Seeing eye to eye: Collaborative efforts to improve quality in ophthalmology
Regional project demonstrates feasibility of collaborative models in ophthalmology and offers lessons in scalability
Across many fields of medicine, healthcare providers and the institutions where they practice have joined together in collaborative associations to improve the quality of the care they deliver.
By sharing data, providing feedback on performance, and swapping best practices, examples abound of how these collaboratives have produced better patient outcomes and well-being, reduced complications and mortality, and decreased costs.
In many cases, quality collaboratives involve dozens of participating hospitals and thousands of providers across a region or state.
But one Michigan regional collaborative, believed to be the first of its kind in ophthalmology, demonstrates how this concept can work with a few dedicated partners uniting to improve quality in a specific area; in this case, ensuring newly diagnosed glaucoma patients are examined according to standard guidelines. The results of this effort were recently published in the American Journal of Ophthalmology.
Primary open angle glaucoma (POAG) is one of the leading causes of blindness worldwide. Early detection can help greatly in preserving visual function, slowing glaucoma’s progression and maintaining patients’ quality of life. However, evidence has shown considerable variation among physicians in consistently administering the major examination elements (of which there are 13) that are recommended to accurately diagnose the condition and determine appropriate treatments.
“Patients with this disease require strict monitoring to ensure they have the best possible outcome,” says Joshua Ehrlich, M.D., M.P.H., an ophthalmologist (and glaucoma specialist) at the University of Michigan Kellogg Eye Center and the study’s lead author. “This means the initial exam needs to be done properly and completely.”
A group of University of Michigan ophthalmologists led Jennifer Weizer, M.D., established a regional collaborative of glaucoma specialists across three different types of practices in Michigan. The collaborative evaluated whether working together helped standardize care across the sites by focusing on adherence to the American Academy of Ophthalmology’s Primary Open-angle Glaucoma (POAG) Preferred Practice Pattern (PPP) guidelines.
Adherence rates for each of the recommended examination elements were determined for each of the three groups at the beginning of the study, and each physician also received his or her individual adherence rates. Physicians across the sites discussed strategies – by phone and email – for improving overall adherence to the guidelines.
The study found that adherence to the guidelines was high across most of the exam elements at all study sites to begin with, but among the examination elements with the lowest baseline adherence, those improved over the course of the study.
The project was also helpful for discerning potential obstacles to collaboration, and for determining strategies for working around them. Standardizing protocols across many different electronic medical record (EMR) systems rose to the top of these issues, since ophthalmologists in the U.S. use more than 100 different EMRs which don’t really communicate well with each other (and only about half are able to transmit their data to the newly founded IRIS Registry, the American Academy of Ophthalmology’s nationwide centralized data repository and reporting tool being utilized for quality improvement). In the Michigan glaucoma collaborative, each of the practice sites was able to program its EMR to remind physicians about the guideline parameters, and this helped improve adherence rates.
The collaborative’s work also highlighted the importance of being able to convene virtually between sites geographically distant from each other in order to review and interpret their pooled data.
“Ophthalmology as a field can seem somewhat fragmented because ophthalmologists are specialized and are not always in the habit of communicating often with our colleagues. These collaboratives represent one way to push beyond those silos and work together to improve the care we deliver,” Weizer days.
The team hopes the results could encourage other networks to come together around other conditions to improve patient care and outcomes through sharing data and collaboratively exchanging ideas.
“Beyond working to improve adherence to guidelines, there are opportunities in ophthalmology to collaborate around decision-making about when to escalate therapy, when patients go to surgery, and other treatment decisions, and then how those decisions impact outcomes down the road,” Ehrlich says.
“While many quality collaborative projects are done on an impressive scale, we’ve found these efforts can be worthwhile on a smaller level and still improve quality and safety,” Weizer says.
“We look to a lot of the big collaboratives in other specialties such as surgery, breast cancer, and cardiology for how to design collaboratives and have them work together effectively,” Weizer says. “For ophthalmology, the magnitude is a bit smaller, since we have fewer physicians than many of these other fields. And some of the outcomes are a bit more complicated to measure, since they’re less cut and dry than mortality rates, for example.”
Other collaborators on the study included Josh Stein, Paul Lee, Jeffrey Wentzloff, Nauman Imami, and Taylor Blachley. Ehrlich, Stein, Weizer, and Lee are also members of the Center for Eye Policy & Innovation (CEPI) at the University of Michigan. Ehrlich, Stein, and Lee are also members of the Institute for Healthcare Policy & Innovation.