ITAP TT1 MC - Glaucoma – Sept 17 ITAP MANAGED CARE WORKING GROUP TASK TEAM 1: CHRONIC DISEASE CONDITIONS (CDL’s) – GLAUCOMA – Explanatory note to the Managed Care minimum reporting data specification (excel spreadsheet) The aim of the project is to measure the value added by managed care organisations, by means of capturing, measuring and reporting on clinical process indicators to demonstrate the clinical outcome/s achieved. Hence this is by no means a representation of the full protocol, policy or guideline on Glaucoma management. Additionally, these process indicators and or outcomes achieved will be reported on within the Annual statutory returns. 1 ITAP TT1 MC - Glaucoma – Sept 17 Meetings and discussions were held with industry representatives and subject matter experts prior to finalising the minimum data specification. 1) Goal The value of managing a disease is to establish measurable goals that result in quality of care. (Diagnosis, treatment and care of all beneficiaries should be in line with evidence base medicine, cost effectiveness and affordability). · Maintain the individuals visual function and related quality of life at a sustainable cost. · Lower IOP and slow rate of visual field deterioration. Target IOP is specific to each individual. · Prevent complications and optimally manage the progression of disease. 2) Identification of beneficiaries that have Glaucoma / or registered on a managed care program Please ensure the relevant consent has been obtained and confidentially maintained when obtaining personal health information. Identification of beneficiaries registered on the program may include · Registered on chronic and or disease management programs · ICD-10 Codes or other relevant clinical coding · Anatomical Therapeutic Chemical Classification System (ATC Class) · National stock numbers (State stock code) 3) Minimum data specification: Process indicators, clinical outcomes and data The level of Active Management of Glaucoma will depend on the nature of the contract, the level of services covered and the fee structure for those services, e.g. screening, medication, procedures etc. 2 ITAP TT1 MC - Glaucoma – Sept 17 The minimum required fields for the effective collection of appropriate data to demonstrate the value of the managed care interventions for the below mentioned categories are detailed by way of process indicators (see attached spreadsheet). · Diagnosis The diagnosis of Glaucoma is made by the specified registered practitioner. o Congenital Glaucoma o Closed Angle Glaucoma o Open Angle Glaucoma · Investigations o Tonometry o Fundus examination o Gonooiscopy o Disc and Nerve Fibre layer analysis o Disc Photography o Optical coherence tomography o Central corneal thickness measurement · Discipline Type The service providers must be registered with their relevant statutory bodies and as indicated by discipline coded list provided by BHF. 4) Treatment – Glaucoma Congenital Glaucoma Closed Angle Glaucoma Open Angle Glaucoma Surgery / Medication Medication, Laser and / or Drainage / Medication (first line / Second line) Cataract Surgery Drainage surgery 3 ITAP TT1 MC - Glaucoma – Sept 17 Medication: - S01E - Antiglaucoma preparations and miotics * Please note these recommendations do not replace the published algorithms, PMB entitlements etc. It is a means of measuring the value and quality of care provided. * The above is merely the initial phase of the ITAP Task Team 1- CDL project and as such is not exhaustive. Full details can be seen on the accompanying excel spreadsheets. 5) Clinical Outcomes measures · Number of all cause admissions · Number of admissions for Glaucoma · Number of Beneficiaries treated on medication alone · Number of Beneficiaries that had surgery · Number of beneficiaries that had repeated surgery / theatre · Cost of medication pre-surgery versus post-surgery * Information in regards to ICD-10 coding may be found on the following site http://www.health.gov.za/index.php/shortcodes/2015-03-29-10-42-47/2015-06-10-09-23-36/2015-06-10-09-26-11 6) Reporting (MCO and Scheme) *Definitions will be the same utilised within the Annual statutory returns – see Circular 10 of 2015. For full details http://www.medicalschemes.com/files/Circulars/Circular10Of2015.pdf All reports to be submitted to the Scheme for inclusion in the Annual Statutory Returns. Please complete the section relevant to the service rendered by your organisation. 4 ITAP TT1 MC - Glaucoma – Sept 17 6.1 By Managed Care Organisation: Management out of hospital - Time period: Benefit year (Reporting period – Start and end) - Per benefit option - Per Scheme - Member - Beneficiary - Service Date (Benefit Year) - Gender – Male / Female - Age (Age of the beneficiary is to be calculated as the Year of Reporting - Year of Birth) a) Program Demographics Actual number of beneficiaries registered for Glaucoma on the Pharmacy Benefit and or Active Number of new registrations in Number of beneficiaries who left Year: Bi- disease management program the period program * Annual (Longer than 6 months on program) Male Female Male Female Male Female Under 1 1 to 4 4 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 5 ITAP TT1 MC - Glaucoma – Sept 17 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 and above Total *Left the program – This may include various reason codes i.e. left the scheme, death, suspensions etc. b) Clinical Management Total Number of beneficiaries Total Number of Beneficiaries that Total Number of Beneficiaries Year: treated with medication only had surgery (Laser / Drainage identified with 2 or more co- Annual Surgery) morbidities Age Female Male Female Male Male Female Groups Under 1 1 to 4 4 to 9 10 to 14 6 ITAP TT1 MC - Glaucoma – Sept 17 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 and above Total Co-morbidities o Hypertension o Diabetes o Eye Injury o Cortisone use 6.2 Management in Hospital - Time period: 1 January to 31 December (Service dates / financial year), define per quarter - Per benefit option - Per Scheme - Hospital Admissions: 7 ITAP TT1 MC - Glaucoma – Sept 17 o All cause admissions o Glaucoma admissions - Hospital Category o Day Admission o Long Stay o Readmission - Gender - Age Admission definitions § Glaucoma related admission - please refer to attached list of ICD10 Codes. § Mortality / Exit codes – Where a hospital notifies the schemes / MCO / Administrator that a member is deceased. See attached § Emergency room – Definition as per Circular 10 of 2015 § Hospital admission · A day case is when admission day is same as discharge date · A long stay is when discharge date is after the admission day. · A re-admission is when a patient from hospital is readmitted within 90 days of previous discharge date. 8 ITAP TT1 MC - Glaucoma – Sept 17 a) Hospital Category: Day Case Scheme Total number Total number Admission per category Mortality Claimed Risk of of admissions Surgical Medical Paediatric Emergency (Exit amount paid admissions (Glaucoma) Room (Only) Codes = amount (All Cause) Related Expire) Male Female Male Female Male Female Male Female b) Hospital Category: Long Stay Scheme Total number Total number Admission per category Mortality Claimed Risk of of related (Exit amount paid admissions admissions Surgical Medical Paediatric Emergency Codes = amount (All Cause) (Glaucoma) Room (Only) Expire) Male Female Male Female Male Female Male Female c) Hospital Category: Re-admission Scheme Total number Total number Admission per category Mortality Claimed Risk of of related (Exit amount paid admissions admissions Surgical Medical Paediatric Emergency Codes = amount (All Cause) (Glaucoma) Room (Only) Expire) Male Female Male Female Male Female Male Female 7) References · Task Team 1 of the Managed Care ITAP working group; · Standard treatment guidelines and Essential medicine list · Circular 10 of 2015 · South African Glaucoma Society 9 Entry and Process Disease Management Verification Indicators Program Algorithm Outcomes Data Spec ICD10 Description ATC Class ATC Class Investigation Tariff Code Tariff Description Program Algorithm Outcome Data specs H40 Glaucoma S01E Antiglaucoma preparations and miotics Initial Diagnosis Date of Diagnosis CDL Algorithm No of hosp admissions (All Cause) Membership H40.0 Glaucoma suspect 3009 Basic capital equipment used in own rooms by ophthalmologists. Only to be charged at first and follow-up consultations. Not to be charged for post-operative follow-up consultations Date of Registration No of hosp admissions (Glaucoma) Scheme name H40.1 Primary open-angle glaucoma 3014 Tonometry per test with maximum of 2 tests for provocative tonometry (one or both eyes) Number of beneficiaries treated with medication only Option name H40.2 Primary angle-closure glaucoma 3003 Fundus contact lens or 90 D lens examination (not to be charged with item 3004 or item 3012) Numer of beneficiaries that underwent surgery Member No H40.3 Glaucoma secondary to eye 3002 trauma Gonioscopy Dependent code H40.4 Glaucoma secondary to eye 3026 Digital Tomography of optic nerve with Scanning Laser Ophthalmoscope (SLO). inflammation Limited to two exams per annum Number of beneficiaries who post surgery Date of birth H40.5 Glaucoma secondary to other eye 3027 disorders Fundus photography 0-5 days post-operative procedure - Theatre revisist Gender H40.6 Glaucoma secondary to drugs 3028 Optical Coherent Tomography (OCT) of Optic nerve or macula: Per eye - annual Repeat surgery - 60 to 360 days post initial surgery H40.8 Other glaucoma 3017 Retinal threshold test inclusive of computer disc storage for Delta of Statpak programs - annual Claims H40.9 Glaucoma, unspecified 3020 Special eye investigations: Pachymetry: Only when own instrument is used, per eye. Only in addition to corneal surgery (once per life) Number of drops before vs after surgery (180days) Date of service H42.8 Glaucoma in other diseases classified elsewhere Cost of drops before surgery versus cost of drops after surgery Doctor type Q15.0 Congenital glaucoma Management Practice number 3026 Digital Tomography of optic nerve with Scanning Laser Ophthalmoscope (SLO).