Transcript Ophthalmic Surgical Outcomes Committee

Field Advisory Committee Report:
OSOD Project 2009
Idea  Reality!
Mary Lawrence, MD, MPH
Quality
OSOD Committee charged with bringing
Ophthalmology into the VA Surgical Quality
Program by:
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Recommending
procedures to include
 outcomes to measure
 preoperative factors
 operative factors
 postoperative factors
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Developing pilot program
Eye Surgery in the VHA
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370,000 operative cases in VHA/yr
48K+ (~12%) ophthalmic surgical cases
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~41K cataract cases (66982, 66984)
Eye cases not included in NSQIP data
collection
To this point, there has been no protocol in
VHA for prospectively measuring outcomes in
terms of Safety or Quality
VA Draft Data:
Eye Surgery Self-Reported Events
1/1/2001 - 6/30/2006 (n = ~200K)
EYE cases
N
Wrong
patient
Wrong
side
Wrong
site
Wrong
procedure
Wrong
Implant
Adverse
Events
45
5
(11.1%)
16
(35.6%)
0
2
(4.4%)
22
(48.9%)
Close Calls
28
4
(14.3%)
22
(78.6%)
0
0
2
(7.1%)
All
Reported
Events
73
9
(12.3%)
38
(52.1%)
0
2
(2.7%)
24
(32.9%)
Highlights of FY 09
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~150 data elements for collection chosen
4 standardized templates developed
QOL instrument chosen: NEI-VFQ
5 pilot sites established(reduced from 6 to 5)
Nurse reviewers hired
Kick-off and Training Meeting, Feb 2009
>1,000 cataract patients enrolled (as of 9/22)
Templates refined for usability (in progress)
Data Elements
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Chose ~150 data elements (risk assessment
items) for collection
Data elements defined
Used NSQIP definitions where possible
 Created new definitions
 Document to be released soon
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Risk Assessment Form created (paper)
Access Database to be released next week
Intraoperative
Cataract
Surgery
Occurences
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en.wikipedia.org
Equipment failure
Bleeding
Perforation, or a hole in the eye
Damage to the cornea
Reaction to medication or
anesthesia
Dropped lenticular fragment
Vitreous loss
Torn capsule
Intraoperative floppy iris
syndrome (IFIS)
Post-operative
Cataract
Surgery
Occurences
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www.eyeworld.org
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www.retinalphysician.com
Increased post-op intraocular
pressure
Diplopia (double vision)
Wound leaks
Clouding of the posterior lens
capsule (also known as a
secondary cataract)
Infection (endophthalmitis)
Inflammation
Displacement of the implanted
lens
Detachment of the retina
Outcomes similar to NSQIP
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30 day re-operation on same eye
30 day mortality
30 day infection (endophthalmitis)
Wrong side surgery
Wrong implant
www.revophth.com
4 Standardized CPRS Templates
1.
2.
3.
4.
Pre-operative H&P *
Operative Report *
Post-operative Note
Pre and Post-opVisual Functioning
Questionnaire *
* now being used at all pilot sites
CPRS Templates
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Nurses glean all data from these 3 templates,
saving time reading entire record and multiple
CPRS notes
Dawn O’Connor and Sandy Kinney, IT
specialists, building the templates
Templates will eventually all be done in
“reminder dialog” format so data collection can
be automated
Reminder dialog format takes 5X longer to
build
Pre-Op H&P Template
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Screen Capture
Op-Note Template—Reminder
Dialog Format
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Screen Capture
Additional Functional
Outcome Measure
VISION
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Improvement in
Snellen Visual Acuity
Validated Visual
Functioning
Assessment of Vision
 pre-op
 post-op
en.wikipedia.org/wiki/Eyeglass_prescription
Five Pilot Sites: Nurse reviewers hired
Boston
Philadelphia
Mary Daly, MD
Michael Sulewski, MD
Tulay Cakiner-Egilmez Miriam Moskowitz, RN,
NP, PhD
MSN
Ella Blair Newcomb
Redshirt, RN
Houston
Elizabeth Baze, MD
Agueda Lara-Smalling,
Saint Louis
RN, MPH
Banks Shepherd, MD
Dale Williams, RN,
Nashville
COMT
Amy Chomsky, MD
Dawn Miller, RN
Kick-off and Training Meeting
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Kick-off Meeting with Workshops
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24-25 February 2009, St. Louis
Agreed to standardized process across sites
Training on data collection
Chart data from templates
 Visual functioning questionnaire
(NEI-VFQ)
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Quality of Vision-Visual Functioning
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Expert: Mae Gordon, Ph.D.
and Karen Clark, B.A., Washington University
School of Medicine, Department of Ophthalmology
and Visual Sciences, Division of Biostatistics
NEI-VFQ
National Eye Institute Visual Functioning Questionnaire
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Developed to measure vision-specific health-related
quality of life
25 question instrument was developed from patient
focus groups representing a diverse set of visual
conditions, the intention being to develop a scale that
can be generalized to all patients with vision deficits,
regardless of cause
Range of eye conditions includes cataract, glaucoma,
AMD, and diabetic retinopathy
What does the NEI-VFQ assess?
Reading
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difficulty with near vision activities
difficulty with distance vision activities
limitations in social functioning due to vision
www.ulpanor.com
role limitations due to vision
dependency on others due to vision
Driving
mental health symptoms due to vision
future expectations for vision
driving difficulties
pain and discomfort in or around the eyes
limitations with peripheral vision
goodbadandugly2.wordpress.com
color vision
NEI-VFQ 25
Reference
Cataract
100
90
80
70
60
50
40
30
20
10
0
General
Near
Distance
Driving
Peripheral
How Difficult?
4. How much difficulty do you have reading
ordinary print in newspapers?
1. No difficulty
2. A little difficulty
3. Moderate difficulty
4. Extreme difficulty
5. Stopped doing this because of eyesight
6. Stopped doing this for other reason or not
interested in doing this
How Often?
18. Do you accomplish less than you would like to
because of your vision?
1. All of the time
2. Most of the time
3. Some of the time
4. A little of the time
5. None of the time
How True?
21. I stay at home most of the time because of my
eyesight.
1. Definitely true
2. Mostly true
3. Not sure
4. Mostly false
5. Definitely false
Face-to-Face Interview
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Introduce self – avoid setting expectations
Purpose
Look up at patient
Speak slowly
Emphasize consonants
Use flip cards for answers
Thank for cooperation
Telephone Interview
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Introduce self, purpose
Check availability for 15 minutes
Confirm connection and clarity
Thank for cooperation
Attempt 3 times
No surrogate
Pt. Self-Completed
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Introduce self, purpose
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Put form on clip board w pencil
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Upon completion, offer help
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Check for skips, double answers, ambiguous
marks
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Thank for cooperation
Bias: Volunteer Bias
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Volunteers are different from those who do
not..
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Mortality in children who did not participate in a Vit A study
in Malaysia was 25 x higher than than Vit A group and 3x
higher than control group
Sommer et. al. Randomized trial of Vit A in Malaysia
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Smokers had lower response rate to smoking questionnaire
67% response in smokers
85% response in non-smokers
NEI-VFQ Multi-Modality
High (Low)
Complexity
Long (Short)
Length
High (Moderate)
Sensitivity
Face-toFace
Telephone
Self
Completed
+
+
-
- OK
- OK
+ OK
- OK
- OK
+ OK
Risk Assessment
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Pre-operative Factors
Systemic
 Ocular
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Intra-operative Factors
 Post-operative Factors
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Data Analysis
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Denver Data Analysis Center
Tracy Schifftner
 Grant Hughes
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O/E Ratios
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Pilot phase will establish
Which of the 150 “mandatory elements” are significant
 What the “expected” ranges may be
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OSOD Committee Work
March 2008 – September 2009
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Weekly conference calls, reduced to bi-weekly Sep 09
Standardize the process
Reach consensus on what, where, when, why, and how!
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Determine ~150 data elements for collection
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Pre-op template #55
Op-note template #63
Post-op template
Define each of the 150 data elements—almost complete
Problem Solve
Share ideas
www.invisium.com
OSOD Committee
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Original OSO Committee
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Mary Lawrence, MD, MPH (Chair)
James Orcutt, MD, PhD (NPD)
Nathan Ravi, MD
Tracy Schifftner Smith, MS
Eric Suhler, MD, MPH
Ivan Suner, MD
Minneapolis
Seattle
St. Louis
Denver
Portland
Durham
Added Clinical Champions for Project Implementation
(obtained approval from facility directors)
 Amy Chomsky, MD
 Mary Daly, MD
 Silvia Orengo-Nania, MD
 Elizabeth Baze, MD
 Michael Sulewski, MD
 George Harocopos, MD
 James (Banks) Shepherd, MD
Nashville
Boston
Houston
Houston
Philadelphia
St. Louis
St. Louis
What’s New and Different with
the OSOD Project?
1.
2.
CPRS templates required for data
collection—Standardization
Functional outcomes are collected—
Quality of Life
Improving Quality and Safety of
Cataract Surgery…