Developing realistic benchmarks for glaucoma care delivery

Figures & data

Table 1. Steps involved in calculating Achievable Benchmarks of Care.¹².

Step	Description
1	Adjust the performance (i.e., appropriateness) scores using the Bayesian estimator technique. $\mathit{Adjusted}\mathit{Performance}\mathit{Fraction}=\left(\mathit{x}+1\right)/\left(\mathit{d}+2\right)$ (x = number of patient encounters that met the indicator criteria, d = total number of eligible patient encounters for that clinical indicator)
2	Rank adjusted performance fractions for each location in descending order (i.e., top to bottom performers).
3	Sequentially add locations in descending order to obtain a sub-set of locations that represented at least 10% of all eligible patient encounters in the dataset.
4	Calculate ABCs using raw data for subset data. $\mathit{ABC}\%=\frac{\mathit{number}\mathit{of}\mathit{patient}\mathit{encounters}\mathit{in}\mathit{subset}\mathit{that}\mathit{met}\mathit{indicator}\mathit{criteria}}{\mathit{total}\mathit{number}\mathit{of}\mathit{eligible}\mathit{patient}\mathit{encounters}\mathit{in}\mathit{subset}}\mathit{x}100\mathrm{\%}$

ABC, Achievable Benchmarks of Care.

Table 2. Ranking of locations by APF proportion (step 2) for iCaretrack clinical indicator of Peripheral anterior chamber assessment by gonioscopy or van Herick’s. Cumulative total of sequential addition of eligible patient encounters to determine a subset of 10% eligible patient encounters (shown in grey). ‘Yes’ indicates number of patient encounters that met indicator criteria and ‘No’ indicates number of eligible patient encounters that did not meet the indicator criteria for that indicator (step 2).

Practice location	Yes	No	Eligible patient encounters	Cumulative total of sequential addition of patient encounters	iCareTrack p	APF p
2	10	0	10	10	1.00	0.92
13	9	1	10	20	0.90	0.83
17	9	1	10	30	0.90	0.83
29	9	1	10	40	0.90	0.83
35	9	1	10	50	0.90	0.83
27	8	2	10	60	0.80	0.75
34	8	2	10	70	0.80	0.75
37	8	2	10	80	0.80	0.75
38	8	2	10	90	0.80	0.75
9	7	3	10	100	0.70	0.67
18	7	3	10	110	0.70	0.67
26	7	3	10	120	0.70	0.67
33	7	3	10	130	0.70	0.67
7	6	4	10	140	0.60	0.58
15	6	4	10	150	0.60	0.58
31	6	4	10	160	0.60	0.58
1	5	5	10	170	0.50	0.50
4	5	5	10	180	0.50	0.50
19	5	5	10	190	0.50	0.50
25	5	5	10	200	0.50	0.50
3	4	6	10	210	0.40	0.42
11	4	6	10	220	0.40	0.42
12	4	6	10	230	0.40	0.42
24	4	6	10	240	0.40	0.42
39	4	6	10	250	0.40	0.42
41	4	6	10	260	0.40	0.42
42	4	6	10	270	0.40	0.42
14	3	7	10	280	0.30	0.33
6	2	8	10	290	0.20	0.25
20	2	8	10	300	0.20	0.25
22	2	8	10	310	0.20	0.25
28	2	8	10	320	0.20	0.25
32	2	8	10	330	0.20	0.25
16	1	9	10	340	0.10	0.17
23	1	9	10	350	0.10	0.17
30	1	9	10	360	0.10	0.17
36	1	9	10	370	0.10	0.17
40	1	9	10	380	0.10	0.17
5	0	10	10	390	0.00	0.00
8	0	10	10	400	0.00	0.00
10	0	10	10	410	0.00	0.00
21	0	10	10	420	0.00	0.00

P, proportion; APF, adjusted performance fraction.

Table 3. Characteristics of the optometry practices (n = 42) and glaucoma patients (n = 42) in the iCaretrack study.⁹.

Characteristic		N (%)
Optometry practice characteristics
Location
	New South Wales	15 (36%)
	Victoria	14 (33%)
	Queensland	10 (24%)
	South Australia	3 (7%)
Remoteness^†
	Major cities	29 (69%)
	Inner regional	8 (19%)
	Outer regional	5 (12%)
Record types
	Electronic record	33 (78%)
	Structured paper record	7 (17%)
	Both electronic and unstructured paper record^‡	2 (5%)
Business model
	Corporate	30 (71%)
	Franchise	7 (17%)
	Independent	5 (12%)
No. of practitioners’ samples per practice, median (range)		5.5 (1–12)
Glaucoma patient records
Patient age, mean ± SD (range)		57.5 ± 16.1 (19–92)
Patient sex
	Male	155 (37%)
	Female	262 (63%)

^†Based on the Australian Standard Geographical Classification (ASGC) using the ASGC Remoteness Area (2006) layer (https://www.health.gov.au/resources/apps-and-tools/health-workforce-locator/app).

^‡Two practices moved from paper to electronic records in early 2013, and as a result some selected records were paper and some were electronic. Abbreviation: SD, Standard deviation.

Table 4. The iCaretrack appropriateness levels with corresponding Achievable Benchmarks of Care for glaucoma care delivery in Australia.

Clinical indicators^†	iCareTrack Appropriateness level %	Eligible patient No.	Benchmark %
History Taking Domain
Initial visit
H1. Age	99	192	100
H2. Ethnicity	0	192	–
H3. Personal ocular history	92	192	100
H4. General health history	97	192	100
H5. History of migraine	40	192	88
H6. Current ocular medication	91	191	100
H7. Current systemic medication	91	192	100
H8. Current and past steroid use	2	192	15
H9. Family ocular history	95	192	100
H10. Diabetic status	60	192	100
H11. High blood pressure	21	192	63
H12. Low blood pressure	2	160	19
H13. Raynaud’s syndrome	0	192	–
Follow up visit
H14. Interval ocular history	95	229	100
H15. Interval systemic medical history	97	229	100
H16. Side effects of ocular medications	14	36	75
H17. Compliance to medication	58	36	89
Physical Examinations Domain
P18. Habitual visual acuity	99	420	100
P19. Pupil reactions	57	420	90
P20. IOP	90	420	100
P21. Time of IOP measurement	89	420	100
P22. Applanation tonometry	42	420	96
P23. Anterior ocular health by slit lamp	95	420	100
P24. Gonioscopy OR van Herick’s	45	420	92
P25. Size of optic disc	5	419	34
P26. Cup-disc ratio	93	419	100
P27. Pattern of the neuroretinal rim	45	419	94
P28. ONH/RNFL Imaging	78	389	100
P29. Visual field assessment SAP	31	420	62
Recall Domain
RC30. Recall (LRGS)‡	100	9	100
RC31. Recall (HRGS, treated, at target IOP)^‡	100	4	100
RC32. Recall (HRGS, treated, not at target IOP)^‡	100	1	–
RC33. Recall (HRGS, not treated)^‡	91	11	100
RC34. Recall (early glaucoma)^‡	88	17	100
RC35. Recall (moderate glaucoma)^‡	84	13	100
RC36. Recall (advanced glaucoma)^‡	100	6	100
RCC Recall combined^§	92	61	100
Referral Domain
RF37. Referral (treated, not at target IOP)^‡	100	9	100
Overall appropriateness	63		74

^†iCareTrack clinical indicators are in an abbreviated format. See appendix 1 for full clinical indicator wording.

^‡Benchmarks calculated from very small patient encounter numbers.

^§The seven recall indicators were combined to calculate a combined benchmark for the recall domain.

IOP, Intraocular pressure; ONH/RNFL, Optic nerve head or retinal nerve fibre layer; SAP, Standard automated perimetry; LRGS, low risk glaucoma suspect; HRGS, high risk glaucoma suspect; RCC, Recall combined.

Figure 1. iCaretrack practice appropriateness scores benchmarked against the benchmarks for glaucoma care clinical indicators. The percentage of practices are shown for at or better than benchmarks (black), at or better than average appropriateness score but worse than the benchmark (dark grey), and worse than average appropriateness score (light grey).

Table

Clinical indicators
	Patients assessed for or with glaucoma should have the following documented during the initial visit:
H1		Age, and
H2		Ethnicity, and
H3		Personal ocular history, and
H4		General health history, and
H5		History of migraine, and
H6		Current ocular medication, and
H7		Current systematic medication, and
H8		Current and past steroid use, and
H9		Family ocular history, and
H10		Diabetic status, and
H11		High blood pressure, and
H12		Low blood pressure, and
H13		Raynaud’s syndrome
	Patients assessed for or with glaucoma should have the following documented during the subsequent visit:
H14		Interval ocular health history, and
H15		Interval general health history, and
H16		Side effects of ocular medications, and
H17		Compliance to medication
	Patients assessed for glaucoma or with ocular hypertension (OHT) or newly diagnosed glaucoma should have a glaucoma examination performed and documented or referred for the following procedures to be organised:
P18		Habitual distance visual acuity, and
P19		Pupil reaction, and
P20		Intraocular pressure (IOP), and
P21		IOP measuring time, and
P22		Applanation tonometry, and
P23		Anterior ocular health by slit lamp, and
P24		Peripheral anterior chamber configuration by gonioscopy or van Herick’s peripheral anterior chamber depth assessment, and
P25		Size of optic disc, and
P26		Cup/disc (C/D) ratio, and
P27		Pattern of the neuroretinal rim, and
P28		Imaging of optic disc and/or optic nerve fibre and/or fundus photography, and
P29		Visual field examination with standard automated perimetry
RC30	Patients with suspected glaucoma (low risk: no family history, no major ocular history, no steroid use, open-angle (van Herick’s: >grade 2 or 0.25 OR gonio: TM≥2 quadrants), thick cornea, 9<IOP<22mmHg) should be advised to have a glaucoma follow-up examination within 6 to 24 months.
RC31	Patients with suspected glaucoma (high risk: with family history, or pigmented dispersion syndrome (PDS), or pseudoexfoliation syndrome (PXS), or IOP>21, or thin cornea (central corneal thickness (CCT)<510), steroid use, or major ocular history, or C/D ratio > 0.5) and are treated and are achieving target IOP should be advised to have a glaucoma follow-up examination within 3 to 12 months.
RC32	Patients with suspected glaucoma (high risk: with family history, or PDS, or PXS, or IOP>21, or thin cornea (CCT<510), steroid use, or major ocular history, or C/D ratio > 0.5) and are treated and are not achieving target IOP should be advised to have a glaucoma follow-up examination within four months.
RC33	Patients with suspected glaucoma (high risk: with family history, or PDS, or PXS, or IOP>21, or thin cornea (CCT<510), steroid use, or major ocular history, or C/D ratio > 0.5) and are not treated should be advised to have a glaucoma follow-up examination within four months.
RC34	Patients with early glaucoma should be advised to have a glaucoma follow-up examination within 12 months.
RC35	Patients with moderate glaucoma should be advised to have a glaucoma follow-up examination within six months.
RC36	Patients with advanced glaucoma should be advised to have a glaucoma follow-up examination within four months.
RF37	Patients (assessed for glaucoma or with OHT) and are treated and not achieving target IOP should be referred to ophthalmologist.

OHT, Ocular hypertension; IOP, Intraocular pressure; C/D, Cup/disc ratio; SAP, Standard automated perimetry; TM, Trabecular meshwork; PDS, Pigment dispersion syndrome; PXS, Pseudoexfoliation syndrome; CCT, Central corneal thickness.

Kiefe CI, Weissman NW, Allison JJ et al. Methodology matters-XII. Identifying achievable benchmarks of care: concepts and methodology. Int J Qual Health Care 1998; 10: 443–447. doi:10.1093/intqhc/10.5.443.

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