Community refinement of glaucoma referrals

The value of virtual glaucoma clinics: a review

Virtual clinics are being utilised to tackle the growing demand for glaucoma healthcare. We conducted a literature search on 28 February 2023 using MEDLINE (PubMed), EMBASE and Web of Science databases. We searched for studies on virtual glaucoma clinics, published in the English language between 2000 and 2023. Studies suggest that virtual glaucoma clinics are a safe and effective alternative to traditional face-to-face clinics for patients with stable and early-to-moderate glaucoma. Patient satisfaction is high across all clinics surveyed. Satisfaction appears to be linked to good communication, trust and improved waiting times. The majority of healthcare professionals are also content with virtual glaucoma clinics. There are no dedicated cost-benefit analyses for virtual glaucoma clinics in the UK. However, virtual clinics in other specialties have reported significant cost savings.

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.

Burden of Glaucoma in the United Kingdom: A Multicenter Analysis of United Kingdom Glaucoma Services

OBJECTIVE

To determine the spectrum of glaucoma-associated health care resource utilization among outpatients attending National Health Service (NHS) hospital glaucoma clinics and the costs of managing glaucoma in this setting.

DESIGN

Retrospective observational cohort study using electronic medical record data.

SUBJECTS

Patients aged ≥ 18 years attending 5 NHS glaucoma clinics in the United Kingdom (2013‒2018) with ≥ 12 months of continuous electronic medical record data.

METHODS

Deidentified Medisoft Ophthalmology electronic medical record data (January 2013‒December 2018) from 43 742 eligible patients were categorized by year of clinic visit. Extracted information included patient demographics, glaucoma diagnoses, topical glaucoma medication prescription start/stop dates, types/numbers of glaucoma clinic visits, glaucoma investigations (visual acuity, intraocular pressure, visual field, and OCT), and glaucoma procedures received over 12 months after the first ("index") visit of the specified year. Direct glaucoma-related health care costs (clinic visits, investigations, procedures, and ongoing glaucoma medication initiated in the clinic) were estimated from event volumes and unit costs (UK national tariffs) and expressed from the direct-payer perspective.

MAIN OUTCOME MEASURES

Glaucoma diagnoses and topical glaucoma medication use at the index clinic visit; numbers of glaucoma clinic visits, investigations and procedures; and glaucoma-related health care costs over 12 months postindex.

RESULTS

For the 2016 cohort (n = 21 719), the estimated average total cost of NHS-provided glaucoma care over 12 months was £405 per patient (medical staff services £209, glaucoma investigations £126, glaucoma medication £40, glaucoma procedures £26). Among this cohort, 40.8% had ocular hypertension/suspected glaucoma, 70% had 0-to-mild visual field impairment, and 14% had undergone a glaucoma procedure. Over 12 months, patients received (mean) 2.0 glaucoma clinic visits and 1.5 visual field tests, and 7% underwent glaucoma procedure(s). Results were similar for the other years examined.

CONCLUSIONS

Cost estimates for managing patients with glaucoma in the UK are required for effective service planning. Appreciable proportions of patients managed in NHS glaucoma clinics may be considered at low risk of blindness (glaucoma suspects and those with ocular hypertension with mild visual field loss) and may be more appropriately managed with alternative, more affordable models of care.

Evaluation of the prevalence of non-diabetic eye disease detected at first screen from a single region diabetic retinopathy screening program: a cross-sectional cohort study in Auckland, New Zealand

OBJECTIVES

To evaluate the prevalence of incidental non-diabetic ocular comorbidities detected at first screen in a large diabetic retinopathy (DR) screening programme.

DESIGN

Cross-sectional cohort study.

SETTING

Single large metropolitan diabetic eye screening programme in Auckland, New Zealand.

PARTICIPANTS

Twenty-two thousand seven hundred and seventy-one participants who attended screening from September 2008 to August 2018.

RESULTS

Hypertensive retinopathy (HTR) was observed in 14.2% (3236/22 771) participants. Drusen were present in 14.0% participants under the age of 55 years, increasing to 20.5% in those 55 years and older. The prevalence of neovascular age-related macular degeneration (AMD) was 0.5% in participants aged<55 years, 2.4% in participants aged 55-75 years and 16% in participants aged>75 years. Retinal vein occlusion and retinal arterial embolus were prevalent in 0.7% and 0.02%, respectively, in participants aged<55 years, increasing to 2.2% and 0.4%, respectively, in those >75 years. Cataracts were common being present in 37.1% of participants over the age of 75 years. Only 386 individuals (1.7%) were labelled as glaucoma suspects. Geographic atrophy, epiretinal membrane, choroidal nevi and posterior capsular opacification had an increased prevalence in older individuals.

CONCLUSIONS

Our data suggest that AMD, HTR and cataracts are routinely detected during DR screening. The incorporation of the detection of these ocular comorbidities during DR screening provide opportunities for patients to modify risk factors (smoking cessation and diet for AMD, blood pressure for HTR) and allow access to cataract surgery.

Ophthalmic nurse practitioner assessment of glaucoma: evaluating agreement within an initiative to enhance capacity in glaucoma clinics

AIMS

A local service evaluation was conducted in order to compare clinical assessment measures and management decisions between an ophthalmic nurse practitioner and a reference standard glaucoma consultant, for patients referred into secondary care with suspected Chronic Open Angle Glaucoma or Ocular Hypertension.

METHODS

One hundred patients were selected. A clinical pathway incorporating the assessment methods recommended by National Institute for Health and Care Excellence (NICE) Glaucoma update 2017 (NG81) was delivered by a single ophthalmic nurse practitioner and the reference standard glaucoma consultant. Clinical findings and outcomes were recorded, with both practitioners being masked to each other's findings. Agreement was determined employing Cohen's kappa, measuring inter-rater agreement allowing for chance agreement.

RESULTS

Agreement was observed as follows: Visual field assessment (kappa k = 0.806, 95% CI 0.661-0.951); Optical Coherence Tomography evaluation (kappa k = 0.648, 95% CI 0.507-0.798); C:D Ratio assessment (Cronbach's alpha α = 0.96, 95% CI 0.88-0.94); Diagnosis (kappa k = 0.874, 95% CI 0.818-0.914); and Treatment planning (kappa κ = 0.844, 95% CI 0.733-0.955). In three cases the nurse practitioner judged the optic nerve to appear normal, where the reference standard examiner detected glaucoma and commenced treatment.

CONCLUSION

This service evaluation demonstrates how an ophthalmic nurse practitioner with appropriate theoretical knowledge and practical training, can develop skills to reach a high level of agreement in patient assessment and management for those patients with suspected glaucoma. Within the limitations of a single centre and single practitioner evaluation, our findings provide evidence that this model of capacity expansion ought to merit wider consideration in secondary care glaucoma services.

Impact of referral refinement on management of glaucoma suspects in Australia

BACKGROUND

In ageing populations, the prevalence of chronic diseases such as glaucoma is projected to increase, placing additional demands on limited health-care resources. In the UK, the demand for secondary care in hospital eye clinics was inflated by high rates of false positive glaucoma referrals. Collaborative care models incorporating referral refinement, whereby glaucoma suspect referrals are triaged by suitably trained optometrists through further testing, can potentially reduce false positive referrals. This study examined the impact of a referral refinement model on the accuracy of glaucoma referrals in Australia.

METHODS

Optometrist-initiated glaucoma suspect referrals to the Glaucoma Management Clinic (Sydney, Australia) were prospectively recruited. Glaucoma suspect referrals arising from two pathways were eligible for inclusion, either directly from a community optometrist (standard care) or following comprehensive assessment at the Centre for Eye Health (referral refinement). Main outcome measures were the positive predictive value and false positive rate of referrals. The impact of referral letter content on management outcomes was also investigated.

RESULTS

Of 464 referrals received between March 2015 and June 2018, 252 were for treatment of naïve glaucoma suspects and eligible for inclusion. Following ophthalmological assessment, 45.6 per cent (n = 115/252) were prescribed treatment for open angle glaucoma or ocular hypertension. Positive predictive value of community optometry referrals was 33.8 per cent (n = 25/74) and 50.6 per cent (n = 90/178) following referral refinement. The first visit discharge (false positive) rate was 26 per cent (n = 19/74) for community referrals compared to four per cent (n = 8/178) with referral refinement. Positive predictive value increased with the number of abnormal clinical examination findings associated with referral (χ² test, p < 0.0001). The number of abnormal findings reported in referrals was significantly higher with referral refinement compared to without (n = 1.9 versus 1.5, t-test, p < 0.0001).

CONCLUSION

Referral refinement can improve the diagnostic accuracy of optometry-initiated referrals for glaucoma suspects in Australia, thereby decreasing unnecessary referrals to hospital and other secondary clinics.

Care pathways for glaucoma detection and monitoring in the UK

Glaucoma presents considerable challenges in providing clinically and cost-effective care pathways. While UK population screening is not seen as justifiable, arrangements for case finding have historically been considered relatively ineffective. Detection challenges include an undetected disease burden, whether from populations failing to access services or difficulties in delivering effective case-finding strategies, and a high false positive rate from referrals via traditional case finding pathways. The enhanced General Ophthalmic Service (GOS) in Scotland and locally commissioned glaucoma referral filtering services (GRFS) elsewhere have undoubtedly reduced false positive referrals, and there is emerging evidence of effectiveness of these pathways. At the same time, it is recognised that implementing GRFS does not intrinsically reduce the burden of undetected glaucoma and late presentation, and obvious challenges remain. In terms of diagnosis and monitoring, considerable growth in capacity remains essential, and non-medical health care professional (HCP) co-management and virtual clinics continue to be important solutions in offering requisite capacity. National guidelines, commissioning recommendations, and the Common Clinical Competency Framework have clarified requirements for such services, including recommendations on training and accreditation of HCPs. At the same time, the nature of consultant-delivered care and expectations on the glaucoma specialist's role has evolved alongside these developments. Despite progress in recent decades, given projected capacity requirements, further care pathways innovations appear mandated. While the timeline for implementing potential artificial intelligence innovations in streamlining care pathways is far from established, the glaucoma burden presents an expectation that such developments will need to be at the vanguard of future developments.

Impact of the Manchester Glaucoma Enhanced Referral Scheme on NHS costs

Objectives

Glaucoma filtering schemes such as the Manchester Glaucoma Enhanced Referral Scheme (GERS) aim to reduce the number of false positive cases referred to Hospital Eye Services. Such schemes can also have wider system benefits, as they may reduce waiting times for other patients. However, previous studies of the cost consequences and wider system benefits of glaucoma filtering schemes are inconclusive. We investigate the cost consequences of the Manchester GERS.

Design

Observational study.

Methods

A cost analysis from the perspective of the National Health Service (NHS) was conducted using audit data from the Manchester GERS.

Results

2405 patients passed through the Manchester GERS from April 2013 to November 2016. 53.3% were not referred on to Manchester Royal Eye Hospital (MREH). Assuming an average of 2.3 outpatient visits to MREH were avoided for each filtered patient, the scheme saved the NHS approximately £2.76 per patient passing through the scheme.

Conclusion

Our results indicate that glaucoma filtering schemes have the potential to reduce false positive referrals and costs to the NHS.

Two-year outcomes of a pilot glaucoma suspect telemedicine monitoring program

Purpose

The purpose of this study was to characterize a pilot program using e-health to monitor glaucoma suspects in a large integrated health system.

Methods

A retrospective chart review of patients enrolled in the first 2 years of a new glaucoma suspect telemedicine monitoring program was conducted. Patients were enrolled in the program after being diagnosed as glaucoma suspects in the regular clinic setting and were eligible for the program if they had better than 20/40 vision, intraocular pressure (IOP) <25 mmHg, a normal baseline visual field, and an optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) without clear evidence of glaucomatous optic nerve damage. Patients were followed annually thereafter with measurements of vision, IOP, and OCT RNFL, which were reviewed at a centralized telemedicine reading center. Patients were retained within the program unless there was evidence of disease progression, in which case they were referred to an ophthalmologist for further evaluation. The first 100 patients received a survey assessing their satisfaction with the program after their first visit. The number of patients who adhered to follow-up recommendations, who were referred to an ophthalmologist for additional evaluation, and who began on IOP-lowering medications was evaluated.

Results

A total of 225 patients were enrolled in this program. Of eligible patients, 97.3% attended their 1-year follow-up visit and 92.5% attended their 2-year follow-up visit. Over the course of 2 years, five patients were referred for further clinic evaluation due to concern for progressive RNFL loss, of which two were started on IOP-lowering medications. No patients were referred to the clinic for vision loss or elevated IOP. In all, 87% of patients said that they would be extremely or quite likely to recommend the program to a friend. More than 80% of patients said that the program was extremely or very helpful, convenient, and professional.

Conclusion

This novel telemedicine program for monitoring low-risk glaucoma suspects achieved high patient retention. Significant disease progression was rare with a few patients requiring referrals back to the clinic setting or initiation of IOP-lowering therapy. Telemedicine is a promising method to follow patients who are glaucoma suspects.

Clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme

Background

Glaucoma referral filtering schemes have operated in the UK for many years. However, there is a paucity of data on the false-negative (FN) rate. This study evaluated the clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme (GERS), estimating both the false-positive (FP) and FN rates.

Method

Outcome data were collected for patients newly referred through GERS and assessed in ‘usual-care’ clinics to determine the FP rate (referred patients subsequently discharged at their first visit). For the FN rate, glaucoma suspects deemed not requiring referral following GERS assessment were invited to attend for a ‘reference standard’ examination including all elements of assessment recommended by National Institute for Health and Care Excellence (NICE) by a glaucoma specialist optometrist. A separate 33 cases comprising randomly selected referred and non-referred cases were reviewed independently by two glaucoma specialist consultant ophthalmologists to validate the reference standard assessment.

Results

1404 patients were evaluated in GERS during the study period; 651 (46.3%) were referred to the Hospital Eye Service (HES) and 753 (53.6%) were discharged. The FP rate in 307 assessable patients referred to the HES was 15.5%. This study reviewed 131 (17.4%) of those patients not referred to the HES through the GERS scheme; 117 (89.3%) were confirmed as not requiring hospital follow-up; 14 (10.7%) required follow-up, including 5 (3.8%) offered treatment. Only one patient (0.8%) in this sample met the GERS referral criteria and was not referred (true FN). There were no cases of missed glaucoma or non-glaucomatous pathology identified within our sample.

Conclusion

The Manchester GERS is an effective glaucoma filtering scheme with a low FP and FN rate.

Difference in intraocular pressure measurements between non-contact tonometry and Goldmann applanation tonometry and the role of central corneal thickness in affecting glaucoma referrals

BACKGROUND

Patients at glaucoma risk are commonly identified by optometrists and subsequently referred to glaucoma specialists. Optometrists mainly use non-contact tonometry (NCT) for intraocular pressure (IOP) measurement.

AIMS

To investigate the role of differences in IOP measurement between NCT and Goldmann applanation tonometry (GAT) and the effect of central corneal thickness (CCT) on these differences in optometrist referrals METHODS: Details of the initial clinical visit of patients referred with IOP > 21 mmHg in either eye as measured by NCT to a consultant glaucoma specialist were retrospectively reviewed. Demographic and referral data, IOP, CCT, and glaucoma diagnosis were obtained. The main outcome measure was the IOP measurement differences between NCT and GAT.

RESULTS

Of the 98 patients referred, only 23% had IOP > 21 mmHg when measured by GAT. NCT (Nidek NT400, Reichert Puff, Pulsair Easy Eye) measured the IOP greater than GAT by a mean of 5.8 mmHg (NCT 24.1 ± 3.5, GAT 18.3 ± 3.0). The effect of CCT on IOP measurement was less for GAT (R² 0.034, p = 0.067) than for NCT (R² 0.088, p = 0.003). The NCT/GAT IOP differences increased with increasing CCT (R² 0.166, p < 0.0001). The NCT/GAT differences decreased with patient age (R² 0.048, p = 0.03). Patients were classified as normal 67% (66/98), ocular hypertension 11% (11/98), glaucoma suspect 14% (14/98), and glaucoma 7% (7/98).

CONCLUSIONS

The difference in IOP measurement between NCT and GAT leads to a possible increase in glaucoma referrals, particularly in patients with thicker corneas. Repeat IOP using GAT and CCT measurement would help in triaging referrals.

Glaucoma referral refinement in Ireland: managing the sensitivity-specificity paradox in optometric practice

PURPOSE

Glaucoma referral refinement (GRR) has proven a successful demand management strategy for glaucoma suspect cases in the United Kingdom (UK). A GRR clinic was established in Dublin, Ireland to investigate the clinical viability of this pathway outside the UK's National Health Service (NHS) structures, and away from the influence of National Institute for Clinical Excellence (NICE) guidance.

METHODS

Glaucoma suspect patients were recruited into the scheme following referral from community optometrists in the greater Dublin area. The GRR exam protocol was designed in consultation with the participating ophthalmology department. The refinement scheme optometrist, trained through apprenticeship style experience at a hospital outpatient clinic, made a tentative management decision after carrying out the GRR exam. The final management decision was made in a 'virtual clinic' by a glaucoma specialist consultant ophthalmologist.

RESULTS

Two hundred and twenty-five glaucoma suspect patients were seen in the scheme. After their first GRR visit, 28% were discharged back to their own optometrist, 42% were monitored in the GRR clinic, and 30% were referred to ophthalmology. After this monitoring cohort were further assessed, a total of 38% of the patients seen within the scheme required referral to ophthalmology. Sixteen percent of the total participant group (n = 225) were lost to follow up. Cohen's κ was used to determine the level of agreement between the scheme optometrist and ophthalmologist. There was substantial agreement, with κ = 0.63 for the first visit management decisions (n = 225). Agreement increased for subsequent monitoring visits with κ = 0.85 for second visits (n = 65), and κ = 0.69 for all management decisions within the scheme (n = 301). We received management outcomes for 44 of the 86 patients referred to ophthalmology. Of these 44, 57% received medical treatment for glaucoma, 34% were monitored without treatment, 2% were discharged, and 7% had comorbidities that were assessed and managed.

CONCLUSION

Of the patients seen within the scheme, 62% did not require referral onward to ophthalmology, thus releasing the significant majority of hospital clinic slots that would previously have been required to examine such patients. The high level of inter-professional decision agreement likely reflects the benefits of pre-scheme apprenticeship style training and ongoing hospital clinic participation by the scheme optometrist. The rate of loss to follow up compares favourably with ophthalmology led, hospital based, glaucoma clinics. Nevertheless, the losses indicate that patient education remains a key priority for future planning.

A systematic review of teleophthalmological studies in Europe

A systematic review of the recent literature regarding a series of ocular diseases involved in European telemedicine projects was performed based on the PubMed, Google Scholar and Springer databases in June 2017. Literature review returned 44 eligible studies; among them, emergency ophthalmology, diabetic retinopathy, glaucoma, age-related macular disease, cataract and retinopathy of prematurity. The majority of studies indicate teleophthalmology as a valid, reliable and cost-efficient method for care-provision in ophthalmology patients which delivers comparable outcomes to the traditional examination methods.

Effectiveness of UK optometric enhanced eye care services: a realist review of the literature

PURPOSE

UK demographic and legislative changes combined with increasing burdens on National Health Service manpower and budgets have led to extended roles for community optometrists providing locally-commissioned enhanced optometric services (EOS). This realist review's objectives were to develop programme theories that implicitly or explicitly explain quality outcomes for eye care provided by optometrists via EOS and to test these theories by investigating the effectiveness of services for cataract, glaucoma, and primary eye care.

METHODS

The review protocol was published on PROSPERO, and RAMESES publication standards were followed. Programme theories were formulated via scoping literature searches and expert consultation. The searching process involved all relevant electronic databases and grey literature, without restrictions on study design. Data synthesis focussed on questioning the integrity of each theory by considering supportive and refuting evidence from the source literature.

RESULTS

Good evidence exists for cataract, glaucoma and primary eye care EOS that: with appropriate training, accredited optometrists manage patients commensurate with usual care standards; genuine partnerships can exist between community and hospital providers for cataract and glaucoma EOS; patient satisfaction with all three types of service is high; cost-effectiveness of services is unproven for cataract and primary eye care, while glaucoma EOS cost-effectiveness depends on service type; contextual factors may influence service success.

CONCLUSIONS

The EOS reviewed are clinically effective and provide patient satisfaction but limited data is available on cost-effectiveness.

A technician-delivered 'virtual clinic' for triaging low-risk glaucoma referrals

PurposeThe purpose of this study is to describe the outcomes of a technician-delivered glaucoma referral triaging service with 'virtual review' of resultant data by a consultant ophthalmologist.Patients and methodsThe Glaucoma Screening Clinic reviewed new optometrist or GP-initiated glaucoma suspect referrals into a specialist ophthalmic hospital. Patients underwent testing by three ophthalmic technicians in a dedicated clinical facility. Data were reviewed at a different time and date by a consultant glaucoma ophthalmologist. Approximately 10% of discharged patients were reviewed in a face-to-face consultant-led clinic to examine the false-negative rate of the service.ResultsBetween 1 March 2014 and 31 March 2016, 1380 patients were seen in the clinic. The number of patients discharged following consultant virtual review was 855 (62%). The positive predictive value of onward referrals was 84%. Three of the 82 patients brought back for face-to-face review were deemed to require treatment, equating to negative predictive value of 96%.ConclusionsOur technician-delivered glaucoma referral triaging clinic incorporates consultant 'virtual review' to provide a service model that significantly reduces the number of onward referrals into the glaucoma outpatient department. This model may be an alternative to departments where there are difficulties in implementing optometrist-led community-based referral refinement schemes.

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.

Clinical model assisting with the collaborative care of glaucoma patients and suspects

BACKGROUND

Optimizing patient management will reduce unnecessary vision loss in glaucoma through early detection. One method is the introduction of collaborative care schemes between optometrists and ophthalmologists.

DESIGN

We conducted a retrospective study to evaluate the impact of the Centre for Eye Health (CFEH) on glaucoma patient outcomes and management in primary optometric care.

PARTICIPANTS

Patients referred to CFEH by optometrists for a glaucoma assessment were eligible for this study if written consent was provided (500 participants were randomly chosen).

METHODS

Clinical data were classified according to disease risk and implemented patient care and analysed against the original diagnosis and patient parameters, followed by statistical analysis.

MAIN OUTCOME MEASURES

Two main parameters were evaluated; suitable referral of patients for glaucoma condition assessment and appropriate implementation of follow-up care.

RESULTS

The majority of patients referred for glaucoma assessment (86.2%) were classified as glaucoma suspects or likely to have glaucoma, indicating suitable referral of patients for a CFEH evaluation. Further, the involvement of CFEH resulted in a false positive rate of 7.8% for those patients who proceeded to ophthalmological care. However, long-term optometric patient care was not maintained for up to a third of primarily lower risk patients.

CONCLUSIONS

The investigated collaborative eye health-care model led to a substantial improvement in appropriate referrals of glaucoma patients to ophthalmologists and could be suitable for optimizing patient care and utilization of resources. Improvement in follow-up of patients by optometrists is required to minimize inappropriately discontinued patient care.

Levels of state and trait anxiety in patients referred to ophthalmology by primary care clinicians: a cross sectional study

Purpose

There is a high level of over-referral from primary eye care leading to significant numbers of people without ocular pathology (false positives) being referred to secondary eye care. The present study used a psychometric instrument to determine whether there is a psychological burden on patients due to referral to secondary eye care, and used Rasch analysis to convert the data from an ordinal to an interval scale.

Design

Cross sectional study.

Participants and Controls

322 participants and 80 control participants.

Methods

State (i.e. current) and trait (i.e. propensity to) anxiety were measured in a group of patients referred to a hospital eye department in the UK and in a control group who have had a sight test but were not referred. Response category analysis plus infit and outfit Rasch statistics and person separation indices were used to determine the usefulness of individual items and the response categories. Principal components analysis was used to determine dimensionality.

Main Outcome Measure

Levels of state and trait anxiety measured using the State-Trait Anxiety Inventory.

Results

State anxiety scores were significantly higher in the patients referred to secondary eye care than the controls (p<0.04), but similar for trait anxiety (p>0.1). Rasch analysis highlighted that the questionnaire results needed to be split into “anxiety-absent” and “anxiety-present” items for both state and trait anxiety, but both subscales showed the same profile of results between patients and controls.

Conclusions

State anxiety was shown to be higher in patients referred to secondary eye care than the controls, and at similar levels to people with moderate to high perceived susceptibility to breast cancer. This suggests that referral from primary to secondary eye care can result in a significant psychological burden on some patients.

The effectiveness of schemes that refine referrals between primary and secondary care--the UK experience with glaucoma referrals: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project

OBJECTIVES

A comparison of glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and guidance.

DESIGN

Retrospective multisite review.

SETTING

The outcomes of clinical examinations by optometrists with a specialist interest in glaucoma (OSIs) were compared with optometrists with no specialist interest in glaucoma (non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, while Manchester and Gloucestershire reviewed OSI findings.

PARTICIPANTS

1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 from Gloucestershire and 269 from Nottingham.

RESULTS

The first-visit discharge rate (FVDR) for all time periods for OSIs was 14.1% compared with 36.1% from non-OSIs (difference 22%, CI 16.9% to 26.7%; p<0.001). The FVDR increased after the April 2009 National Institute for Health and Clinical Excellence (NICE) glaucoma guidelines compared with pre-NICE, which was particularly evident when pre-NICE was compared with the current practice time period (OSIs 6.2-17.2%, difference 11%, CI -24.7% to 4.3%; p=0.18, non-OSIs 29.2-43.9%, difference 14.7%, CI -27.8% to -0.30%; p=0.03). Elevated intraocular pressure (IOP) was the commonest reason for referral for OSIs and non-OSIs, 28.7% and 36.1%, respectively, of total referrals. The proportion of referrals for elevated IOP increased from 10.9% pre-NICE to 28.0% post-NICE for OSIs, and from 19% to 45.1% for non-OSIs.

CONCLUSIONS

In terms of 'demand management', OSIs can reduce FVDR of patients reviewed in secondary care; however, in terms of 'patient safety' this study also shows that overemphasis on IOP as a criterion for referral is having an adverse effect on both the non-OSIs and indeed the OSIs ability to detect glaucomatous optic nerve features. It is recommended that referral letters from non-OSIs be stratified for risk, directing high-risk patients straight to secondary care, and low-risk patients to OSIs.

Patterns of adherence to NICE glaucoma guidance in two different service delivery models

PURPOSE

To assess adherence patterns to the UK National Institute of Health and Clinical Excellence (NICE) guidelines on glaucoma management (2009) in a tertiary referral centre shared care setting and in a district general hospital (DGH) setting.

METHOD

We performed a retrospective case note analysis of 200 patients from two centres between January and June 2010. The two centres involved were a consultant-guided teaching hospital optometry-led shared care setting (setting 1) and a consultant-led DGH clinic setting (setting 2). The main outcome measures were compliance with eight of the main NICE guidelines on glaucoma diagnosis and management (2009).

RESULTS

Both centres showed good adherence to the guidelines regarding the choice of initial treatment (96% vs 100%, settings 1 and 2, respectively) and arranging appropriate monitoring intervals (92% vs 86%). However, significant differences were seen when assessing whether an optic disc image was obtained at the initial visit (74% vs 10%), whether an appropriate initial assessment was performed (96% vs 58%), whether patients' review interval complied with the NICE guidance regardless of hospital cancellations (92% vs 66%), and whether concordance with medication was checked (88% vs 24%) (settings 1 and 2, respectively, P<0.01-Fisher's exact test).

CONCLUSION

Our study provides evidence to suggest that a hospital-based shared care service with trained optometrists using assessment sheets compares favourably to non-specialist glaucoma care delivered by ophthalmologists.

The Portsmouth-based glaucoma refinement scheme: a role for virtual clinics in the future?

BACKGROUND

Glaucoma referrals continue to impart a significant burden on Hospital Eye Services (HES), with a large proportion of these false positives.

AIMS

To evaluate the Portsmouth glaucoma scheme, utilising virtual clinics, digital technology, and community optometrists to streamline glaucoma referrals.

METHOD

The stages of the patient trail were mapped and, at each step of the process, 100 consecutive patient decisions were identified. The diagnostic outcomes of 50 consecutive patients referred from the refinement scheme to the HES were identified.

RESULTS

A total of 76% of 'glaucoma' referrals were suitable for the refinement scheme. Overall, 94% of disc images were gradeable in the virtual clinic. In all, 11% of patients 'attending' the virtual clinic were accepted into HES, with 89% being discharged for community follow-up. Of referrals accepted into HES, the positive predictive value (glaucoma/ocular hypertension/suspect) was 0.78 vs 0.37 in the predating 'unrefined' scheme (95% CI 0.65-0.87). The scheme has released 1400 clinic slots/year for HES, and has produced a £244 200/year cost saving for Portsmouth Hospitals' Trust.

CONCLUSION

The refinement scheme is streamlining referrals and increasing the positive predictive rate in the diagnosis of glaucoma, glaucoma suspect or ocular hypertension. This consultant-led practice-based commissioning scheme, if adopted widely, is likely to incur a significant cost saving while maintaining high quality of care within the NHS.

Glaucoma screening during regular optician visits: the feasibility and specificity of screening in real life

PURPOSE

To determine the feasibility and specificity of glaucoma screening during regular optician visits.

METHODS

In four optician shops, glaucoma screening was offered to 400 consecutive visitors aged 45 years or above. If the visitor agreed to participate, an intraocular pressure measurement and - in those with a pressure below 25 mmHg - a frequency-doubling perimeter (FDT) C20-1 visual field screening test were performed. Those with an elevated pressure or at least one reproducibly abnormal test location on FDT were referred to our hospital.

RESULTS

Three-hundred and fifty-two of 400 consecutive visitors (88%) were screened. Fifteen of the unscreened visitors were not screened because they were already regularly checked by an ophthalmologist related to glaucoma. Forty-two of 352 screened participants (12%) were referred. Of these 42 referrals, seven were diagnosed with glaucoma, 10 were diagnosed with ocular hypertension (OHT), 12 did not have any eye disease, seven had an eye disease other than glaucoma or OHT that was diagnosed previously and six were newly diagnosed with an eye disease other than glaucoma or OHT. The specificity of the screening protocol was 91% (95% confidence interval 88-94%).

CONCLUSIONS

Glaucoma screening at the optician shop was feasible, but the specificity of the screening protocol was rather low. With more stringent cut-off points (30 mmHg; at least two reproducibly abnormal test locations), the specificity could be improved to 96% (94-98%), apparently without a significant loss of sensitivity. This suggests that screening during regular optician visits might be a viable approach.

Evaluation of the effectiveness of ophthalmic assistants as screeners for glaucoma in North India

AIM

To assess whether ophthalmic assistants are effective in screening people for glaucoma in India.

METHODOLOGY

The study subjects were examined by both trained ophthalmic assistants and an ophthalmologist in both hospital and community settings. Specific tests for the diagnosis of glaucoma suspects included visual field examination using frequency doubling technology perimetry, intraocular pressure measurement (Tonopen), A-scan central anterior chamber depth measurement and dilated optic disc examination. The findings recorded by the ophthalmic assistants were masked to the ophthalmologist to avoid measurement bias.

RESULTS

In the hospital setting, there was a substantial level of agreement between the ophthalmic assistants and the ophthalmologist in the diagnosis of glaucoma suspects (89.29%, k=0.7, 95% confidence interval (CI)=0.54-0.86). The diagnostic accuracy of the ophthalmic assistants in detecting glaucoma suspects was high for sensitivity (95.2%, 95% CI=91.4-97.7%) but lower for specificity at 71.4% (95% CI=60.0-78.7%).In the community setting, there was a moderate level of agreement between the ophthalmic assistants and the ophthalmologist in the diagnosis of glaucoma suspects (78.23%, k=0.50, 95% CI=0.37-0.64). The diagnostic accuracy of the ophthalmic assistants in detecting glaucoma suspects was moderate for sensitivity (82.9, 95% CI=69.7-91.5%) but lower for specificity at 76.8% (95% CI=72.7-79.5%).

CONCLUSION

Ophthalmic assistants can be used for opportunistic case detection of glaucoma suspects in the community. Structured training of the ophthalmic assistants together with enhanced clinical experience would improve their performance in detecting glaucoma suspects in the community.

Assessment of referrals to the hospital eye service by optometrists and GPs in Bradford and Airedale

PURPOSE

To investigate the content of referrals to a hospital eye department and describe differences between referring clinician (optometrist or GP) and referral formats.

METHODS

A random sample of 433 new referrals to Bradford Royal Infirmary hospital eye service (HES) during 2007 and 2008 were retrospectively analysed.

RESULTS

Three hundred and eleven referrals (72%) were from optometric practice and 122 (28%) from general practice. Optometric referrals were mainly for cataract and posterior capsular opacification (27%), glaucoma or suspect glaucoma (20%) and diabetic retinopathy (10%).

CONCLUSIONS

The proportion of referrals to the hospital eye service from optometrists appears to be increasing (1988: 39%, 1999: 48%, present study 72%). GPs mainly refer patients with anterior segment disorders, particularly lid lesions, based on direct observation and symptoms. Optometrists refer patients with a wide range of ocular diseases and include fundus observations and visual acuity measurements in their referrals. There is a need to inform optometrists of what content is required in a referral to the HES from GOS sight tests, at least for the common referral conditions such as age-related cataract and suspect open-angle glaucoma. Referral forms specifically designed for these commonly referred conditions are likely to improve referral quality.

The Carmarthenshire Glaucoma Referral Refinement Scheme, a safe and efficient screening service

AIM

It has been previously shown that community refinement of glaucoma referrals is an efficient way to investigate and treat glaucoma suspects. The potential for false negatives has not been explored previously and we describe a scheme in which effort has been made to both assess and control for this, and report on its success.

METHODS

Trained optometrists were recruited to examine and investigate the patients referred with suspected glaucoma, with a view to decreasing false-positive rates in accordance with an agreed protocol. The randomly selected notes of 100 patients referred onward to the Hospital Eye Service (HES) by trained, accredited optometrists, and the notes and optic disc images of 100 randomly selected patients retained in the community were examined in order to determine the efficiency and safety of the scheme.

RESULTS

The scheme resulted in a 53% reduction in the total number of referrals to HES with a cost saving of £117 per patient. Analysis of patients referred resulted in a diagnosis of glaucoma or retention of patients in HES with suspected glaucoma in 83% and a good correlation between the hospital and optometric measurements. Analysis of notes and optic nerve images of patients not referred indicated no compromise on patient safety.

CONCLUSION

This study suggests that suspected glaucoma can be successfully refined in the community with benefits to both the patient and the hospital. We also suggest that such a scheme may be safe as well as cost-effective, a conclusion that has not as yet been reached by any other study.

The Peterborough scheme for community specialist optometrists in glaucoma: a feasibility study

PURPOSE

This study assessed the role of specialist optometrists who were working in the community and sharing the care for glaucoma patients with, and under close supervision of, a consultant ophthalmologist working in the Hospital Eye Services (HES) to ensure high-quality standards, safety, and care.

METHODS

From February 2005 onwards, the majority of all new glaucoma referrals to our eye department were diverted to our specialist optometrists in glaucoma (SOGs) in their own community practices. Selected patients in the HES setting who were already diagnosed with stable glaucoma were also transferred to the SOGs. The completed clinical finding details of the SOGs, including fundus photographs and Humphrey visual field tests, were scrutinised by the project lead.

RESULTS

This study included 1184 new patients seen by specialist optometrists between February 2005 and March 2007. A total of 32% of patients were referred on to the hospital, leaving the remaining 68% patients to be seen for at least their next consultation in the community by the SOGs. The following levels of disagreement were observed between SOGs and the project lead: on cup:disc ratio (11%), visual field interpretation (7%), diagnosis (12%), treatment plan (10%), and outcome (follow-up interval and location) (17%).

CONCLUSION

This study indicates that there is potential for a significant increase in the role of primary care optometry in glaucoma management. The study also confirms a need for a significant element of supervision and advice from a glaucoma specialist. The important issue of cost effectiveness is yet to be confirmed.

Can a community optometrist-based referral refinement scheme reduce false-positive glaucoma hospital referrals without compromising quality of care? The community and hospital allied network glaucoma evaluation scheme (CHANGES)

BACKGROUND/AIMS

To describe the design, activity, and quality of the referral refinement phase of a novel glaucoma shared-care scheme.

METHODS

Eight Optometrists with a Specialist Interest in glaucoma (OSI) were trained to perform a community-based comprehensive glaucoma evaluation of low-risk glaucoma hospital referrals (only one/none of the following factors noted for either eye: abnormal optic disc, abnormal visual field, abnormal intraocular pressure (IOP; 22-28 mmHg or IOP asymmetry)) using equipment standardized to that of the hospital glaucoma service.

RESULTS

One hundred and thirty-eight (27%) of a total of 512 glaucoma-related referrals were deemed 'low risk'. Their choice of OSI discharged 40 (35%). The consultant agreed (virtually) with the decision to discharge with 28 (70%) and disagreed with 12 (30%). Comparing findings between OSI and consultant for 99 referred patients, sensitivity, specificity, and negative predictive values for a suspicious optic disc were 78, 61, and 79%, respectively. For an IOP of >21 mmHg, they were 74, 85, and 90%, respectively. For an occludable anterior chamber angle (Van Herick's versus gonioscopy), they were 69, 88, and 94%, respectively.

CONCLUSION

This referral refinement process can reduce numbers of false-positive referrals attending the hospital glaucoma service while retaining a relatively high level of examination quality.

Patient profile and management in advanced glaucoma

Purpose: to study patient characteristics and management profile in advanced glaucoma. Method: A retrospective study of 87 case notes of patients registered blind due to glaucoma, and cross-sectional interview of 29 patients. Results: advanced glaucoma at presentation was documented in 43 cases (49%). Insufficient optometry assessment was significantly associated with advanced disease (p = 0.0339). Normal tension glaucoma patients were significantly more likely to present with advanced disease compared to other types of glaucoma (p = 0.0034). Poor compliance with medication was significantly higher in those with hearing loss (p = 0.0168). Patients with advanced field defect at presentation and those with poor compliance had significantly higher social deprivation scores compared to others on the blind register (p < 0.0001). Nine (10%) patients had partial registration before full registration and 29 (33%) patients had late registration. Of the 29 patients interviewed, 20 (69%) did not demonstrate basic knowledge regarding their disease or its management; nor had they received written information on glaucoma or instructions on drop technique. Conclusion: Special care pathways are required in advanced glaucoma taking into account co-existent morbidity, disease education and compliance.

The accuracy of accredited glaucoma optometrists in the diagnosis and treatment recommendation for glaucoma

AIM

To compare the diagnostic performance of accredited glaucoma optometrists (AGO) for both the diagnosis of glaucoma and the decision to treat with that of routine hospital eye care, against a reference standard of expert opinion (a consultant ophthalmologist with a special interest in glaucoma).

METHODS

A directly comparative, masked, performance study was undertaken in Grampian, Scotland. Of 165 people invited to participate, 100 (61%) were examined. People suspected of having glaucoma underwent, within one month, a full ophthalmic assessment in both a newly established community optometry led glaucoma management scheme and a consultant led hospital eye service.

RESULTS

Agreement between the AGO and the consultant ophthalmologist in diagnosing glaucoma was substantial (89%; kappa = 0.703, SE = 0.083). Agreement over the need for treatment was also substantial (88%; kappa = 0.716, SE = 0.076). The agreement between the trainee ophthalmologists and the consultant ophthalmologist in the diagnosis of glaucoma and treatment recommendation was moderate (83%, kappa = 0.541, SE = 0.098, SE = 0.98; and 81%, kappa = 0.553, SE = 0.90, respectively). The diagnostic accuracy of the optometrists in detecting glaucoma in this population was high for specificity (0.93 (95% confidence interval, 0.85 to 0.97)) but lower for sensitivity (0.76 (0.57 to 0.89)). Performance was similar when accuracy was assessed for treatment recommendation (sensitivity 0.73 (0.57 to 0.85); specificity 0.96 (0.88 to 0.99)). The differences in sensitivity and specificity between AGO and junior ophthalmologist were not statistically significant.

CONCLUSIONS

Community optometrists trained in glaucoma provided satisfactory decisions regarding diagnosis and initiation of treatment for glaucoma. With such additional training in glaucoma, optometrists are at least as accurate as junior ophthalmologists but some cases of glaucoma are missed.

An analysis of patients discharged from a hospital-based glaucoma case-finding clinic over a 3-year period

PURPOSE

To analyse the false positive referrals by community optometrists to a glaucoma case-finding clinic over a 3-year period.

METHODS

A retrospective study was undertaken of the 531 patients who were referred by community optometrists and discharged after their first visit to the glaucoma case-finding clinic at the Oxford Eye Hospital between 2003 and 2005. The number of patients who were referred on the basis of one, two or three abnormal parameters was determined. The specific reason why the presumed abnormal parameter was considered normal by a glaucoma specialist was determined from the patients' records.

RESULTS

The referral was based on only one presumed abnormal parameter in 65.5-74.3% of patients (minimum-maximum percentage per year, 2003-2005). Physiological cupping was present in 21.5-29.5%, asymmetrical cupping because of asymmetrical disc size in 6.4-8.2% and asymmetrical cupping in the presence of similar disc size in 1.9-5.1%. An intraocular pressure (IOP) within the normal range was measured in 17.6-20.8% and an IOP between 22 and 25 mmHg in association with a central corneal thickness of >588 microm was found in a further 11.5-15.4%. In 11.5-16.1% of patients who were referred because of an abnormal visual field, no field defect was found when the test was repeated. A cause other than glaucoma was responsible for an abnormal visual field defect in 1.2-6%.

CONCLUSION

This study identifies the factors responsible for false positive referrals to a hospital-based glaucoma case-finding clinic. By considering these factors and by combining test data, the number of unnecessary referrals could be reduced in the future.

Agreement between optometrists and ophthalmologists on clinical management decisions for patients with glaucoma

BACKGROUND/AIMS

Although optometrists have become an accepted part of the team in many hospital glaucoma clinics, their decision making ability has not been assessed formally. This study aims to document the accuracy and safety of clinical work undertaken by optometrists in the hospital setting by investigating their management decisions on follow up of patients with glaucoma.

METHODS

Four optometrists and three medical clinicians examined 50 patients each. Clinical findings were recorded as usual in the hospital records but management decisions were documented separately on a specially designed data collection form. Subsequently, the patient records and clinical findings were reviewed retrospectively and independently by two consultant ophthalmologists, who were masked to the management decisions of the optometrists and medical clinicians. The consultants' management decisions were then compared with those made by the optometrists and medical clinicians. Percentage agreements were computed together with kappa (kappa), or weighted kappa, statistics where appropriate.

RESULTS

Agreement between consultants and optometrists was 55% (kappa = 0.33) for evaluation of visual field status, 79% (kappa = 0.67) for medical management, 72-98% for other aspects of patient management, and 78% (weighted kappa = 0.35) for scheduling of next clinic appointment. Very similar levels of agreement were found between consultants and medical clinicians.

CONCLUSION

Agreement between optometrists and consultants, in glaucoma clinical decision making, was at least as good as that between medical clinicians and consultants. Within an appropriate environment, optometrists can safely work as part of the hospital glaucoma team in outpatient clinics.