Better Operative Outcomes Software Tool - Nuzul Rianti, MD Mayang Rini, MD
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Better Operative Outcomes Software Tool Nuzul Rianti, MD Mayang Rini, MD
BOOST
(Better Operative Outcomes Software Tool)
Nuzul Rianti, MD
Mayang Rini, MD
This paper has been reviewed and approved
By supervisor of Community Ophthalmology
Mayang Rini, MD
Community Ophthalmology
Cicendo Eye Hospital, National Eye Centre
Faculty of Medicine, Padjadjaran University
Bandung, March 2021
CONTENTS
1 6
INTRODUCTION BOOST
7
Phase I
Benchmarking
8
Phase II
Quality improvement
9
The Benefit of Boost
The study provides a
number of useful insights
11
Next Steps
What is the future of the
innovation? Will it be
scaled up/rolled out?
Where will it be used in the
future? If the innovation
was not successful, will it
be adapted and further
tested?
INTRODUCTION
“Why is it important
to measure cataract surgical
quality”
C ataract was the leading cause
of blindness worldwide
(responsible for 35.1% of vision loss)
cost effective healthcare
interventions, resulting in rapid
visual rehabilitation in the large
and the second cause of visual majority of cases. When treated by
impairment (25.1%), after skilled surgeons, 90% of patients can
uncorrected refractive errors achieve good vision (best-corrected
(52.3%) in 2015. The good news is visual acuity of 6/12 or better), and
that cataract blindness can be an equal proportion are satisfied
effectively treated with surgery. with their surgical result.
Cataract surgery is one of the most
1
In western countries, patients training additional surgeons and
most often undergo surgery before providing equipment could help to
experiencing severe visual address both issues, but success also
impairment. However, cataract depends on monitoring surgical
remains a major public health quality. A study from Kenya showed
problem in many developing that monitoring the visual outcomes
countries. Many national plans for of cataract surgery is associated with
preventing blindness in developing improving those outcomes.
countries have led to increased Monitoring surgical quality allows
cataract surgical rates. However, clinicians and healthcare
poor surgical outcomes and administrators to identify issues and
inadequate access to surgery are take action to improve practice,
major impediments to the reduction patient outcomes and centre
of blindness from cataract. performance because “if you
Improving surgical capacity by measure it, you can manage it.”
A successful cataract outcome monitoring
and continuous quality improvement system will assist
practitioners and centres to identify and implement ongoing
improvements in eye care delivery
2
Why
Why don’t wedon't we routinely
routinely measure Low access to systems and
measure cataract surgical tools to support continuous
cataract surgical outcomes? quality improvement
outcomes?
Weak culture of quality
V isual acuity after cataract
surgery has traditionally
been measured weeks to
months after the operation, since
wound healing can change
assurance in surgical centres
Low postoperative follow-up
rate, because of the challenges
getting patients to return to
refractive power, and gradual surgical sites several weeks
resolution of common following their procedure.
complications such as corneal However, these issues can be
oedema can substantially improve addressed by setting up a good
vision. Less often, visual decline cataract outcome monitoring and
from surgical complications can continuous quality improvement
also occur. (CQI) system. This can assist
Postoperative visual practitioners and centres to
outcomes are often difficult to identify and implement ongoing
assess, particularly in developing improvements in eye care
countries, where the rates are as delivery.
low as 20-30%. This is due to
several factors, including:
What needs to be in place?
T he following
below are the
essential elements of
monitoring and CQI
system that can assist
practitioners and
implement ongoing
improvements in eye
care delivery.
a successful outcome centres to identify and
1. Quality standards
Defining a ‘good’ outcome, between discharge and 12 weeks
especially with modern small- after cataract surgery. Recently,
incision surgery, is the foundation the large-scale multicenter
of an effective CQI system. The observational study “Prospective
World Health Organization Review of Early Cataract
(WHO) recommends that 80% of Outcomes and Grading
patients have uncorrected visual (PRECOG)” found a high
acuity (VA) of ≥6/18 in the correlation between visual
operated eye at any time outcomes at 40 or more days and
3
3 or fewer days postoperatively immediately after surgery, when
raising the prospect that vision patient follow-up rates are the
outcomes could be measured highest.
Table 1. Standard for postoperative visual acuity
PRECOG standards for WHO standards for
postoperative assessment postoperative assessment
(1–3 days after surgery) (6 weeks after surgery)
Good (6/6-6/18) >60% >80%
Borderline (
BOOST
Cataract BOOST Blindness, International Council of Ophthalmology,
is a simple, free and The Fred Hollows Foundation, Orbis International,
easy-to-use app. The Sightsavers International, Aravind Eye Care
BOOST app was Systems, and Standard Chartered Bank’s Seeing is
created by a group of Believing Fund. This application is an international
non-governmental effort, and is available in seven different languages:
organizations (NGOs) English, French, Spanish, Russian, Chinese,
to allow users to easily Vietnamese and Indonesian.
measure and improve This design of this tool is based on the
surgical outcomes, PRECOG study at 40 hospitals in 12 low and middle-
even where rates of income countries, showing that measuring vision
patient follow-up are immediately after surgery is a valid indicator of
low. Better Operative quality. It enables hospital administrators and
Outcomes Software surgeons to record results the day after surgery,
Tool has been then analyse and benchmark their results against
supported by a other users around the world. It also suggests
consortium of leading strategies to improve surgical quality where results
eye health are poor. All data is 100% anonymous. It can be
organizations, downloaded at the Google Play Store by searching
including: for ‘BOOST Cataract’, and data can be accessed
International Agency online at https://boostcataract.org/
for the Prevention of
The BOOST app takes users through a step-by-step process to measure and analyse
results through two phases:
6
Phase I: Assesses existing cataract surgical quality based on post-operative
uncorrected VA measured
1-3 days after surgery.
Data is recorded and
automatically analysed
against a baseline
(from the PRECOG
study)
All patient data is de-
identified and includes:
o Age and Gender
o Pre-op Corrected
VA and post-op
Uncorrected VA in
operated eye
o Surgical technique
After entering 60 records, users can choose to share and compare their data
anonymously against other users, either locally or globally.
Select ‘Charts’ in the main menu to graphs showing composition by age
group and by gender; and Uncorrected VA outcomes at
discharge as ‘Good’, ‘Moderate’ or ‘Poor’
Phase I
7Phase II: Analyses results from 20 consecutive cases where poor vision ( 6 weeks after surgery.
Causes of Poor Visual Outcome are recorded (Inappropriate case
selection/comorbidities; Surgical Complication; Refractive problems).
BOOST then suggests specific measures to correct issues and helps users
determine most common causes for poor outcomes, helping to identify training
needs and improve quality.
Phase
II
8What are the
of BOOST
o Easy to access: The Cataract BOOST app is a small file, o Private: No patient
available for download at a wide variety of websites. identifiers are
o Easy to use: collected (other than
The Cataract BOOST app is designed for use across age and gender), and
a variety of convenient platforms, including outcomes are only
Android cell phones, laptops and desktops. uploaded
BOOST guides users through simple steps to collect (anonymously) to the
and analyse data to assess and improve their cloud if users select
surgical quality. this option.
o Built on experience: By designers of the most widely- o Responsive to user
used existing surgical monitoring systems at ICEH and requirements: The
Aravind. design of the Cataract
o Informative and evidence based: The Cataract BOOST BOOST app is based on
app allows users (surgeons and hospital the results of an
administrators) to benchmark performance against extensive needs
data in the cloud, either locally or globally. analysis carried out at
Initially, benchmarking will be carried out against nearly 100 hospitals in
baseline data on 4000 patients from the PRECOG Africa, Asia, Latin
dataset, and subsequently against other users. America and the
Benchmarking compares the proportion of patients Pacific in 2015.
with good (≥6/18) and poor (Monitoring the quality and outcomes of cataract surgeries
remains an ongoing priority for eye health organizations,
hospitals and health service providers worldwide. To drive
continuous quality improvements in cataract surgical
services, there must be an increased focus on measuring the
coverage and quality of surgical outcomes.
10Next Steps
What is the future of the innovation? Will it be scaled up/rolled
out? Where will it be used in the future? If the innovation was not successful,
will it be adapted and further tested?
The BOOST study improvements to clinical
demonstrated limited protocols are likely
success in improving required.
monitoring practice, and References
highlighted the influence The BOOST consortia of 1. Fortané M, Resnikoff S, Congdon N, et
of surgical technique, partner organizations al. Outcomes of cataract surgery
surgery setting and have commenced performed by non-physician surgeons
surgeon training on planning for the ongoing in rural Northern Cameroon: Use of
the Better Operative Outcomes
quality of outcomes. management of the
Software Tool (BOOST) - A follow-up
Further investigation is software. All partners study. J Clin Exp Ophthalmol.2019;10:
needed to determine have indicated their 800.
whether BOOST alone commitment to ensuring 2. Congdon N, Yan X, Sisay A, et al.
can improve surgical BOOST continues to be a Assessment of cataract outcomes in
performance, but based widely available, free settings where follow-up is poor:
PRECOG, a multicentre obseravtonal
on the result of resource for
study. Lancet Glob Health
prospective study ophthalmologists, 2013;1:e37-45.
conducted by Fred cataract surgeons and 3. Yorston D, Gichuhi S, Wood M, et al.
Hollows suggest hospitals. Does prospective monitoring improve
additional interventions cataract surgery outcomes in Africa?.
may be required to yield The consortia partners Br J Ophthalmol 2002;86:543-547.
4. Congdon N, Dodson S, Chan VF, et al.
meaningful will continue to explore
Improving the practice of cataract
improvements in funding opportunities to surgical outcome measurement.
outcomes - for example enable scale-up and Community Eye Health.
systematic rollout of BOOST for 2019;31(104),91-92.
improvements to the users that can benefit 5. World Health Organization (2010)
ways surgical centres from a simple, low-cost Global initiative for the elimination of
avoidable blindness: Action plan
engage with outcome monitoring tool.
2006-2011.
data and identify and 6. BOOST android manual. Available at
implement centre wide http://boostcataract.org/ResourceFil
eDetails.aspx?FileN=androidcourse
7. Moo E. Innovation fund project final
report. The Fred Hollows Foundation.
2020;1-23.
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