Impact of direct electronic optometric referral with ocular imaging to a hospital eye service

Effect of implementation of an electronic consult referral platform (eConsult) to triage retina referrals in Manitoba

OBJECTIVE

eConsult allows specialists to diagnose and recommend treatment plans for nonurgent conditions without the need for patient travel. Our purpose is to evaluate the effectiveness of eConsult in reducing unnecessary in-person retinal consultations in Manitoba.

DESIGN

Retrospective eConsult chart review.

PARTICIPANTS

Any person for whom an eConsult was submitted for a retina problem in Manitoba between November 2020 and October 2023 (n = 196).

METHODS

The primary objective was to quantify eConsults requiring no in-person referral, routine in-person referral, or urgent (within 4 weeks) in-person referral. Secondary objectives included describing characteristics of eConsults and quantifying the amount of time spent on the platform by both the referring provider and the specialist. On the basis of these variables, patient travel, consultation time, and specialist billings savings were calculated.

RESULTS

66.8% of eConsults did not require in-person assessment (n = 131), 24.5% required to be seen on a routine basis (n = 48), and 8.7% required to be seen within 4 weeks (n = 17). This translated to a net cost of $2,660.43 for the provincial government in billings over 3 years, but 81 990 km saved in patient travel. 99% of eConsults came from optometrists (n = 194). Referring providers spent an average of 10.6 ± 9.4 minutes on the platform per referral, and the specialist consultant spent 9.1 ± 6.6 minutes.

CONCLUSION

eConsult is a potentially cost-effective way to address increasing demand for retinal services, reduce wait times by reducing unnecessary referrals, and facilitate data sharing between optometrists and ophthalmologists.

Implementing teleophthalmology services to improve cost-effectiveness of the national eye care system

BACKGROUND AND PURPOSE

Optometrist-assisted and teleophthalmology-enabled referral pathway (OTRP) for community optometry referrals has the potential to improve the capacity and efficiency of eye care delivery systems through risk stratification and limiting the number of improved referrals. This study investigates the expected future costs and benefits of implementing OTRP under various possible organizational set-ups relevant to a Danish context.

METHODS

A decision-analytic model (decision tree) with a one-year time horizon was constructed to portray alternative future patient referral pathways for people examined in optometry stores for suspected ocular posterior segment eye disease. The main outcomes were total healthcare costs per patient, average waiting time from eye examination in store until the start of treatment or end of referral pathway, and quality-adjusted life-years (QALY) gained. The economic evaluation compares the general ophthalmologist referral pathway (GO-RP) with a potential reimbursement model for the optometrist-assisted teleophthalmology referral pathways (R-OTRP) and a procurement model for the optometrist-assisted teleophthalmology referral pathways (P-OTRP).

RESULTS

The cost per individual with suspected ocular posterior segment eye disease was estimated to be £116 for GO-RP and £75 and £94 for P-OTRP and R-OTRP respectively. The average waiting time for diagnosis or end of referral pathway was 25 weeks for GO-RP and 5.8 and 5.7 for P-OTPR and R-OTPR respectively. QALY gain was 0.15 for P-OTRP/R-OTRP compared to 0.06 for GO-RP.

CONCLUSION

OTRP is effective in reducing unnecessary referrals and waiting times, increasing patients' HRQoL, and decreasing the costs of diagnosing individuals with suspected ocular posterior segment eye disease.

The effectiveness of interventions for optometric referrals into the hospital eye service: A review

PURPOSE

Ophthalmic services are currently under considerable stress; in the UK, ophthalmology departments have the highest number of outpatient appointments of any department within the National Health Service. Recognising the need for intervention, several approaches have been trialled to tackle the high numbers of false-positive referrals initiated in primary care and seen face to face within the hospital eye service (HES). In this mixed-methods narrative synthesis, we explored interventions based on their clinical impact, cost and acceptability to determine whether they are clinically effective, safe and sustainable. A systematic literature search of PubMed, MEDLINE and CINAHL, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), was used to identify appropriate studies published between December 2001 and December 2022.

RECENT FINDINGS

A total of 55 studies were reviewed. Four main interventions were assessed, where two studies covered more than one type: training and guidelines (n = 8), referral filtering schemes (n = 32), asynchronous teleophthalmology (n = 13) and synchronous teleophthalmology (n = 5). All four approaches demonstrated effectiveness for reducing false-positive referrals to the HES. There was sufficient evidence for stakeholder acceptance and cost-effectiveness of referral filtering schemes; however, cost comparisons involved assumptions. Referral filtering and asynchronous teleophthalmology reported moderate levels of false-negative cases (2%-20%), defined as discharged patients requiring HES monitoring.

SUMMARY

The effectiveness of interventions varied depending on which outcome and stakeholder was considered. More studies are required to explore stakeholder opinions around all interventions. In order to maximise clinical safety, it may be appropriate to combine more than one approach, such as referral filtering schemes with virtual review of discharged patients to assess the rate of false-negative cases. The implementation of a successful intervention is more complex than a 'one-size-fits-all' approach and there is potential space for newer types of interventions, such as artificial intelligence clinical support systems within the referral pathway.

Assessment of optometrists' referral accuracy and contributing factors: A review

PURPOSE

In the UK, ophthalmology has the highest number of outpatient appointments within the National Health Service. False-positive referrals from primary care are one of the main factors contributing to the oversubscription of hospital eye services (HESs). We reviewed the accuracy of referrals originating from primary care optometrists and contributing factors, such as condition type and years since registration.

RECENT FINDINGS

Of the 31 studies included in the review, 22 were retrospective analyses of referrals and appointments at the HES. Eight were prospective studies, and one used online clinical vignettes. Seven assessed the accuracy of referrals for all ocular conditions. The remaining studies focused on glaucoma (n = 11), cataracts (n = 7), emergency conditions (n = 4), neovascular age-related macular degeneration (n = 1) and paediatric binocular vision (n = 1). The diagnostic agreement for suspected emergency ocular conditions was the lowest, with only 21.1% of referrals considered to require urgent attention in one study. For glaucoma, the first-visit discharge rate was high (16.7%-48%). Optometrist referral accuracy was overall 18.6% higher than General Medical Practitioners'; however, the two mainly referred different ocular conditions. Female optometrists made more false-positive referrals than males (p = 0.008). The proportion of false positives decreased by 6.2% per year since registration (p < 0.001).

SUMMARY

There was significant variation in referral accuracy across different ocular conditions, partly due to differences when defining accurate referrals. Optometrists working in primary care are generally more limited in their resources than the HES. Thus, choosing the cautious option of referral when they are unsure could be in the patients' best interests. The possible effect of increased use of advanced imaging on referrals requires evaluation. Although interventions such as refinement schemes have been put in place, these vary across regions, and their approaches such as virtual referral triaging may reduce unnecessary HES face-to-face appointments and promote communication between primary and secondary care.

Integration of Refractive Services Provided by Optometrists into the Portuguese National Health Service

Introduction

Refractive error is a public health concern and even with relatively simple and cost-effective interventions it remains usually outside national health services (NHSs) not ensuring universal health coverage. This study aimed to generate evidence about the availability and accessibility of refractive services in Portugal and to present a plan for more efficient services.

Methods

A situation analysis of the Portuguese existing refractive services within the NHS was conducted based on three health systems building blocks: service delivery access, service coverage, and workforce. A strengths, weaknesses, opportunities, and threats analysis was performed based on existent evidence to identify internal and external factors that can facilitate or hinder the integration of refractive services within the NHS. The number of eye care personnel to be integrated in the NHS was calculated considering the minimum ratios recommended by national and international technical reports.

Results

Portugal has no specific services to address refractive errors within the NHS. Treatment of refractive error occurs at the level of eye care general services. There are 39 NHS eye care services, all hospital-centred and divided into three large groups, according to technical differentiation, the technology required, and workforce capacity. The workforce available is composed of ophthalmologists and orthoptists, together with nurses and other general paramedical assistants. 3 Portuguese municipalities have more than 1 NHS eye care service, 35 have 1 NHS eye care service, and 240 municipalities (in the mainland) have none. In 2021, 52% of the hospitals providing eye care services did not meet the recommended response times. Centralization of eye care services in urban areas, undifferentiated referral systems, and a shortage in the workforce per inhabitant was observed.

Conclusions

Portuguese NHS has all the requirements to reorientate refractive care from the current hospital-based model to primary care. The country also has a trained and qualified workforce to address this condition. Evidence demonstrates that the provision of refractive services at primary care is efficient and effective and translates into an opportunity to identify other visual conditions.

Ophthalmologic emergency room visits during COVID-19 lockdown–Characterization from Haifa, Israel

Purpose

To characterize quantitative differences among ophthalmologic emergency room (OER) encounters at Rambam Health Care Campus during a 6-week complete lockdown at the peak of the first COVID-19 wave as compared to a corresponding uneventful period a year earlier.

Methods

A retrospective chart analysis of all OER encounters during the lockdown and non-lockdown period was conducted. Patients were stratified into primary ophthalmological conditions (OER visits) and cases in which ophthalmologic consultations were requested by a non-ophthalmologist (OER consultations). The following parameters were compared: total number of cases, age, gender, chief complaint/diagnosis categorized into major entities, and discharge vs. hospitalization. For continuous variables a t-test was used and for categorical variables a chi-squared or Fisher’s exact test was used. A 2-sided p value <0.05 was considered statistically significant.

Results

The total number of patients in the lockdown and non-lockdown groups was 486 and 992, respectively, showing a 51% decrease in visits during lockdown. In the non-lockdown and lockdown groups 56% and 61% of patients were male (p = 0.07), with an average age of 42 (range 0–97, SD 23) and 43 (range 0–90, SD 22) years, respectively (p = 0.44). No statistically significant proportional increase was found for any diagnostic category between the OER visits (p = 0.07) and OER consultation groups (p = 0.77). Nevertheless, analysis revealed a non-significant increase in the proportion of eye trauma from 14.8% to 21.2%, and reduction in eyelid conditions from 10.7% to 5.8%. The total number of OER visits demanding urgent intervention on admission was 43 (non-lockdown) and 24 (lockdown), while hospitalization ratio (hospitalizations/visits) was 8.8% and 10.6%, respectively (p = 0.44).

Conclusions

During the COVID-19 lockdown the guideline for patients in Israel was to avoid unnecessary hospital visits. Since patients tended to avoid the OER rather uniformly regardless of their specific eye condition, determining the risk-benefit of such recommendations and identifying high-risk sub-populations are critical public health issues.

Evaluation of the Manchester COVID-19 Urgent Eyecare Service (CUES)

INTRODUCTION

Pressure on capacity in ophthalmology alongside the coronavirus (COVID-19) pandemic led to the development of the COVID-19 Urgent Eyecare Service (CUES), allowing patients to receive a prompt ophthalmic consultation, including remotely. The aim of this study was to conduct a service evaluation of CUES in Manchester.

METHODS

Data were collected both prospectively and retrospectively from both primary and secondary care over an 8-week period from June to August 2020.

RESULTS

In primary care CUES in Greater Manchester (GM) 2461 patients were assessed, with a majority self-referring to the service (68.7%, n = 1844). 91.7% of cases initially screened for CUES were deemed eligible and given a telemedicine appointment in GM; 53.3% of these cases required face-to-face consultation. 14.3% of cases seen within in GM CUES (351 out of 2461) were provisionally referred to secondary care. Contemporaneously the main provider emergency eyecare department (EED) attendances were reduced by 37.7% per month between April and December 2020 inclusive, compared to the same months in 2019. Patients attending a CUES face-to-face assessment were more likely to have a diagnosis in agreement with secondary care, compared to patients referred in from telemedicine assessment only (P < 0.05).

CONCLUSION

This evaluation of CUES demonstrates a high level of primary care activity alongside a sustained reduction in EED cases. The case-mix of patients seen within EED following referral appears to be of a less benign nature than those cases seen prior to the introduction of CUES.

Clinical decision support in primary care for better diagnosis and management of retinal disease

Misdiagnosis of retinal disease is a common problem in primary care that can lead to irreversible vision loss and false-positive referrals, resulting in inappropriate use of health services. Clinical decision support systems describe tools that leverage information technology to provide timely recommendations that assist clinicians in the decisions they make about the care of a patient. They, therefore, have the potential to reduce the rate of misdiagnosis by promoting evidence-based medicine and more effective and efficient healthcare. This narrative review aims to support primary care practitioners in better understanding the current and emerging capacity of clinical decision support systems in eye care. Different types of clinical decision support systems are discussed, using current examples and evidence from the available literature to demonstrate how they may improve diagnostic effectiveness and aid the management of retinal disease. Comments are made on the future directions of clinical decision support in primary eye care and the potential applications of artificial intelligence.

A Systematic Review of Current Teleophthalmology Services in New Zealand Compared to the Four Comparable Countries of the United Kingdom, Australia, United States of America (USA) and Canada

BACKGROUND

Over 700,000 New Zealanders (NZ), particularly elderly and Māori, live without timely access to specialist ophthalmology services. Teleophthalmology is a widely recognised tool that can assist in overcoming resource and distance barriers. Teleophthalmology gained unprecedented traction in NZ during the COVID-19 pandemic and subsequent lockdown. However, its provision is still limited and there are equity issues. The aim of this study was to conduct a systematic review identifying, describing and contrasting teleophthalmology services in NZ with the comparable countries of Australia, USA, Canada and the United Kingdom.

METHODS

The electronic databases Embase, PubMed, Web of Science, Google Scholar and Google were systemically searched using the keywords: telemedicine, ophthalmology, tele-ophthalmology/teleophthalmology. The searches were filtered to the countries above, with no time constraints. An integrative approach was used to synthesise findings.

RESULTS

One hundred and thirty-two studies were identified describing 90 discrete teleophthalmology services. Articles spanned from 1997 to 2020. Models were categorised into general eye care (n=21; 16%); emergency/trauma (n=6; 4.5%); school screening (n=25; 19%); artificial intelligence (AI) (n=23; 18%); and disease-specific models of care (MOC) (n=57; 43%). The most common diseases addressed were diabetic retinopathy (n=23; 17%); retinopathy of prematurity (n=9; 7%); and glaucoma (n=8; 6%). Programs were mainly centred in the US (n=72; 54.5%), followed by the UK (n=29; 22%), then Canada (n=16; 12%), Australia (n=13; 10%), with the fewest identified in NZ (n=3; 2%). Models generally involved an ophthalmologist consultative service, remote supervision and triaging. Most models involved local clinicians transmitting fed-forward or live images.

CONCLUSION

Teleophthalmology will likely play a crucial role in the future of eye care. COVID-19 has offered a unique opportunity to observe the use of teleophthalmology services globally. Feed-forward and, increasingly, live-based teleophthalmology services have demonstrated feasibility and cost-effectiveness in similar countries internationally. New Zealand's teleophthalmology services, however, are currently limited. Investing in strategic partnerships and technology at a national level can advance health equities in ophthalmic care.

Danish teleophthalmology platform reduces optometry referrals into the national eye care system

Objective

The purpose of this study was to evaluate the stratification of follow-up and referral pathways after implementation of a systematic cloud-based electronic-referral teleophthalmological service for optometry-initiated ocular posterior segment disease referrals to the Danish national eye care system.

Methods and Analysis

A retrospective cohort study was conducted in the period from 1 August 2018 to 31 July 2019. Patients with suspected ocular posterior segment disease reviewed by the telemedical ophthalmology service were included. The service stratified patients into the categories: no need for follow-up, follow-up by optometrist, follow-up by the telemedical service and referral to the national Danish eye care service.

Results

From a pool of 386 361 customers, 9938 patients were enrolled into this study. 19.5% of all patients were referred to the Danish national eye care system, while 80.5% of the patients in the telemedical service were not, in the period from 1 August 2018 to 31 July 2019. 14.4% of the optometrist referrals did not need any follow-up, while a majority of 66.1% needed some follow-up either by the optometrist themselves or within the telemedical service.

Conclusion

Optometrist posterior segment disease referrals can be considerably reduced with a risk stratified approach and optimal use of technology. New models can improve and streamline the healthcare system.

Clinical outcomes of the Centre for Eye Health: an intra-professional optometry-led collaborative eye care clinic in Australia

Clinical relevance: This novel clinical model is the first of its kind in Australia and was designed to help reduce unnecessary referrals into overburdened public systems by utilising pre-existing community-based resources.Background: The Centre for Eye Health (CFEH) is an intra-professional optometry-led care clinic offering an alternative pathway to traditional ophthalmology-based pathways (public hospital clinics or private practices) for 'at-risk' patients requiring ocular imaging, diagnostic and management services. This study evaluates the CFEH integrated eye-care model in the identification of chronic eye diseases within the community.Methods: A retrospective random clinical audit of over 750 medical records of patients referred to the CFEH between July 2016 and June 2019 was conducted. Demographics of patients, referral type, final diagnosis and recommended management plans were extracted from this subset. Clinic key performance indicators (referral turnaround time, and net cost per patient appointment) were also extracted.Results: Of the 755 referrals associated with the audited records, 77.4% resulted in the identification of patients with or at-risk of developing eye diseases with 73.5% of this cohort requiring ongoing monitoring at CFEH or referral to ophthalmology. Although the CFEH model is not designed to diagnose or manage acute conditions, 1.5% of patients in this pathway required same day ophthalmological or medical intervention. The cost per patient was equivalent to hospital eye departments costs.Conclusion: This integrated care pathway has the potential to reduce unnecessary referrals from optometrists to hospital ophthalmological service by offering a safe and effective alternate pathway. The majority of patients seen within this pathway were able to be monitored within optometry-led services. This is a unique clinical model utilising inter-professional referrals within optometry which has the potential to reduce preventable blindness within the community through the early detection of eye diseases.

Investigating the Role of Optometrists in Teleophthalmology and the Implications of Increasing Access to Advanced Imaging Techniques and Digital Referral: A Systematic Search and Review

Introduction: The objective of this systematic search and review was to investigate the role of optometrists in teleophthalmology and digital referral. We examine the implications of the optometric communities' increasing access to advanced imaging, such as optical coherence tomography (OCT), in ophthalmic telemedicine schemes. Methods: A systematic search was conducted, using PubMed and Embase, in April of 2019. Eight hundred eight (n = 808) texts were retrieved and 99 articles were deemed eligible for full-text review. Twenty-six (n = 26) studies were included in the qualitative synthesis. All studies involved optometrists as principal service providers. Results: Findings demonstrate that optometrist-facilitated teleophthalmology results in consistent reductions in hospital referrals and waiting times, as well as high patient satisfaction. Optometrists are identified as crucial to the success of many projects and their access to advanced imaging technology is observed to position optometry practices as the most convenient location to establish a teleophthalmology program. OCT imaging demonstrated the potential to increase diagnostic accuracy and is increasingly prevalent in optometry practice. The importance of additional training for optometrists participating in teleophthalmology schemes is highlighted, as is the need for appropriate remuneration for those involved. Conclusion: The role of community-based ophthalmic care in reducing demands on hospital eye services (HES) is highlighted by our results, demonstrating that optometrist-facilitated teleophthalmology can dramatically reduce referrals and streamline care. In addition, the increasing prevalence of OCT in optometric practice represents an underutilized resource for HES.

Quality and targeting of new referrals for ocular complications of diabetes from primary care to a public hospital ophthalmology service in Western Sydney, Australia

Patients with diabetes require regular examination for eye disease, usually in primary care settings. Guidelines recommend patients with at least moderate non-proliferative diabetic retinopathy (NPDR) be referred to an ophthalmologist for treatment; however, poorly targeted referrals lead to access blocks. The quality of new referrals associated with diabetes to a public ophthalmology service in Sydney, New South Wales, Australia, were assessed for referral completeness and targeting. A cross-sectional audit of medical records for new patients referred to Westmead Hospital Eye Clinic in 2016 was completed. Completeness of medical and ophthalmic information in referrals and subsequent patient diagnosis and management in 2016-17 was recorded. Sub-analyses were conducted by primary care referrer type (GP or optometrist). In total, 151 new retinopathy referrals were received; 12% were sent directly to a treatment clinic. Information was incomplete for diabetes status (>60%), medical (>50%) and ophthalmic indicators (>70%), including visual acuity (>60%). GP referrals better recorded medical, and optometrists (37%) ophthalmic information, but information was still largely incomplete. Imaging was rarely included (retinal photos <1%; optical coherence tomography <3%). Median appointment wait-time was 124 days; 21% of patients received treatment (laser or anti-vascular endothelial growth factor) at this or the following encounter. Targeting referrals for ocular complication of diabetes to public hospitals needs improvement. Education, feedback and collaborative care mechanisms should be considered to improve screening and referral in primary care.

Implementation of a cloud-based referral platform in ophthalmology: making telemedicine services a reality in eye care

BACKGROUND

Hospital Eye Services (HES) in the UK face an increasing number of optometric referrals driven by progress in retinal imaging. The National Health Service (NHS) published a 10-year strategy (NHS Long-Term Plan) to transform services to meet this challenge. In this study, we implemented a cloud-based referral platform to improve communication between optometrists and ophthalmologists.

METHODS

Retrospective cohort study conducted at Moorfields Eye Hospital, Croydon (NHS Foundation Trust, London, UK). Patients classified into the HES referral pathway by contributing optometrists have been included into this study. Main outcome measures was the reduction of unnecessary referrals.

RESULTS

After reviewing the patient's data in a web-based interface 54 (52%) out of 103 attending patients initially classified into the referral pathway did not need a specialist referral. Fourteen (14%) patients needing urgent treatment were identified. Usability was measured in duration for data input and reviewing which was an average of 9.2 min (median: 5.4; IQR: 3.4-8.7) for optometrists and 3.0 min (median: 3.0; IQR: 1.7-3.9) min for ophthalmologists. A variety of diagnosis was covered by this tool with dry age-related macular degeneration (n=34) being most common.

CONCLUSION

After implementation more than half of the HES referrals have been avoided. This platform offers a digital-first solution that enables rapid-access eye care for patients in community optometrists, facilitates communication between healthcare providers and may serve as a foundation for implementation of artificial intelligence.

Digital ophthalmology in Scotland: benefits to patient care and education

Tackling visual impairment remains an important public health issue. Due to limited resources and the increasing demand on hospital eye services (HES), delivery of quality eye care within the community is essential. Training of clinical ophthalmic specialists and allied health-care professionals in the detection and management of common eye conditions can thus help to reduce the burden of eye disease and improve prognostic outcomes. Digital imaging has become a useful tool in facilitating eye-care delivery in both the community and hospital setting. In the last decade, the advent of electronic image exchange via a centralized referral unit in Scotland has revolutionized screening for ophthalmic disease, referrals, and shared care between community and HES clinicians. A government-led initiative known as the Scottish Eyecare Integration Project introduced electronic transfer of digital images within referrals from community optometrists to HES, which greatly reduced outpatient waiting times and improved patient satisfaction. The catalogue of live clinical information and digital images that resulted from the project led to the creation of a virtual learning platform through the University of Edinburgh. Participating professionals involved in eye care have interactive discussions about common eye conditions by sharing digital images of cases and investigations on a global online platform. This has received worldwide attention and inspired the creation of other university courses, e-learning platforms in eye-health education, and shared-care schemes in the screening of eye disease. We show that digital ophthalmology plays a vital role in the integration of community and HES partnership in delivery of patient care and in facilitating eye-health education to a global audience.

Models of care in tele-ophthalmology: A scoping review

The objective of this review was to identify and describe telehealth models of care for ophthalmic services. We conducted a scoping review of the literature to identify how ophthalmic care can be delivered by telehealth. We searched the PubMed database to identify relevant articles which were screened based on pre-defined inclusion criteria. For included articles, data were extracted, categorised and analysed. Synthesis of findings was performed narratively. The scoping review included 78 articles describing 62 discrete tele-ophthalmic models of care. Tele-ophthalmic models of care can be used for consultative service, screening, triage and remote supervision. The majority of services were for general eye care and triage ( n = 17; 26%) or emergency services ( n = 8; 12%). The most common conditions for disease-specific models of care were diabetic retinopathy ( n = 14; 21%), and glaucoma ( n = 8; 12%). Most models of care involved local clinicians capturing images and transmitting them to an ophthalmologist for assessment. This scoping review demonstrated tele-ophthalmology to be feasible for consultation, screening, triage and remote supervision applications across a broad range of ophthalmic conditions. A large number of models of care have been identified and described in this review. Considerable collaboration between patient-end clinicians and substantial infrastructure is typically required for tele-ophthalmology.

The Effectiveness, cost-effectiveness and acceptability of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual randomised balanced incomplete block trial

BACKGROUND

Patients with neovascular age-related macular degeneration (nAMD) usually attend regular reviews, even when the disease is quiescent. Reviews are burdensome to health services, patients and carers.

OBJECTIVES

To compare the proportion of correct lesion classifications made by community-based optometrists and ophthalmologists from vignettes of patients; to estimate the cost-effectiveness of community follow-up by optometrists compared with follow-up by ophthalmologists in the Hospital Eye Service (HES); to ascertain views of patients, their representatives, optometrists, ophthalmologists and clinical commissioners on the proposed shared care model.

DESIGN

Community-based optometrists and ophthalmologists in the HES classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomography images. Participants' classifications were validated against experts' classifications (reference standard).

SETTING

Internet-based application.

PARTICIPANTS

Ophthalmologists had to have ≥ 3 years post-registration experience in ophthalmology, have passed part 1 of the Royal College of Ophthalmologists, Diploma in Ophthalmology or equivalent examination, and have experience in the age-related macular degeneration service. Optometrists had to be fully qualified, be registered with the General Optical Council for ≥ 3 years and not be participating in nAMD shared care.

INTERVENTIONS

The trial sought to emulate a conventional trial in comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed; therefore, there were no interventions. Participants received training prior to assessing vignettes.

MAIN OUTCOME MEASURES

Primary outcome - correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes - frequencies of potentially sight-threatening errors, participants' judgements about specific lesion components, participant-rated confidence in their decisions and cost-effectiveness of follow-up by community-based optometrists compared with HES ophthalmologists.

RESULTS

In total, 155 participants registered for the trial; 96 (48 in each professional group) completed training and main assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702 out of 2016 (84.4%) and 1722 out of 2016 (85.4%) correct classifications, respectively [odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.25; p = 0.543]. Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the pre-specified limit of 10% absolute difference (0.298 on the odds scale). Frequencies of sight-threatening errors were similar for optometrists and ophthalmologists [57/994 (5.7%) vs. 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p = 0.789]. Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their lesion classifications than optometrists. The mean care-pathway cost for assessment was very similar by group, namely £397.33 for ophthalmologists and £410.78 for optometrists. The optometrist-led monitoring reviews were slightly more costly and less effective than ophthalmologist-led reviews, although the differences were extremely small. There was consensus that optometrist-led monitoring has the potential to reduce clinical workload and be more patient-centred. However, potential barriers are ophthalmologists' perceptions of optometrists' competence, the need for clinical training, the ability of the professions to work collaboratively and the financial feasibility of shared care for Clinical Commissioning Groups.

CONCLUSIONS

The ability of optometrists to make nAMD retreatment decisions from vignettes is non-inferior to that of ophthalmologists. Various barriers to implementing shared cared for nAMD were identified.

FUTURE WORK RECOMMENDATIONS

The Effectiveness, cost-effectiveness and acceptability of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES) study web application was robust and could be used for future training or research. The benefit of reducing HES workload was not considered in the economic evaluation. A framework of programme budgeting and marginal analysis could explicitly explore the resource implications of shifting resources within a given health service area, as the benefit of reducing HES workload was not considered in the economic evaluation. Future qualitative research could investigate professional differences of opinion that were identified in multidisciplinary focus groups.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN07479761.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 80. See the NIHR Journals Library website for further project information.

Investigation of time to first presentation and extrahospital factors in the treatment of neovascular age-related macular degeneration: a retrospective cross-sectional study

OBJECTIVES

To assess the time from symptom onset to treatment for neovascular age-related macular degeneration (nvAMD) and to measure the awareness of AMD in Southeast Scotland.

DESIGN

Retrospective cross-sectional study.

SETTING

Secondary care, Southeast of Scotland.

METHODS

Patients treated with intravitreal therapy (IVT) for nvAMD in Southeast Scotland between 2013 and 2015 were identified using a treatment register. Notes were retrospectively reviewed. We measured time from: (A) symptom onset to first presentation at primary care, (B) referral to ophthalmic clinic appointment and (C) ophthalmic clinic appointment to first IVT treatment. To investigate AMD awareness, we performed a cluster random sample survey of patients visiting non-AMD ophthalmic clinics using a previously validated 12-item questionnaire.

RESULTS

195 patients (mean age 78 years) were included in the study. The mean delays between the different stages-A, B and C-were 54.2 (95% CI ±13), 28.2 (95% CI ±4.0) and 31.5 (95% CI ±3.6) days, respectively. There was an additional mean delay of 7.5 (95% CI ±1.6) days when patients were indirectly referred by optometrists via general practitioners (P<0.05). 140 patients (mean age 78) participated in the awareness survey; 62.1% reported being 'aware' of AMD but only 37.3% described AMD symptoms correctly.

CONCLUSIONS

There was a significant delay at every step of the nvAMD care pathway. The causes for this were multifactorial and included delays in first presentation to a healthcare provider, referral from primary care and initiation of secondary care treatment. Our data are likely to underestimate prehospital delays as a large number of cases are likely to have undefined symptoms and onset. We also identified suboptimal awareness of AMD which could account for a substantial delay in presentation from symptom onset. These findings highlight the need to address AMD awareness and the need for urgent treatment to prevent avoidable vision loss resulting from nvAMD.

Advanced imaging for the diagnosis of age-related macular degeneration: a case vignettes study

Background

The aim of this study is to evaluate the diagnosis, staging, imaging and management preferences, and the effect of advanced imaging among practising optometrists in age‐related macular degeneration (AMD).

Methods

Up to 20 case vignettes (computer‐based case simulations) were completed online in a computer laboratory in random order by 81 practising optometrists of Australia. Each case presented findings from a randomly selected patient seen previously at the Centre for Eye Health for a macular assessment in the following order: case history, preliminary tests and colour fundus photography. Participants were prompted to provide their diagnosis, management and imaging preference. One additional imaging result (either modified fundus photographs and infrared images, fundus autofluorescence, or optical coherence tomography [OCT]) was then provided and the questions repeated. Finally, all imaging results were provided and the questions repeated a third time.

Results

A total of 1,436 responses were analysed. The presence of macular pathology in AMD was accurately detected in 94 per cent of instances. The overall diagnostic accuracy of AMD was 61 per cent using colour fundus photography. This improved by one per cent using one additional imaging modality and a further four per cent using all imaging. Across all responses, a greater improvement in the diagnostic accuracy of AMD occurred following the presentation of OCT findings (versus other modalities). OCT was the most preferred imaging modality for AMD, while multimodal imaging was of greatest benefit in cases more often misdiagnosed using colour fundus photography alone. Overall, the cohort also displayed a tendency to underestimate disease severity.

Conclusion

Despite reports that imaging technologies improve the stratification of AMD, our findings suggest that this effect may be small when applied among practising optometrists without additional or specific training.

Collaborative care of non-urgent macular disease: a study of inter-optometric referrals

Purpose

Diseases involving the macula and posterior pole are leading causes of visual impairment and blindness worldwide and may require prompt ophthalmological care. However, access to eye‐care and timely patient management may be limited due to inefficient and inappropriate referrals between primary eye‐care providers and ophthalmology. Optometrists with a special interest in macular disease may be useful as a community aid to better stratify and recommend best‐practice management plans for suitable patients. This study assesses such a notion by appraising the optometric referral patterns of patients with suspected macular disease to an intermediate‐tier optometric imaging clinic.

Methods

We performed a retrospective review of patient records and referrals using patients examined at Centre for Eye Health (CFEH) for an initial or follow up macular assessment between the 1/7/2013 and 30/6/2014 (n = 291). The following data were analysed: patient demographic characteristics, primary reason for referral, diagnosed/suspected condition, CFEH diagnosis and recommended management plan.

Results

The number of referrals stipulating a diagnosis, confirmed after evaluation at CFEH was 121 of 291 (42%). After evaluation at CFEH, the number of cases without a specific diagnosis was approximately halved (reduced from 47% to 23%), while the number of cases with no apparent defect or normal aging changes rose from 1% to 15%. Overall diagnostic congruency for specified macular conditions was high (58–94%); cases were seldom (30/291, 10%) found to have a completely different macular condition. 244 of 291 (84%) patients seen at CFEH were recommended ongoing optometric care: either with the referring optometrist or through recall to CFEH. Referral to an ophthalmologist was recommended in 47 instances (16%).

Conclusions

More widespread adoption of intermediate‐tier optometric eye‐care referral pathways in macular disease (following opportunistic primary care screening) has the potential to reduce the number of cases with non‐specific diagnoses and to increase those with a diagnosis of normal aging changes or no apparent disease. The majority of cases seen under this intermediate‐tier model required ongoing optometric care only and did not require face‐to‐face consultation with an ophthalmologist.

Electronic Referrals and Digital Imaging Systems in Ophthalmology: A Global Perspective

Ophthalmology departments face intensifying pressure to expedite sight-saving treatments and reduce the global burden of disease. The use of electronic communication systems, digital imaging, and redesigned service care models is imperative for addressing such demands. The recently developed Scottish Eyecare Integration Project involves an electronic referral system from community optometry to the hospital ophthalmology department using National Health Service (NHS) email with digital ophthalmic images attached, via a virtual private network connection. The benefits over the previous system include reduced waiting times, improved triage, e-diagnosis in 20% without the need for hospital attendance, and rapid electronic feedback to referrers. We draw on the experience of the Scottish Eyecare Integration Project and discuss the global applications of this and other advances in teleophthalmology. We focus particularly on the implications for management and screening of chronic disease, such as glaucoma and diabetic eye disease, and ophthalmic disease, such as retinopathy of prematurity where diagnosis is almost entirely and critically dependent on fundus appearance. Currently in Scotland, approximately 75% of all referrals are electronic from community to hospital. The Scottish Eyecare Integration Project is globally the first of its kind and unique in a national health service. Such speedy, safe, and efficient models of communication are geographically sensitive to service provision, especially in remote and rural regions. Along with advances in teleophthalmology, such systems promote the earlier detection of sight-threatening disease and safe follow-up of non-sight-threatening disease in the community.

Effectiveness of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial

OBJECTIVES

To compare the ability of ophthalmologists versus optometrists to correctly classify retinal lesions due to neovascular age-related macular degeneration (nAMD).

DESIGN

Randomised balanced incomplete block trial. Optometrists in the community and ophthalmologists in the Hospital Eye Service classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomographic images. Participants' classifications were validated against experts' classifications (reference standard).

SETTING

Internet-based application.

PARTICIPANTS

Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care.

INTERVENTIONS

The trial emulated a conventional trial comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed. Therefore, there were no interventions and the trial was virtual. Participants received training before assessing vignettes.

MAIN OUTCOME MEASURES

Primary outcome-correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes-potentially sight-threatening errors, judgements about specific lesion components and participants' confidence in their decisions.

RESULTS

In total, 155 participants registered for the trial; 96 (48 in each group) completed all assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (OR 0.91, 95% CI 0.66 to 1.25; p=0.543). Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the prespecified limit of 10% absolute difference (0.298 on the odds scale). Optometrists and ophthalmologists made similar numbers of sight-threatening errors (57/994 (5.7%) vs 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their classifications than optometrists.

CONCLUSIONS

Optometrists' ability to make nAMD retreatment decisions from vignettes is not inferior to ophthalmologists' ability. Shared care with optometrists monitoring quiescent nAMD lesions has the potential to reduce workload in hospitals.

TRIAL REGISTRATION NUMBER

ISRCTN07479761; pre-results registration.

The Evolution of Teleophthalmology Programs in the United Kingdom: Beyond Diabetic Retinopathy Screening

Modern ophthalmic practice in the United Kingdom is faced by the challenges of an aging population, increasing prevalence of systemic pathologies with ophthalmic manifestations, and emergent treatments that are revolutionary but dependent on timely monitoring and diagnosis. This represents a huge strain not only on diagnostic services but also outpatient management and surveillance capacity. There is an urgent need for newer means of managing this surge in demand and the socioeconomic burden it places on the health care system. Concurrently, there have been exponential increases in computing power, expansions in the strength and ubiquity of communications technologies, and developments in imaging capabilities. Advances in imaging have been not only in terms of resolution, but also in terms of anatomical coverage, allowing new inferences to be made. In spite of this, image analysis techniques are still currently superseded by expert ophthalmologist interpretation. Teleophthalmology is therefore currently perfectly placed to face this urgent and immediate challenge of provision of optimal and expert care to remote and multiple patients over widespread geographical areas. This article reviews teleophthalmology programs currently deployed in the United Kingdom, focusing on diabetic eye care but also discussing glaucoma, emergency eye care, and other retinal diseases. We examined current programs and levels of evidence for their utility, and explored the relationships between screening, teleophthalmology, disease detection, and monitoring before discussing aspects of health economics pertinent to diabetic eye care. The use of teleophthalmology presents an immense opportunity to manage the steadily increasing demand for eye care, but challenges remain in the delivery of practical, viable, and clinically proven solutions.

The design and implementation of a study to investigate the effectiveness of community vs hospital eye service follow-up for patients with neovascular age-related macular degeneration with quiescent disease

Introduction

Standard treatment for neovascular age-related macular degeneration (nAMD) is intravitreal injections of anti-VEGF drugs. Following multiple injections, nAMD lesions often become quiescent but there is a high risk of reactivation, and regular review by hospital ophthalmologists is the norm. The present trial examines the feasibility of community optometrists making lesion reactivation decisions.

Methods

The Effectiveness of Community vs Hospital Eye Service (ECHoES) trial is a virtual trial; lesion reactivation decisions were made about vignettes that comprised clinical data, colour fundus photographs, and optical coherence tomograms displayed on a web-based platform. Participants were either hospital ophthalmologists or community optometrists. All participants were provided with webinar training on the disease, its management, and assessment of the retinal imaging outputs. In a balanced design, 96 participants each assessed 42 vignettes; a total of 288 vignettes were assessed seven times by each professional group.

The primary outcome is a participant's judgement of lesion reactivation compared with a reference standard. Secondary outcomes are the frequency of sight threatening errors; judgements about specific lesion components; participant-rated confidence in their decisions about the primary outcome; cost effectiveness of follow-up by optometrists rather than ophthalmologists.

Discussion

This trial addresses an important question for the NHS, namely whether, with appropriate training, community optometrists can make retreatment decisions for patients with nAMD to the same standard as hospital ophthalmologists. The trial employed a novel approach as participation was entirely through a web-based application; the trial required very few resources compared with those that would have been needed for a conventional randomised controlled clinical trial.

A survey of current and anticipated use of standard and specialist equipment by UK optometrists

PURPOSE

To investigate current and anticipated use of equipment and information technology (IT) in community optometric practice in the UK, and to elicit optometrists' views on adoption of specialist equipment and IT.

METHODS

An anonymous online questionnaire was developed, covering use of standard and specialist diagnostic equipment, and IT. The survey was distributed to a random sample of 1300 UK College of Optometrists members.

RESULTS

Four hundred and thirty-two responses were received (response rate = 35%). Enhanced (locally commissioned) or additional/separately contracted services were provided by 73% of respondents. Services included glaucoma repeat measures (30% of respondents), glaucoma referral refinement (22%), fast-track referral for wet age-related macular degeneration (48%), and direct cataract referral (40%). Most respondents (88%) reported using non-contact/pneumo tonometry for intra-ocular pressure measurement, with 81% using Goldmann or Perkins tonometry. The most widely used item of specialist equipment was the fundus camera (74% of respondents). Optical Coherence Tomography (OCT) was used by 15% of respondents, up from 2% in 2007. Notably, 43% of those anticipating purchasing specialist equipment in the next 12 months planned to buy an OCT. 'Paperless' records were used by 39% of respondents, and almost 80% of practices used an electronic patient record/practice management system. Variations in responses between parts of the UK reflect differences in the provision of the General Ophthalmic Services contract or community enhanced services. There was general agreement that specialised equipment enhances clinical care, permits increased involvement in enhanced services, promotes the practice and can be used as a defence in clinico-legal cases, but initial costs and ongoing maintenance can be a financial burden. Respondents generally agreed that IT facilitates administrative flow and secure exchange of health information, and promotes a state-of-the-art practice image. However, use of IT may not save examination time; its dynamic nature necessitates frequent updates and technical support; the need for adequate training is an issue; and security of data is also a concern.

CONCLUSION

UK optometrists increasingly employ modern equipment and IT services to enhance patient care and for practice management. While the clinical benefits of specialist equipment and IT are appreciated, questions remain as to whether the investment is cost-effective, and how specialist equipment and IT may be used to best advantage in community optometric practice.

Improving patient access to prevent sight loss: ophthalmic electronic referrals and communication (Scotland)

INTRODUCTION

With the number of people with sight loss predicted to double to four million people in the UK by the year 2050, preventable visual loss is a significant public health issue. Sight loss is associated with an increased risk of falls, accidents and depression and evidence suggests that 50% of sight loss can be avoided. Timely diagnosis is central to the prevention of sight loss. Access to care can be a limiting factor in preventable cases. By improving referrals and access to hospital eye services it is possible to treat and minimise the number of patients with preventable sight loss and the impact this has on wider society.

CLINICAL PILOT STUDY

In 2005, NHS Fife took part in a flagship pilot funded by the Scottish government e-health department to evaluate the feasibility, safety, clinical effectiveness, and cost of electronic referral with images of patients directly from community optometrists to Hospital Eye Service (HES). The pilot study showed that electronic referral was feasible, fast, safe, and obviated the need for outpatient appointments in 128 (37%) patients with a high patient satisfaction.

CENTRALISED OPHTHALMIC ELECTRONIC REFERRAL UNIT

The results of the pilot study were presented and in May 2007, the electronic referral system was rolled out regionally in southeast Scotland. Referrals were accepted at a single site with vetting by a trained team and appointments were allocated within 48 hours. Following the implementation of electronic referral, waiting times were reduced from a median of 14 to 4 weeks. Significantly fewer new patients were seen (7462 vs 8714 [p < 0.001]). There were also fewer casualties (1984 vs 2671 [p < 0.001]) and 'did not arrive' (DNA) new patients (503 vs 635 [p < 0.001]).

EYE CARE INTEGRATION PROJECT (SCOTLAND)

In 2010 the Scottish Government Health Department committed £ 6.6 million to community and hospital ophthalmic services forming the Eyecare Integration Project in 2011. The main aim of this project was to create electronic communication between community optometry practices and hospital eye departments. Five electronic forms were specifically designed for cataract, glaucoma, macula, paediatric and general ophthalmic disease. A Virtual Private Network was created which enabled optometrists to connect to the Scottish clinical information gateway system and send referrals to hospital and receive referral status feedback. Numerous hurdles have been encountered and overcome in order to deliver this project.

DISCUSSION

An efficient unique system has been described within the NHS whereby the provision of eye care has been modernised by creating a user-friendly electronic interface between the community and HES. This system ensures patients are vetted into the correct specialist clinic and thus will be less likely to go blind from treatable conditions. Urgent conditions will continue to be prioritised and savings made with efficiencies gained can be re-invested towards better overall patient care.

Ophthalmic digital image transfer: benefits to triage, patient care and resource

PURPOSE

Hospital capacity in the UK is currently significantly challenged due to new treatments, targets and resource limitations. There have been significant improvements in training, equipment and shared care services in community primary care optometry services. Despite this the challenges to ophthalmic service delivery are considerable. One area of potential benefit is the effect on outcome when a clinical image is attached to a referral. We aimed to quantify the effect of attaching digital images to ophthalmic referrals.

METHODS

Retrospective analysis of 358 consecutive optometry referrals to the Hospital Eye Service in Dunfermline, Scotland using electronic referral with digital images. All images were screened by consultant ophthalmologists.

RESULTS

The patients were aged between 9 and 100 years (mean age 63.6 years). Sixty four (18%) referrals were deemed urgent (requiring appointment within 24-60 h), with the majority, 28 (8%) being wet macular degeneration. One hundred and seventy (48%) were deemed routine (appointment within 2-6 weeks), with categories including macular disease, glaucoma, cataract, optic disc and retinal abnormalities. Twenty seven (8%) patients were already attending the hospital eye service, or had been referred previously for the same condition. Categories were mainly glaucoma, diabetic retinopathy and cataract. Ninety-five (25%) were 'e-diagnosed' based on image and referral information (i.e. with no secondary eye care appointment). Diagnosis included glaucoma suspect (22, 6%), macular pathology (12, 3%), abnormal looking discs (9, 2.5%) and cataract (9, 2.5%). The overall 'did not attend' rate for those patients seen in the hospital eye service (254) was <1% (two patients).

CONCLUSIONS

The attachment of digital images improved the quality of referral triaging from optometry to secondary eye care in the hospital eye service. It allowed detection of sight threatening disease early and more appropriate allocation of patients to specific specialist clinics at first visit. They allowed safe and speedy 'e-diagnosis' of a subgroup, saving hospital capacity and minimising patient inconvenience. Indirectly the service also reduced the 'did not attend' rate. With recent improvements in camera and internet technology digital images will have an ever increasing role in secondary eye care as it continues to adapt to meet modern demands.

Delay between symptom onset and clinic attendance following TIA and minor stroke: the BEATS study

BACKGROUND

rapid specialist assessment of patients with transient ischaemic attack (TIA) reduces the risk of recurrent stroke. National guidelines advise that high-risk patients are assessed within 24 h and low-risk patients within 7 days.

AIM

to quantify delay and map pathways taken by patients from symptom onset to specialist assessment.

DESIGN

retrospective cohort study.

SETTING

rapid access TIA clinic.

METHODS

structured interviews with 278 patients newly diagnosed with TIA (222) or minor stroke (56), and examination of medical records.

RESULTS

of the 133 high-risk TIA patients, 11 (8%) attended the clinic within 24 h of symptom onset; of the 89 low-risk TIA patients, 47 (53%) attended within 7 days. Median delay between symptom onset and seeking help from a healthcare professional (HCP) was 4.0 h (IQR 0.5, 41.3). Delay was less if symptoms were correctly interpreted but not reduced by a publicity campaign (FAST) to encourage an urgent response. Most patients (156, 56%) first contacted a general practitioner (GP) and 46 (17%) called an ambulance or attended the emergency department. Over a third (36%) had a second consultation with an HCP before attending the clinic, and this was more likely in those presenting to paramedics, out of hours GP services or optometry. Time to clinic attendance was less if an emergency pathway was used and greater if patients were seen by a second HCP.

CONCLUSIONS

factors contributing to delay include incorrect interpretation of symptoms and failure to invoke emergency services. Delays after presentation could be addressed by direct referral by out of hours services, paramedics and optometrists.

Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign

PURPOSE

Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively.

METHOD

A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction.

RESULTS

Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001).

DISCUSSION

Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

Improving the effectiveness of electronic health record-based referral processes

Electronic health records are increasingly being used to facilitate referral communication in the outpatient setting. However, despite support by technology, referral communication between primary care providers and specialists is often unsatisfactory and is unable to eliminate care delays. This may be in part due to lack of attention to how information and communication technology fits within the social environment of health care. Making electronic referral communication effective requires a multifaceted "socio-technical" approach. Using an 8-dimensional socio-technical model for health information technology as a framework, we describe ten recommendations that represent good clinical practices to design, develop, implement, improve, and monitor electronic referral communication in the outpatient setting. These recommendations were developed on the basis of our previous work, current literature, sound clinical practice, and a systems-based approach to understanding and implementing health information technology solutions. Recommendations are relevant to system designers, practicing clinicians, and other stakeholders considering use of electronic health records to support referral communication.

Action on AMD. Optimising patient management: act now to ensure current and continual delivery of best possible patient care

In recent years, there have been significant advances in the clinical management of patients with wet age-related macular degeneration (wet AMD)—a rapidly progressing and potentially blinding degenerative eye disease. Wet AMD is responsible for more than half of registered severe sight impairment (blindness) in the United Kingdom, and patients who are being treated for wet AMD require frequent and long-term follow-up for treatment to be most effective. The clinical workload associated with the frequent follow-up required is substantial. Furthermore, as more new patients are diagnosed and the population continues to age, the patient population will continue to increase. It is thus vital that clinical services continue to adapt so that they can provide a fast and efficient service for patients with wet AMD. This Action on AMDdocument has been developed by eye health-care professionals and patient representatives, the Action on AMDgroup. It is intended to highlight the urgent and continuing need for change within wet AMD services. This document also serves as a guide for eye health-care professionals, NHS commissioners, and providers to present possible solutions for improving NHS retinal and macular services. Examples of good practice and service development are considered and can be drawn upon to help services meet the recommended quality of care and achieve best possible outcomes.

Teleophthalmology with optical coherence tomography imaging in community optometry. Evaluation of a quality improvement for macular patients

Purpose

To describe a quality improvement for referral of National Health Service patients with macular disorders from a community optometry setting in an urban area.

Methods

Service evaluation of teleophthalmology consultation based on spectral domain optical coherence tomography images acquired by the community optometrist and transmitted to hospital eye services.

Results

Fifty patients with suspected macular conditions were managed via telemedicine consultation over 1 year. Responses were provided by hospital eye service-based ophthalmologists to the community optometrist or patient within the next day in 48 cases (96%) and in 34 (68%) patients on the same day. In the consensus opinion of the optometrist and ophthalmologist, 33 (66%) patients required further “face-to-face” medical examination and were triaged on clinical urgency. Seventeen cases (34%) were managed in the community and are a potential cost improvement. Specialty trainees were supervised in telemedicine consultations.

Conclusion

Innovation and quality improvement were demonstrated in both optometry to ophthalmology referrals and in primary optometric care by use of telemedicine with spectral domain optical coherence tomography images. E-referral of spectral domain optical coherence tomography images assists triage of macular patients and swifter care of urgent cases. Teleophthalmology is also, in the authors’ opinion, a tool to improve interdisciplinary professional working with community optometrists. Implications for progress are discussed.

Quality of optometry referrals to neovascular age-related macular degeneration clinic: a prospective study

OBJECTIVES

To evaluate the quality of referrals to a neovascular age-related macular degeneration clinic from optometrists using the standard Rapid Access Referral Form (RARF) from the Royal College of Ophthalmologists.

DESIGN

A prospective study. Prospective data were gathered from all optometry referrals using the RARF, between the periods of December 2006 to August 2009. These were assessed for accuracy of history, clinical signs and final diagnosis as compared to a macula expert.

SETTING

Highlands NHS Trust.

PARTICIPANTS

All patients referred to the eye department at NHS Highlands Trust using the RARF.

MAIN OUTCOME MEASURES

The symptoms of neovascular age-related macular degeneration correctly identified by optometrists, and the signs of neovascular age-related macular degeneration correctly identified by optometrists.

RESULTS

Fifty-four RARFs were received during this period, there was an overall agreement with symptomatology in 57.4% of cases. Optometrists scored less well in recognizing the clinical signs of neovascular age-related macular degeneration, with the poorest scores for recognizing macular oedema (44.4%) and drusen (51.9%). Twenty (37%) patients referred had neovascular age-related macular degeneration.

CONCLUSIONS

RARFs make up the minority of referrals to the neovascular age-related macular degeneration clinic. Optometrists find it difficult to accurately elicit the signs of macula disease.