Resident Compliance with the AmericanAcademy of Ophthalmology PreferredPractice Pattern Guidelines for PrimaryOpen-Angle Glaucoma

Sally S. Ong, BS,1,2 Krishna Sanka, MD,1,3 Priyatham S. Mettu, MD,1 Thomas M. Brosnan, MD,4

Sandra S. Stinnett, DrPH,1 Paul P. Lee, MD,5 Pratap Challa, MD1

Purpose: To examine resident adherence to preferred practice pattern (PPP) guidelines set up by theAmerican Academy of Ophthalmology for follow-up care of primary open-angle glaucoma (POAG) patients.

Design: Retrospective chart review.Participants: One hundred three charts were selected for analysis from all patients with an International

Classification of Diseases, Ninth Revision, code of open-angle glaucoma or its related entities who underwenta follow-up evaluation between July 2, 2003, and December 15, 2004, at the resident ophthalmology clinic in theDurham Veteran Affairs Medical Center.

Methods: Follow-up visits of POAG patients were evaluated for documentation of 19 elements in accor-dance to PPP guidelines.

Main Outcome Measures: Compliance rates for the 19 elements of PPP guidelines first were averaged in allcharts, and then were averaged per resident and were compared among 8 residents between their first andsecond years of residency.

Results: The overall mean compliance rate for all 19 elements was 82.6% for all charts (n ¼ 103), 78.8% forfirst-year residents, and 81.7% for second-year residents. The increase from first to second year of residency wasnot significant (P> 0.05). Documentation rates were high (>90%) for 14 elements, including all components of thephysical examination and follow-up as well as most components of the examination history and managementplan. Residents documented adjusting target intraocular pressure downward, local or systemic problems withmedications, and impact of visual function on daily living approximately 50% to 80% of the time. Documentationrates for components of patient education were the lowest, between 5% and 16% in all charts.

Conclusions: Residents’ compliance with PPP guidelines for a POAG follow-up visit was very high for mostelements, but documentation rates for components of patient education were poor. Adherence rates to PPPguidelines can be used as a tool to evaluate and improve resident performance during training. However, furtherstudies are needed to establish the advantages of using PPP guidelines for resident education and to determine ifsuch assessments can lead to improved patient care.

Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussedin this article. Ophthalmology 2013;120:2462-2469 ª 2013 by the American Academy of Ophthalmology.

Primary open-angle glaucoma (POAG) is one of the leadingcauses of irreversible blindness in the United States, with anestimated 2.71 million people affected in 2011.1 As thepopulation ages and the number of immigrants increases,this number is projected to increase to 7.32 million in2050.1 Glaucoma is one of the 4 most prevalent eyediseases in the elderly population.2 A cross-sectional studyof Medicare beneficiaries showed that, in 2008, the preva-lence rates for open-angle glaucoma suspects and diagnosedcases were 4.5% and 6.4%, respectively.3 In addition, theLos Angeles Latino Eye Study recently reported that theincidence of open-angle glaucoma in Latinos is higherthan that found in non-Hispanic whites, although still lowerthan that observed in Afro-Caribbeans.4 Therefore,glaucoma is projected to become an increasingly prevalentand important problem in the future.

2462 � 2013 by the American Academy of OphthalmologyPublished by Elsevier Inc.

Numerous studies have shown that glaucoma hasa significant impact on quality of life, comparable withother chronic, debilitating diseases like osteoporosis, type2 diabetes, and dementia.5e12 Compared with controls,glaucoma patients were more likely to report dysfunctionin near and central vision, peripheral vision, night vision,and color vision as well as glare and physical limitationslike decreased outdoor mobility and independence.13e17

Glaucoma patients also are reported to have higherlevels of anxiety and depression.18e20 This increasedburden of disease has profound implications for health-care spending and resource allocation. In 2006, theaverage yearly cost of glaucoma treatment ranged from$623 for suspects or patients with early disease to$2511 for patients with end-stage disease.21 Therefore,it is becoming increasingly important that consistent

ISSN 0161-6420/13/$ - see front matterhttp://dx.doi.org/10.1016/j.ophtha.2013.05.019

Ong et al � Resident Compliance with the AAO PPP for POAG

high-quality evidence-based care be delivered for allglaucoma patients.

The American Academy of Ophthalmology (AAO) isa leader in developing preferred practice pattern (PPP)guidelines based on the best available scientific data.22,23

Five previous studies examined the rate of conformance toPPP guidelines for POAG care.24e28 The first study exam-ined clinic visits documented between 1989 and 1992 in anacademic public clinic in Los Angeles, California. This wasa tertiary referral clinic for glaucoma cases and mostly wasstaffed by residents from the University of Southern Cali-fornia.24 The authors found documentation of examinationfindings on the initial visit that ranged from 70% fora pupil examination to 100% for intraocular pressure(IOP) measurement. The second study completed chartreviews for patients treated between 1989 and 1993 by 8private, community-based ophthalmologists in the LosAngeles area and found compliance rates for the initial visitthat ranged from 39.4% for a pupil examination to 100.0%for IOP.25 The third study examined records of patientsenrolled in 6 managed care plans between 1997 and 1999and found that during the initial evaluation, compliancerates ranged from 1.3% for target IOP level to 98.6%for visual acuity examination.26 The third study alsoexamined documentation of recommended processes forfollow-up studies and found high adherence rates, whichranged from 80.4% for interval ocular history to 96.9% forIOP.26 In the fourth study, records of all individuals enrolledin commercial health plans in the United HealthcareResearch database between 1995 and 2001 were reviewed,and the authors found that only 46% of patients had atleast 1 billed visual field and 13% of patients underwentsome sort of optic nerve head imaging during a medianfollow-up of 440 days.27 Finally, using a large claimsdatabase, 300 charts of subjects with a prostaglandinprescription claim between 2001 and 2004 were selectedfor analysis, and the authors reported that physicianadherence to guidelines varied from 19% for setting oftarget IOP to 90% for performing IOP measurements, discevaluations, imaging, and visual field tests during bothinitial and follow-up visits.28

None of the previously published studies specifically hadexamined conformance to PPP guidelines for POAG ina residency program. Glaucoma, besides cataract and dia-betic retinopathy, is one of the most frequently encountereddiagnoses managed by residents during training. There were2 previously published studies of resident compliance toAAO PPP guidelines in cataract and diabetic retinopathy.Both studies examined charts completed by residents at theProvidence Veterans Affairs Medical Center between 2006and 2007 and found an overall 81% compliance rate to theCataract in the Eye PPP29 and an overall 52% compliancerate to the Diabetic Retinopathy PPP.30 Monitoringcompliance to evidence-based guidelines among trainees isespecially important because guidelines can evaluate varia-tions in clinical care,31 can help to guide future practicebeyond residency, and can improve patient care andclinical outcomes.32 It is also an important part of residentcurricula and education because gaps between perceivedand actual documentation of examination findings

recommended by PPP guidelines, when present, can beaddressed during training.33 To our knowledge, this is thefirst study examining adherence to AAO PPP guidelinesfor POAG specifically in a resident ophthalmology clinic.The purpose of this study was to examine residents’documentation of examination findings in a POAG follow-up visit with respect to history, physical examination,management plan, follow-up, and patient education.

Methods

The study protocol was reviewed and granted exemption by theDurham Veteran Affairs Medical Center Institutional ReviewBoard because it was considered to be a quality assurance project.The Durham Veteran Affairs Medical Center is a part of the UnitedStates Department of Veterans Affairs, which provides patient careand benefits to men and women who have served in the UnitedStates military. The study population included patients with anInternational Classification of Diseases, Ninth Revision, diagnosisof open-angle glaucoma (365.10) or one of its related entities,including POAG (365.11), residual stage of open-angle glaucoma(365.15), and glaucomatous atrophy of the optic disc (377.14) seenfor a follow-up evaluation between July 2, 2003, and December 15,2004, at the resident ophthalmology clinic in the Durham VeteranAffairs Medical Center. The International Classification ofDiseases, Ninth Revision, is published by the World HealthOrganization, and its original purpose was to categorize diseasesfor mortality and morbidity statistics. Increasingly, however, it isalso being used as an international standard in clinical care andresearch to track disease patterns, to study clinical outcomes, and todistribute resources.34 Patient visits to the resident glaucoma clinicwere identified between the inclusion periods, and only those chartswith specific International Classification of Diseases, NinthRevision, diagnosis codes (see above) were included in the study.A total of 463 consecutive appointments were reviewed, anda total of 103 consecutive glaucoma charts from unique patientswere included in the study. Only the first follow-up visit wasincluded, and those with repeat visits, incomplete data, or missingcharts were excluded. This time period was selected specificallybecause it preceded the use of an electronic medical record systemat the Durham Veterans Affairs Hospital. All information in themedical record had to be handwritten by the resident, and therewere no standard prepopulated forms in use. Therefore, all the datawere entered by a resident, and not by support staff or faculty.

Charts included in the study were divided among 3 evaluators(P.C., T.M.B., and K.S.). Four additional charts were set aside andevaluated independently by each of the 3 graders to assess inter-evaluator reliability. The 103 charts then were reviewed forcompliance with a checklist based on Major Recommendations forCare from the 2003 AAO PPP guidelines for POAG (Table 1).Recommendations from the AAO PPP guidelines for POAG areeach given 2 ratings: one based on its importance to the careprocess and the second based on the strength of evidence fromthe literature to support the recommendation made.23 The firstrating, based on the importance to quality of care, is categorizedinto 3 levels: level A, defined as the most important; level B,classified as moderately important; and level C, described asrelevant but not critical. The second rating, based on strength ofevidence, also is divided into 3 levels: from level I, whichincludes at least 1 properly conducted, well-designed random-ized, controlled trial, to level III, which includes descriptivestudies, case reports, and reports of expert committees or organi-zations. Except for 2 elements categorized as level Bdgeneralassessment of impact of visual function on daily living and

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Table 1. Resident Compliance with 19 Elements of the American Academy of Ophthalmology Preferred Practice Pattern for PrimaryOpen-Angle Glaucoma for the Follow-up Visit

Total Year 1 (n [ 8) Year 2 (n [ 8)

P ValueDocumented Applicable % Compliance% Compliance/

Resident% Compliance/

Resident

Examination history1. Interval ocular history 97 102 95.1 93.3 92.7 0.92. Interval systemic history 100 103 97.1 94.8 97.9 0.23. Local or systemic problems with medications 59 101 58.4 33.5 51.0 0.34. Impact of visual function on daily living 50 102 49.0 25.4 35.4 0.65. Verification of appropriate medication use 94 102 92.2 97.9 96.9 0.8Total mean compliance 400 510 78.4 69.0 75.4 0.4

Physical examination6. Visual acuity 103 103 100.0 100.0 100.0 NA7. Slit-lamp biomicroscopy 102 102 100.0 100.0 100.0 NA8. Measurement of IOP 103 103 100.0 100.0 100.0 NA9. Evaluation of optic nerve and visual fields 80 86 93.0 100.0 89.6 0.1Total mean compliance 388 394 98.5 100.0 98.3 0.1

Management plan for patients receiving medical therapy10. Reconsider current IOP and its relationship to the

target IOP at each visit99 102 97.1 94.4 96.9 0.7

11. At each examination, discuss and documentcompliance

64 71 90.1 83.3 95.8 0.2

12. Perform gonioscopy if indicated 30 30 100.0 100.0 100.0 NA13. Reconsider treatment regimen if indicated 59 59 100.0 100.0 100.0 NA14. If a drug fails to reduce IOP, discontinue and use

an alternate agent17 17 100.0 100.0 100.0 NA

15. Adjust target pressure downward if indicated 14 17 82.4 100.0 66.7 NATotal mean compliance 283 296 95.6 93.1 97.3 0.3

Follow-up16. Appropriate follow-up interval 83 86 96.5 97.1 100.0 0.417. Adjustment of follow-up interval after addition or

deletion of medication24 25 96.0 100.0 100.0 NA

Total mean compliance 107 111 96.4 96.9 100.0 0.4Patient education for patients with medical therapy18. Advise to alert ophthalmologist to physical or

emotional changes with glaucoma medications.5 97 5.2 5.6 2.5 0.6

19. Refer for appropriate vision rehabilitation and socialservices if indicated.

5 31 16.1 25.0 0.0 0.5

Total mean compliance 10 128 7.8 10.2 3.6 0.2Overall mean compliance 1188 1439 82.6 78.8 81.7 0.4

IOP ¼ intraocular pressure; NA ¼ not applicable. Boldface indicates overall mean compliance.

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frequency and time of last glaucoma medications and verificationof appropriate usedthe other 17 elements of the 2003 AAO PPPguidelines for POAG were all rated level A.23 Additionally, all 19elements were supported by level III evidence.23

The AAO PPP guidelines suggest that, at each examination,providers should “record dosage and frequency of use of medicaltherapy, discuss compliance, and document patient’s response torecommendations for therapeutic alternatives or diagnostic proce-dures” (Table 1, item 11).23 In addition, some elements of themanagement plan category were indicated only under certaincircumstances. According to the 2003 AAO PPP guidelines,gonioscopy was recommended if “there is a suspicion of angleclosure, anterior chamber shallowing or anterior-chamber angleabnormalities or when miotic therapy is introduced or increased”and periodically in phakic patients (e.g., 1e5 years) if lens changeswere present (Table 1, item 12). Additionally, providers wereadvised to reconsider a treatment regimen if target IOP was notachieved and maintained after taking into account potential risksand benefits of additional or alternative treatment (Table 1, item

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13). In the same vein, AAO PPP guidelines recommend thediscontinuation of a drug and the suggestion of an alternateagent if the former is unable to reduce IOP (Table 1, item 14).Also, target pressure should be adjusted downward if disc orvisual change is progressive, with the stipulation that “the extentof further reduction should be at least 15% lower than thecurrent average IOP” (Table 1, item 15).23

The 2003 AAO guidelines for follow-up designated an intervalof 1 to 6 months for those with target IOP achievement, noprogression of damage, and duration of control of less than 6months; 3 to 12 months for those with target IOP achievement, noprogression of damage, and duration of control of more than 6months; 1 week to 3 months for those with target IOP achievementas well as progression of damage; 2 days to 3 months for those withno target IOP achievement and no progression of damage; and 2days to 1 month for those with no target IOP achievement but withprogression of damage.23 Within the recommended intervals,factors that further dictated the frequency of evaluation includedthe severity of damage, the stage of disease, the rate of

Ong et al � Resident Compliance with the AAO PPP for POAG

progression, the extent to which the IOP exceeded the targetpressure, and the number and significance of other risk factorsfor damage to the optic nerve (Table 1, item 16).23 Additionally,according to the guidelines, when a provider deleted or addeda medication, a follow-up visit should be planned at an appro-priate interval to evaluate the medication change (Table 1, item17).23

The AAO PPP guidelines also provided detailed recommen-dations about patient education.23 Providers were called to advisepatients to report physical or emotional changes that occur whentaking glaucoma medications (Table 1, item 18). They are also torefer for or encourage the use of appropriate vision rehabilitationand social services for patients with considerable visualimpairment or blindness (Table 1, item 19).

Compliance rates for the 19 elements of the follow-up studywere calculated and presented in 2 ways (see Table 1). First, datawere abstracted from a follow-up visit from each of the 103 charts,and percent compliance for the 19 elements was averaged across allcharts (n ¼ 103). Second, for 8 residents who had staffed visits inboth their first and second years of residency, compliance rates foreach element were averaged per resident and were compared acrossyears using a paired t test (n ¼ 8 residents for first year; n ¼ 8residents for second year). Statistical analysis was performed usingJMP Pro version 9 (SAS Inc, Cary, NC).

Results

Of the 103 charts evaluated, 31 charts were scored by grader 1, 32were scored by grader 2, and 40 were scored by grader 3. Forvalidation of the scoring, we used a subset data set assessed by all 3evaluators and found 95% or more agreement, suggesting minimalinterevaluator variability as a source of bias in the study. The 103POAG clinic visits documented in the charts were staffed by a totalof 14 Duke Eye Center residents. Eight of the residents staffedstudy visits in both their first and second years of residency. For theother 6 residents, 5 staffed study visits only in their first year ofresidency and 1 resident staffed study visits only in his second yearof residency. In total, 65 of the 103 records were documented by 13first-year residents and the remaining 38 records were documentedby 9 second-year residents. The number of records documented byeach resident varied from 1 to 6 per year. The checklist results areincluded in Table 1. The bolded row presents overall meancompliance rates. For the 8 residents for whom there wererecords from their first and second years of residency,compliance rates were averaged per resident, compared acrossyears, and presented Table 1. Total mean compliance for the 19elements was 82.6% for all charts (n ¼ 103), 78.8% for first-year residents (n ¼ 8), and 81.7% for second-year residents (n ¼8). The total mean compliance rates for first- and second-yearresidents were not statistically significantly different.

History

The mean compliance rate for this section is 78.4% for all charts,69.0% for first-year residents, and 75.4% for second-year residents.Although there is a trend toward improved compliance from year 1to year 2, a paired t test showed that the difference was notsignificant. Although residents’ compliance rates were more than90.0% for 3 of the 5 elements in this category, documentation rateswere lower for asking for local or systemic problems with medi-cations (58.4% in all charts, 33.5% by first-year residents, and51.0% by second-year residents) and general assessment of theimpact of visual function on daily living (49.0% in all charts,25.4% by first-year residents, and 35.4% by second-year residents).

Physical Examination

Visual acuity, slit-lamp biomicroscopy, and IOP measurementwere documented in 100.0% of the 103 records. Optic nerve andvisual field evaluation were documented at a lower rate of 93.0%for all charts, 100.0% by first-year residents and 89.6% by second-year residents.

Management Plan for Patients Receiving MedicalTherapy

Residents’ total mean compliance rate for this category was 95.6%for all charts, 93.1% by first-year residents, and 97.3% by second-year residents. Documentation of the adjustment of target pressuredownward in the presence of disc or visual field change was thelowest in this category. Of the 17 times it was indicated in allcharts, 14 (82.4%) were documented. In comparing across years,this element was indicated only for 1 resident, who scored 100% inhis first year and 66.7% in his second year. However, documen-tation of patient compliance on medical therapy was 90.1% for allcharts, 83.3% by first-year residents, and 95.8% by second-yearresidents. Again, this increase across years was not statisticallysignificant. Meanwhile, reconsideration of current IOP and itsrelationship to target IOP was documented at high levels (97.1%for all charts, 94.4% by first-year residents, and 96.9% by second-year residents). Additionally, performance of gonioscopy, recon-sideration of treatment regimen, and use of an alternate agent whenindicated each had a 100.0% compliance rate in all charts.

Follow-up

The mean compliance rate for this category was 96.4% for allcharts, 96.9% by first-year residents and 100.0% by second-yearresidents. Compliance rates for the 2 elements in this categorywere both 96.0% or more for all charts. First, documentation ratesof an appropriate follow-up interval were 97.1% by first-yearresidents and 100.0% by second-year residents. Second, adjust-ment of follow-up interval after deletion or addition of medicationboth had a 100.0% compliance rate in first- and second-yearresidents.

Patient Education for Patients with Medical Therapy

Compliance rates for this category were the lowest among allcategories studied. This category required written documentationof a discussion of this topic on the chart. The total mean compli-ance was 7.8% for all charts, 10.2% by first-year residents, and3.6% by second-year residents. Specifically, residents’ documen-tation of encouraging patients to alert their ophthalmologist tophysical or emotional changes when taking glaucoma medicationswas 5.2% for all charts, 5.6% by first-year residents, and 2.5% bysecond-year residents. Referral for appropriate vision rehabilitationand social services, however, was documented in 16.1% of allcharts and 25.0% by first-year residents and 0.0% by second-yearresidents.

Discussion

This study is the first to document residents’ compliance toAAO PPP guidelines for POAG during a follow-up visit.We found an overall mean compliance rate to the POAGPPP of 82.6% across all charts, a rate that is comparablewith that found for residents’ overall compliance to theCataract in the Eye PPP (81%)29 and higher than that foundfor the Diabetic Retinopathy PPP (52%).30 Granted,

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meaningful differences in study design were present across all3 studies. A substantial number of elements in the Cataractin the Eye PPP emphasized surgical management andpostoperative follow-up,29 elements that were not applicableto the POAG PPP, which offered recommendations formedical management of the disease. The study examiningresident compliance to the Diabetic Retinopathy PPP alsodiffered from our study because they reviewed elements inan initial examination,30 whereas we examined elements ofa follow-up visit.

In addition to averaging compliance rates across allcharts, we also compared performance across years oftraining. In this analysis, we averaged compliance rates perresident to remove any potential bias caused by examiningeach chart as an independent entity when an unequalnumber of charts was documented by each resident, whichcould have resulted in mean compliance rates that skewtoward the performance of residents with a greater numberof charts. Nonetheless, we maintained the primary analysisof averaging across charts, and not per resident, to allow forcomparisons with other studies, which averaged compliancerates across charts only. When averaged per resident, theoverall compliance rate for 8 residents with records fromboth years was 78.8% in their first year and 81.7% in theirsecond year. Although residents’ performance improvedslightly from year 1 to year 2, the difference was notstatistically significant. Other elements with improvementfrom the first year to the second year included intervalsystemic history (from 94.8% to 97.9%), local or systemicproblems with medications (from 33.5% to 51.0%),discussion and documentation of compliance (from 83.3%to 95.8%), and appropriate follow-up interval (from 97.1%to 100.0%). Elements on which residents scored lower intheir second year included evaluation of optic nerve andvisual fields (100.0% vs. 89.6%), advising patients to alertthe ophthalmologist to physical or emotional changes withmedications (5.6% vs. 2.5%), and referral to appropriatevision rehabilitation and social services if indicated (25.0%vs. 0.0%). None of the changes across years was statisticallysignificant (P> 0.05).

Previous studies on compliance with the AAO PPP forPOAG typically have assessed documentation of examina-tion findings either on the initial or follow-up visit, but notboth.24e26 Because our study looked at compliance forfollow-up visits, it is challenging to draw direct comparisonsbetween our study and previous studies on initial visits. Forexample, studies in the early 1990s by Albrecht and Lee24

and Hertzog et al25 reported compliance in initialexaminations only. However, the 2003 study by Fremontet al26 of 2321 patients enrolled in 6 health maintenanceorganizations examined eye care providers’ compliancewith 4 elements on follow-up visits. Residents in ourstudy documented higher levels of compliance in all 4elements when compared with providers in the managedcare plan network. Providers in the 2003 study documentedinterval ocular history in 80.4% of visits. In comparison,residents in our study documented this element in 95.1% ofvisits. Performance of physical examination elements in the2003 study was 95.6% for visual acuity examination, 96.9%for IOP check, and 82.5% for slit-lamp examination. By

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contrast, residents in our study had full or 100.0% compli-ance rates for all 3 elements.

In 2005, Friedman et al27 examined billing rates forvisual field and optic nerve examinations in a largedatabase of 1712 glaucoma suspects and 3623 diagnosedglaucoma patients and found that although 82.7% ofsuspects had 1 billed follow-up office visit duringa median follow-up of 440 days, only 46.4% had had at least1 billed visual field evaluation and 13.3% had undergonesome form of optic nerve head imaging. The rates wereslightly higher for diagnosed glaucoma patients, but thedifference was not statistically significant. In contrast, ourstudy examined compliance rates at 1 moment in time, notover a period of time, and found a high rate of evaluation ofoptic nerve and visual fields by residents (93.0% in allcharts). In 2007, the same group of authors reportedphysician adherence to PPP in a large claims database usinga sample of 300 charts (3650 visits) and found that physi-cians completed IOP measurements, disc evaluations, andimaging and visual field tests on 90% of open-angle glau-coma patients; gonioscopy and central corneal thicknessmeasurement on half of patients; and setting of target IOPon only 19% of patients.28 By comparison, residents in ourstudy had high compliance rates for IOP, optic nerve, visualfield evaluations and gonioscopies (90.0% or more). Asmentioned previously, our study used the 2003 PPP,which did not include measurements of central cornealthickness and setting of target IOP, and thereforecomparisons of these 2 elements could not be made.

In our study, compliance rates were high (>90.0%) forall elements in the physical examination (visual acuity, slit-lamp, IOP, optic nerve, and visual field evaluations) andfollow-up (appropriate follow-up interval and intervaladjustment after addition or deletion of a medication).Adherence to guidelines for management plan also was high(>90.0%) for all elements (reconsider current IOP andrelationship to target IOP, discussion of compliance,gonioscopy if indicated, reconsideration of treatmentregimen, and use of alternate agent), except for adjustmentof target pressure downward if disc or visual field changeworsened (82.4% for all charts). Given the consistentassociation shown between higher IOP and progressive disccupping35 and visual field loss,36 this is one area thateducational efforts should be directed toward.

In the examination history category, compliance rates forinterval ocular and systemic history and verification ofappropriate medical use were high (>90.0%). However,discussion of local or systemic problems with medicationswas documented in only 58.4% of all charts. Ocular dropscan be absorbed systemically and can cause systemic sideeffects. Discussing adverse effects from glaucoma medica-tions is especially important in the elderly because thispopulation is more likely to be taking multiple medicationsand therefore is more likely to be increasing their suscep-tibility to drugedrug interactions.37 Furthermore, decline ofrenal and hepatic clearance and decrease in counter-regulatory mechanisms in the elderly can result in exag-gerated effects of standard drug dosing.37 Moreover, wefound a low documentation rate of the impact of visualfunction on daily living in the same category. In only half

Ong et al � Resident Compliance with the AAO PPP for POAG

of the charts examined was this element documented.Determining and documenting patients’ ability to performdaily activities of living after visual loss resulting fromglaucoma is an important component of patient care andeducation. Furthermore, several tools (e.g., the 25-itemNational Eye Institute Visual Function Questionnaire andthe Assessment of Disability Related to Vision) have beendeveloped to increase patients’ awareness of how effectivelythey perform activities of daily living.38 The 25-itemNational Eye Institute Visual Function Questionnaire isa self-reported measurement of health-related quality of lifethat has been designed to assess the effects of visualimpairment on physical functioning, emotional well-being,and social functioning.39 The Assessment of DisabilityRelated to Vision, by comparison, is a third-generationperformance-based test to assess physical functioning.38

Although the 25-item National Eye Institute Visual Func-tion Questionnaire is a subjective tool based on self-reporting, the Assessment of Disability Related to Visionis an objective instrument based on the subject’s ability toperform specific tasks. Awareness of their own visual defi-cits can prevent patients from putting themselves inhazardous situations and can help them to evaluate the risksand benefits of treatment more realistically.38 Awareness ofvisual deficits presumably would be a bigger impetus forpatients to comply with medical therapy, as compared withcomments on change in IOP and visual field. For all thesereasons, it is essential to have high documentation rates forthe discussion of effects of medication locally andsystemically and for the evaluation of impact of visualdysfunction on daily living. Nevertheless, it is alsoimportant to recognize that that these rates may understatethe extent to which these discussions had occurred becauseresidents could have discussed but not documented theseelements. Thus, there should be increased emphasis in theresidency curriculum not only on having these discussions,but also on documenting such discussions in the patientrecord.

Additionally, documentation of patient education byresidents was poor, with advising of patients to alert theirophthalmologist to physical or emotional changes withmedications occurring in only 5.2% of all visits. Further-more, the compliance rate was low when stratified by yearof residency (5.6% for year 1 and 2.5% for year 2), sug-gesting that it is not a function of continued education orexperience in the clinic. As mentioned previously, adverseeffects from medications are more likely to occur in theelderly.37 Because glaucoma is also more prevalent in theelderly, it is imperative that any changes that occur withmedications be monitored closely so that appropriate andtimely modifications can be made.

Another element with a low documentation rate wasreferral for appropriate vision rehabilitation or socialservices, which was 16.1% for all charts. Again, adherencefor this element decreased from years 1 to 2 of residency(from 25.0% to 0.0%). These rates should be improvedbecause low-vision rehabilitation programs have beenshown to be effective in decreasing patient difficulty inperforming activities of daily living. Activities involvingnear work such as reading newspapers and telephone books

and determining the accuracy of bills are the most likely torespond to rehabilitation through the use of magnifiers andtelescopes.40,41 Therefore, vision rehabilitation can improvea patient’s quality of life substantially and should be anintegral part of healthcare. Given all these reasons, the 2elements under patient education should be taught andemphasized more consistently in residency programs.

There are several limitations to this study. This wasa retrospective chart-based review, and residents could haveprovided care that was not documented. Elements thatrequired documentation of discussions with patients weremore likely to score lower than history and examinationelements. For example, residents could have discussed theside effects of medications or the importance of alertingtheir ophthalmologist if they experienced these effects, but ifthey failed to document this in the charts, then they wouldnot receive credit. This may have contributed to the poorcompliance rates calculated for these elements. Also relatedto the use of paper charts in this study is the fact that theUnited States Department of Veterans Affairs has sincemigrated to using electronic medical records dubbed theComputerized Patient Record System. Electronic medicalrecords are thought to improve organization and efficiencyand could result in different compliance rates if the studywere repeated with an electronic medical record in use.Another weakness of this study is associated with the use ofthe 2003 PPP guidelines. Because the clinic visits docu-mented in this study occurred between 2003 and 2004, the2003 guidelines were used. The most recent AAO PPPdocument was released in 2010 and includes additionalelements not found in the 2003 guidelines, for example,measurements of central corneal thickness, patient educationon the effects of keratorefractive surgery, and the impact ofimplantation of a multifocal lens on visual outcome, amongothers.42 Furthermore, because the charts in this study wereextracted from the Department of Veterans Affairs, whichcaters to a population that is predominantly male,43 resultsfrom this study may not be generalized to clinic settingsand patient populations outside the Veterans Affairs system.

Our experience with this study has led us to believe thatthe AAO’s PPP guidelines can be used as an instrument toassess residents’ successful achievement of core compe-tencies created by the Accreditation Council for GraduateMedical Education to evaluate a residency program’seducational effectiveness and quality.44 The 6 corecompetencies include medical knowledge, patient care,professionalism, communication and interpersonal skills,practice-based learning and improvement, and systems-based practice.44 Currently, program directors developtheir own evaluation tools to assess resident performance.We suggest using the AAO’s PPP guidelines as anobjective and standardized way to evaluate residentperformance across programs. For example, the PPPguidelines for POAG examined in this study overlap withmultiple elements of the Accreditation Council forGraduate Medical Education’s core competencies,including (1) patient care (i.e., data gathering, makinginformed decisions about diagnostic interventions,developing management plans, and counseling andeducating patients), (2) medical knowledge (i.e., knowing

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Ophthalmology Volume 120, Number 12, December 2013

and applying appropriate basic and clinical sciences inpatient services), (3) practice-based learning and improve-ment (i.e., using evidence-based medicine in clinical care),and (4) systems-based practice (i.e., advocating for high-quality patient care and assisting patients in dealing withsystems complexities).44

On the whole, our study demonstrated that residents hadhigh compliance rates with elements in a POAG follow-upvisit with slight improvements from years 1 to 2, exceptfor specific elements under history and patient education.More emphasis on education is needed to help improveresident compliance in evaluating local or systemic prob-lems with medication, assessing the impact of visual func-tion on daily living, encouraging patients to alert providersto physical or emotional changes that occur with glaucomamedications, and referring patients with significant visualimpairment or blindness to use appropriate vision rehabili-tation and social services. Monitoring trainee compliance toguidelines can be an important tool to assess if corecompetencies are met, and if not, additional education maybe given to improve adherence rates. The use of PPP scoringalso can be used by individuals for self-study and reflectionto fulfill the practice-based learning competency. There arenow indications that adherence to evidence-based guidelinesmay translate into superior patient care and improvedoutcomes.28,32 Improved physician scores on a PPP-basedmetric have been shown to predict better detection of wors-ening cup-to-disc ratio.28 Moreover, trainees themselvesperceive enhanced educational and patient care outcomeswith the use of evidence-based medicine guidelines.31,32

However, further studies are needed to establish the advan-tages of using PPP guidelines for resident education and todetermine if such assessments can lead to improved patientcare.

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Footnotes and Financial Disclosures

Originally received: August 24, 2012.Final revision: May 17, 2013.Accepted: May 21, 2013.Available online: August 5, 2013. Manuscript no. 2012-1313.1 Duke Eye Center, Duke University School of Medicine, Durham, NorthCarolina.2 Duke-NUS Graduate Medical School, Singapore, Republic of Singapore.3 Eye Centers of Racine and Kenosha, Racine, Wisconsin.4 Brosnan Eye Associates, Asheville, North Carolina.5 W. K. Kellogg Eye Center, University of Michigan Medical School, AnnArbor, Michigan.

Financial Disclosure(s):The author(s) have no proprietary or commercial interest in any materialsdiscussed in this article.

Supported by a Goh Foundation Research Award of Duke-NUS GraduateMedical School, Singapore, Republic of Singapore (S.S.O.); HeedOphthalmic Foundation Fellowship, Cleveland, Ohio (P.S.M.); andResearch to Prevent Blindness, Inc., New York, New York (P.C.). Thefunding organizations had no role in the design or conduct of this research.

Correspondence:Pratap Challa, MD, Duke Eye Center, 2351 Erwin Road, Durham,NC 27710. E-mail: pratap.challa@duke.edu.

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