Factors influencing outcome satisfaction after cataract surgery: patient-reported insights from the RayPro database

Abstract

Background

Patient-reported outcome measures (PROMs) have become crucial in assessing cataract surgery, especially with increasing patient expectations. The RayPro database offers a platform for tracking PROMs after surgery. The purpose of this study is to investigate determinants of patient satisfaction following cataract surgery by analysing PROMs.

Methods

A multicentre, retrospective, observational study was conducted analysing the PROMs recorded in the RayPro database (Rayner, Worthing, UK) from May 2019 to February 2024. Inclusion criteria were age ≥ 18 years, uneventful cataract surgery, valid consent to the study, and at least 1 questionnaire response. Email questionnaires were sent at 1 week, 3 months, and 12 months postoperatively, in which patients scored their outcome satisfaction, surgeon and hospital satisfaction, spectacle independence, and dysphotopsia on a 0–10 scale. Correlations of PROMs with outcome satisfaction were determined for the overall cohort and for eyes categorized by type of implanted intraocular lens (IOL).

Results

2589 patients (2589 eyes) from 119 hospitals (26 countries) were included. Outcome satisfaction showed strong to moderate negative correlation with daytime and nighttime dysphotopsia at 3 months (r=-0.522, p < 0.001; r=-0.430; p < 0.001, respectively), strengthening at 12 months (r=-0.609, p < 0.001; r=-0.541; p < 0.001, respectively). Outcome satisfaction showed weak to no correlation with spectacle independence for distance, intermediate, and near vision at 3 months (r = 0.209, p < 0.001; r = 0.160, p < 0.001; r = 0.071, p = 0.007, respectively). Similar correlations between outcome satisfaction and dysphotopsia and between outcome satisfaction and spectacle independence were observed in monofocal as well as presbyopia-correcting IOLs. In the overall cohort, surgeon and hospital satisfaction at 1 week were strongly correlated with each other (r = 0.592, p < 0.001), while both were moderately correlated with outcome satisfaction at 3 months (r = 0.344, p < 0.001; r = 0.339, p < 0.001, respectively) and 12 months (r = 0.307, p < 0.001; r = 0.314; p < 0.001, respectively).

Conclusion

Dysphotopsia was strongly correlated with patient dissatisfaction, and the correlation strengthened over time. Outcome satisfaction was weakly correlated with spectacle independence, and moderately correlated with surgeon and hospital satisfaction. Thus, postoperative visual quality and quality of care provided by surgeon and hospital can influence patient satisfaction.

Introduction

In the era of increasingly sophisticated cataract surgery and rising patient expectations, visual acuity alone is an inadequate measure to assess the effectiveness of cataract surgery in meeting all of the patients’ visual needs [1]. There is an ongoing paradigm shift towards prioritizing functional vision outcomes, or patient-reported outcome measures (PROMs), as more comprehensive indicators of the true benefit of cataract surgery [2,3,4]. PROM questionnaires can assess visual function, visual symptoms, and vision-related quality of life, providing insights that can aid surgeons in targeting outcomes beyond quantitative visual gain which truly matter to patients, thereby improving the quality of care and increasing patient satisfaction [2, 5].

However, despite their recognized benefits in evaluating cataract surgery, PROMs are not yet widely implemented in clinical practice. While several clinically validated PROMs have been developed for use in cataract patients [5], their adoption in routine practice remains limited due to the administrative and logistical load of collecting PROMs in-person or by post [2]. Over the years, technological advances have led to the introduction of electronic modes of PROM collection, including web-based and email questionnaires. These methods are associated with lower costs, greater time efficiency, and easier integration into clinic workflow [6], thereby providing a possible solution for routine PROM collection.

The RayPro database (Rayner, Worthing, UK) is the first digital platform designed to proactively collect PROMs following cataract surgery [7]. Launched in 2019, RayPro enables surgeons to follow up consenting patients after cataract surgery with short email questionnaires at specific timepoints up to 3 years post-surgery. Patient feedback on their postoperative spectacle independence, quality of vision, and satisfaction are collated by the database to provide real-time, long-term metrics for clinical decision-making [7].

The aim of this study was to report the insights from PROMs recorded on the RayPro database over a 4-year period. We evaluated the correlations of patient satisfaction with different PROMs, namely spectacle independence, dysphotopsia, and satisfaction with surgeon and hospital, in order to identify the determinants of patient satisfaction following cataract surgery. Due to the potential confounding effect of differing visual needs in patients undergoing monofocal intraocular lens (IOL) implantation versus presbyopia-correcting IOL implantation, determinants of satisfaction were also investigated in patients categorized by type of implanted IOL.

Methods

Study design

This was a multicenter, retrospective, observational study of cataract surgery-related PROMs documented in the RayPro database from 119 hospitals across 26 countries, from May 2019 to February 2024.

Inclusion criteria for the study were age ≥ 18 years, uneventful cataract surgery, physical and cognitive ability to consent to the study and to complete the RayPro questionnaire, and a minimum of 1 response to the survey. In patients undergoing bilateral cataract surgery, only one eye was included randomly.

Exclusion criteria were refusal to consent, physical and cognitive inability to give valid consent and to complete the RayPro questionnaire, and no response to the survey. Patients with ocular comorbidities were not excluded to ensure that the study population was representative of patients undergoing cataract surgery in routine clinical practice.

The RayPro questionnaire collects no patient identifiable data. Patient responses are kept anonymous and the surgeon cannot see individual answers [7]. The RayPro database is completely anonymized, and other than patients’ feedback, the only other data collected are location (country, hospital) and date of surgery, type of IOL implanted, and date of survey completion. Positive opt-in is required for collection of email address at the time of registration. Opt-in consent is reconfirmed for each follow-up survey, enabling patients to opt-out at any time.

This study followed the tenets of the Declaration of Helsinki. Informed consent was obtained with RayPro patient information leaflets. Institutional ethical approval was not required due to the retrospective nature of the study, which involved the analysis of anonymized patient feedback voluntarily provided by participants. No surgical data was involved, there was no impact on patient treatment or outcomes, and the study fully complied with the GDPR (General Data Protection Regulation).

The RayPro database

RayPro is a comprehensive online PROM platform which is free for users of Rayner IOLs and available at a monthly subscription for users of other IOLs [7]. Patients are registered into the RayPro database by surgeons or nurses at the time of cataract surgery. Questionnaires are automatically emailed to patients at six timepoints after cataract surgery and anonymous patient responses are compiled in real time into a dashboard, which can be accessed by surgeons on their desktop browser or mobile application. Data can be filtered and analyzed by date range, country, hospital, and IOL model. A comparison view feature allows users to contrast the real-world performance of different IOLs. Data can also be exported to Microsoft Excel (Microsoft, Redmond, WA) for further analysis.

Data collection

RayPro automatically emails the PROM questionnaires at 1 week, 1 month, 3 months, 1 year, 2 years, and 3 years postoperatively. The 1-week questionnaire contains 2 questions on patient satisfaction with the surgeon and the hospital, with responses rated from 0 (not at all satisfied) to 10 (extremely satisfied). At 1 month, the clinically validated Cat-PROM5 questionnaire is emailed; a detailed description of the questionnaire is available in the literature [8]. The 3-month questionnaire contains 7 questions: 1 question on satisfaction with the outcome of surgery (rated from 0 [not at all satisfied] to 10 [extremely satisfied]), 3 questions on frequency of spectacle use for distance, intermediate, and near activities (rated from 0 [always] to 10 [never]), 1 question on whether target refraction was achieved (response choices: yes/no/not sure), and 2 questions on presence of dysphotopsia during day and night (rated from 0 [never] to 10 [frequent and bothersome]). The 1-year questionnaire contains 6 questions: 1 question on satisfaction with the outcome of surgery (rated from 0 to 10), 2 questions on presence of dysphotopsia during day and night (rated from 0 to 10), and 3 questions on whether patient has undergone additional corneal laser procedures, intraocular laser procedures, or supplementary IOL implantation (response choices: yes/no). The same questions on additional laser or IOL procedures comprise the 2- and 3-year questionnaires.

For this study, data collected by the RayPro database at 1 week, 3 months, and 12 months were analyzed.

Statistical analysis

Descriptive statistics (mean, standard deviation) were used to summarize spectacle independence, dysphotopsia, and satisfaction outcomes. Correlations of outcome satisfaction with other PROMs were determined using Pearson’s correlation coefficient (r). Subgroup analyses were performed based on the IOL type (monofocal, extended depth-of-focus or EDOF, and trifocal) and material (hydrophobic acrylic versus hydrophilic acrylic) to avoid potential confounding due to differences in the implanted IOLs. Mann-Whitney U and Kruskal-Wallis tests were used to compare differences between groups. A p < 0.05 was considered statistically significant.

Results

Demographics

A total of 6557 patients were registered in the RayPro database during the study period, of which 3968 patients were excluded and 2589 patients (2589 eyes) were included in the study, as per the inclusion and exclusion criteria (Fig. 1). Among the 2589 included patients, 1645 (64%) responded at 1 week, 1487 (57%) responded at 3 months, and 681 (26%) responded at 1 year. Table 1 shows the demographic details.

Fig. 1

Flowchart of patient inclusion and exclusion

Table 1 Demographic data. IOL = intraocular lens

Outcomes in the overall cohort

Table 2A shows satisfaction, spectacle independence, and dysphotopsia scores on a 0–10 scale (0 = lowest satisfaction / spectacle independence / dysphotopsia, and 10 = highest satisfaction / spectacle independence / dysphotopsia.

Table 2 A. Results of questionnaire answers (0—lowest; 10—highest)

Table 2 B. results of questionnaire (0– lowest; 10– highest) categorized by lens material

Table 2 C. results of questionnaire (0– lowest; 10– highest) categorized by lens type

At 3 months, mean spectacle independence was greater for distance (7.65 ± 3.7; n = 1471) than for intermediate and near vision (6.94 ± 3.7; n = 1464, and 5.57 ± 4.1; n = 1458, respectively). Mean daytime and nighttime dysphotopsia scores decreased slightly from 3 months to 12 months (3.05 ± 2.8; n = 476 to 2.73 ± 2.7 ;n = 678, and 3.35 ± 3.0; n = 472 to 2.78 ± 2.7; n = 669, respectively). Mean outcome satisfaction was maintained at similar levels from 3 months to 12 months (8.43 ± 2.0; n = 1487, to 8.23 ± 2.2; n = 681).

Outcomes by answer to target refraction question

Outcomes were compared between patients responding “yes” (n = 1043; 72.8%) and “no” (n = 143; 10%) to target refraction question at 3 months (patients who were “not sure” (n = 247; 17.2%) were excluded from the analysis). The “yes” group had higher outcome satisfaction at 3 months and 12 months (p < 0.001 for both timepoints). While near-distance spectacle independence at 3 months was comparable (p = 0.043), greater spectacle independence for distance and intermediate vision was observed in the “yes” group (p < 0.001). Lower daytime and nighttime dysphotopsia scores were noted in the “yes” group at 3-month and 12-month timepoints (p < 0.001).

Outcomes by IOL material and type

There were no statistically significant differences in spectacle independence, dysphotopsia, and outcome satisfaction between hydrophobic and hydrophilic lens material (Table 2B).

On comparing monofocal, EDOF, and trifocal IOLs, spectacle independence scores at all distances were highest with trifocal IOLs (p < 0.001) (Table 2C). There were no significant differences in daytime and nighttime dysphotopsia at 3 months (p = 0.419 and p = 0.648, respectively), daytime dysphotopsia at 12 months (p = 0.775), and outcome satisfaction at 3 months and 12 months (p = 0.268, and p = 0.751, respectively).

Correlations of PROMs in the overall cohort

Table 3 shows correlations between outcomes in the overall cohort. At 3 months, outcome satisfaction showed weak to negligible positive correlations with spectacle independence (distance: r = 0.209, p < 0.001; intermediate: r = 0.160, p < 0.001; near: r = 0.071; p = 0.007). In comparison, outcome satisfaction showed strong to moderate negative correlation with daytime and nighttime dysphotopsia at 3 months (r=-0.522; p < 0.001, and r=-0.430; p < 0.001, respectively), which strengthened at 12 months (r=-0.609; p < 0.001, and r=-0.541; p < 0.001, respectively).

Table 3 Pearson correlations. Outcomes satisfaction correlated with spectacle independence and dysphotopsia

Outcome satisfaction at 3 months and 12 months showed moderate positive correlations with surgeon (r = 0.344; p < 0.001, and r = 0.307; p < 0.001, respectively) and hospital (r = 0.339; p < 0.001, and r = 0.314, p < 0.001, respectively) satisfaction at 1 week.

Correlations of outcomes by answer to target refraction question

Outcome satisfaction showed moderate positive correlations with surgeon satisfaction (r = 0.344, p < 0.001) and hospital satisfaction (r = 0.339, p < 0.001) at 1 week, and moderate to weak positive correlations with spectacle independence at 3 months (distance: r = 0.209, p < 0.001; intermediate: r = 0.160, p < 0.001; near: r = 0.071, p = 0.007). At 12 months, outcome satisfaction and dysphotopsia showed moderate negative correlations in the “yes” group and (daytime dysphotopsia: r=-0.480, p < 0.001; nighttime dysphotopsia: r=-0.509, p < 0.001) and strong negative correlations in the “no” group (daytime dysphotopsia: r=-0.745, p < 0.001; nighttime dysphotopsia: r=-0.661, p < 0.001). A moderate positive correlation was observed between outcome satisfaction at 3 months and 12 months in the “yes” group (r = 0.372, p < 0.001), while a strong positive correlation was seen in the “no” group (r = 0.689, p < 0.001). In both groups, a strong positive correlation was observed between surgeon and hospital satisfaction at 1 week (“yes” group: r = 0.656, p < 0.001; “no” group: r = 0.686, p < 0.001).

Correlations of outcomes by IOL type

Table 4 shows correlations of outcomes categorized by IOL type.

Table 4 Correlations by lens type (Trifocal, EDOF and Monofocal)

Outcome satisfaction showed weak to negligible positive correlations with spectacle independence at 3 months for all IOL types, except for moderate positive correlation with spectacle independence at distance with EDOF IOLs (r = 0.332, p < 0.001).

At 3 months, outcome satisfaction with all IOL types showed strong to moderate negative correlations with daytime and nighttime dysphotopsia. At 12 months, negative correlation of outcome satisfaction with daytime dysphotopsia strengthened for all IOL types, while negative correlation of outcome satisfaction with nighttime dysphotopsia was slightly decreased for trifocal and EDOF IOLs, and increased for monofocal IOLs.

Outcome satisfaction at 3 and 12 months showed moderate to weak positive correlations with surgeon satisfaction at 1 week for all IOL types except moderate to strong positive correlation with EDOF IOLs (r = 0.436 and r = 0.661, respectively; p < 0.001 for both).

Discussion

Electronic modes of PROM collection represent a possible solution to the lack of routine assessment of patient-reported outcomes, as they are associated with reduced administrative load and efficient delivery of patient responses [6]. The RayPro database is an automated yet proactive method of collecting patient feedback on visual symptoms, functional vision, and satisfaction outcomes post-cataract surgery [7]. Long-term trends from real-world results can generate valuable comparative data for monitoring treatment efficacy as well as for optimization of clinical decision-making.

In this study, outcome satisfaction was found to have a moderate to strong negative correlation with dysphotopsia in the overall cohort (p < 0.001) and across all IOL types (p < 0.001), suggesting that a lower incidence of dysphotopsia is associated with greater patient satisfaction. This is consistent with previous studies where dysphotopsia has been found to be a significant determinant of satisfaction post-cataract surgery [9,10,11]. Kinard et al. investigated patient satisfaction factors in a cohort of pseudophakic patients with high expected postoperative satisfaction due to the absence of surgical complications, ocular comorbidities, and ocular complaints [9]. Even after the elimination of all possible confounders, their study found dysphotopsia to be the only parameter that correlated with patient satisfaction after at least 1 year postoperatively (r=-0.60; p < 0.0001). Furthermore, dysphotopsia was found to be highly correlated with the NEI VF-11R survey (r = 0.58; p < 0.0001), suggesting that dysphotopsia was not a minor annoyance and instead contributed largely to postoperative functional vision loss.

In our study, the negative correlation of satisfaction with dysphotopsia strengthened after 1 year (p < 0.001). Outcome satisfaction also showed a strong negative correlation with dysphotopsia in patients who were dissatisfied with target refraction at 3 months (p < 0.001), with a strong positive correlation between outcome satisfaction at 3 months and 12 months (p < 0.001). Taken together, these findings suggest that the impact of dysphotopsia on patient satisfaction is likely to increase over time. In a study by Welch et al., dysphotopsia was found to have a significant and strong correlation with patient dissatisfaction 24 months after surgery (r = 0.602; p < 0.0001), while visual acuity, posterior capsular opacification, and IOL optic capsular overlap were not significantly correlated with satisfaction [10]. Although neuroadaptation has been postulated to reduce the incidence of negative dysphotopsia (temporal, arc-shaped shadows) over time, neuroadaptation has not been found to have as meaningful an effect on the incidence of positive dysphotopsia (glares, halos, flashes) [12]. Persistent dysphotopsia can cause debilitating visual symptoms, sometimes requiring IOL explantation and exchange [13,14,15]. Thus, it is vital for cataract surgeons to focus not only on obtaining a target visual acuity outcome, but to also provide good visual quality in order to achieve maximum patient satisfaction.

The current study found that patients who responded “yes” to the target refraction question had greater spectacle independence than those who responded “no” (p < 0.001, p < 0.001, and p = 0.043 for distance, intermediate, and near vision, respectively). However, correlation analysis showed satisfaction with surgical outcome to be weakly correlated to spectacle independence in the overall cohort (p < 0.001, p < 0.001, and p = 0.007 for distance, intermediate, and near vision, respectively). Additionally, although higher spectacle independence was observed with trifocal and EDOF IOLs compared to monofocal IOLs (p < 0.001), there was no significant difference between IOL types in terms of outcome satisfaction at 3 months (p = 0.268) and 12 months (p = 0.751). It was thought that the inclusion of both monofocal and presbyopia-correcting IOL implantations could have confounded results due to differing patient expectations for different lenses, since monofocal IOL recipients are likely counselled about the need for spectacles postoperatively and have low expectations of spectacle independence post-surgery, whereas spectacle independence is a greater priority for users of presbyopia-correcting IOLs [16]. Hence, we performed a correlation analysis of outcomes categorized by IOL type, with the expectation that a cohort of only premium IOL recipients would perhaps demonstrate a stronger correlation of spectacle independence with patient satisfaction. However, except for a moderate positive correlation with far-distance spectacle independence in EDOF IOLs, outcome satisfaction was weakly correlated with spectacle independence at all distances across all IOL types. This suggests that even for presbyopia-correcting IOL recipients, the absence of dysphotopsia appears to be a stronger factor for patient satisfaction than spectacle independence. This is consistent with a systematic review of patient-reported outcomes after cataract surgery, where no significant differences in patient satisfaction were observed between monofocal and multifocal IOLs despite greater spectacle independence in the latter [17]. Suboptimal subjective visual experience due to blurred vision, photic phenomena, and decreased contrast sensitivity following multifocal IOL implantation is known to be a major cause of patient dissatisfaction, requiring IOL exchange in refractory cases [13,14,15].

This study also found that surgeon and hospital satisfaction at 1 week were strongly correlated with each other (r = 0.592; p < 0.001), while surgeon and hospital satisfaction were both found to be moderately correlated with surgical outcome satisfaction at 3 months and 12 months (p < 0.001). This suggests that factors other than treatment outcome may contribute to patient satisfaction with medical care, consistent with previous studies where patient satisfaction was observed to be correlated with various aspects of patient care such as shorter waiting times, better patient-physician communication, provision of sufficient information regarding disease condition and treatment, as well as effective preoperative psychoprophylaxis to manage patient expectations [18,19,20,21]. Thus, enhancing the patient experience by providing quality healthcare can further improve patient satisfaction.

A limitation of this study is its retrospective design. The generalizability of the findings may also be limited by the inclusion of ocular comorbidities, which can be potential confounders as they can affect patient satisfaction post-cataract surgery [18]. These limitations are inherent to the study design, as the aim of this study was to collect the evidence and analyse the insights from the real-world usage of PROMs in routine clinical practice. Despite the aforementioned limitations, the results of this study can be considered relevant due to the large sample size and multicentric study population.

Insights from the patient-reported outcomes recorded in the RayPro database suggest that dysphotopsia is the most significant determinant of outcome satisfaction after cataract surgery and its contribution to patient dissatisfaction increases over time. Satisfaction with surgeon and satisfaction with hospital were found to be highly correlated with each other, while both were moderately correlated to surgical outcome satisfaction, suggesting that quality patient care by the treating surgeon and hospital may contribute to patient satisfaction with medical care, independent of the surgical outcome achieved.