Developing specialty-wide standards of practice: the experience of ophthalmology

Network Meta-analysis for Clinical Practice Guidelines: A Case Study on First-Line Medical Therapies for Primary Open-Angle Glaucoma

BACKGROUND

Network meta-analysis compares multiple treatment options for the same condition and may be useful for developing clinical practice guidelines.

PURPOSE

To compare treatment recommendations for first-line medical therapy for primary open angle-glaucoma (POAG) from major updates of American Academy of Ophthalmology (AAO) guidelines with the evidence available at the time, using network meta-analysis.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Library were searched on 11 March 2014 for randomized, controlled trials (RCTs) of glaucoma monotherapies compared with placebo, vehicle, or no treatment or other monotherapies. The AAO Web site was searched in August 2014 to identify AAO POAG guidelines.

STUDY SELECTION

Eligible RCTs were selected by 2 independent reviewers, and guidelines were selected by 1 person.

DATA EXTRACTION

One person abstracted recommendations from guidelines and a second person verified. Two people independently abstracted data from included RCTs.

DATA SYNTHESIS

Guidelines were grouped together on the basis of literature search dates, and RCTs that existed at 1991, 1995, 1999, 2004, and 2009 were analyzed. The outcome of interest was intraocular pressure (IOP) at 3 months. Only the latest guideline made a specific recommendation: prostaglandins. Network meta-analyses showed that all treatments were superior to placebo in decreasing IOP at 3 months. The mean reductions (95% credible intervals [CrIs]) for the highest-ranking class compared with placebo were as follows: 1991: β-blockers, 4.01 (CrI, 0.48 to 7.43); 1995: α2-adrenergic agonists, 5.64 (CrI, 1.73 to 9.50); 1999: prostaglandins, 5.43 (CrI, 3.38 to 7.38); 2004: prostaglandins, 4.75 (CrI, 3.11 to 6.44); 2009: prostaglandins, 4.58 (CrI, 2.94 to 6.24).

LIMITATION

When comparisons are informed by a small number of studies, the treatment effects and rankings may not be stable.

CONCLUSION

For timely recommendations when multiple treatment options are available, guidelines developers should consider network meta-analysis.

PRIMARY FUNDING SOURCE

National Eye Institute, National Institutes of Health.

Resident compliance with the american academy of ophthalmology preferred practice pattern guidelines for primary open-angle glaucoma

PURPOSE

To examine resident adherence to preferred practice pattern (PPP) guidelines set up by the American Academy of Ophthalmology for follow-up care of primary open-angle glaucoma (POAG) patients.

DESIGN

Retrospective chart review.

PARTICIPANTS

One hundred three charts were selected for analysis from all patients with an International Classification of Diseases, Ninth Revision, code of open-angle glaucoma or its related entities who underwent a follow-up evaluation between July 2, 2003, and December 15, 2004, at the resident ophthalmology clinic in the Durham Veteran Affairs Medical Center.

METHODS

Follow-up visits of POAG patients were evaluated for documentation of 19 elements in accordance to PPP guidelines.

MAIN OUTCOME MEASURES

Compliance rates for the 19 elements of PPP guidelines first were averaged in all charts, and then were averaged per resident and were compared among 8 residents between their first and second years of residency.

RESULTS

The overall mean compliance rate for all 19 elements was 82.6% for all charts (n = 103), 78.8% for first-year residents, and 81.7% for second-year residents. The increase from first to second year of residency was not significant (P>0.05). Documentation rates were high (>90%) for 14 elements, including all components of the physical examination and follow-up as well as most components of the examination history and management plan. Residents documented adjusting target intraocular pressure downward, local or systemic problems with medications, and impact of visual function on daily living approximately 50% to 80% of the time. Documentation rates for components of patient education were the lowest, between 5% and 16% in all charts.

CONCLUSIONS

Residents' compliance with PPP guidelines for a POAG follow-up visit was very high for most elements, but documentation rates for components of patient education were poor. Adherence rates to PPP guidelines can be used as a tool to evaluate and improve resident performance during training. However, further studies are needed to establish the advantages of using PPP guidelines for resident education and to determine if such assessments can lead to improved patient care.

Initial management of ocular hypertension and primary open-angle glaucoma: an evaluation of the royal college of ophthalmologists' guidelines

PURPOSE

The purpose of this study was to identify any consensus of opinion among consultant ophthalmologists in Wales with respect to the initial management of glaucoma referrals based on the published guidelines of the Royal College of Ophthalmologists (RCO) and to compare consultant opinion with the practice in a typical hospital.

METHOD

The RCO guidelines document was studied to identify clear statements, which could be adopted as standards for audit purposes. A questionnaire was designed and sent to all consultant ophthalmologists in Wales (n=37) to obtain their opinions. An audit was performed of 100 consecutive patients referred to our unit as glaucoma suspects with regard to initial management. Descriptive statistical analysis was performed.

RESULTS

A good response rate for a postal questionnaire was obtained (81%) with 79.1% of responders finding the guidelines of at least some help. Levels of agreement with the definitions of ocular hypertension (OH) and primary open-angle glaucoma (POAG) were 76.7 and 86.7%, respectively. There was consensus of consultant opinion regarding many of the elements of the baseline clinical assessment with the significant exceptions of the necessity for dilated fundoscopy, gonioscopy, retinal nerve fibre layer assessment, and drawing of optic discs. The various 'clinical scenarios' for management of the RCO document were not all endorsed. The clinical audit results of the initial management of glaucoma referrals accurately reflected the consensus of the consultant opinion.

DISCUSSION

The RCO guidelines document represents a useful contribution to the management of patients with OH and POAG. Nevertheless, considerable variation in opinion exists concerning even the most basic areas. With the advent of clinical governance, bridging the gap between the conclusions of College working parties and realities of everyday practice will assume greater importance.

Health, medicine, and ophthalmology: facing the facts and paying the piper LVI Edward Jackson Memorial Lecture

PURPOSE

To describe the sources of tension within the health care system and methods for pursuing their solution.

METHODS

Presentation of observations pertinent to patient, provider, and payer perspectives relevant to the cost, delivery, and quality of care and their impact on health.

RESULTS

Societal forces, not just wealth, are major determinants of both health and the costs of health care.

CONCLUSIONS

Tensions created by rising health care costs in the face of finite societal resources will increase in the years ahead. These can be resolved only by realizing new efficiencies in care, and prioritizing, through an explicit process, the care that is to be provided.

Diagnostic yield of the routine dilated fundus examination

OBJECTIVE

This study aimed to estimate the risk of errors of omission inherent in the elimination of the routine dilated fundus examination in asymptomatic patients presenting for routine eye checkups, or in patients with purely refractive complaints.

DESIGN

The study design was a retrospective chart review.

PARTICIPANTS

The authors reviewed the records of initial visits of more than 3800 patients drawn from the practices of 3 board-certified ophthalmologists with substantial general ophthalmology components. Patients with best-corrected visual acuity in either eye of poorer than 20/25, myopia greater than -3.00 diopters, or other risk factors for disease of the fundus or optic nerve (such as ocular hypertension, glaucoma, previous ocular surgery, diabetes mellitus, and history of retinal detachment) were excluded. The authors identified 1094 such records that documented the findings of dilated fundus examination, including indirect ophthalmoscopy.

MAIN OUTCOME MEASURES

The authors recorded the prevalence of all fundus abnormalities, of those deemed clinically significant, and those beyond the view of routine examination with the direct ophthalmoscope. Findings were stratified by patient age.

RESULTS

Of the 1094 eligible records, 53 (4.84%) had recorded fundus abnormalities. Of these, 23 were of no adverse ophthalmologic consequences and were considered clinically insignificant. Of the 30 (2.74%) potentially significant findings, only 3 were located beyond the view of routine examination with the direct ophthalmoscope (0.274%; 95% confidence limits: 0.56%-0.80%). The prevalence of fundus findings increased strongly with increasing patient age, from 2.4% younger than age 20 to 14.8% older than age 60. Clinically significant findings increased from 0.8% younger than age 20 to 8.9% older than age 60.

CONCLUSIONS

The authors estimate the rate of detection through routine dilated fundus examination of clinically significant fundus lesions in asymptomatic patients at 2.73% (95% confidence limits, 1.86%-3.80%). One tenth of these are beyond the view of the direct ophthalmoscope. The prevalence of fundus abnormalities increases tenfold with increasing patient age.

Epidemiology and the health care revolution

PURPOSE

Revolutions in the health care marketplace, with their implied dependence upon the population perspective, have renewed interest in epidemiologic methods and their application.

METHODS

As a way of organizing questions, data, and answers, epidemiology is once again the core scientific discipline for a multidimensional paradigm shift that emphasizes five facets of health care. First, the health of enrolled populations, rather than merely treatment of sick individuals presenting for care. Second, assessment of the "time, place, and person" of disease burden--who is healthy, who is not, and what it will take to maximize their health. Third, the causative factors for disease and the factors or characteristics that promote health. Fourth, the development of evidence-based clinical guidelines for clinicians and consumers alike. Fifth, evaluation of the impact providers are having on the health of populations (outcomes), individually and collectively.

RESULTS

Thoughtful consideration of all of the above factors depends upon epidemiologic data and insights brought to a firm and conclusive end point capable of supporting policy.

CONCLUSIONS

Credibility will require that epidemiologists (and the symbiotic media) exercise far greater restraint in drawing definitive conclusions and speculations from often starting but meager data.

Glaucoma care and conformance with preferred practice patterns. Examination of the private, community-based ophthalmologist

BACKGROUND

Practice guidelines are becoming more prominent in the provision of medical care. A previous study demonstrated a high rate of conformance with recommended patterns of care for patients with open-angle glaucoma in an academic, public clinic setting. This study seeks to examine conformance within the private, community-based setting in which the vast majority of healthcare is delivered.

METHODS

One-hundred ninety-three charts (average, 24 charts each from 8 different practices) of patients who received diagnoses for at least 2 years of open-angle glaucoma were evaluated retrospectively for conformance with recommendations from the American Academy of Ophthalmology's Preferred Practice Pattern (PPP) for primary open-angle glaucoma. The criteria were evaluated in three areas: (1) the performance of specified examination steps at the initial visit; (2) the performance of specified examination steps at follow-up; and (3) the time interval between follow-up visits.

RESULTS

In 56.4% of patients who had stable moderate to severe glaucomatous damage, documentation of examination findings on the initial visit ranged from 39.4% for a pupil examination to 100% for intraocular pressure. At the initial visit, visual fields were obtained or scheduled in 90.2% of eyes, gonioscopy was performed in 51.3%, and the disc/nerve fiber layer status was noted in 97.9%. On follow-up, 44% of patients had documentation concerning the status of their glaucoma, but only 23.3% of patients had an optic nerve head drawing or photograph within 15 months of the most recent visit. In addition, the authors found that 37.8% of patient charts had neither an optic nerve head drawing nor a photograph documented after the initial visit. Finally, although 92.2% of patients with glaucoma were scheduled for follow-up within the time intervals recommended by the PPP, patients with uncontrolled or unstable glaucoma were the least likely to be followed up within PPP-recommended time intervals.

CONCLUSIONS

Chart reviews from private, community-based ophthalmologists show that some initial examination steps such as gonioscopy and pupil examination are performed to widely varying degrees. While patients are generally likely to be scheduled for follow-up within PPP-recommended intervals, patients with unstable glaucoma are the least likely to be so scheduled. In addition, the visual appearance of the optic nerve is recorded for a relatively low percentage of patients. Additional data are needed from other geographic areas and other practice settings and for other patterns of care to more fully assess provider behavior relative to PPPs.

Conformance with preferred practice patterns in caring for patients with glaucoma

BACKGROUND

Practice guidelines are becoming more prominent in the provision of medical care. However, the limited data that exist suggests that conformance in ophthalmic care may be low.

METHODS

A retrospective study of 120 charts of patients with open-angle glaucoma was conducted to evaluate conformance with recommendations from the American Academy of Ophthalmology's Preferred Practice Pattern for open-angle glaucoma. The criteria were operationalized for evaluation of three dimensions: (1) the performance of specified examination steps at the initial visit; (2) the performance of specified examination steps at follow-up; and (3) the time interval between follow-up visits.

RESULTS

In a sample where 70% of patients had stable moderate to severe glaucomatous damage, documentation of examination findings on the initial visit ranged from 70% for a pupil examination to 100% for intraocular pressure. At the initial visit, visual fields were obtained or scheduled in 92% of eyes, gonioscopy in 85%, and the disc/nerve fiber layer status in 98%. On follow-up, 90% of patients had an optic nerve head drawing or photograph within 9 months of the most recent visit. Finally, 100% of patients were scheduled for follow-up within the time intervals recommended by the Preferred Practice Pattern.

CONCLUSIONS

Unlike the situation with diabetic retinopathy and corneal ulcers, there appears to be a high rate of conformance with recommended patterns of care for patients with open-angle glaucoma in a public clinic setting. Additional data are needed from other practice settings and for other patterns of care to not only assess the quality of care but to help guide revisions in preferred practice patterns.

Guidelines to shape clinical practice. The role of medical societies: the Dutch experience in comparison with recent developments in the American approach

In the last few years there has been a growing interest in the development of guidelines for care. The most important aim of these guidelines is to improve the quality of care by changing the daily practice of physicians in the desired direction. Therefore besides the scientific basis of guidelines, emphasis should be placed on the implementation of guidelines. Experience in the Netherlands, where medical societies contribute significantly to the procedure of consensus guidelines development, are described in comparison with new ideas in the U.S.A. regarding criteria setting. Involvement of physician organisations to the development procedure is a necessary requirement for guidelines to shape clinical practice. Furthermore, some interventions used in The Netherlands for improving implementation of guidelines in daily practice are mentioned.