The delivery of eye health services is changing in Australia, with an increasing focus on clinical benchmarking in practice. The hope is that by benchmarking eye diseases detected, referrals made, and services provided, quality of care and eye health outcomes will be improved.
But, is there a danger that benchmarking could also lead to overdiagnosis?
Data is everything.
“Data collection will help us close the loop in eye health,” says Lyn Brodie, chief executive officer of Optometry Australia. “It will help us identify how many people are being referred on to ophthalmologists and what the outcome is for those patients. We need data on the full patient journey.”
Data also provides evidence about delivery of eye health that is invaluable when advocating to government for continued Medicare funding, research into new treatments and services.
It is only by reviewing how you are personally tracking against the benchmark that you can consider how you might approach items differently
According to Ms Brodie, Medicare item numbers are not designed to provide this level ofevidence. She says item 10914 is too general to provide useful information because it covers comprehensive examinations of people with a range of progressive conditions (glaucoma, macular degeneration, cataract etc). Item 10915 for diabetic eye disease examinations has low usage, because optometrists often choose to use other item numbers when seeing diabetic patients. As such, the usage of Item 10915 does not provide the full picture of how many diabetic patients are being seen by optometrists.
Programs like KeepSight, an initiative launched in October 2018 to increase screening of diabetic patients for diabetic eye disease, require evidence of success to maintain financial support. The government/ industry collaborative program has been funded with an investment of AU$5 million over five years by Specsavers. At this stage, the Federal government has only committed an initial $1 million dollars. It is hoped that by demonstrating the program’s capacity to get the 50 per cent of diabetic Australians – 630,000 people – not currently engaged in eye care to seek an eye examination, more government funding will be committed. Data is the key and ophthalmologist Dr Peter Van Wijngaarden, who led the development of KeepSight over five years, is very much aware of this. At the program launch at Parliament House in Canberra he said, “From the outset, measuring the outcomes of the program is a priority and we will do this by drawing on the expertise of our colleagues at the Centre for Eye Research Australia”.
early career optometrists particularly, will embrace the opportunity to be part of this research driven data collection project…
Speaking at the KeepSight launch, Peter Larsen Optometry Director at Specsavers echoed the sentiment. “Specsavers has seamlessly linked its practice management to the Oculo platform, which is linked to the KeepSight portal. The data gathered as a consequence will provide valuable knowledge for stakeholders, which can be used to evolve the program. Additionally, it will make it easier for optometrists to send relevant information to their patients to improve outcomes.”
DATA TO DRIVE PROFESSIONAL DEVELOPMENT
Specsavers is in a fortunate position. With over 380 stores and more than six million customers across Australia and New Zealand, all using the same practice management software and the Oculo platform to manage patient journeys, the organisation is able to gather significant, meaningful data about prevalence of vision impairment and eye disease. This data is also enabling Specsavers to set benchmarks and draw comparisons on disease detection, referrals and item numbers between stores and individuals.
“Benchmarks are set up for each optometrist and the group of optometrists within each store to self-reflect on their own performance,” explains Mr Larsen. “It is only by reviewing how you are personally tracking against the benchmark that you can consider how you might approach items differently – if you are over-indexing on one item or referral type and under-indexing on another. Until now, optometrists have had no real way of knowing how they are tracking against others in their practice, their state or the nation. With benchmark reports they do and this covers not just item numbers but also disease detection, referral rates and more.”
According to Specsavers data, from 1 January – 2 December 2018, Specsavers stores made a total of 145,962 referrals, comprising 30,191 for glaucoma, 7,925 for diabetic eye disease, 29,995 for medical retinal, 40,812 for cataract and 55,274 referrals for ‘other ocular conditions’.
Bailey Nelson, which now has 59 stores across Australia, New Zealand, the United Kingdom and Canada, is also using Oculo to determine referral rates, and is in discussion with the organisation to use data analytics on disease prevalences and detection (the group currently uses internal data metrics to track disease and management plans). Robyn Weinberg, eyecare director, says the data coming through after two years is helping drive professional development.
“Benchmarking has been a really positive initiative for us and, after two years, we’re starting to get some very useful data. Young optometrists coming out of university are well skilled in terms of using technology for disease detection, however they are still gaining experience. By benchmarking, we’re able to identify those who need further upskilling in very specific areas, or support,” she said.
At Luxottica, clinical benchmarking has been underway for some years. Initially this involved analysing billing patterns, that are reflective of the level of clinical care provided, and more recently, with the introduction of digital technologies, the organisation is analysing ultra wide digital retinal scans and optical coherence tomography scans.
“We have looked at ratios of various clinical tests and optometry procedures,” explained Peter Murphy, Luxottica’s Director of Eyecare and Community. “We are transitioning to collect more data analytics that best capture the level of clinical care, such as referral rates, and interactions with GPs and ophthalmologists.”
Mr Murphy said Luxottica’s primary objective of benchmarking data is “to ensure the best possible level of clinical care. We would also like to ensure a consistent experience between different optometrists and across our network of stores. Mostly we are looking for a consistently high standard of care, but we also inspect the outliers in the data, and try and understand the reasons for any wide variances. If there are unanticipated outliers we may discuss the findings with relevant parties.”
He said optometrists understand the value of benchmarking. “In general, our optometrists are always keen to learn and grow from any relevant feedback they receive. They are looking to continuously improve the level of clinical care they provide to their patients.”
However, to be useful he said, “reports need to be framed in the right context and with the right intent. They also need to be communicated to our optometrists in a timely and professional manner.”
DRIVING PUBLIC COMMUNICATION STRATEGIES
According to Luke Cahill, President of Optometry NSW/ACT, data gathered through benchmarking can be invaluable when developing key public communications about eye health.
“Statistically significant data from benchmarking can be used to educate the public about the prevalence of particular conditions, and about our ability to detect and manage those conditions.”
However, he said, gathering statistically significant data from right across the sector will be one of the greatest challenges.
overdiagnosis can also occur in eye health, particularly if results of eye examinations are not interpreted within the context of the patient and the overall clinical picture
“As an Association, we represent all optometrists – independent and corporate – so any benchmarking we do, and correspondent messaging or advocacy needs to reflect the entire profession. Ideally we need to get the big picture of eye health in Australia by merging data from all practice models. Luxottica and Specsavers have their own data systems which makes it relatively easy for these organisations to capture data from their practices in a consistent way. Independents use a variety of practice management software and this is the challenge. The last thing we want to do is come out with data that is flawed.”
Lyn Brodie said the Association is working to identify specific data needed, then will seek to work with existing software providers to determine a way to gather it. “We don’t need all optometrists to gather statistically significant data, but we do need a representative number. I believe early career optometrists particularly, will embrace the opportunity to be part of this research driven data collection project because ultimately, it will drive improved patient outcomes,” she said.
With over 1,800 optometrists and 500 ophthalmologists now using Oculo in Australia, and membership growing in New Zealand, there is no doubt that this digital platform will be a useful resource for data collection.
Kate Taylor, chief executive officer of Oculo, looks forward to facilitating an evidence based future for optometry. “Oculo is keen to support how data can improve individual patient outcomes and the health system overall. Specsavers uses their Oculo data to enable them to have insights on their own clinical practice. We want to work with other groups – optometry and ophthalmology – so that they can gain insights from their own data. Clearly, the key point is to uphold patient privacy and data sovereignty, so that commercial and clinical privacy is always protected.”
THE FLIP SIDE
Along with the much discussed issue of data privacy, there is a danger that benchmarking may lead to overdiagnosis of disease. If for example, a health professional is presented with a report that indicates their rate of detection is lower than their colleagues, will this cause anxiety about their ability to detect disease? Will they feel pressured to perform better by referring on more liberally, when in fact there is no need?
Will public awareness of rates of disease detection increase patient anxiety, encouraging them to doctor shop and seek out unnecessary screenings?
Growing concern about overdiagnosis right across the international health care sector has resulted in an annual international ‘Preventing Overdiagnosis’ conference, which this year will be held in Sydney.
According to Preventing Overdiagnosis Inc, “Overdiagnosis can happen when people without symptoms are diagnosed and then treated for a disease that won’t actually cause them any symptoms”.1
The disease detection does not benefit the patient and can end up being harmful due to continual screening and over medication. Overdiagnosis can also put unnecessary strain on resources and delay access to treatment for those patients most in need.
Some research has identified that public screening campaigns are resulting in over diagnosis of cancers including breast, prostate, thyroid, and kidney.1
Luke Arundel, from Optometry Australia, cautions that overdiagnosis can occur in eye health, particularly if results of eye examinations are not interpreted within the context of the patient and the overall clinical picture.
“Optical coherence tomography (OCT), for instance, can give you a wealth of data, but the value of that data depends on how you interpret it,” said Mr Arundel.
“‘Red disease’ may occur where nonexistent disease is incorrectly indicated by the instrument. High refractive error, tilted discs or physiological differences with ethnicity may lead to the machine incorrectly interpreting the data, particularly when the normative databases they are comparing to are often not very large. Recent research2 suggests the false positive rate with OCTs is as high as 15 to 36 per cent.
“Continual expansion of normative databases, increases in processing power and advances in machine learning, deep learning and artificial intelligence to assist in identifying normal and abnormal results will all help to reduce the risks of over diagnosis in the future,” he said.
Back at Specsavers, benchmarking has shown that the roll out of OCTs across Specsavers stores, along with CPD education has doubled rates of glaucoma detection. Mr Larsen is proud of this achievement but realistic about the risk of overdiagnosis as well.
“We know that until now – and for many years – 50 per cent of people with glaucoma have remained undiagnosed. So, the first issue as practitioners must be to lift our referral rates if we are to have any chance of diagnosing 100 per cent of people who already have glaucoma (but don’t know they do) – we need to double them at the very least.
“Issue two is that we need to constantly review the quality of the referrals being made – i.e. the positive versus false positive rates. This work will commence in earnest in 2019 although a pilot positive / false positive study will be available in mid-2019 with ophthalmologists grading the suitability of 500+ referrals from optometrists. This will give us a first glimpse of the real rate. It’s important to note also that, while we believe the false positive rate is dropping dramatically as optometrists become more adept at the systematic use of structural and functional testing, the reality is that we must avoid any use of anecdotal evidence if we are to be taken seriously,” said Mr Larsen.
“We must ‘measure to prove’ from this point onwards – evidence in the form of optometry / ophthalmology data should be the only mark of real evidence of both referral rates, diagnosis rates and positive/ false positive rates. Allied to this is the proactive work that ophthalmology is undertaking with optometrists, including our own, to coach on improved quality of referrals. This is the beauty of collaboration, targeted at improved eye health outcomes for all Australians and New Zealanders.”
- www.preventingoverdiagnosis.net/?page_id=1176 2. Leal-Fonseca M, Rebolleda G, Oblanca N, et al. A Comparison of false positives in retinal nerve fiber layer, optic nerve head and macular ganglion cellinner plexiform layer from two spectral-domain optical coherence tomography devices. Invest Ophthalmol Vis Sci. 2016;57(10):4194-204.