Vision Care Clinical Advisory Group & Ministry of Health and Long-Term Care January 2013 (Updated October 2013)

Transcription

1 Quality-Based Procedures Clinical Handbook for Cataract Surgery Vision Care Clinical Advisory Group & Ministry of Health and Long-Term Care January 2013 (Updated October 2013)

2 Quality-Based Procedures: Clinical Handbook for Cataract Surgery 2

3 Table of Contents Purpose... 5 Introduction to Quality-Based Procedures... 6 The Cataract QBP: Encouraging Best Practice... 6 Best Practice Guidelines Patient Groups having Cataract Surgery Corrected Vision Nearing the Threshold Required to Maintain Driving or Occupational Requirements Simultaneous Bilateral Surgery Procedures on the Second Eye Combined Pathology Corneal Disease Glaucoma Retinal Disease Macular Disease Removal to Facilitate Other Disease Management Paediatric Cataract Removal <1 year years years Complex Cataracts Visual Impairment Secondary to Cataracts Cataract Clinical Pathways Corrected Vision Nearing the Threshold Required to Maintain Driving or Occupational Requirements Simultaneous Bilateral Surgery Procedures on the Second Eye Combined Pathology Corneal Disease Glaucoma Retinal Disease Macular Disease Removal to Facilitate Other Disease Management Paediatric Cataract Removal <1 year years years Complex Cataracts Quality-Based Procedures: Clinical Handbook for Cataract Surgery 3

4 2.8 Visual Impairment Secondary to Cataracts QBP Cataract Definition Limitations of Cataract QBP Definition using NACRS methodology Revised QBP Cataract Definition using CACS ON Methodology Performance Measurement and Indicators Provincial Integrated Quality Scorecard and Parameters Cataract Surgery Indicators Quality Targets Appendix 1: Vision Care Clinical Advisory Group Membership Appendix 2: Consulted Work Appendix 3: Definition of Cataract Cohorts for each Clinical Pathway Quality-Based Procedures: Clinical Handbook for Cataract Surgery 4

5 Purpose The Cataract Surgery Quality Based Procedure -- Clinical Handbook incorporates the findings of the Cataract Surgery Clinical Pathway and Best Practices Report developed by the Vision Care Clinical Advisory Group of the Ministry of Health and Long-Term Care in More specifically, this clinical handbook includes the evidence-based best practice pathways, performance measurements and indicators for cataract surgery as outlined by the Vision Care Clinical Advisory Group. In addition, feedback from physicians and hospitals over the last year, has also been used to refine the Cataract Surgery QBP definitions to better reflect the group of cataract patient who indeed most closely fall into the clinical pathways and outcomes. Through further NACRS and CACS data and costing analytics, it has also been determined that some cataract patient types fall outside the parameters of the QBP for Cataract Surgery. For this reason, the Cataract Surgery QBP definition has been further refined for 14/15 implementation. The Handbook has been prepared for informational purposes only. Note that the Handbook does not mandate health care providers to provide services in accordance with the recommendations included herein. The recommendations included in this document are not intended to take the place of the professional skill and judgment of health care providers. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 5

6 Introduction to Quality-Based Procedures The Excellent Care for All Act (ECFAA) received royal assent in June ECFAA is a key component of a broad strategy that improves the quality and value of the patient experience by providing patients with the right care at the right time, and in the right place through the application of evidence-informed health care. ECFAA positions Ontario to implement reforms and develop the levers needed to mobilize the delivery of high quality, patient-centred care. In January 2012, the government introduced Ontario s Action Plan for Health Care, communicating the vision to make Ontario the healthiest place in North America to grow up and grow old. Health System Funding Reform (HSFR), implemented in April 2012, is one of the main pillars of Ontario s Action Plan for Health Care, supporting high quality patient care, access to health care services and investment in the health care system. The HSFR Strategy will shift Ontario s hospital, long-term care and community care access centre (CCAC) funding to a system that creates the right financial environment for health care providers to deliver high quality, evidence-based care. One of the key levers of HSFR is the implementation of Quality-Based Procedures (QBPs) supporting best-practice patient care. The Cataract QBP: Encouraging Best Practice Commencing April 2012, as part of Patient-Based Funding implementation, the ministry has introduced the Cataract QBP aimed to accelerate quality improvement and improve system value. The Cataract QBP demonstrates a significant opportunity to reduce practice variation, attain cost efficiencies and catalyze alignment of quality with funding. The Vision Care Clinical Advisory Group was convened to guide the development of evidenceinformed practices for Cataract Surgery in Ontario. The role of the Advisory Group was to: Review and validate the composition of the adult and pediatric patient groups for Cataract Surgery; Reach consensus on evidence-informed best practices to ensure that Ontarians receive the right care, at the right time, in the right place; Quality-Based Procedures: Clinical Handbook for Cataract Surgery 6

7 Determine potential process improvement opportunities across the continuum of care; and Provide recommendations on evaluation metrics including quality indicators. To foster partnership and strengthen clinician engagement, the Vision Care Clinical Advisory Group was comprised of clinical ophthalmology leaders from across the province. The membership of the Vision Care Clinical Advisory Group is outlined in Appendix 1. The best practices and pathways recommended by the Vision Care Clinical Advisory Group have been used to define the cataract surgery patient groups included in the Cataract Surgery QBP. The Ministry is responsible for development of evidence-based pricing of the Cataract Surgery QBP to encourage health service providers to: Adopt best practice standards; Re-engineer clinical processes to improve patient outcomes; and Develop innovative care delivery models to enhance the experience of patients. These practice changes, together with adoption of evidence-based practices, will improve the overall patient experience and clinical outcomes and help create a sustainable model for health care delivery. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 7

8 Best Practice Guidelines 1.0 Patient Groups having Cataract Surgery The Vision Care Clinical Advisory Group reviewed the various types of the patients who require cataract surgery and their characteristics. Section 1.0 defines those patient groups that require a designated clinical care pathway. It should be noted that some patients may follow more than one pathway. For example, a patient may require surgery to maintain occupational requirements yet may have advanced glaucoma. In this circumstance, the additional components of the second pathway are added to the first. 1.1 Corrected Vision Nearing the Threshold Required to Maintain Driving or Occupational Requirements The group encompasses patients who have binocular visual impairment, placing the patient at imminent risk of losing the ability to drive (Highway Traffic Act) or maintain current employment. 1.2 Simultaneous Bilateral Surgery This group includes patients receiving immediate sequential bilateral cataract surgery in both eyes during the same surgical episode. 1.3 Procedures on the Second Eye To clearly differentiate from Simultaneous Bilateral Cataract Surgery, procedures on the second eye have been defined as cataract surgery on the second eye performed in a second surgical episode. 1.4 Combined Pathology In some instances the removal of cataracts for functional or visual reasons (pathway 1.1 or 1.8) will occur on patients with other ocular diseases that may limit the potential for visual recovery and may require additional care. These instances are described below. Patients who have milder disease which does not require additional care or have the potential to affect vision would not usually follow these pathways. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 8

9 1.4.1 Corneal Disease This group encompasses cataract extraction on a patient with corneal disease Glaucoma This group encompasses cataract extraction on a patient with glaucoma Retinal Disease This group encompasses cataract extraction on a patient with retinal disease that does not involve the macula Macular Disease This group encompasses cataract extraction on a patient with macular disease. 1.5 Removal to Facilitate Other Disease Management This group encompasses instances where the removal of cataracts will occur on patients to facilitate the management of the other eye disease. Vision function improvement is not the primary outcome expected of surgery in this circumstance. 1.6 Paediatric Cataract Removal In select cases, removal of cataracts will occur on patients under the age of fourteen and these patients require specialized pediatric ophthalmology care <1 year This group encompasses cataract extraction on a patient less than one year of age years This group encompasses cataract extraction on a patient between one and seven years of age years This group encompasses cataract extraction on a patient between eight and fourteen years of age. Patients greater than fourteen years of age would be captured under the other recommended inclusion groups. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 9

10 1.7 Complex Cataracts This group encompasses patients who enter cataract surgery in one of the other pathways and develop complications during surgery. 1.8 Visual Impairment Secondary to Cataracts This group encompasses patients who have functional impairment secondary to cataracts yet do not fit into another category, e.g., ambulation, quality of life. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 10

11 2.0 Cataract Clinical Pathways Best practice recommendations in the form of Cataract Clinical Pathways were developed as follows by the Vision Care Clinical Advisory Group for each of the patient groups described in Section 1.0. The pathways are intended to encompass the full episode of care for each patient group, incorporating best practices in each surgical episode. The Advisory Group recommended that the facility in use must be accredited and meet appropriate surgical standards prior to surgery. All of the following patient pathways recognize this principle prior to surgery. Technical definitions used to identify patient cohorts for each of the clinical pathways from hospital administrative databases are outlined in appendix Corrected Vision Nearing the Threshold Required to Maintain Driving or Occupational Requirements Most patients have cataracts removed for this reason or because of functional limitations. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 11

12 Corrected Vision Nearing the Threshold Required to Maintain Driving or Occupational Requirements Pre-operative Process Best corrected vision measured within 3 months of decision to treat with cycloplegia when required. Complete eye examination including a dilated fundus examination at time of decision to treat disclosing no additional pathology requiring management. Keratometry and biometry (note 1). Communication to patient and clear documentation of expectation of surgery. Informed consent obtained. Procedure Patient to be NPO depending on the degree of anasthesia provided. Surgical site must be marked on the patient. Pre-operative surgical checklist must be completed. Pupil dilation performed. Povidone prep or equivalent completed. Patient monitored (note 2). Operative report completed and unexpected events documented. Post-operative Process Observation and medical monitoring until stable. Oral and written discharge instructions provided to patient. Date and place of follow up care provided to patient in writing. Follow-Up Care Patient follow up with surgeon within 24 hours post surgery. Second follow up with surgeon, 1 week post surgery (note 3). Follow up within 4-6 weeks of surgery to determine final improvement in vision and absence of pathology (note 4). Note to primary eye care practitioner and primary care provider outlining the patient s clinical course during and following the procedure and status at the time of last visit (note 5). 1) Routine medical examination not required. 2) Patient monitoring of sedated patients must not be done by surgeon. If patent is sedated with intravenous medication, minimum staffing, in addition to surgeon, includes a second physician, RN or other RHP who is not assisting in the procedure and is trained to monitor patients undergoing sedation or regional anesthesia. Rarely, some cataract cases will require general anesthesia and in those cases, appropriate arrangements must be made to ensure a dedicated anesthesiologist is available. 3) This care may be delegated to referring ophthalmologist or optometrist with demonstrated competence to recognize complications following the procedure in circumstances where geography prevents return to the surgeon. All results must be communicated to the surgeon. 4) May be delegated to referring eye care practitioner. If delegated, the results and findings must be communicated to surgeon. 5) To be provided at time of last follow up by the surgeon. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 12

13 2.2 Simultaneous Bilateral Surgery Both eyes must meet criteria for surgery in one of the other pathways specified within this handbook. * Each eye will follow an individual pathway with appropriate documentation. During the procedure, each eye is to be treated as a separate procedure with separate drape, separate preparation, and separate instruments, separate pack, and separate drugs and solutions. * Meeting criteria for surgery of the second eye may not be required for patients with severe disabilities with surgeon discretion. 2.3 Procedures on the Second Eye The second eye must meet criteria for surgery in one of the other pathways specified within this handbook, except for those undergoing surgery because of anticipated or realized aniseikonia induced by the first surgery which is unacceptable to the patient. The second eye will follow an individual pathway with appropriate documentation. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 13

14 2.4 Combined Pathology Separate pathways have been developed for instances where the removal of cataracts will occur for functional or visual reasons in patients with other ocular diseases of sufficient severity that they may limit the potential for visual recovery and may require additional care Corneal Disease Corneal Disease Pre-operative Process Nature of corneal disease documented. Pachymetry and specular microscopy, where indicated. Appropriate measures taken to stabilize disease, as necessary Complete eye examination including a dilated fundus examination at time of decision to treat, disclosing no additional pathology requiring management. Keratometry and biometry (note 1). Communication to patient and clear documentation of expectation of surgery. Informed consent obtained. Procedure Patient to be NPO depending on the degree of anesthesia to be provided. Surgical site must be marked on the patient. Pre-operative surgical checklist must be completed. Pupil dilation performed. Povidone prep or equivalent completed. Patient monitored (note 2). Operative report completed and unexpected events documented. Post-operative Process Observation and medical monitoring until stable. Oral and written discharge instructions provided to patient. Date and place of follow up care provided to patient in writing. Follow-Up Care Patient follow up with surgeon within 24 hours post surgery. Second follow up with surgeon within 1 week. Follow up with surgeon dependent on clinical course. Ocular and functional status documented (e.g. vision, corneal clarity). Note to primary eye care practitioner and primary care provider outlining the patient s clinical course during and following the procedure and status at the time of last visit (note 3). 1) Routine medical examination not required. 2) Patient monitoring of sedated patients must not be done by surgeon. If patent is sedated with intravenous medication, minimum staffing, in addition to surgeon, includes a second physician, RN or other RHP who is not assisting in the procedure and is trained to monitor patients undergoing sedation or regional anesthesia. Rarely, some cataract cases will require general anesthesia and in those cases, appropriate arrangements must be made to ensure a dedicated anesthesiologist is available. 3) To be provided at time of last follow up by the surgeon. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 14

15 2.4.2 Glaucoma Glaucoma Pre-operative Process Intraocular pressure target met and glaucoma stable preoperatively, or intraocular pressure target anticipated to be achieved following cataract surgery Best corrected vision measured within 3 months of decision to treat with cycloplegia when required. Complete eye examination, including gonioscopy, and a dilated fundus examination at time of decision to treat disclosing no additional pathology requiring management. Keratometry and biometry (note 1). Communication to patient and clear documentation of expectation of surgery. Informed consent obtained. Procedure Patient to be NPO depending on the degree of anesthesia to be provided. Surgical site must be marked on the patient. Pre-operative surgical checklist must be completed. Pupil dilation performed. Povidone prep or equivalent completed. Measures taken to avoid intraoprative IOP spikes. Consideration given to administration of agents to prevent postoperative IOP rise. Patient monitored (note 2). Operative report completed and unexpected events documented. Post-operative Process Observation and medical monitoring until stable. Intraocular pressure measured on the day of surgery and measures taken to mitigate intraocular pressure rise, if present (note 3). Oral and written discharge instructions provided to patient. Date and place of follow up care provided to patient in writing. Follow-Up Care Patient follow up with surgeon within 24 hours post surgery. Second follow up with surgeon within 1 week. Third follow up with surgeon within 4-6 weeks to ensure intraocular pressure remains at target. Follow up with surgeon dependent on clinical course. Ocular and functional status documented (e.g. intraocular pressure, optic nerve). Note to primary eye care practitioner and primary care provider outlining the patient s clinical course during and following the procedure and status at the time of last visit (note 4). 1) Routine medical examination not required. 2) Patient monitoring of sedated patients must not be done by surgeon. If patent is sedated with intravenous medication, minimum staffing, in addition to surgeon, includes a second physician, RN or other RHP who is not assisting in the procedure and is trained to monitor patients undergoing sedation or regional anesthesia. Rarely, some cataract cases will require general anesthesia and in those cases, appropriate arrangements must be made to ensure a dedicated anesthesiologist is available. 3) In eyes at risk of permanent vision loss due to intraocular pressure spike (e.g. advanced glaucomatous optic nerve damage), if it is advisable to monitor intraocular pressure on the day of surgery. 4) To be provided at time of last follow up by the surgeon. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 15

16 2.4.3 Retinal Disease Retinal Disease Pre-operative Process Nature of retinal disease documented. Appropriate measures taken to stabilize disease, as necessary, during preoperative process. Best corrected vision measured within 3 months of decision to treat with cycloplegia when required. Complete eye examination including a dilated fundus examination at time of decision to treat disclosing no additional pathology requiring management. Keratometry and biometry (note 1). Communication to patient and clear documentation of expectation of surgery. Informed consent obtained. Procedure Patient to be NPO depending on the degree of anesthesia to be provided. Surgical site must be marked on the patient. Pre-operative surgical checklist must be completed. Pupil dilation performed. Povidone prep or equivalent completed. Patient monitored (note 2). Operative report completed and unexpected events documented. Post-operative Process Observation and medical monitoring until stable. Oral and written discharge instructions provided to patient. Date and place of follow up care provided to patient in writing. Follow-Up Care Patient follow up with surgeon within 24 hours post surgery. Second follow up with surgeon within 1 week. Follow up with surgeon within 4-6 weeks of surgery to detrmine improvement in vision and absence of pathology. Dilated fundus examination to ensure retinal pathology is stable (note 3). Note to primary eye care practitioner and primary care provider outlining the patient s clinical course during and following the procedure and status at the time of last visit (note 4). 1) Routine medical examination not required. 2) Patient monitoring of sedated patients must not be done by surgeon. If patent is sedated with intravenous medication, minimum staffing, in addition to surgeon, includes a second physician, RN or other RHP who is not assisting in the procedure and is trained to monitor patients undergoing sedation or regional anesthesia. Rarely, some cataract cases will require general anesthesia and in those cases, appropriate arrangements must be made to ensure a dedicated anesthesiologist is available. 3) This is normally done at the 1 week visit and repeated prior to discharge from care, but could be done less or more frequently depending on the nature of the pathology. 4) To be provided at time of last follow up by the surgeon. Should be done prior to discharge of care by the surgeon. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 16

17 2.4.4 Macular Disease Macular Disease Pre-operative Process Nature of macular disease documented. Appropriate measures taken to stabilize disease, as necessary, during preoperative process. Best corrected vision measured within 3 months of decision to treat with cycloplegia when required. Complete eye examination including a dilated fundus examination at time of decision to treat disclosing no additional pathology requiring management. Keratometry and biometry (note 1). Communication to patient and clear documentation of expectation of surgery. Informed consent obtained. Procedure Patient to be NPO depending on the degree of anesthesia to be provided. Surgical site must be marked on the patient. Pre-operative surgical checklist must be completed. Pupil dilation performed. Povidone prep or equivalent completed. Patient monitored (note 2). Operative report completed and unexpected events documented. Post-operative Process Observation and medical monitoring until stable. Oral and written discharge instructions provided to patient. Date and place of follow up care provided to patient in writing. Follow-Up Care Patient follow up with surgeon within 24 hours post surgery. Second follow up with surgeon within 1 week. Follow up with surgeon within 4-6 weeks of surgery to determine improvement in vision and absence of pathology Dilated fundus examination to ensure retinal pathology is stable (note 3). Note to primary eye care practitioner and primary care provider outlining the patient s clinical course during and following the procedure and status at the time of last visit (note 4). 1) Routine medical examination not required. 2) Patient monitoring of sedated patients must not be done by surgeon. If patent is sedated with intravenous medication, minimum staffing, in addition to surgeon, includes a second physician, RN or other RHP who is not assisting in the procedure and is trained to monitor patients undergoing sedation or regional anesthesia. Rarely, some cataract cases will require general anesthesia and in those cases, appropriate arrangements must be made to ensure a dedicated anesthesiologist is available. 3) This is normally done at the 1 week visit and repeated prior to discharge from care, but could be done less or more frequently depending on the nature of the pathology. 4) To be provided at time of last follow up by the surgeon. Should be done prior to discharge of care by the surgeon. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 17

18 2.5 Removal to Facilitate Other Disease Management Within this pathway, the removal of cataracts will occur on patients to facilitate the management of other pathology. Vision function improvement is not the primary outcome expected of surgery in this circumstance. Removal to Facilitate Other Disease Management Pre-operative Process Nature of other disease and reasons for removing cataract documented. Complete eye examination including a dilated fundus examination at time of decision to treat disclosing no additional pathology requiring management. Keratometry and biometry (note 1). Communication to patient and clear documentation of expectation of surgery. Informed consent obtained. Procedure Patient to be NPO depending on the degree of anesthesia to be provided. Surgical site must be marked on the patient. Pre-operative surgical checklist must be completed. Pupil dilation. Povidone prep or equivalent completed. Treatment of other disease during same surgical episode (note 2). Patient monitored (note 3). Operative report completed and unexpected events documented. Post-operative Process Observation and medical monitoring until stable. Oral and written discharge instructions provided to patient. Date and place of follow up care provided to patient in writing. Follow-Up Care Patient follow up with surgeon within 24 hours post surgery. Second follow up with surgeon dependent on other pathology and required treatment. Follow up with surgeon must document ocular status, vision, and outcome of other disease management. Note to primary eye care practitioner and primary care provider outlining the patient s clinical course during and following the procedure and status at the time of last visit (note 4). 1) These tests are optional in this pathway. Routine medical examination not required. 2) Treatment of other disease under same anaesthetic, if possible. 3) Patient monitoring of sedated patients must not be done by surgeon. If patent is sedated with intravenous medication, minimum staffing, in addition to surgeon, includes a second physician, RN or other RHP who is not assisting in the procedure and is trained to monitor patients undergoing sedation or regional anesthesia. Rarely, some cataract cases will require general anesthesia and in those cases, appropriate arrangements must be made to ensure a dedicated anesthesiologist is available. 4) To be provided at time of last follow up by the surgeon. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 18

19 2.6 Paediatric Cataract Removal Pediatric cataract removal requires many more processes than in an adult and requires a general anesthetic. If the cataract is bilateral, the second eye should be completed as soon as possible after the first <1 year Patient < 1 year Pre-operative Process Visual function assessment and evaluation for systemic co morbidity. Complete eye examination at time of decision to treat disclosing no additional pathology requiring management (note 1). Communication to patient and clear documentation of expectation of surgery. Informed consent obtained. Procedure Patient to be NPO, withholding oral food and liquids. Surgical site must be marked on the patient. Pre-operative surgical checklist must be completed. Pupil dilation. Povidone prep or equivalent completed. Cataract extraction with anterior vitrectomy (note 2). Operative report completed and unexpected events documented. Post-operative Process Observation and medical monitoring until stable. Oral and written discharge instructions provided to patient. Date and place of follow up care provided to patient in writing to patient. Follow-Up Care Patient follow up with surgeon within 24 hours after surgery. Second follow up with surgeon at least weekly for up to one month (note 3). Follow up beyond this point at variable intervals to be provided by the surgeon or another ophthalmologist who is capable of managing the visual rehabilitation and monitoring for complications. Note to primary eye care practitioner and primary care provider outlining the patient s clinical course during and following the procedure and status at the time of last visit (note 4). Eye exam Under Anesthesia (EUA) usually required with B scan and other imaging as needed to assess for additional anterior and posterior segment pathology. A scan and keratometry as needed to calculate for possible IOL implantation. 1) Additional ocular procedures may be required because of underlying pathology and should be completed, if possible, during the same anesthetic episode. 2) Post-operative EUA, at 1 week, to assess IOP, inflammation, vitreous, retina and lens status. EUA is often required in the month following the first one. Additional EUAs may be required, depending on the status of the eye and comorbid conditions. 3) To be provided at time of last follow up by the surgeon. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 19

20 years If the cataract is bilateral, the second eye should be completed within 3 months of initial surgery, depending on age and complexity. Patient 1-7 Years Pre-operative Process Visual function assessment and evaluation for systemic co morbidity. Complete eye examination at time of decision to treat disclosing no additional pathology requiring management (note 1). Communication to patient and clear documentation of expectation of surgery. Informed consent obtained. Procedure Patient to be NPO, withholding oral food and liquids. Surgical site must be marked on the patient. Pre-operative surgical checklist must be completed. Pupil dilation. Povidone prep or equivalent completed. Cataract extraction with anterior vitrectomy (note 2). Operative report completed and unexpected events documented. Post-operative Process Observation and medical monitoring until stable. Oral and written discharge instructions provided to patient. Date and place of follow up care provided to patient in writing. Follow-Up Care Patient follow up with surgeon within 24 hours after surgery. Second follow up with surgeon 2-3 times within 1 month of surgery. Follow up beyond this point at variable intervals to be provided by the surgeon or another ophthalmologist who is capable of managing the visual rehabilitation and monitoring for complications. Note to primary eye care practitioner and primary care provider outlining the patient s clinical course during and following the procedure and status at the time of last visit (note 3). 1) Eye exam Under Anesthesia (EUA) may be required to obtain lens power calculations. 2) Vitrectomy may not be necessary after age 3. Additional ocular procedures may be required because of underlying pathology and should be completed, if possible, during the same anesthetic episode. 3) To be provided at time of last follow up by the surgeon. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 20

21 years Pre-operative testing similar to adult process outlined in 2.1, however, the procedure is often completed under general anesthetic. 2.7 Complex Cataracts This pathway is followed when patients have cataract surgery and develop complications during surgery which require additional components to the planned procedure, additional procedures or altered follow up. As the clinical scenarios vary considerably it is not possible to delineate steps which should be followed in a pathway similar to the others. It is expected that the events which transpired during the operation would be detailed in the operative report and that the situation would be managed by the surgeon until stable and documented in the patient s chart. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 21

22 2.8 Visual Impairment Secondary to Cataracts This pathway has been developed for patients who have functional visual impairment secondary to cataracts, yet do not fit into another category. Visual Impairment Secondary to Cataracts Pre-operative Process Visual function assessment and best corrected vision measured within 3 months of decision to treat with cycloplegia when required. Complete eye examination including a dilated fundus examination at time of decision to treat disclosing no additional pathology requiring management. Keratometry and biometry (note 1). Communication to patient and clear documentation of expectation of surgery. Informed consent obtained. Procedure Patient to be NPO depending on the degree of anesthesia to be provided. Surgical site must be marked on the patient. Pre-operative surgical checklist must be completed. Pupil dilation performed. Povidone prep or equivalent completed. Patient monitored (note 2) Operative report completed and unexpected events documented. Post-operative Process Observation and medical monitoring until stable. Oral and written discharge instructions provided to patient. Date and place of follow up care provided to patient in writing. Follow-Up Care Patient follow up with surgeon within 24 hours post surgery. Second follow up with surgeon, 1 week post surgery (note 3). Follow up within 4-6 weeks of surgery to determine final improvement in vision and absence of pathology (note 4). Note to primary eye care practitioner and primary care provider outlining the patient s clinical course during and following the procedure and status at the time of last visit (note 5). 1) Routine medical examination not required. 2) Patient monitoring of sedated patients must not be done by surgeon. If patent is sedated with intravenous medication, minimum staffing, in addition to surgeon, includes a second physician, RN or other RHP who is not assisting in the procedure and is trained to monitor patients undergoing sedation or regional anesthesia. Rarely, some cataract cases will require general anesthesia and in those cases, appropriate arrangements must be made to ensure a dedicated anesthesiologist is available. 3) This care may be delegated to referring ophthalmologist or optometrist with demonstrated competence to recognize complications following the procedure in circumstances where geography prevents return to the surgeon. All results must be communicated to the surgeon. 4) May be delegated to referring eye care practitioner. If delegated, results and findings must be communicated to surgeon. 5) To be provided at time of last follow up by the surgeon. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 22

23 3.0 QBP Cataract Definition Further refinement of the patient definitions in NACRS for inclusion and exclusion in the Cataract QBP has occurred using the most current CACS ON methodology and Ontario Case Costing Initiative (OCCI) data. This work is necessary so that the Cataract QBP volumes can more closely match the clinical pathways identified in Section 2.0 and resource considerations. In this way, the methodology to identify patient inclusion criteria within the pathway that represent a more homogeneous group of cataract patients by resource use and cost has been achieved. In some circumstances however, all or some patients in a pathway have been found to be high resource use in OCCI and therefore have been excluded in the QBP for Cataract Surgery. As noted previously, the Cataract Surgery QBP relates only to day surgery cases. The Cataract QBP does not include inpatient cataract surgery. The Cataract QBP applies only to outpatient same day cataract surgery and will use inclusion and exclusion criteria based on NACRS and CACS ON methodology starting in 2014/ Limitations of Cataract QBP Definition using NACRS methodology The Cataract Surgery QBP definition for outpatient same day cataract surgery used to date was based solely on National Ambulatory Care Reporting System (NACRS) as follows: main intervention is a lens extraction for cataract i.e., main intervention starts with "1CL89" functional centre is Operating Room or Day Surgery i.e., the MIS Visit Functional Centre code begins with "7126" or "7136" health card issuing province is Ontario i.e., province issuing hcn= "ON" main intervention is neither cancelled nor performed Out-of-Hospital i.e., the main Intervention status attribute is not = A (abandoned), the main intervention out of hospital indicator is not = Y A number of limitations have been identified using this methodology. These include that there has been no diagnosis typing and that using the main intervention only has created a bias in the patient identification such that more costly cases have been captured in the QBP definition. To correct for this in 2014/15, the Cataract QBP definition will contain additional CACS ON inclusion criteria. Exclusion criteria have also been clearly identified. The revised definition was developed by first Quality-Based Procedures: Clinical Handbook for Cataract Surgery 23

24 examining the patient characteristics and resource use for each pathway and then adjusting the criteria to achieve a simpler definition. 3.2 Revised QBP Cataract Definition using CACS ON Methodology With the most recent CACS ON grouping methodology, the coding algorithm loops through all intervention occurrences automatically for the most resource intensive intervention for CACS ON assignment. This eliminates the need to determine the main or first intervention as most resource intensive or most clinically significant. Starting 2014/15 the NACRS definition for inclusion in the QBP Cataract Surgery (below) will be supplemented by an additional criteria using CACS ON methodology main intervention is a lens extraction for cataract i.e., main intervention starts with "1CL89" functional centre is Operating Room or Day Surgery i.e., the MIS Visit Functional Centre code begins with "7126" or "7136" health card issuing province is Ontario i.e., province issuing hcn= "ON" main intervention is neither cancelled nor performed Out-of-Hospital i.e., the main Intervention status attribute is not = A (abandoned), the main intervention out of hospital indicator is not = Y ADDITIONAL CRITERIA (NEW) Limited to cases in CACS ON group C060 (Cataract Removal / Lens Insertion) In addition, the following exclusions will be applied. EXCLUSIONS (NEW) Bilateral cataracts are excluded (cases with main intervention location attribute = B ) Pediatric cases are excluded by excluding patients under 18 years of age and procedures performed in children s hospitals Complications, represented by cases with any diagnosis that starts with T, are excluded Cases with any intervention of ICL89NPLO or ICL89VRLO are excluded Cases with general anaesthetic (any of the anaesthetic technique variables = 1 ) are excluded in 14/15. The methodology analysis revealed a wide variation in practice at some hospitals on the use of general anesthetic for day surgery cataract cases, with no obvious clinical reason noted. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 24

25 Further analysis will occur related to this exclusion. More refined and limited exclusion criteria will be developed for 15/16. Methodology testing reveals that using the above CACS ON criteria improves the identification of a more homogeneous group of patients more reflective of the typical cataract surgery case of this QBP. Table 1. Analysis of Patient Homogeneity Using NACRS compared to NACRS & CACS ON Methodology CASES RIW Mean Hours Mean NACRS Methodology Cohort 131, NACRS & CACS ON Methodology Cohort 125, Cases Excluded using NACRS & CACS ON methodology 5, Additional analysis on the clinical pathways was done using the main intervention in addition to CACS ON restrictions. Patient volumes excluded from new QBP cohort are outlined below. These were confirmed to be clinically appropriate. The excluded cases are in a CACS ON other than C060, bilateral cataract cases, cases with diagnosis starting with T and cases with general anesthesia. Refinement of general anesthesia exclusions is in progress. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 25

26 Clinical Pathway Volumes in 11/12 RIW Mean Hours Mean Distribution of Cases Included in Cataract Surgery QBP using CACS methodology for each Clinical Pathway ( INCLUSIONS) 1.1 /1.8 (default group) 41, unilateral second eye 83, combined pathology 1, Total 125, Distribution of Cases Excluded from Cataract Surgery QBP using CACS methodology for each Clinical Pathway ( EXCLUSIONS) 1.1 /1.8 (default group) bilateral unilateral second eye 1, combined pathology 1, removal for disease management pediatric complex cataracts Total 5, Quality-Based Procedures: Clinical Handbook for Cataract Surgery 26

27 4.0 Performance Measurement and Indicators In order to monitor the implementation of the Cataract QBP and support ongoing quality improvement, the Vision Care Clinical Advisory Group developed cataract surgery indicators. Section 4.0 of this report defines the indicators recommended by the Advisory Group to support the monitoring and evaluation of the impact of the Cataract QBP and provide benchmark information for ophthalmologists and administrators that will enable mutual learning and promote ongoing quality improvement. 4.1 Provincial Integrated Quality Scorecard and Parameters To monitor and evaluate the impact of QBPs and to support ongoing improvement, the ministry is developing a Provincial Integrated Quality Scorecard (the scorecard). The Advisory Group s work related to indicator development will form a component of the scorecard. The following parameters of the scorecard have been used as a framework to guide development of the cataract indicators. Parameter Effectiveness Appropriateness Integration Value Access Definition Degree of achieving desirable outcomes given the correct provision of evidencebased healthcare services to all who could benefit, but not to those who would not benefit. Degree to which provided healthcare is relevant to the clinical needs of the patient, given the current best evidence. Degree to which all parts of the health system are organized, connected and work with one another to provide high quality care. Best system use of available resources to yield maximum benefits or results. Ease with which health services are reached. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 27

28 4.2 Cataract Surgery Indicators The following cataract surgery indicators have been developed by the Advisory group. In total, these indicators reflect the quality of cataract surgery performed in the province. Health System Goal Quality Principles Cataract Indicator Improve effectiveness by reducing variation in clinical outcomes Improve appropriateness by reducing practice variations and variations in volumes Improve integration across the continuum of care Improve value by reducing unwarranted Supporting positive clinical outcomes Providing the right patient care Ensuring appropriate follow up care Facilitating communication within the patient journey Supporting efficiency within Proportion of patients who develop wound leak, severe uveitis, cystoid macular edema, infectious endophthalamitis, retinal detachment, and capsule rupture Proportion of patients requiring emergent care following surgery Proportion of patients who receive capsulotomy (note 1) Proportion of patients in pathway 1 who achieve the desired visual outcome (note 2) Proportion of patients in pathway 1 who receive cataract surgery without vision dropping below the threshold required to maintain driving or occupational requirements Proportion of patients in pathway 8 who achieve improved visual function (note 2) Proportion of patients who were referred with cataracts who do not have surgery Proportion of cataract surgery patients who are 65 years of age and older by institution Proportion of patients who have final summary completed and sent at time of last visit with surgeon Proportion of cataracts completed within QBP funding Proportion of cataract patients who receive the Quality-Based Procedures: Clinical Handbook for Cataract Surgery 28

29 variation in resource utilization Improve access to care the patient journey Ensuring timely surgery Supporting care close to home surgical facility s standard intraocular lens (and pay no additional fee) by facility/institution Variation of age-specific rate of cataract surgery between LHINs Wait time for Visit to Specialist (Wait 1) Wait time for Surgery (Wait 2) Wait time by priority level (I-IV) by LHIN Proportion of patients who leave their LHIN to receive cataract surgery 1) This procedure may occur several years after cataract surgery. 2) This should be in the patient record and should be tracked by the institution performing the surgery. 4.3 Quality Targets The Advisory Group has recommended the following quality targets to support quality of care: 95% of patients will achieve the expected result following cataract surgery 100% of patients will receive cataract surgery without vision dropping below the threshold required to maintain driving or occupational requirements Quality-Based Procedures: Clinical Handbook for Cataract Surgery 29

30 Appendix 1: Vision Care Clinical Advisory Group Membership The clinical pathway and best practice evidence was developed by a panel of experts including the following ophthalmologists, academics, and health care leaders: Dr. Phil Hooper, Chair Dr. Mark Bariciak Dr. Chaim Bell Dr. Kyle Brydon Dr. Andrew Budning Dr. Robert Campbell Dr. Walter Delpero Dr. Sherif El-Defrawy Dr. Todd Urton Marnie Weber Ophthalmologist, London Health Sciences Centre Ophthalmologist, Sault Area Hospital Physician, Scientist, University of Toronto, Mount Sinai Hospital Ophthalmologist, St. Thomas-Elgin General Hospital Ophthalmologist (Paediatric), The Credit Valley Hospital and Trillium Health Care Centre, The Hospital for Sick Children Ophthalmologist, Queen's University, Hotel Dieu Hospital, Kingston Ophthalmologist, The Ottawa Hospital Ophthalmologist, Kensington Eye Institute Ophthalmologist, Queens University Executive Director, Strategic Developments, University Health Network Quality-Based Procedures: Clinical Handbook for Cataract Surgery 30

31 Appendix 2: Consulted Work The clinical pathway and best practice evidence was developed with the following works: Appleby, J. & Devlin, N. (2004). Measuring success in the NHS: Using patient-assessed health outcomes to manage the performance of healthcare providers. Report commissioned by the Dr. Foster Ethics Committee. Kings Fund: London. College of Physicians and Surgeons of Ontario (2010). Report on Out-of-Hospital Standards. Desai, P., Reidy, A., Minassian, D.C., Vafidis, G., & Bolger, J. (1996). Gains from cataract surgery: visual function and quality of life. Br Ophthalmol. 80: EUREQUO. Associated works. European Registry of Quality Outcomes for Cataract and Refractive Surgery. Gothwal, V., Wright, T., Lamoureux, E., & Pesudovs, K. (2010). Measuring outcomes of cataract surgery using the Visual Function Index-14. Cataract Refract Surg. Javitt, J., Jacobson, G., & Schiffman, R. (2003). Validity and reliability of the cataract TyPE Spec: An instrument for measuring outcomes of cataract extraction. Am J Ophthalmol. 136: Larkin, H. (2007). Dutch Insurers now require cataract surgeons to provide quality data. EuroTimes. Larkin, H. (2010). EUREQUO Helps Audit: Netherlands registry includes 75% of cataract cases, helps surgeons assess performance. EuroTimes. 15(11): 29. McAlinden, C., Gothwal, V., Khadka, J., Wright, T., Lamoureux, E., & Pesudovs, K. (2011). A head-tohead comparison of 16 cataract surgery outcome questionnaires. Ophthalmology. 118: Ontario Health Technology Council (2009). Intraocular Lenses for the Treatment of Age-Related Cataracts. Ontario s Anesthesiologists & Eye Physicians and Surgeons of Ontario (2012). Sedation standards for uncomplicated cataract surgery under topical anesthesia. Pesudovs, K., Caudle, L., Rees, G., & Lamoureux, E. (2008). Validity of a visual impairment questionnaire in measuring cataract surgery outcomes. J Cataract Refract Surg. 34: Rosen, P., Kaplan, R., & David, K. (2005). Measuring the Outcomes of cataract surgery using the Quality of Well-Being Scale and VF-14 Visual Function Index. J Cataract Refract Surg. 3: Quality-Based Procedures: Clinical Handbook for Cataract Surgery 31

32 Rosenthal, R., Goldacre, M., Cleary, R., Coles, J., Fletcher, J., & Mason, A. (eds). (1999). Health Outcome Indicators: Cataract. Report of a working group to the Department of Health. Oxford: National Centre for Health Outcomes Development. Stenevi, U., Lundstrom, M., & Thorburn, W. (1997). An outcome study of cataract surgery based on a national register. Acta Ophthalmol. Scand. 75: Wasfi, E., Pai, P., & Abd-Elsayed, A. (2008). Patient satisfaction with cataract surgery. Int. Arch of Med. 1:22. Quality-Based Procedures: Clinical Handbook for Cataract Surgery 32