Prioritising Priorities

Friday, 15 Sep 2017

As the public becomes increasingly alarmed by stories about patients going blind as they wait for treatment, a group has been busy beavering away behind the scenes to fine tune the Clinical Priority Assessment Criteria (CPAC)* for surgical eye care, including a relevant Impact on Life questionnaire. Leading the development is Auckland-based ophthalmologist Dr Dean Corbett, chair of the CPAC steering group for ophthalmology. Here, Dr Corbett outlines why this is being done and where it is currently at.  


 In any circumstances where resources are limited and demand is high, there is a need for rationing. This applies to food and water in refugee camps or medical supplies in a time of need.

We are faced with this problem right now in ophthalmology in New Zealand. In fact, we’re facing it across all our elective surgical services, whether for hip replacements, coronary bypasses, bariatric surgery, as well as any form of surgical eye care. No longer is there just a demand that outstrips supply for operations such as cataract surgery. We now face an ever-increasing elderly population and expanding treatment options, such as intravitreal anti-VEGF’s for macular degeneration, that is resulting in a large mismatch of resources compared with demand.

This has led to the realisation that we need to allocate our efforts in a way that is most effective. By ‘effective’ the Ministry of Health and its advisors mean that outcomes must be measured and quantified and, most importantly, analysed in a way that makes sense. Hence the science behind PROs (patient-reported outcomes) and PROMs (patient-reported outcome measures) has exploded.

Previously, elective surgical intervention has been delivered by a “Dr knows best” approach with few metrics employed to judge how well the intervention has been received. But now, work across multiple specialties in the different Clinical Priority Assessment Criteria (CPAC) workshops, including ophthalmology, has allowed us to look more objectively at outcomes and agree parameters with input from both surgeon and patient to generate priority weightings. These priority weightings are unique to each specialty. In ophthalmology, they have been developed by a multidisciplinary team comprising ophthalmologists, optometrists, GPs, lay people, patients, biostatisticians, bioethicists, physicians and politicians. Thus, all CPAC have a balance between clinical weighting and patient-derived Impact on Life (IoL) scores.

Much time and effort has been spent on the Impact on Life (IoL) or patient-derived scoring tool. For this to be most useful, the concept of a generalised questionnaire that can be used across all elective interventions has been developed. It is anticipated that as time passes, patients will become more and more familiar with this tool and understand that it is their way of adding input to the planning and treatment of their condition.

The IoL tool has undergone many modifications since it was first introduced for cataract surgery in 2005, and then subsequently in plastic and reconstructive surgery in 2008. In its current form it has, however, been shown to be representative of a patient’s view of how their condition is affecting their life. It has had input from experts in questionnaire development and has been validated by a group of actual patients and been shown to be robust in its usage.

In the ophthalmic care model, the CPAC are designed to assess and appropriately prioritise patients wanting to access cataract care across our health system. The ophthalmology criteria (including the IoL tool) have also now been reviewed as appropriate for the entire elective ophthalmic care spectrum, so can be viewed as a true “whole-of-ophthalmology” tool, but will not be fully accepted until the pilot programme by two district health boards (DHBs) has been completed this year.

The ultimate vision for the CPAC tool is that patients will be prioritised far more efficiently both across the country and within their own communities so valuable DHB resources can be used to deliver interventions rather than having to deal with assessments as well.

In time to come, we will also have a much better understanding of what we are achieving as we will be able to compare IoL scores pre- and post-intervention. In a perfect world, we could then apply this data to a generic measure of disease burden model, such as QALY (quality-adjusted life-year), which includes both the quality and quantity of life lived, to gain more meaningful information about cost utility. This could then guide allocation funding toward the most beneficial interventions.

*Also known as Clinical Prioritisation System (CPS) tools

This article was published in the June 2017 issue of NZ Optics and has been reproduced with permission. 


Auckland Eye - New Zealand Centre of Excellence for Eye Care