As with all of medicine, ophthalmologists are constantly looking for ways to improve the effectiveness of the clinical care they provide to their patients. In furtherance of this objective, Leadership Development Program participants develop programs that investigate new therapies and/or give guidance to eye physicians and surgeons on the provision of safe, effective, patient-centered, timely efficient and equitable care.. Recent LDP quality of care projects include the following.
Evaluation of the reporting of choroidal and ciliary body melanomas to the North Carolina Central Cancer Registry
Kathleen B. Gordon, MD, LDP XIX, Class of 2017 - North Carolina Society for Eye Physicians and Surgeons
Purpose: Hospitals in North Carolina are responsible for reporting cases of cancers including ocular tumors to the North Carolina Central Cancer Registry (NCCCR). Recently there has been significant concern about the possibility of an increase in the incidence of uveal melanoma in one region in North Carolina. Data available through the NCCCR did not support this suspected change. A preliminary investigation discovered that there were relevant cases missing from the NCCCR database. The purpose of this study is to determine whether there are gaps in reporting cases of ocular tumors to the NCCCR and if so, to determine the causes.
Methods: This study was performed at the University of North Carolina at Chapel Hill (UNC.) An IRB approved chart review was performed to evaluate the completeness of reporting tumors of the eye and ocular adnexa diagnosed, treated and/or followed at UNC to the NCCCR. ICD9 and ICD10 codes were used to identify cases seen between 2006-2016. The tumor registrars at UNC provided a list of patients diagnosed, treated and/or followed at UNC with a diagnosis of all ocular cancers who were reported to the NCCCR between these same dates. For the purposes of this study we focused on the reporting of choroidal and ciliary body melanoma cases seen at UNC between 2010-2015. The two lists were compared and discrepancies noted.
Results: There was a significant gap in the number of choroidal and ciliary body melanoma patients cared for at UNC and those reported to the NCCCR. Based on ICD 9 and 10 codes, there were 66 patients diagnosed, followed and/or treated with ciliary body or choroidal melanomas at UNC between 2010 and 2015. Of those, only 41 were reported through the UNC Cancer Registry to the NCCCR. The State Registrars reviewed the missing cases and identified 2 of them in their database that may have been reported through another entity. Therefore, 23 of 66 cases were not reported to the NCCCR.
After meeting with the tumor registrars at UNC, there were several barriers to complete reporting identified.
Imaging protocols: For confirmation of disease, registrars look for the results of diagnostic tests such as MRIs and CTs. At UNC where Epic is utilized as the Health Care System’s EMR, tumor registrars looked for imaging results under the ‘Imaging’ tab. If there was nothing reported there, the patients were sometimes excluded because of ‘lack of imaging’. On further review, all of the cases excluded for this reason had diagnostic ultrasounds. At our institution, the results of the ultrasound are reported directly in the patient note.
Lack of pathology: The lack of pathology is a significant barrier. Uveal melanomas are often diagnosed based on clinical exam and ancillary testing. Tumor registrars look for confirmatory biopsies. Unless a patient was enucleated, pathology was not available and some patients were excluded for this reason.
Language used by the physician in the patient record: If the patient’s record stated that a tumor was referred to UNC because of a ‘suspected melanoma’ and the diagnosis was confirmed at the UNC, the tumor was considered to have been ‘diagnosed’ at the practice of the referring physician. Though not consistent with what is stated in the NCCCR reporting manual, these tumors were sometimes but not always excluded. Unless the referring practice (likely outpatient) was linked to a tumor registry, the case would not have been reported to any entity.
Registrars look for language such as ‘no evidence of disease’. Describing a treated melanoma as a ‘stable tumor’ created confusion and the case might have been excluded for this reason.
One patient was not considered to have uveal melanoma because there was mention of ciliary body involvement.
Though outside of the scope of this study, there were other ‘language barriers.’ The registrars do not report skin tumors to the NCCCR. However, patients with conjunctival tumors, such as conjunctival squamous cell carcinoma, were excluded because these were believed to be skin tumors.
Residence at time of diagnosis: Some tumors were excluded because the tumors were treated but not diagnosed at UNC but this was not consistent. Some tumors were excluded because they were diagnosed but not treated at UNC but this was not consistent. The North American Association of Central Cancer Registries' National Interstate Data Exchange Agreement allows North Carolina to exchange data on cancer cases diagnosed or treated in surrounding states but this was not utilized with regard to uveal melanoma.
Conclusions: The North Carolina Central Cancer Registry (NCCCR) is responsible for collecting data for all cancer cases diagnosed or treated in North Carolina. The data is used for research to investigate the causes of cancer and to evaluate geographic and behavioral risk. The data is also used by state and county health departments to target resources for health education and screening services. In addition, national organizations (CDC’s National Program of Cancer Registries and the North American Association of Central Cancer Registries) pool the data for national estimates of cancer incidence.
According to the North Carolina Central Cancer Registry 2016 Cancer Collection and Reporting Manual: “North Carolina facilities are legislatively mandated to report any case of cancer meeting the North Carolina definition, regardless of affiliation or Class of Case. If your facility participates in the diagnosis, staging, treatment or continuing care for a patient during the first course of treatment, progression of disease or recurrence the case must be reported to NCCCR. Rigorous data quality standards apply to all cases, regardless of class of case or type of reporting source.” [From p. 23 North Carolina Central Cancer Registry 2016 Cancer Collection and Reporting Manual.]
Nearly one third of cases of ciliary body or choroidal melanomas evaluated at UNC between 2010 and 2015 were not reported to the state cancer registry. It is unlikely that these cases were accounted for in other registries that contribute to the pooled national cancer data. Because UNC is one of the 3 major centers in North Carolina to which uveal melanoma patients are referred, it is likely that uveal melanoma cases are significantly under-reported in our state. Based on the data contained in the NCCCR at this time, it is difficult to know if there are changing patterns in the demographics of uveal melanoma in North Carolina.
Future studies will focus on:
- Increased collaboration between physicians and registrars in order to improve the process of abstracting cases and ensure complete reporting
- The development of a uniform process to be used by the 3 major referral centers for ocular tumors in North Carolina
- Improved data sharing about tumors of the eye and ocular adnexa diagnosed or treated across state lines.
Improving Community Ophthalmic Care through Urgent Care Eye Exam
Natasha L. Herz, MD, LDP XIX, Class of 2017 - Washington DC Metropolitan Ophthalmological Society
Purpose: Provide training to urgent care providers to improve their ability to assess and diagnose the red eye, enabling more accurate and appropriate referral to ophthalmology and avoiding unnecessary delays in treatment.
Methods: A power point presentation was developed to teach the urgent care provider what signs and symptoms to document, how to perform an eye exam with the equipment available in the typical urgent care setting, and when urgent referral to an ophthalmologist is necessary. Urgent care centers in the immediate 10-mile radius were contacted to offer this education to their providers free of charge.
Results: Increasing demand for access to urgent care with decreased wait times and increased after-hour availability has triggered the development of urgent care centers and minute clinics across the Washington DC Metro area. Unfortunately, the training of urgent care providers to conduct eye examinations is quite variable. Subsequently many patients are misdiagnosed and improperly treated for serious eye conditions including herpes keratitis and dermatitis treated with steroids, unrecognized corneal foreign bodies treated as “pink eye,” bacterial keratitis treated as “pink eye,” and iritis treated as “pink eye.” I found 25 urgent care clinics in my immediate 10-mile radius and contacted them to offer my Eye Exam for Urgent Care course. Three of them chose to have me give this presentation to them and felt they were much better equipped to assess ophthalmic complaints. Since my presentation, I have received multiple calls from these centers and was able to give them much better advice regarding appropriate treatment and follow-up because they had performed a quality urgent eye exam.
Conclusions: The demand for after-hours care has brought a large number of urgent care centers into the Washington DC Metro area. In an effort to maintain a high quality of eye care with this model and continue to keep ophthalmologists as leaders of the eye care team, the Eye Exam for Urgent Care course will continue to be offered to the local urgent care centers. I will encourage the members of the Washington DC Metro Ophthalmology Society to join in this effort as it is beneficial to our community and indirectly to our advocacy efforts.