The iCareTrack Study

This project measured the appropriateness of eye care delivery in NSW, by developing clinical indicators and conducting an on-site record review of up to 40 optometry and ophthalmology practices across the state.

View a poster of this project presented at the ACI Ophthalmology Network Eyes on the Future Forum, 2017.

Aim

To measure compliance with eye care clinical indicators and identify patient and practitioner factors that can lead to inappropriate care delivered to patients in NSW.

Benefits

• Improves quality and appropriateness of eye care delivery in NSW.
• Provides evidence-based clinical indicators for glaucoma, diabetic retinopathy and preventative eye care.
• Provides a tested methodology for on-site record reviews, to ensure eye care is aligned to clinical indicators.
• Educates clinicians on factors that can impact appropriateness of care.

Background

Reducing unwarranted clinical variation is an important step towards improving the efficiency and effectiveness of care delivered to patients. To achieve this, clinical indicators have been developed by medical colleges, specialist bodies and other healthcare organisations in Australia and around the world. These indicators are based on best available evidence and are used to assess the quality and appropriateness of care delivered to patients.

However, a study in the United States found that only around half of all patients receive evidence-based care for common conditions¹ and there is considerable variation in the care that is provided. In 2012, an Australian study called CareTrack was conducted, which aimed to determine the percentage of healthcare encounters where Australians received appropriate care (in line with clinical guidelines). It showed that an average of 57% of Australian adults received appropriate care across 22 health conditions, ranging from 14% to 90%².

Eye care was not included in the CareTrack study, but the 2016 National Eye Health Survey found that more than 50% of Australians who had a visual impairment were undiagnosed³. As a result, it was determined that a better understanding of eye care delivery was required, to guide priorities in this area, monitor quality improvement projects and inform clinicians, consumers and the community.

Implementation

• Clinical indicators for glaucoma, diabetic retinopathy and preventative eye care were created, based on existing evidence-based clinical practice guidelines. These conditions were selected based on the burden of disease in NSW and the availability of Australian clinical practice guidelines. The indicators were developed using a modified Delphi method, which is a communication tool that draws on expert opinions to develop theories and projections for the future. Guidelines were reviewed based on:
  • impact on health outcomes
  • ability to assess the guideline by record review
  • relevance to Australian eye care settings.
• Feasibility studies were conducted in April-May 2016 and January-April 2017, using the clinical indicators. One ophthalmology and six optometry practices were recruited for a record review, to measure how eye care delivery aligned with the clinical indicators. Different sampling methods were applied to cater to the range of diverse record management systems and record types. For practices without diagnostic coding, sampling by patient, visit and appointment date was undertaken.
• A full on-site record review will be undertaken in late 2017 and early 2018, across approximately 40 optometry and ophthalmology practices in NSW. These practices will be randomly selected and use the clinical indicators and sampling methodology deemed to be most successful in the feasibility study. A record review manual will be developed to guide this process.

Project status

Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.

Key dates

• Clinical indicators development: October 2015 – May 2017
• Feasibility study 1: January 2016 – June 2016
• Feasibility study 2: November 2016 – May 2017
• Full on-site record review start: Late 2017

Implementation site

School of Optometry and Vision Science, UNSW Sydney

Partnerships

• Centre for Healthcare Resilience and Implementation Science, Macquarie University
• UNSW Faculty of Science Research Program
• Westmead Institute for Medical Research, University of Sydney

Results

• The feasibility study showed that regular diabetic eye checks were recommended 89% of the time, which is higher than the 78% reported in the National Eye Health Survey³.
• The process of conducting a record review and reporting the preliminary findings to optometry and ophthalmology practices led to positive changes, including:
  • modification of record forms and training to reinforce the importance of addressing the chief complaint and recording the patient history.
  • the addition of a diagnostic coding for new patients with diabetes, to improve patient management and promote a strong culture of evaluation.
• For practices without diagnostic coding, sampling by patient was the most promising method to identify patients with glaucoma and diabetes, compared to sampling by visit and appointment date.
• The feasibility study provided an insight into the logistical difficulties that may be encountered in the large-scale record review. As a result, it was determined that experienced eye care professionals will be required to make ‘judgement calls’ on parts of the review process.

Lessons learnt

• The record review manual and clinical indicators developed can be applied to other studies in the areas of glaucoma, diabetic retinopathy and preventative eye care.
• Different sampling strategies used at different practices are inevitable with the diverse nature of eye care practices and record systems.
• The record review provided clear, actionable feedback that was useful for clinical practices and highlighted the importance of measuring care delivered to patients.
• Clinicians can use the process in quality improvement activities, by repeating the record review before and after interventions. This process can also identify overuse, underuse and misuse of care.

References

• McGlynn EA, Asch SM, Adams J et al. The quality of health care delivered to adults in the United States. New England Journal Medicine 2003; 348(26): 2635-2645.
• Runciman WB, Hunt TD, Hannaford NA et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Medical Journal Australia 2012; 197(2): 100-105.
• Foreman J, Keel S, Xie J et al. The National Eye Health Survey 2016. Vision 2020 Australia: Melbourne, Victoria; 2016.

Further reading

• Claiborne JS, Hauser SL. T2 clinical research: judgment day. Annals of Neurology 2008; 63(3): A15-6.
• Braithwaite J, Matsuyama Y, Mannion R et al. How to do better health reform: a snapshot of change and improvement initiatives in the health systems of 30 countries. International Journal for Quality in Health Care 2016; 28(6): 843-846.

Contact

Terry Ho
PhD Student
School of Optometry and Vision Science, UNSW Sydney
Phone: 0406 789 625
kam.ho@unsw.edu.au