Patient and ophthalmic care provider perceptions of cataract surgery outcome: Findings from an exploratory qualitative study

Background
Cataract is an extremely common, potentially blinding age-related condition that can be treated through cataract surgery. Currently in the UK decisions on which patients should be offered cataract surgery, and assessments of surgery outcome are primarily based on visual acuity measurements. Cataract surgery has high success rates, but in a minority of cases patients can report dissatisfaction and/or worse visual ability after surgery despite visual acuity improvements post-operatively. Little is known about patients’ decisions to have cataract surgery, their expectations of surgery outcome, and whether these match clinician assessments of surgery outcome measures.
This study aimed to explore patient and provider perceptions of outcome of cataract surgery, expectations of surgery, and understand areas of discordance between them.
Methods
This qualitative study was carried out as part of a NIHR Grant Funded Programme for Applied Research and was based in four hospital sites in the South West of England. Face-to-face or telephone interviews with patients who presented with “mismatched perceptions of outcome” i.e. patients were dissatisfied with surgery outcome even though surgery was successful and resulted in improved visual acuity, or patients were satisfied with outcome even though surgery resulted in complications and/or decrease or no improvement in visual acuity. This recruitment strategy allowed for interviews to focus on patients’ perceptions of outcome, compare with objective outcome assessments, and explore reasons for discordance.
Face to face or telephone interviews were also carried out with ophthalmologists, ophthalmic nurses and optometrists involved in post-operative care, and who had experiences with patients who presented perceptions of outcome not matching clinical outcome assessments.
Recordings were transcribed verbatim, anonymised, and analysed using thematic analysis.
Results
Interviews with seven patients and nine ophthalmic care providers were carried out.
Patients’ perception of outcome was influenced by functional aspects of their vision and its impact on vision related quality of life. Providers considered the patients perceptions of vision-related quality of life alongside visual acuity informally when considering the appropriateness of surgery for individual patients, but the outcome measured in post-operative assessments to define surgery success was visual acuity.
Factors involved in discordant perceptions of outcome were: (1) medical technology limitations e.g. unintended intraocular lens side-effects, capability of measuring and explaining the full range of patient optical experiences; (2) patient-provider communication: most often patients’ experiences and expectations of post-operative visual ability were not addressed during patient counselling, resulting in unrealistic expectations and surgery misconceptions, and precluded surgery-related decisions to be informed by patients’ preferences and experiences e.g. when considering lens power and refractive goals; (3) patient characteristics: clinical profile complexity e.g. presence of visual co-morbidities, pre-surgery visual ability, and personality were thought to influence perceived outcomes.
Individualised advice on the risks and potential outcomes of surgery, emerged as a way to improve decision-making for both patients and clinicians, and address mismatched outcome expectations. Several barriers such as time, complex care pathways, and the challenges in adopting new technologies and ways of working, were thought to impede on efforts to address current gaps.
Implications
Findings highlight the importance of patient-centred shared decision-making to address unrealistic expectations and improve clinical and patient decision-making and outcomes. Incorporating appraisals of vision-related quality of life alongside visual acuity in pre- and post-operative assessments may facilitate the inclusion of patient experiences and preferences in decision-making and outcome conversations.