1. Health outcome conference July 2004 Quality Assurance in Ophthalmic Service Monitoring Cataract Surgery Outcome Dr. Goh Pik Pin Consultant Ophthalmologist Selayang Hospital

2. Health outcome conference July 2004 Introduction Why monitor treatment outcome? Patient satisfaction -standard of treatment Self-audit – continuous professional development Set standard or norm- monitor service performance Practice of medicine - competent, accountable and ethical

3. Health outcome conference July 2004 How? Current methods of quality assurance : 1.Legislation- hospital licensing law 2. Professional self-regulation - specialty board 3.Informal peer review- census, log book 4. Formal accreditation and credentialing

4. Health outcome conference July 2004 Limitations 1.Subjective- e.g. inspection by external reviewer 2.Arbitrary- e.g. must have performed minimum x number of procedures before credentialing,  competence 3.No explicit reference to agreed standard

5. Health outcome conference July 2004 More Objective & Better Methods 1.Bench marking 2.Continuous quality monitoring Statistical process control (SPC) technique – trend of performance e.g. Cumulative Sum (CUSUM)

6. Health outcome conference July 2004 Cataract Surgery Outcome What do we measure? 1.Best Corrected Visual Acuity Snellen, LogMar 2.Visual Function Glare disability, contrast sensitivity 3.Quality of Life VF 14, Vision Related Sickness Impact Profile, Catquest (Sweden), etc

7. Health outcome conference July 2004 Cataract Surgery Outcome Methods 1.Population Based Survey Rapid assessment on cataract surgery service -WHO India, China, Nepal, Australia 2.Centre / Providers Based Studies International Cat. Surgery Outcome Study- USA,Canada, Denmark, Spain European Cataract Outcome Group-1998 USA- Medicare beneficiaries, NEON, PORT UK-National Cataract Surgery Survey-1997 Sweden-National Swedish Cataract Register-1992 Malaysia-MOH Census & National Cataract Surgery Registry 3.Individual surgeon Surgical log books Statistical Processes Control – Cumulative Sum (CUSUM)

8. Health outcome conference July 2004 Ministry Of Health Hospitals Annual Census- Cataract service 1.Quantity 2.Practice pattern- day care, Phaco/ECCE, IOL 3.Quality measurements Waiting time Ratio of cataract surgeon to patients Post-op infective endophthalmitis Unplanned return to operating theatre 31 MOH Hospitals Standard census format Defined numerator and denominator

9. Health outcome conference July 2004 Rate of Post-Op Endophthalmitis

10. Health outcome conference July 2004 www.crc.gov.my/ncsr ) National Cataract Surgery Registry (NCSR, www.crc.gov.my/ncsr ) Establish –2002 Prospective systematic data collection 32 centers (MOH, army & universities hospitals, 1 private) Data collection- integrated into daily work Objectives: to determine frequency of cataract surgery to monitor outcome and factors influencing outcomes to evaluate cataract surgery services

11. Health outcome conference July 2004 NCSR Data collected 1.Patient characteristics Age, gender, 1 st eye, ocular & systemic co-morbidity, presenting vision 2.Practice Pattern Day care, anaesthesia, operation, IOL, Viscoelastic 3.Outcome measurements Intra-op & post-op complications Post-op BCVA by 12 weeks Factors contributing to poor visual outcome 4.QA indicators Post-op infective endophthalmitis Unplanned return to OT within 1 week

12. Health outcome conference July 2004 NSCR Annual Report 2002 & 2003 2002 n-=12,798 (%) 2003 n=16,811 (%) Day care surgery3837 Conventional -ECCE Small Incision - Phacoemulsification 54 40 48 46 First eye70

13. Health outcome conference July 2004 NCSR Cataract Surgery Outcome AllECCEPEA 2002 2003 86% 89% 83% 85% 91% 93%

14. Health outcome conference July 2004 NCSR Best corrected vision  6/12 at 12 weeks post operation 2002 % 2003 % All8689 ECCE8385 Phacoemulsification9193

15. Health outcome conference July 2004 Best Corrected Vision (  6/12) – phacoemulsification,year 2002

16. Health outcome conference July 2004 Cataract Surgery Outcome International comparison * All patient (with & without ocular co-morbidity) SurveyUK NCSS 1997 N=18,000 USA NEO N 1997 N=3342 Aust VIP 2000 N=249 Europe ECOG 2000 N= M’sia NCSR 2003 N=16,811 BCVA 6/12 or better 92%96%*85% *84%89% 93% Phaco 85% ECCE

17. Health outcome conference July 2004 Statistical Process Control – Cumulative Sum (CUSUM) CUSUM chart Graph representation of the trend in outcomes of consecutive procedures performed over time by same surgeon Early detection of unacceptable rate of adverse outcome Applications Monitoring of trainees Continuous surgical audit

18. Health outcome conference July 2004 What is CUSUM charting?

19. Health outcome conference July 2004 CUSUM Consultant Trainee

20. Health outcome conference July 2004 CUSUM Chart for ECCE (NCSR)

21. Health outcome conference July 2004 Conclusion Quality assurance in ophthalmic service Mandatory Continuous - trend Sustainable - integrated into daily work process Surgeons - appreciative self audit for continuous professional development Providers - continuous quality monitoring Confidentially and medico-legal implication - issues to be considered

22. Health outcome conference July 2004 Acknowledgement Dr Mariam Ismail National Head of Ophthalmology Service, MOH Head, Ophthalmology Department,Hospital Selayang D.Lim Teck Onn Head, Clinical Research Centre, MOH Dr.G.Arumugam President,Ophthalmological Soicety Singapore Society of Ophthalmology