Field Advisory Committee Report: OSOD Project 2009 Idea  Reality! Mary Lawrence, MD, MPH

1. Field Advisory Committee Report:OSOD Project 2009Idea  Reality!Mary Lawrence, MD, MPH

2. Quality OSOD Committee charged with bringing Ophthalmology into the VA Surgical Quality Program by: • Recommending • procedures to include • outcomes to measure • preoperative factors • operative factors • postoperative factors • Developing pilot program

3. Eye Surgery in the VHA • 370,000 operative cases in VHA/yr • 48K+ (~12%) ophthalmic surgical cases • ~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

4. VA Draft Data: Eye Surgery Self-Reported Events1/1/2001 - 6/30/2006 (n = ~200K)

5. Highlights of FY 09 ~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)

6. Data Elements • 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 • Risk Assessment Form created (paper) • Access Database to be released next week

7. Intra-operative Cataract SurgeryOccurences • 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) en.wikipedia.org

8. Post-operative Cataract SurgeryOccurences • 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 www.eyeworld.org www.retinalphysician.com

9. Outcomes similar to NSQIP • 30 day re-operation on same eye • 30 day mortality • 30 day infection (endophthalmitis) • Wrong side surgery • Wrong implant www.revophth.com

10. 4 Standardized CPRS Templates Pre-operative H&P * Operative Report * Post-operative Note Pre and Post-opVisual Functioning Questionnaire * * now being used at all pilot sites

11. CPRS Templates 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

12. Pre-Op H&P Template Screen Capture

13. Op-Note Template—Reminder Dialog Format Screen Capture

14. Additional FunctionalOutcome Measure VISION • Improvement in Snellen Visual Acuity • Validated Visual Functioning Assessment of Vision • pre-op • post-op en.wikipedia.org/wiki/Eyeglass_prescription NEI-VFQ

15. Five Pilot Sites: Nurse reviewers hired Boston Mary Daly, MD TulayCakiner-Egilmez NP, PhD Houston Elizabeth Baze, MD Agueda Lara-Smalling, RN, MPH Nashville Amy Chomsky, MD Dawn Miller, RN Philadelphia Michael Sulewski, MD Miriam Moskowitz, RN, MSN Ella Blair Newcomb Redshirt, RN Saint Louis Banks Shepherd, MD Dale Williams, RN, COMT

16. Kick-off and Training Meeting • Kick-off Meeting with Workshops • 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)

17. Quality of Vision-Visual Functioning • Expert: Mae Gordon, Ph.D. and Karen Clark, B.A., Washington University School of Medicine, Department of Ophthalmology and Visual Sciences, Division of Biostatistics

18. NEI-VFQ National Eye Institute -Visual Functioning Questionnaire • 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

19. What does the NEI-VFQ assess? Reading www.ulpanor.com Driving goodbadandugly2.wordpress.com • difficulty with near vision activities • difficulty with distance vision activities • limitations in social functioning due to vision • role limitations due to vision • dependency on others due to vision • mental health symptoms due to vision • future expectations for vision • driving difficulties • pain and discomfort in or around the eyes • limitations with peripheral vision • color vision

20. NEI-VFQ 25

21. 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

22. 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

23. 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

24. Face-to-Face Interview • Introduce self – avoid setting expectations • Purpose • Look up at patient • Speak slowly • Emphasize consonants • Use flip cards for answers • Thank for cooperation

25. Telephone Interview • Introduce self, purpose • Check availability for 15 minutes • Confirm connection and clarity • Thank for cooperation • Attempt 3 times • No surrogate

26. Pt. Self-Completed • Introduce self, purpose • Put form on clip board w pencil • Upon completion, offer help • Check for skips, double answers, ambiguous marks • Thank for cooperation

27. Bias: Volunteer Bias • Volunteers are different from those who do not.. • 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 • Smokers had lower response rate to smoking questionnaire 67% response in smokers 85% response in non-smokers

28. NEI-VFQ Multi-Modality

29. Risk Assessment • Pre-operative Factors • Systemic • Ocular • Intra-operative Factors • Post-operative Factors

30. Data Analysis • Denver Data Analysis Center • Tracy Schifftner • Grant Hughes • O/E Ratios • Pilot phase will establish • Which of the 150 “mandatory elements” are significant • What the “expected” ranges may be

31. OSOD Committee WorkMarch 2008 – September 2009 • Weekly conference calls, reduced to bi-weekly Sep 09 • Standardize the process • Reach consensus on what, where, when, why, and how! • Determine ~150 data elements for collection • 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

32. OSOD Committee • Original OSO Committee • Mary Lawrence, MD, MPH (Chair) Minneapolis • James Orcutt, MD, PhD (NPD) Seattle • Nathan Ravi, MD St. Louis • Tracy Schifftner Smith, MS Denver • Eric Suhler, MD, MPH Portland • Ivan Suner, MD Durham • Added Clinical Champions for Project Implementation (obtained approval from facility directors) • Amy Chomsky, MD Nashville • Mary Daly, MD Boston • Silvia Orengo-Nania, MD Houston • Elizabeth Baze, MD Houston • Michael Sulewski, MD Philadelphia • George Harocopos, MD St. Louis • James (Banks) Shepherd, MD St. Louis

33. What’s New and Different with the OSOD Project? CPRS templates required for data collection—Standardization Functional outcomes are collected—Quality of Life

34. Improving Quality and Safety of Cataract Surgery…