ophthalmology at the St. Louis VA Medical Center.
When Vollman started his ophthalmology job, a three-year, five-site pilot program on cataract surgery results had begun, but there were potentially hundreds of questions that could be asked for the study and decisions had to be made on which to use.
“Dave determined a smaller, more manageable set of study goals, as well as the methods for collecting and analyzing the data,” Shepherd said. “The results of this work may reach beyond eye care and may be replicated in other surgical practices.”
With his combined post-graduate degree in business administration and medicine, and an interest in statistics and systems analysis, Vollman not only helped craft the questions, he co-wrote the bulk of the preliminary analysis and recommendations when the study was completed.
The results answered at least one very important question—whether or not complication rates for cataract surgery in the VA health care system were higher than in private-sector hospital systems. The project validated that the rates are quite low and comparable to the private sector, Shepherd said.
With the conclusion of the pilot project, Vollman was selected for a lead role on a follow-up pilot now underway, to collect and study similar data from across the Veterans Health Administration (VHA), the VA’s health system.
For this project, Vollman worked both with fellow clinicians and software developers to build a tool for collecting meaningful data sets that practitioners find useful and user-friendly. From scratch, they created the online templates that clinicians across VHA will use to enter information about each patient’s condition and experiences before, during and after surgery.
Cataract surgery has a success rate of more than 90 percent nationally and very low rates of post-operative complications. But without taking a broad look at results, it is difficult to see patterns and address what goes wrong. Use of the new system could help make the procedure even safer.
“A lot of our complications occur very infrequently, so to determine risk factors we need a large data set that is only available across VA,” Vollman said.
For example, if there is a problem with a particular procedure or device, it won’t be recognized within individual clinics, said Dr. Mary Lawrence, deputy director of the joint VA and Department of Defense Vision Center of Excellence. But a view across the entire national system will catch complications almost in real time, she said. “We need a better process to reduce human errors in the operating room as well as equipment malfunctions and adverse reactions to drugs.”
Elizabeth Baze, staff ophthalmologist at the Houston VA Medical Center, said that with the data collected from specific surgeries, we will be “looking at our patients and telling them the odds of a good outcome and the odds of a poor outcome. If the data show someone is likely to have a bad outcome, we might recommend other options.”
Vollman found that working as an ophthalmologist in the VHA he has a great balance between providing surgical care and his interest in process and quality improvement.
“My main priority is providing quality patient care for the veterans,” he said. “I get to build strong relationships and impact patients’ lives over a long period of time.”