Impact of practicing internal benchmarking on continuous improvement of cataract surgery outcomes: a retrospective observational study at Aravind Eye Hospitals, India

OBJECTIVE

We aim to assess the effectiveness of a cataract surgery outcome monitoring tool used for continuous quality improvement. The objectives are to study: (1) the quality parameters, (2) the monitoring process followed and (3) the impact on outcomes.

DESIGN AND PROCEDURES

In this retrospective observational study we evaluated a quality improvement (QI) method which has been practiced at the focal institution since 2012: internal benchmarking of cataract surgery outcomes (CATQA). We evaluated quality parameters, procedures followed and clinical outcomes. We created tables and line charts to examine trends in key outcomes.

SETTING

Aravind Eye Care System, India.

PARTICIPANTS

Phacoemulsification surgeries performed on 718 120 eyes at 10 centres (five tertiary and five secondary eye centres) from 2012 to 2020 were included.

INTERVENTIONS

An internal benchmarking of surgery outcome parameters, to assess variations among the hospitals and compare with the best hospital.

OUTCOME MEASURES

Intraoperative complications, unaided visual acuity (VA) at postoperative follow-up visit and residual postoperative refractive error (within ±0.5D).

RESULTS

Over the study period the intraoperative complication rate decreased from 1.2% to 0.6%, surgeries with uncorrected VA of 6/12 or better increased from 80.8% to 89.8%, and surgeries with postoperative refractive error within ±0.5D increased from 76.3% to 87.3%. Variability in outcome measures across hospitals declined. Additionally, benchmarking was associated with improvements in facilities, protocols and processes.

CONCLUSION

Internal benchmarking was found to be an effective QI method that enabled the practice of evidence-based management and allowed for harnessing the available information. Continuous improvement in clinical outcomes requires systematic and regular review of results, identifying gaps between hospitals, comparisons with the best hospital and implementing lessons learnt from peers.

Toward Universal Eye Health Coverage-Key Outcomes of the World Health Organization Package of Eye Care Interventions: A Systematic Review

Importance

Despite persistent inequalities in access to eye care services globally, guidance on a set of recommended, evidence-based eye care interventions to support country health care planning has not been available. To overcome this barrier, the World Health Organization (WHO) Package of Eye Care Interventions (PECI) has been developed.

Objective

To describe the key outcomes of the PECI development.

Evidence Review

A standardized stepwise approach that included the following stages: (1) selection of priority eye conditions by an expert panel after reviewing epidemiological evidence and health facility data; (2) identification of interventions and related evidence for the selected eye conditions from a systematic review of clinical practice guidelines (CPGs); stage 2 included a systematic literature search, screening of title and abstracts (excluding articles that were not relevant CPGs), full-text review to assess disclosure of conflicts of interest and affiliations, quality appraisal, and data extraction; (3) expert review of the evidence extracted in stage 2, identification of missed interventions, and agreement on the inclusion of essential interventions suitable for implementation in low- and middle-income resource settings; and (4) peer review.

Findings

Fifteen priority eye conditions were chosen. The literature search identified 3601 articles. Of these, 469 passed title and abstract screening, 151 passed full-text screening, 98 passed quality appraisal, and 87 were selected for data extraction. Little evidence (≤1 CPG identified) was available for pterygium, keratoconus, congenital eyelid disorders, vision rehabilitation, myopic macular degeneration, ptosis, entropion, and ectropion. In stage 3, domain-specific expert groups voted to include 135 interventions (57%) of a potential 235 interventions collated from stage 2. After synthesis across all interventions and eye conditions, 64 interventions (13 health promotion and education, 6 screening and prevention, 38 treatment, and 7 rehabilitation) were included in the PECI.

Conclusions and Relevance

This systematic review of CPGs for priority eye conditions, followed by an expert consensus procedure, identified 64 essential, evidence-based, eye care interventions that are required to achieve universal eye health coverage. The review identified some important gaps, including a paucity of high-quality, English-language CPGs, for several eye diseases and a dearth of evidence-based recommendations on eye health promotion and prevention within existing CPGs.

Demand for Tertiary Eye Care Services in Developing Countries

PURPOSE

To analyze the experience of a large developing country tertiary ophthalmology system to identify generalizable information relevant for those planning similar centers elsewhere.

DESIGN

Retrospective utilization analysis.

METHODS

A historical review of the development of the Aravind Eye Care system was undertaken to evaluate the services provided by various tertiary services of the system. Demand for services is inferred based on the utilization statistics described below and distance traveled by patients to obtain services.

RESULTS

Utilization of subspecialty services increased logarithmically for 17 years in all specialties. At all centers except one historically focused on glaucoma, retina services had the highest demand among subspecialty surgical services. The proportion of tertiary care patients among all new outpatients (39% in 2009 and 45% in 2013) and the proportion of specialty surgical and treatment procedures among all procedures (30% in 1997 and 49% 2013) increased over time. More patients traveled long distances (>100 kilometers) to receive specialty services than to receive cataract services (30% vs 23%).

CONCLUSIONS

These observations suggest that in regions where tertiary services are not widely available, (1) patients demand (travel further for) tertiary care more than general ophthalmology services; (2) demand for services can expand rapidly for many years; (3) tertiary care services tend to grow over time as a proportion of all services provided; and (4) retina services are the most highly demanded subspecialty surgical services. In such settings, it is likely that considerable latent demand exists; planned tertiary eye centers should anticipate sustained growth of tertiary services.

The Endophthalmitis Kit

PURPOSE

This study aimed to provide essential first-intervention material for treatment of bacterial and fungal endophthalmitis in a ready-to-use kit.

DESIGN

A prospective investigational study.

METHODS

We have developed the Endophthalmitis Kit (E-kit), which contains most essential devices and antibacterial and antifungal antibiotics for initial treatment of bacterial and fungal endophthalmitis. The easy-to-prepare antibiotics includes vancomycin, ceftazidime, and voriconazole. We used visual analog scale to score the health personnel comfort of each content of the kit in 20 consecutive patients with endophthalmitis where the E-Kit was used.

RESULTS

The visual analog scale score was highest for the antibiotics and least for eye speculum. The 2-step preparation of antibiotics was easier than the current 4-step preparation.

CONCLUSIONS

The E-Kit benefit included accurate and easy preparation of antibiotics and antifungal, safe vitreous biopsy and intravitreal injection, and reduced ordering time and inventory cost.