Objetivos y funciones de puestos

The MOHLTC recently published the report,” Quality Indicators for Cataract Quality-Based Procedures Baseline Results” (October 2014). In this report 18 different quality indicators covering six different domains are listed.

The six domains are: Effectiveness, Appropriateness, Integration, Efficiency, Access and Patient- Centeredness.

Out of this larger list, four indicators have been selected and reported on. These are:

 Effectiveness - Rate of Complications following Cataract Surgery

 Access indicators

o 90th Percentile Wait-Times for Cataract Surgery – Time from Decision to Treat to Surgery (Wait 2) for Priorities 2-4

o Volume and Volume Proportions of Cataract Surgeries by Age Group o Distance from Home to Provider

The first indicator is a clinical quality measure, the other three are system performance measures . It is expected that the MOHLTC will continue to develop quality indicators and provide reports profiling both clinical outcomes and performance measures. . To quote from the report:

It should be noted that indicator refinement will be an iterative process that the ministry will undertake in collaboration with its partners and experts in ophthalmologic care. Ten quality indicators for future development have been identified by the Clinical Expert Advisory Group (see page 13) but due to identified issues with current data quality and availability, could not be included in this report. Provider feedback has indicated a need to continue to pursue the development of specific data definitions and data quality in corresponding areas of evidence-informed cataract care in the province.

Quality Indicators for Future Development 1. Wait time for visit to specialist (Wait 1)

2. Proportion of patients requiring emergent care following surgery 3. Proportion of patients who receive capsulotomy (note 1)

4. Proportion of patients in pathway 1 who achieve the desired visual outcome (note 2)

5. Proportion of patients in pathway 1 who receive cataract surgery without vision dropping below the threshold required to maintain driving or occupational requirements

6. Proportion of patients in pathway 8 who achieve improved visual function (note 2)

60 7. Proportion of patients who were referred with cataracts who do not have surgery

8. Proportion of cataract surgery patients who are 65 years of age and older by institution

9. Proportion of patients who have final summary completed and sent at time of last visit with surgeon 10. Proportion of cataract patients who receive the surgical facility’s standard intraocular lens (and pay no

additional fee) by facility/institution Notes:

1) This procedure may occur several years after cataract surgery.

2) This should be included on the patient record and should be tracked by the institution performing the surgery.

It should be noted this list of developmental indicators is preliminary and will evolve over time as appropriate measures for assessing the intended and unintended impact of cataract QBP implementation are identified.

Clinical Outcome Quality Measure - cataract surgery complication rate

The cataract surgery complication rate for the South West LHIN in both 2012 and 2013 was 0.3%. The overall provincial rate was 0.4% for both years¹⁸.

The report interpreted the results as follows:

 At the provincial level, complication rates following surgery among cataract QBP cases remained steady between the 2011 and 2012 fiscal years at 0.4%

 Values ranged from a high of 1.2% in the Central West LHIN in FY 2011 to a low of 0.2% in the North Simcoe Muskoka LHIN in FY 2011 and South East LHIN in FY 2012.

Cataract surgery is currently lacking a clinical outcome measure that is robust and applicable across all types of cataract surgery. In practical terms, the presenting reasons for cataract surgery vary as does the underlying disease. The Cataract Surgery Quality Based Procedure – Clinical Handbook (October2013) makes this clear when eight different clinical best practice pathways for cataract surgery were profiled.

In The Current State of Vision Care report it was noted that while a number of important quality indicators have been identified, few are actually measured at the present time. The following recommendation was made:

Future State Recommendation 34.0

Each hospital and the medical staff that provides cataract and other ophthalmologic services should take the necessary steps to identify specific clinical performance indicators that they will use to measure clinical

practices and outcomes on an on-going basis. This will enable both internal and external stakeholders to know that best clinical practices are being followed and that clinical outcomes are being documented and reported.

This recommendation still holds and is brought forward for consideration.

Target of Recommendation:

All hospitals that provide cataract and other ophthalmic services and affiliated physicians

Finance and Resource Impact:

Staff and physician resources to develop and report on meaningful clinical performance indicators that measure clinical practices and outcomes

18Quote from the report: This indicator assesses the proportion of patients 18 years of age and older who underwent cataract surgery in Ontario and subsequently developed severe uvetitis, infectious endophthalamitis, retinal detachment or capsule rupture in the 2011 and 2012 fiscal years. Results are expressed as rates per 100 cataract QBP patients. It should be noted that in 2010 a coding consideration resulted in no cases being captured in the definition of the cataract QBP patient cohort and therefore results are not available for that fiscal year. In addition, indicator results were not adjusted for patient complexity and therefore provide only crude rates of complications following surgery.

61 Intended Outcome:

All hospitals and ophthalmologists will be able to demonstrate that they are offering quality, standards-based clinical services with positive outcomes.

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As noted above, three of the four quality indicators reported by the MOHLTC are system quality or system performance measures.

ACCESS: Proportion of Cases Completed within Target Wait Time – Time from Decision to Treat to Surgery (Wait 2): Priorities 2-4 – Highlights:

 The proportion of non-urgent cataract cases whose surgeries were completed within target wait times decreased every fiscal year in Ontario between 2011 and 2013.

 The proportion of priority 2 cataract cases whose surgeries were completed within the target wait time of 42 days decreased every fiscal year in Ontario between 2011 and 2013.

 The proportion of priority 3 cataract cases whose surgeries were completed within the target wait time of 84 days decreased in Ontario between fiscal years 2011 and 2013.

 The proportion of priority 4 cataract cases whose surgeries were completed within the target wait time of 182 days decreased every fiscal year in Ontario between 2011 and 2013.

 Fewer cataract surgeries were performed in Ontario in FY 2011 than 2012.

ACCESS: Volume and Volume Proportions of Cataract Surgeries by Age Group

• The greatest volume of cataract surgeries were accounted for by the 65-74 and 75-84 age groups, with the overall number of surgeries in each of these cohorts reaching close to 50,000 in both of the 2011 and 2012 fiscal years

• There was a decrease in the volume of surgeries performed across all age groups between the 2011 and 2012 fiscal years

• Among all LHINs, the Central East LHIN had the highest volume of QBP cataract surgeries in both fiscal years

• Conversely, the lowest volume of surgeries among all Ontario LHINs in both years were performed in the North West LHIN

In the South West LHIN 81% of patients were 65 or older ACCESS: Distance from Home to Provider

 At a provincial level the proportion of cataract patients who traveled five kilometers or less to receive surgery declined slightly in each of the 2010, 2011 and 2012 fiscal years

 A higher proportion of Ontario’s cataract patients traveled over 200 kilometers to receive surgery in each of the fiscal years of observed results

 Overall, LHIN level performance remained relatively stable in each distance category across fiscal years

 The North East LHIN had the highest observed increase in the proportion of patients traveling over 200 kilometers for surgery with this group accounting for only 6% of all surgeries in FY 2010 but increasing to 10%

in FY 2012

 The highest observed decrease in patients traveling less than five km for surgery was in the North West LHIN (20% of all surgeries in FY 2010 and 17% in FY 2012)

In the South West LHIN 48% of all patients travelled 10 kilometers or less to get their cataract surgery.

Future State Recommendation 35.0

Hospitals and ophthalmologists within the South West LHIN should monitor and review performance data and opportunities for improvement based on both local and provincial quality indicators that measure quality and system performance.

62 Target of Recommendation:

All hospitals in the South West LHIN that offer ophthalmology services and affiliated ophthalmologists

Financial and Resource Impact:

Meeting time for those involved, administrative support services, data support services

Intended Outcome:

The hospitals and ophthalmologists in the South West LHIN will be open to opportunities to improve performance based on both system performance and quality outcome measures.

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System Leadership – planning and responding to the Future of Vision Care