Postoperative management of cataract surgery patients by ophthalmologists and optometrists

Quality indicators in a community optometrist led cataract shared care scheme

PURPOSE

Cataract shared care schemes involving community optometrists show wide variation in practice. We report on defined key performance indicators (KPIs) which improve accountability between stakeholders.

METHODS

In this prospective study over nine months at a UK public hospital, we evaluated the outcomes of consecutive direct cataract referrals from community optometrists against two KPIs agreed under a service-level agreement between the Hospital Eye Service and community optometrists: (1) 85% of patients listed for cataract listing at first consultation; and (2) 90% postoperative feedback return rate on patients discharged to community optometrists. A detailed analysis on referral triage, surgical listing and postoperative form return rate is reported in this study.

RESULTS

A total of 733 direct cataract referrals were received using a designated referral form of which 86% were listed for cataract surgery. The predominant reason for not listing was a failure to reach the visual threshold set by the local clinical commissioning guidelines. Out of 569 cataract surgical episodes, 402 (71%) patients were discharged on the same day of surgery to community optometrist follow up. Completed postoperative feedback was returned from 374 patients (93%).

CONCLUSION

Direct cataract referrals from accredited community optometrists led to a majority of patients receiving a definitive clinical decision during first consultation. Postoperative community follow up reduced hospital visits and allowed for convenient consultation closer to home following uncomplicated cataract surgery. A service-level agreement with an accreditation scheme measured against KPIs enhances the accountability of stakeholders involved in the cataract shared care scheme.

Changing trends in postoperative cataract care: impact of electronic patient records in optometrist-delivered shared care

BACKGROUND

This study evaluates a community optometrist-delivered postoperative care scheme in patients discharged from the hospital ophthalmology department following uncomplicated cataract surgery.

AIM

The aim of this study is to assess the efficacy of electronic patient records (EPR) in facilitating co-managed cataract care.

METHODS

We performed a retrospective analysis of a prospectively maintained Medisoft EPR database of postoperative cataract review data at a single centre, Sligo University Hospital (SUH), which serves a large and predominantly rural catchment area. All patients undergoing cataract surgery at SUH from October 2012 to September 2013 were included in this study. A total of 39 optometric practices, all with access to the Medisoft EPR software, participated in this pilot co-management scheme.

RESULTS

One thousand four hundred and twenty-two cataract surgeries were performed in SUH (55% female, 45% male); 1011 patients (71%) were discharged to the community on the day of cataract surgery. Complete postoperative feedback (i.e. data on refraction, visual acuity and intraocular pressure) was available in 97% of these patients compared to 50% of patients reviewed in the hospital. Patients followed up by optometrists were twice as likely to have complete postoperative clinical details (RR = 1.934, 95% CI: 1.759-2.126, p < 0.0001). Overall, 65% of operations were performed on first eyes. Hospital doctors were more likely to document requirement for second eye surgery compared to community optometrists (RR = 1.434, 95% CI: 1.302-1.580, p < 0.0001).

CONCLUSIONS

Optometrists provided an excellent postoperative care service with superior postoperative feedback rates compared to hospital doctors. EPRs facilitate a postoperative shared-care pathway that is of high quality and efficiency with major economic advantages.

Diversity and consistency: The challenge of maintaining quality in a multidisciplinary workforce

Non-physician clinicians have become prominent providers of patient services within the practice of medicine. They include nurse practitioners and clinical nurse specialists, physician assistants, the alternative and complementary disciplines (chiropractic, naturopathy and acupuncture), mental health providers (psychologists, clinical social workers, counsellors and therapists) and specialty disciplines (optometrists, podiatrists, nurse anaesthetists and nurse–midwives). Although these various disciplines have differing histories and philosophic frameworks, which create distinctive approaches to patient care, they have shared a struggle to obtain recognition and autonomy through state licensure, to expand their state-granted practice prerogatives and to achieve broader reimbursement from third-party payers and managed care. Most entered into a growth spurt beginning in the early 1990s. All now provide care that not only overlaps that of physicians but that complements and supplements that care. The central question is, how does their care contribute to quality? The evidence thus far shows that non-physician clinicians throughout the range of disciplines can produce high-quality outcomes under particular circumstances. However, the strongest body of evidence is derived from care that is at the least complex end of the clinical spectrum or that is provided under the umbrella of physicians. Unfortunately, few studies have critically examined the outcomes of non-physician clinicians at the leading edge of their practice prerogatives and under conditions that are free of physician oversight. Thus, while the principle that they can deliver high quality care within the practice of medicine is unequivocally true, more research is needed to test this principle under conditions of greater clinical complexity and autonomy, and, pending the results of such research, caution must be exercised in applying this principle too broadly.

Quality care and practice variation: the roles of practice guidelines and public profiles

Goals of the quality-of-care initiative are to improve the structure, process, and outcome of health care. The effectiveness of methods to improve quality have been largely unverified. Most methods are costly to implement and time-consuming to perform; some threaten professional autonomy. The characteristic feature of modern medicine that fuels the debate over quality is the variation in the delivery of health care. This review examines the "variation phenomenon" in medicine and the roles that practice guidelines and physician profiling have in improving health care, in general, and for adult cataract, in particular.