Measure Overview
Use in CMS Programs
- Measure finalized in rulemaking in 2017.
- Measure implemented in Ambulatory Surgical Center Quality Reporting Program (ASCQRP) in 2021.
Description
This measure is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy.
Measure Specification
All cataract surgery patients who had an unplanned anterior vitrectomy.
N/A
N/A
All cataract surgery patients.
None.
N/A
Measure Information
Endorsement History
N/A
Measure Performance in Program
Measure Score by Performance Year
Impact Summary: This measure aligns with the Ambulatory Surgical Center Quality Reporting (ASCQR) objectives by enabling both facilities and consumers to evaluate and compare the quality of care for cataract surgery provided in the ambulatory surgical center (ASC) setting and ensuring that care processes support the best possible patient outcomes. Specifically, the measure assesses the percentage of cataract surgery patients who experience an unplanned anterior vitrectomy (a lower score indicates better quality of care).
Figure 1 shows negligible change in median score over the last 5 years, although the highest 5% of the scores decreased from 1.4% or greater in 2020 to about 1.1% or greater in 2023-2024. Table 1 shows that if all entities performed at least at the average, the estimated rate of patients with an unplanned anterior vitrectomy could decrease from about 0.5% to about 0.07%, a small increase that may potentially leading to better health outcomes.
For this measure, Battelle reviewed the following publicly available datasets available at Hospitals data archive | Provider Data Catalog:
- Hospitals_02_2026.zip (which contains data from 2024)
- Hospitals_08_2025.zip (which contains data from 2023)
- Hospitals_07_2024.zip (which contains data from 2022)
- Hospitals_10_2023.zip (which contains data from 2021)
- Hospitals_07_2022.zip (which contains data from 2020)
Battelle analyzed all numeric values in column “ASC-14 Rating*” from the corresponding ASC_Facility.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 5 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: This figure shows negligible change in median score over the last 5 years, although the highest 5% of the scores decreased from 1.4% or greater in 2020 to about 1.1% or greater in 2023-2024. For this measure, a lower score indicates better quality of care.
Score Distribution for Most Recent Years
About Table 1: Table 1 illustrates the distribution of scores across deciles for the most recent year of data available.
Table 1. Importance (Decile by Measure Score, 2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 0.47 (3.52) | 0 | 0.01 | 0.08 | 0.13 | 0.19 | 0.26 | 0.34 | 0.45 | 0.63 | 2.62 |
| Entities | 1,640 | 164 | 164 | 164 | 164 | 164 | 164 | 164 | 164 | 164 | 164 |
Table 1 Interpretation: Nearly 20% of the entities have a score at or near 0%, and about 80% have a score less than 0.5%. If the average performance of Decile 3 (0.8%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, the estimated rate of patients with an unplanned anterior vitrectomy could decrease from about 0.5% to about 0.07%, potentially leading to better health outcomes.
Meaningfulness
Importance
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
Data Stream Burden Reduction
Data Stream Burden Reduction
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Alignment with the Patient Health Care Journey
Alignment with the Patient Health Care Journey
This criterion will be evaluated as part of the full Preliminary Assessment available in September.