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Sustainable cataract surgical outcome monitoring: Multifaceted intervention in Cambodia
572
CORRESPONDENCE MATERIALS AND METHODS
Sustainable cataract surgical outcome monitoring: Multifaceted intervention in Cambodia
The computerized cataract surgical record form program from the International Center for Eye Health, London, United Kingdom, was introduced as a clinical audit at the CTEH in 2007. Inclusion and exclusion criteria followed the standardized form, and results were analyzed annually. 3 The pertinent indicators that are routinely generated by the program (Table 1) were analyzed, and the results from 2007 to 2013 (supervision by expatriate ophthalmologists) were compared with those from 2014 to 2016 (supervision by local ophthalmologists). Analysis was done with the chi-square test (Statsdirect, version 3.0.192).
Cataract surgery is performed not only in high-income countries but, increasingly, also in low- and middle-income countries. It is one of the most commonly performed surgical procedures. The quantitative output has not been accompanied by an equivalent increase in available data on the quality of cataract surgeries generated by routinely performed continuous clinical audit.1 Although it has been suggested that prospective monitoring yields improvements in postoperative visual outcomes and in challenging environments of low-income countries,2 most data about the quality of cataract surgeries are still generated by population-based crosssectional studies, which are useful to monitor long-term developments but are not suitable for monitoring the results of individual surgeons or eye units. There is also no evidence as to whether interventions to introduce a clinical audit in an eye department in a low-income country by expatriate ophthalmologists are sustainable in the long-term. We report the results of an intervention that had been implemented at the Caritas Takeo Eye Hospital (CTEH), one of the main teaching tertiary eye hospitals in Cambodia. Until 2013, the staff of the eye hospital was supported by expatriate ophthalmologists, who supervised the introduction of cataract surgical outcomes monitoring. Since 2014, monitoring has been performed by fullytrained Cambodian ophthalmologists without supervision by expatriate ophthalmologists. We report the most salient results in 2 periods supervised by different groupsd2007 to 2013 and 2014 to 2016dand discuss the factors that accompanied the intervention.
RESULTS Overall, the mean monthly number of cataract surgeries increased from 2014 onward and a significantly higher number of surgeries were performed by resident ophthalmologists. The overall rate of reported complications decreased from 7.0% to 2.9%, and significantly fewer surgeries were done in eyes with comorbidities. This did not result in a reduction in surgeries with a poor visual outcome at discharge. There was a remarkable increase in patients presenting for the first postoperative follow-up visit, which might be a consequence of transportation fees for patients being waived starting in 2014 as part of a Cambodian health voucher program.A DISCUSSION Preliminary results suggest that the introduction of cataract surgical outcome monitoring as a continuous clinical audit in a Cambodian tertiary rural eye hospital was a sustainable intervention with comparable results in poor visual outcomes at discharge and good and poor outcomes at followup visits in the 2 supervised periods. However, further research is needed to explore the factors that contributed
Table 1. Main results of cataract surgery monitoring in the 2 periods. Measurement Total cataract surgeries*
Years 2007–2013, n/% (95% CI)
Years 2014–2016, n/% (95% CI)
P Value
12 187
6 740
d
145
187
Mean cataract surgeries per month* Cataract surgeries in eyes with additional comorbidities
1434/11.8 (11.2-12.3)
Cataract surgeries performed by resident ophthalmologists
2949/24.2 (23.4-25.0)
d (5.4-6.6)
!.0001
2442/36.2 (35.1-37.4)
!.0001
409/6.1
!.0001
Overall complications
859/7.0
(6.6-7.5)
194/2.9
(2.5-3.3)
Posterior capsule rupture/vitreous loss
495/4.1
(3.7-4.4)
96/1.4
(1.2-1.7)
!.0001
3107/46.1 (45.1-47.5)
!.0001
Good visual outcome at discharge (presenting DVA 6/6–6/18)
6235/51.2 (50.3-52.1)
Poor visual outcome at discharge (presenting DVA !6/60)
1126/9.2
Presenting for 1st follow-up
8264/67.8 (67.0-68.7)
5640/82.7 (82.0-83.8)
Good visual outcome at 1st follow-up (presenting DVA)
4657/56.4 (55.3-57.5)
3170/56.2 (54.9-57.5)
Poor visual outcome at 1st follow-up (presenting DVA) Good visual outcome at 1st follow-up (best DVA with full refraction or pinhole) Poor visual outcome at 1st follow-up (best DVA with full refraction or pinhole)
667/8.1
(8.7-9.8)
(7.5-8.7)
5922/71.7 (70.8-7.7) 484/5.9
(5.4-6.4)
647/9.6
412/7.3
(8.7-10.1)
.74 !.0001 .8
(6.5-7.9)
.05
3993/70.8 (69.5-71.9)
.23
316/5.6
(5.1-6.3)
.67
DVA Z distance visual acuity *Number only
Q 2017 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter http://dx.doi.org/10.1016/j.jcrs.2017.03.003
CORRESPONDENCE
to the successful intervention. The conceptual framework of individual policy by Lomas and Haynes4 has been used to examine maintenance of high-quality performance of health workers in low-resource settings5; eg, it has been suggested that dissemination of clinical guidelines has been less successful than multifaceted interventions, including supervision and audit with feedback. In Cambodia, the introduction of cataract surgical outcomes monitoring was leveraged by the demand of international funding organizations to monitor the quality of cataract surgeries as well as by defining cataract surgical outcomes monitoring as good clinical standard practice by the National Program for Eye Health of the Cambodian Ministry of Health.3 Simultaneously, cataract surgical outcomes monitoring was integrated in an overarching effort to improve the Health Information System at central and peripheral levels of the Cambodian Eye Health System. The continuous surgical hands-on training that had been provided during the period from 2007 to 2013 might have contributed to the decreasing percentage of surgical complications and better postoperative outcomes. This development together with regular feedback guaranteeing confidentiality might have led to ophthalmologists and resident doctors perceiving cataract surgical outcomes monitoring as worthwhile rather than as a threat. However, underreporting of complications, or even a rejection of patients with comorbidities, cannot be ruled out.
573 Manfred M€ orchen, MD, FEBO, MPH(c) Chea Ang, MD Neang Mao, MD Te Serey Bonn, MPH
REFERENCES 1. Benzimra JD, Johnston RL, Jaycock P, Galloway PH, Lambert G, Chung AKK, Eke T, Sparrow JM, the EPR User Group. The Cataract National Dataset electronic multicentre audit of 55 567 operations: antiplatelet and anticoagulant medications. Eye 2009; 23:10–16. Available at: http://www. nature.com/eye/journal/v23/n1/pdf/6703069a.pdf. Accessed February 24, 2017 2. Yorston D, Gichuhi S, Wood M, Foster A. Does prospective monitoring improve cataract surgery outcomes in Africa? Br J Ophthalmol 2002; 86:543–547. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1771115/pdf/bjo08600543.pdf. Accessed February 24, 2017 €rchen M, Mao N, Ang C, Bonn TS. Outcome and monitoring of cataract 3. Mo surgical services at Takeo Province, Cambodia. Asia Pac J Ophthalmol 2012; 1:340–344 4. Lomas J, Haynes RB. A taxonomy and critical review of tested strategies for the application of clinical practice recommendations: from “official” to “individual” clinical policy. Am J Prev Med 1988; 4 (suppl 4):77–94; discussion 95–97 5. Rowe AK, De Savigny D, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet 2005; 366:1026–1035 OTHER CITED MATERIAL A. Federal Ministry for Economic Cooperation and Development. Every person counts. Promoting the inclusion of persons with disabilities in the health sector €r Internationale in Cambodia. Eschborn, Germany, Deutsche Gesellschaft fu Zusammenarbeit (GIZ) GmbH. Available from: https://health.bmz.de/ghpc/ case-studies/Every_person_counts/Every_person_counts_long_ENG.pdf. Accessed February 24, 2017
Volume 43 Issue 4 April 2017
CORRESPONDENCE MATERIALS AND METHODS
Sustainable cataract surgical outcome monitoring: Multifaceted intervention in Cambodia
The computerized cataract surgical record form program from the International Center for Eye Health, London, United Kingdom, was introduced as a clinical audit at the CTEH in 2007. Inclusion and exclusion criteria followed the standardized form, and results were analyzed annually. 3 The pertinent indicators that are routinely generated by the program (Table 1) were analyzed, and the results from 2007 to 2013 (supervision by expatriate ophthalmologists) were compared with those from 2014 to 2016 (supervision by local ophthalmologists). Analysis was done with the chi-square test (Statsdirect, version 3.0.192).
Cataract surgery is performed not only in high-income countries but, increasingly, also in low- and middle-income countries. It is one of the most commonly performed surgical procedures. The quantitative output has not been accompanied by an equivalent increase in available data on the quality of cataract surgeries generated by routinely performed continuous clinical audit.1 Although it has been suggested that prospective monitoring yields improvements in postoperative visual outcomes and in challenging environments of low-income countries,2 most data about the quality of cataract surgeries are still generated by population-based crosssectional studies, which are useful to monitor long-term developments but are not suitable for monitoring the results of individual surgeons or eye units. There is also no evidence as to whether interventions to introduce a clinical audit in an eye department in a low-income country by expatriate ophthalmologists are sustainable in the long-term. We report the results of an intervention that had been implemented at the Caritas Takeo Eye Hospital (CTEH), one of the main teaching tertiary eye hospitals in Cambodia. Until 2013, the staff of the eye hospital was supported by expatriate ophthalmologists, who supervised the introduction of cataract surgical outcomes monitoring. Since 2014, monitoring has been performed by fullytrained Cambodian ophthalmologists without supervision by expatriate ophthalmologists. We report the most salient results in 2 periods supervised by different groupsd2007 to 2013 and 2014 to 2016dand discuss the factors that accompanied the intervention.
RESULTS Overall, the mean monthly number of cataract surgeries increased from 2014 onward and a significantly higher number of surgeries were performed by resident ophthalmologists. The overall rate of reported complications decreased from 7.0% to 2.9%, and significantly fewer surgeries were done in eyes with comorbidities. This did not result in a reduction in surgeries with a poor visual outcome at discharge. There was a remarkable increase in patients presenting for the first postoperative follow-up visit, which might be a consequence of transportation fees for patients being waived starting in 2014 as part of a Cambodian health voucher program.A DISCUSSION Preliminary results suggest that the introduction of cataract surgical outcome monitoring as a continuous clinical audit in a Cambodian tertiary rural eye hospital was a sustainable intervention with comparable results in poor visual outcomes at discharge and good and poor outcomes at followup visits in the 2 supervised periods. However, further research is needed to explore the factors that contributed
Table 1. Main results of cataract surgery monitoring in the 2 periods. Measurement Total cataract surgeries*
Years 2007–2013, n/% (95% CI)
Years 2014–2016, n/% (95% CI)
P Value
12 187
6 740
d
145
187
Mean cataract surgeries per month* Cataract surgeries in eyes with additional comorbidities
1434/11.8 (11.2-12.3)
Cataract surgeries performed by resident ophthalmologists
2949/24.2 (23.4-25.0)
d (5.4-6.6)
!.0001
2442/36.2 (35.1-37.4)
!.0001
409/6.1
!.0001
Overall complications
859/7.0
(6.6-7.5)
194/2.9
(2.5-3.3)
Posterior capsule rupture/vitreous loss
495/4.1
(3.7-4.4)
96/1.4
(1.2-1.7)
!.0001
3107/46.1 (45.1-47.5)
!.0001
Good visual outcome at discharge (presenting DVA 6/6–6/18)
6235/51.2 (50.3-52.1)
Poor visual outcome at discharge (presenting DVA !6/60)
1126/9.2
Presenting for 1st follow-up
8264/67.8 (67.0-68.7)
5640/82.7 (82.0-83.8)
Good visual outcome at 1st follow-up (presenting DVA)
4657/56.4 (55.3-57.5)
3170/56.2 (54.9-57.5)
Poor visual outcome at 1st follow-up (presenting DVA) Good visual outcome at 1st follow-up (best DVA with full refraction or pinhole) Poor visual outcome at 1st follow-up (best DVA with full refraction or pinhole)
667/8.1
(8.7-9.8)
(7.5-8.7)
5922/71.7 (70.8-7.7) 484/5.9
(5.4-6.4)
647/9.6
412/7.3
(8.7-10.1)
.74 !.0001 .8
(6.5-7.9)
.05
3993/70.8 (69.5-71.9)
.23
316/5.6
(5.1-6.3)
.67
DVA Z distance visual acuity *Number only
Q 2017 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter http://dx.doi.org/10.1016/j.jcrs.2017.03.003
CORRESPONDENCE
to the successful intervention. The conceptual framework of individual policy by Lomas and Haynes4 has been used to examine maintenance of high-quality performance of health workers in low-resource settings5; eg, it has been suggested that dissemination of clinical guidelines has been less successful than multifaceted interventions, including supervision and audit with feedback. In Cambodia, the introduction of cataract surgical outcomes monitoring was leveraged by the demand of international funding organizations to monitor the quality of cataract surgeries as well as by defining cataract surgical outcomes monitoring as good clinical standard practice by the National Program for Eye Health of the Cambodian Ministry of Health.3 Simultaneously, cataract surgical outcomes monitoring was integrated in an overarching effort to improve the Health Information System at central and peripheral levels of the Cambodian Eye Health System. The continuous surgical hands-on training that had been provided during the period from 2007 to 2013 might have contributed to the decreasing percentage of surgical complications and better postoperative outcomes. This development together with regular feedback guaranteeing confidentiality might have led to ophthalmologists and resident doctors perceiving cataract surgical outcomes monitoring as worthwhile rather than as a threat. However, underreporting of complications, or even a rejection of patients with comorbidities, cannot be ruled out.
573 Manfred M€ orchen, MD, FEBO, MPH(c) Chea Ang, MD Neang Mao, MD Te Serey Bonn, MPH
REFERENCES 1. Benzimra JD, Johnston RL, Jaycock P, Galloway PH, Lambert G, Chung AKK, Eke T, Sparrow JM, the EPR User Group. The Cataract National Dataset electronic multicentre audit of 55 567 operations: antiplatelet and anticoagulant medications. Eye 2009; 23:10–16. Available at: http://www. nature.com/eye/journal/v23/n1/pdf/6703069a.pdf. Accessed February 24, 2017 2. Yorston D, Gichuhi S, Wood M, Foster A. Does prospective monitoring improve cataract surgery outcomes in Africa? Br J Ophthalmol 2002; 86:543–547. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1771115/pdf/bjo08600543.pdf. Accessed February 24, 2017 €rchen M, Mao N, Ang C, Bonn TS. Outcome and monitoring of cataract 3. Mo surgical services at Takeo Province, Cambodia. Asia Pac J Ophthalmol 2012; 1:340–344 4. Lomas J, Haynes RB. A taxonomy and critical review of tested strategies for the application of clinical practice recommendations: from “official” to “individual” clinical policy. Am J Prev Med 1988; 4 (suppl 4):77–94; discussion 95–97 5. Rowe AK, De Savigny D, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet 2005; 366:1026–1035 OTHER CITED MATERIAL A. Federal Ministry for Economic Cooperation and Development. Every person counts. Promoting the inclusion of persons with disabilities in the health sector €r Internationale in Cambodia. Eschborn, Germany, Deutsche Gesellschaft fu Zusammenarbeit (GIZ) GmbH. Available from: https://health.bmz.de/ghpc/ case-studies/Every_person_counts/Every_person_counts_long_ENG.pdf. Accessed February 24, 2017
Volume 43 Issue 4 April 2017