Making Eye Health a Population Health Imperative Vision for Tomorrow (2016) / Chapter Skim
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7 Toward a High-Quality Clinical Eye and Vision Service Delivery System
7 Toward a High-Quality Clinical Eye and Vision Service Delivery System
Pages 325-380
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From page 325... ...
The first section discusses the importance of consistent evidence-based guidelines to inform care seeking and providing behaviors, especially in the context of vision screenings and comprehensive eye examinations. The second section examines the role of continuous quality improvement initiatives in promoting high-quality eye and vision care.
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From page 326... ...
Third, they promote a culture of accountability by enabling performance comparisons and encouraging the uniform adoption of best practices. To promote clear and consistent messaging about whom needs what care and when, it is important that a single set of evidence-based guidelines be available to the public, especially in the context of vision screenings and comprehensive eye examinations.
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Comprehensive eye examinations and vision screenings have different
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. Dilation -- This procedure uses medicated drops to dilate the pupil, allowing an eye care provider to view and assess the inside of the eye with a special magnify ing lens (NEI, 2016)
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A comprehensive eye exam is more sensitive and specific and can precisely measure the extent -- and identify the cause -- of decreased visual acuity and the presence of eye disease and disorders and conditions of the eye and visual system, in addition to providing other assessments of eye health and functioning. The costs of comprehensive eye examinations are briefly mentioned in Chapter 6.
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Conflicting study results and relatively limited research on the costeffectiveness of vision screenings for specific eye diseases and conditions and comprehensive eye examinations for asymptomatic patients can also impede efforts to align existing guidelines (see, e.g., AHRQ, 2012; Burr et al., 2007; Gangwani et al., 2014; Jones and Edwards, 2010; Karnon et al., 2008; Rein et al., 2012a,b)
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. e AAO states that "routine comprehensive annual adult eye examination in individuals under the age of 40 unnecessarily escalates the cost of eye care" and is not indicated without specific risk factors or symptoms (AAO, 2015a)
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omprehensive eye examinations are not necessary (but can be performed) for healthy asymptomatic children who have passed an acceptable vision screening test, have no subjective visual symptoms, and have no personal or familial risk factors for eye disease" (AAO, 2012b)
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.2 Vision Screening Guidelines Guidelines specific to vision screenings may also differ and, in some instances, even contradict one another. In a joint policy statement on pediatric vision screenings in community, school, and primary care settings, the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS)
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. AOA is currently updating its clinical practice guidelines, many of which are almost 15 years old, to better reflect recent research.3 Again, the import of these examples is not to endorse or criticize a particular set of 3 Personal communication, R
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. In contrast, visual acuity screening by a primary care provider of all children ages 3 to 5 years to detect amblyopia or amblyopia risk factors received a B grade recommendation (USPSTF, 2011)
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Although a literature review found limited direct evidence supporting the comparative benefit of screening over not screening in pediatric populations, USPSTF noted that good evidence supporting the accuracy of screening methods and the effectiveness of treatments suggests that screening is more likely to lead to improved eye health than no screening (Chou et al., 2011; USPSTF, 2011)
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Although the committee was not constituted to evaluate or identify the most effective tools for evaluating guidelines for eye and vision health, it is important that the development of evidence-based guidelines adhere to particular standards, to the extent possible, to ensure robust and comprehensive support for recommended actions. 6 The Appraisal of Guidelines for Research and Evaluation (AGREE)
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. AOA has developed 18 consensus-based guidelines and two evidencebased guidelines, Eye Care of the Patient with Diabetes Mellitus, and the Comprehensive Adult Eye and Vision Examination (AOA, 2014, 2015d)
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.10 Improving the Consistency of Eye and Vision Care Guidelines Coming to consensus on recommended care is critical to create clear messaging that targets both patients and non–eye care providers about the need for regular eye care services. From a population health perspective, prioritizations for guideline development should be influenced by the number of people affected, the severity and reversibility of vision loss that can occur, the diversity with which the condition is currently managed, the number of health care professionals who typically engage with patients about a specific disease or condition, and the breadth of the literature currently available.
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An adherence to established guidelines provides the baseline from which to Develop Trustworthy Clinical Practice Guidelines Identify Gaps in Translate Clinical Eye and Guidelines into Vision Care Practice Analyze Trends in Monitor Eye and Eye and Vision Vision Health Health Outcomes Outcomes FIGURE 7-1 Continuous quality improvement framework. SOURCE: Adapted from Kneib, 2009.
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has employed its Quality Enhancement Research Initiative to identify opportunities for improving eye care and preventing vision loss among veterans with diabetes (Krein et al., 2008)
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. The NQF has endorsed several quality measures related to counseling and eye examinations for patients with AMD, eye examination and follow-up care for patients with diabetic retinopathy, examination of the optic nerve head and treatment outcomes for patients with glaucoma, and complications and outcomes after cataract surgery.12 Unfortunately, NQF has not endorsed -- and the National Quality Measures Clearinghouse does not list -- other measures related to eye and vision care, including those pertaining to vision screening and the subsequent referral and follow-up of adult patients, referral to vision rehabilitation and support services for patients with irreversible vision impairment, correction of identified 12 NQF-endorsed,eye care–related quality measures include Primary Open-Angle Glaucoma: Optic Nerve Evaluation (NQF-0086)
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From page 343... ...
PROMOTING DIAGNOSIS AND FOLLOW-UP CARE TRANSITIONS THROUGH INTEGRATION Identifying who needs what care at what time is only part of the equation to promoting appropriate eye care. In many cases, especially in the context of vision screening, additional follow-up care will be necessary to provide prescription lenses or other types of clinical treatments or monitoring.
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From page 344... ...
. Similarly, by providing vision screenings and referring patients as appropriate to eye and vision care providers, primary care providers can help identify potentially vision-threatening problems and refer patients to an ophthalmologist or optometrist for a comprehensive eye examination to make a definitive diagnosis, establishing productive and ongoing professional relationships.
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Holley and Lee (2010) interviewed focus groups of nurse practitioners, physician assistants, and rural and academic primary care physicians in order to identify barriers to referring patients to eye care.
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For example, an RTC conducted in the Netherlands compared different methods of monitoring glaucoma patients and found that eye care provided to stable glaucoma patients and patients at risk of glaucoma by ophthalmic technicians and optometrists working in hospital-based glaucoma follow-up units was equal in quality and lower in cost than care provided by hospital-based residents and ophthalmologists specializing in glaucoma care (Holtzer-Goor et al., 2010) .16 Compared to monitoring of stable glaucoma patients and patients at-risk of glaucoma by glaucoma specialists (i.e., ophthalmologists specializing in glaucoma)
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From page 347... ...
. In the United Kingdom, the National Health Service's Chronic Eye Care Services Programme supported eight pilot projects that sought to improve care pathways for the treatment of glaucoma, AMD, and vision impairment through better integration of the eye care workforce (McLeod et al., 2006)
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Incorporating Vision and Eye Health into Emerging Medical Models of Care According to the American College of Physicians, the patient-centered medical home (PCMH) is a "care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand" (ACP, 2016)
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. Despite the success of PACT and other PCMH models at reducing health care costs and improving some measures of care quality and access, it is not clear what impact these models have had on eye health, as research on the impact of the PCMH model on eye care is limited.
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Among a core set of clinical quality measures recommended by the Patient-Centered Medical Home Evaluators' Collaborative for evaluating and comparing the effectiveness of PCMH programs, the sole vision-related measure was the percentage of patients ages 18 to 75 with type 1 or 2 diabetes who received a retinal eye exam as a component of comprehensive diabetes care (Rosenthal et al., 2012) .18 The 2014 Standards and Guidelines for NCQA's Patient-Centered Medical Home, which provide guidance for assessing the quality of care offered by practices using the PCMH model, do not explicitly require the collection of vision-related clinical data, the inclusion of vision-specific components within the patient health assessment, or the use of vision screenings except where recommended by major public health agencies or organizations (NCQA, 2014b)
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.21 Excluding optometrists from participating in the PCSP program may eliminate the contribution of a critical cohort of eye care providers and may limit the degree to which eye and vision care can be easily incorporated into specific PCMH models and medical neighborhoods. Accountable care organizations (ACOs)
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For example, it is important to determine how PCMHs, ACOs, and other integrated models of care that promote collaborative practice -- as well as the policies that inform their organization, adoption, and performance monitoring and quality improvement activities -- can be adapted to best meet current and future eye and vision health needs. Strategies and actions to better support integration of clinical eye and vision services with vision rehabilitation, social services, public health departments, and other stakeholders are also needed.
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. The adoption of EHRs by eye care specialists may be impeded by concerns about its effects on the quality of clinical documentation.
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of recording patient data on the accuracy and speed of clinical documentation of ophthalmology residents and fellows and found that sensitivity was highest for the keyboardbased method, while paper-based documentation performed better than the other methods in terms of positive ratio and documentation speed.27 Other studies have found associations between EHR implementation in some eye care practices and significantly longer nonclinical documentation times, as well as increases in the amount of time that eye care providers spend on clinical examinations (Chiang et al., 2013; Pandit and Boland, 2013)
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found that just 27 to 33 percent of specialty practices participating in the Massachusetts eHealth Collaborative projected a positive 5-year ROI; on average, the participating specialty practices expected to lose $50,722 per physician over 5 years. However, ROI varied considerably with practice size and type, with primary care practices showing smaller losses, practices with six or more physicians showing positive ROI, and ROI improving for all practices over longer periods.
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. It can potentially encourage at-risk patients to seek preventive eye care and adhere to recommended guidelines for receiving comprehensive eye examinations.
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. In order to cultivate the practices and knowledge needed to meet the multidisciplinary needs of eye care patients and address fragmentation of the vision care system, eye care providers, medical professionals working in primary care and medical specialties, allied health professionals, social workers, and members of the public health workforce must all be aware of the services offered by other health care and public health disciplines and must engage cooperatively with professionals in those disciplines on the development and implementation of treatment plans.
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performed a synthesis of systematic reviews and found that, despite heterogeneity among interventions, IPE was frequently well received by students and had a positive impact on care quality patient outcomes. A systematic review found limited evidence that IPE improves patient outcomes, provider adherence to clinical guidelines, patient satisfaction, or clinical processes.
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programs could potentially foster collaboration in the eye care workforce. Eye and Vision Health in Medical and Population Health Education All physicians are generally trained in the fundamentals of ophthalmic diseases and examination.
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, public health professionals need to be knowledgeable about eye and vision health. To support efforts to improve eye and vision health, public health professionals need to be able to ascertain and communicate information about community health to providers, understand the roles that different eye care specialists and other health care providers play in advancing vision and eye health, and have a reasonable appreciation for the types of effective treatments or interventions that are available.
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. Currently, only a few of the research efforts and educational materials available through the National Center concern the interprofessional education of eye care providers (NCIPE, 2016b,c)
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Cultivating Leadership and Teamwork Beyond knowledge of clinical and population health management, health care personnel and public health practitioners will need leadership abilities that allow them to cultivate trust between different groups and sectors and the capacity to form and articulate a shared vision to unite different stakeholders. Leadership programs exist for public health workers, optometrists, and ophthalmologists.
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. Despite these broader gains, many gaps in the cultural competency of eye care remain.
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Establishing clear messaging about who should receive what care and when is essential to educating not only the public, but also health care and population health fields. A single set of evidence-based guidelines, especially in the context of vision screenings and comprehensive eye examinations, that adhere to specific development standards can improve the uniformity and quality of patient care, establish a consistent baseline from which to measure improvement, and promote accountability for eye and vision health outcomes and care processes.
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Other measures related to vision screenings, general eye examinations, and vision rehabilitation are still lacking. Addressing the key research gaps and opportunities (see Box 7-5)
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2013. American Academy of Ophthalmology and American Academy of Optometry to explore educational opportunities to advance quality eye care.
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http://www.ahrq.gov/professionals/ clinicians-providers/resources/rice/index.html#Projects (accessed April 7, 2016)
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2014. Eye care of the patient with diabetes mellitus.
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2013. Adoption of electronic health records and preparations for demonstrating meaningful use: An American Academy of Ophthalmology survey.
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2008. Adoption and perceptions of electronic health record systems by ophthalmologists: An American Academy of Ophthalmology survey.
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2013. High-risk populations for vision loss and eye care underuti lization: A review of the literature and ideas on moving forward.
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:1376–1379. Interprofessional Education Collaborative Expert Panel.
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2008. Improving eye care for veterans with diabetes: An example of using the QUERI steps to move from evidence to implementation: QUERI series.
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2006. Evaluation of the chronic eye care services programme: Final report.
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. http://www.qualityforum.org/QPS/0059 (accessed April 29, 2016)
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2016. The US Preventive Services Task Force rec ommendation on vision screening in older adults: A narrow view.
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2004. Comparison of preschool vision screen ing tests as administered by licensed eye care professionals in the Vision in Preschoolers Study.
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Community Eye Health 20(64)
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2015c. An evaluation of cataract surgery clinical practice guidelines.
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