Evaluation of a minor eye conditions scheme delivered by community optometrists

An evaluation of optometric advanced skills within a UK tertiary based setting

INTRODUCTION

Hospital-based optometrists are undertaking extended roles across ophthalmology that may require them to perform advanced skills (AS). Moorfields Eye Hospital (MEH) is the largest UK employer of hospital-based optometrists, it was sought to investigate which AS are being performed at this centre and how they align to the four pillars of advanced clinical practice (ACP).

METHODS

An online survey was sent to MEH optometrists in May 2022 that asked about professional status, sub-specialties worked, qualifications, acquisition and validation of AS, research and leadership.

RESULTS

Ninety-six optometrists with mean post-qualification experience was 16.2 years (SD 10.4) responded to the survey. There were 84 AS that covered clinical, leadership and research, with respondents achieving a mean of 11.8 (SD 10.3). Those with independent prescribing (IP) qualifications (n = 52) had a higher number of AS compared to non-IP optometrists (p = 0.03). There were 68 clinical AS across the sub-specialties (23 clinical AS were common in ≥2 sub-specialties), 49 out of 120 clinical AS could be performed by at least 60% of staff. Twenty-six optometrists identified with leadership, 56 had undertaken research/audit, 27 had published within a peer-reviewed journal and half of the time spent in active research was funded.

CONCLUSION

AS are being performed by optometrists within a tertiary eye hospital that supports ACP. IP optometrists had higher self-reported AS but current educational frameworks don't accommodate for some AS. Targeted AS courses with competency-based sign-off may further support high-quality patient care. Further research is required on how advanced care practitioners can support workforce transformation.

The burden of acute eye conditions on different healthcare providers: a retrospective population-based study

BACKGROUND

The demand for acute eyecare exponentially outstrips capacity. The public lacks awareness of community eyecare services.

AIM

To quantify the burden of acute eyecare on different healthcare service providers in a national population through prescribing and medicines provision by GPs, optometrists, and pharmacists, and provision of care by accident and emergency (A&E) services. A secondary aim was to characterise some of the drivers of this burden.

DESIGN AND SETTING

A retrospective data-linkage study set in Wales, UK.

METHOD

Analysis of datasets was undertaken from the Secure Anonymised Information Linkage Databank (GP and A&E), the Eye Health Examination Wales service (optometry), and the Common Ailments Scheme (pharmacy) during 2017-2018.

RESULTS

A total of 173 999 acute eyecare episodes delivered by GPs (168 877 episodes) and A&E services (5122) were identified during the study. This resulted in 65.4 episodes of care per 1000 people per year. GPs prescribed a total of 87 973 653 prescriptions within the general population. Of these, 820 693 were related to acute eyecare, resulting in a prescribing rate of 0.9%. A total of 5122 eye-related and 905 224 general A&E attendances were identified, respectively, resulting in an A&E attendance rate of 0.6%. Optometrists and pharmacists managed 51.8% (116 868) and 0.6% (2635) of all episodes, respectively. Older females and infants of both sexes were more likely to use GP prescribing services, while adolescent and middle-aged males were more likely to visit A&E. GP prescribing burden was driven partially by economic deprivation, access to services, and health score. Season, day of the week, and time of day were predictors of burden in GP and A&E.

CONCLUSION

Acute eyecare continues to place considerable burden on GP and A&E services in Wales, particularly in urban areas with greater economic deprivation and lower overall health. This is likely to increase with a rapidly ageing population. With ongoing pathway development to better utilise optometry and pharmacy, and improved public awareness, there may be scope to change this trajectory.

Impact of an email advice service on filtering and refining ophthalmology referrals in England

PURPOSE

The growing capacity-demand imbalance has necessitated the accelerated digital transformation of eye care services. The role of Oxford Eye Hospital's (OEH) email advice service has become even more relevant in the post-Covid era. We sought to evaluate its impact on referrals to secondary care.

METHODS

The consultant-led OEH email advice service primarily targets primary eye care personnel (optometrists and GPs) requiring clinical advice on patient referral. Emails received between September and November 2020 were analysed for demographic data, contents, characteristics, and outcomes. Thematic analysis was performed. A user feedback survey was conducted.

RESULTS

A total of 828 emails were received over the 3-month study period (mean 9.1/day). They were predominantly from optometrists (77.9%) and general practitioners (16.1%). Of the 81.0% (671) relating to clinical advice, over half (54.8%) included images from a variety of modalities, and following review, over half (55.5%) were deemed suitable for management in the community, while 36.5% were referred directly to appropriate subspecialty clinics. Only 8.1% required urgent assessment in eye casualty. Thematic analysis showed that this service was most useful for retinal lesions, optical coherence tomography abnormalities, and borderline abnormal optic discs. No adverse events were identified. User feedback was very positive.

CONCLUSION

A secure email advice service is a safe and low-maintenance modality that provides direct and efficient two-way communication between primary and secondary eye care professionals. It allows rapid response to clinical queries, referral filtering and refinement, and streamlining of patient referral pathways. Users (predominantly optometrists) were overwhelmingly positive about its usefulness in clinical practice.

Impact of Community Eye Clinics (CEC) on Specialist Eye Clinic Referrals

PURPOSE

Community Eye Clinics (CEC) increase accessibility of specialist ophthalmic services in the community, reducing demand for tertiary eye services. This paper aims to evaluate the impact of CEC on first-visit referrals from Hougang Polyclinic (HOU) to Tan Tock Seng Hospital Ophthalmology Specialist Outpatient Clinic (SOC).

METHODS

A retrospective analysis was performed on first-visit referrals from Hougang Polyclinic (HOU) to Tan Tock Seng Hospital Ophthalmology Specialist Outpatient Clinic (SOC) over a similar 3-months period before and after the introduction of CEC in August 2018 (1 January to 31 March in 2018 and 2019, respectively). Data pertaining to patients' presenting complaints, referral reasons, final diagnoses, follow-up plans, and need for ophthalmic intervention were obtained.

RESULTS

We included 978 patients in our study. There was a 27.5% reduction in the number of first-visit referrals seen at SOC after the establishment of CEC. Patients were more likely to be referred on to sub-specialty eye clinics (10.8% vs. 12.9%, p= p = .304) and receive more ophthalmic interventions (15% vs. 16.3%, p = .066) than prior to CEC.

CONCLUSION

The CEC provides greater accessibility to eye care within the community. Optometrists are upskilled to manage patients with stable eye conditions, whilst eye specialists can provide timely care to the SOC for patients with more severe eye conditions.

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.

Referrals from community optometrists in England and their replies: A mixed methods study

PURPOSE

Community optometrists, through routine eye examinations, identify patients with disease or ocular abnormalities requiring referral to the Hospital Eye Service. In many cases no reply to the referral letter is received, resulting in some patients being re-referred unnecessarily, potentially increasing the number of other patients who lose sight whilst on hospital waiting lists. This study investigated, qualitatively and quantitatively, factors influencing optometric referrals and replies.

METHODS

The three-phase, sequential mixed methods study started with a literature review and qualitative phase, interviewing stakeholders to identify issues for exploration in subsequent phases. The second, quantitative phase, undertook documentary analysis of 349 patient referral records from three optometric practice modalities (domiciliary, independently owned, and corporate chain) in England. A final qualitative phase obtained views from stakeholders to explore unexplained findings from the first two phases.

RESULTS

Phase 1 identified communication, financial, professional and technological issues for further exploration. In Phase 2, the referral rate was 22.2% for domiciliary provider, 2.1% for independent practice and 2.5% for the corporate chain, with the variation most likely explained by patient age and associated ophthalmic disease, illness and disability. The referral reply rate was 5.7% for domiciliary provider, 25.0% for independent practice and 4.9% for the corporate chain. The community optometrist remained unaware of the outcome of their referral in 72.8% of cases. Qualitative analyses indicate the main factors influencing referral reply rates are technology, the General Medical Practitioner, community optometrists' utility to and utility of the National Health Service and patient mobilisation.

CONCLUSIONS

The low referral reply rate creates a break in the feedback loop required to raise the standard of referrals and avoid unnecessary re-referral. Of the factors identified that influence referral reply rates, technology is key in view of the increasing use of online referral platforms. Feedback to the referring optometrist should be embedded in such systems.

A prospective evaluation of the clinical safety and effectiveness of a COVID-19 Urgent Eyecare Service across five areas in England

Purpose

Although urgent primary eye care schemes exist in some areas of England, their current safety is unknown. Accordingly, the aim of the present study was to quantify the clinical safety and effectiveness of a COVID‐19 Urgent Eyecare Service (CUES) across Luton, Bedford, Hull, East Riding of Yorkshire and Harrogate.

Methods

Consenting patients with acute onset eye problems who had accessed the service were contacted to ascertain what the optometrist's recommendation was, whether this worked, if they had to present elsewhere and how satisfied they were with the CUES.

Results

A total of 27% (170/629) and 6.3% (28/445) of patients managed virtually and in person, respectively, did not have their acute eye problem resolved. Regression analysis revealed that patients who attended a face‐to‐face consultation were 4.66 times more likely to be correctly managed [Exp (β) = 5.66], relative to those solely managed virtually. Optometrists' phone consultations failed to detect conditions such as stroke, intracranial hypertension, suspected space occupying lesions, orbital cellulitis, scleritis, corneal ulcer, wet macular degeneration, uveitis with macular oedema and retinal detachment. Of referrals to hospital ophthalmology departments, in total, 19% were false‐positives. Patients, however, were typically very satisfied with the service. Uptake was associated with socioeconomic status.

Conclusion

The present study found that a virtual assessment service providing optometrist tele‐consultations was not effective at resolving patients' acute‐onset eye problems. The range and number of pathologies missed by tele‐consultations suggests that the service model in the present study was detrimental to patient safety. To improve this, optometrists should follow evidence based guidance when attempting to manage patients virtually, or in person. For example, patients presenting with acute‐onset symptoms of flashing lights and/or floaters require an urgent dilated fundus examination. Robust data collection on service safety is required on an ongoing basis.

Analysis of UK eye casualty presentations

CLINICAL RELEVANCE

Optometrists upskilling and participating in enhanced optometric schemes has the potential to improve service accessibility and alleviate pressure on hospital eye services.

BACKGROUND

There is a growing demand for eye care in the UK with rising hospital attendances thought to be due in part to an ageing population and a shift in behaviour to favour emergency secondary care.

METHODS

Records of first-time presentations to the eye casualty department at the County Hospital (Wye Valley NHS Trust), Hereford, UK, over a month were analysed retrospectively and sequentially. The proportion of patients from optometrist referrals with conditions potentially requiring pharmacological intervention, that could have been retained within community optometry by an independent prescriber, was assessed. For general practitioner and self-referrals, the reasons for visit were compared to the Minor Eye Conditions Service criteria for inclusion. Patient conditions reviewed at the hospital following their initial presentation were grouped according to those who could have been discharged to a commissioned optometric service.

RESULTS

The records of 421 patients were organised by the source of referral and condition diagnosed by the hospital practitioner. Thirty-three percent of optometrist referrals could have been managed by an independent prescribing optometrist. Ninety-two percent of patients presenting from general practitioner referrals and 83 percent of self-referrals could have been assessed via the local optometric scheme. Sixty-six percent of patients attending hospital for follow-up could have been seen within the community.

CONCLUSION

The present analysis highlights the value of commissioned local optometric community services to address acute ocular symptoms and the value of an independent prescribing qualification in helping to further alleviate the burden on hospital emergency eye services. The large number of self-referrals suggests that the general public needs to be further educated on services that are available at a community optometry level.

Referrals from community optometrists to the hospital eye service in England

PURPOSE

In the UK, most referrals to the hospital eye service (HES) originate from community optometrists (CO). This audit investigates the quality of referrals, replies, and communication between CO and the HES.

METHODS

Optometric referrals and replies were extracted from three practices in England. If no reply letter was found, the records were searched at each local HES unit, and additional replies or records copied. De-identified referrals, replies and records were audited by a panel against established standards to evaluate whether the referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated.

RESULTS

A total of 459 de-identified referrals were extracted. The RR ranged from 3.6%-8.7%. The proportion of referred patients who were seen in the HES unit was 63%-76%. From the CO perspective, the proportion of referrals for which they received replies ranged from 26%-49%. Adjusting the number of referrals for cases when it would be reasonable to expect an HES reply, RRR becomes 38%-62%. Patients received a copy of the reply in 3%-21% of cases. Referrals were made to the appropriate service in over 95% of cases, were judged necessary in 93%-97% and were accurate in 81%-98% of cases. The referral reply addressed the reason for the referral in 93%-97% and was meaningful in 94%-99% of cases. The most common conditions referred were glaucoma, cataract, anterior segment lesions, and neurological/ocular motor anomalies. The CO/HES dyad (pairing) in the area with the lowest average household income had the highest RR.

CONCLUSIONS

In contrast with the Royal College of Ophthalmologists/College of Optometrists joint statement on sharing patient information, CO referrals often do not elicit a reply to the referring CO. Replies from the HES to COs are important for patient care, benefitting patients and clinicians, and minimising unnecessary HES appointments.

Optometrist referrals to an emergency ophthalmology department: a retrospective review to identify current practise and development of shared care working strategies, in England

BACKGROUND

Direct referrals from optometrists account for up to 10% eye casualty attendances. Despite this, there remains a paucity of literature on optometrist referrals to eye casualty. A better understanding of these referrals could be helpful in the development of shared care emergency pathways. Diagnostic agreement between optometrists and ophthalmologists for emergency referrals can be used to identify areas for development of shared care working strategies in emergency ophthalmology.

METHODS

A retrospective evaluation of 1059 consecutive optometric emergency referrals to Moorfields Eye Hospital was conducted. Referrals were only included when a letter or documentation for the reason for referral was provided. Diagnostic information from the referring optometrist and casualty doctor was summarised for each patient by an investigator (VMT) and recorded on a single spreadsheet. These clinical summaries were compared by a second independent investigator (IJ) and marked as agreeing, disagreeing or uncertain. Each clinical summary was then mapped to a diagnostic category using key word searches which were manually re-checked against the original summaries. Information on the timing of the referral and the outcome at the emergency department visit was also collated. Inter-observer agreement for diagnostic categories was measured using kappa coefficients.

RESULTS

Diagnostic agreement ranged between kappa 0.59 and 0.87. It was best for diagnoses within the red eye category (kappa 0.87). Compliance with College of Optometrists referral guidance ranged between 11 and 100%. More than half of referrals for elevated intra-ocular pressure were discharged at the eye casualty visit. Overall, 54% of patients were managed with advice alone, 39% required treatment following referral and 7% required onward referral from eye casualty.

CONCLUSION

The majority of patients referred by optometrists were managed with advice alone. A collaborative approach at the point referral could be helpful to improve referral efficiency.

Agreement in clinical decision-making between independent prescribing optometrists and consultant ophthalmologists in an emergency eye department

BACKGROUND

The specialty-registration of independent prescribing (IP) was introduced for optometrists in 2008, which extended their roles including into acute ophthalmic services (AOS). The present study is the first since IP's introduction to test concordance between IP optometrists and consultant ophthalmologists for diagnosis and management in AOS.

METHODS

The study ran prospectively for 2 years at Manchester Royal Eye Hospital (MREH). Each participant was individually assessed by an IP optometrist and then by the reference standard of a consultant ophthalmologist; diagnosis and management were recorded on separate, masked proformas. IP optometrists were compared to the reference standard in stages. Cases of disagreement were arbitrated by an independent consultant ophthalmologist. Cases where disagreement persisted after arbitration underwent consensus-review. Agreement was measured with percentages, and where possible kappa (Κ), for: diagnosis, prescribing decision, immediate management (interventions during assessment) and onward management (review, refer or discharge).

RESULTS

A total of 321 participants presented with 423 diagnoses. Agreement between all IP optometrists and the staged reference standard was as follows: 'almost perfect' for diagnosis (Κ = 0.882 ± 0.018), 'substantial' for prescribing decision (Κ = 0.745 ± 0.034) and 'almost perfect' for onward management (0.822 ± 0.032). Percentage-agreement between all IP optometrists and the staged reference standard per diagnosis was 82.0% (CI 78.1-85.4%), and per participant using stepwise weighting was 85.7% (CI 81.4-89.1%).

CONCLUSIONS

Clinical decision-making in MREH's AOS by experienced and appropriately trained IP optometrists is concordant with consultant ophthalmologists. This is the first study to explore and validate IP optometrists' role in the high-risk field of AOS.

Ophthalmic emergencies presenting to the emergency department at the University Hospital of Wales, Cardiff, UK

BACKGROUND

Community-based optometry services are increasingly used as a primary resource for patients with acute eye problems. The Eye Health Examination Wales (EHEW) is an example of one such established scheme. The aim of the project was to show how the aforementioned pathway has affected the presentation of ocular conditions to a general emergency department and the eye casualty department at the same hospital.

METHODS

Clinical data were collected prospectively over a one-month period. The records of 100 consecutive patients with ocular pathology presenting to a general emergency department were analysed. Numbers were also obtained for the number of patients seen under the EHEW scheme by community optometrists for the same period. The notes of patients referred to ophthalmology or back out to the community optometry scheme were followed to monitor for re-attendance in either setting.

RESULTS

Eighty-five per cent of patients were walk-in cases. The most common diagnosis made in the emergency department was 'no abnormality found' in 37 per cent. Eighty per cent of all conditions were discharged from the emergency department. Fifteen per cent of all cases, mainly foreign body-related, were followed up in the emergency eye clinic and 10 per cent were sent to EHEW for follow-up. No cases re-presented to a hospital service at a later date.

CONCLUSION

At least 37 per cent of emergency department cases could have been potentially avoided had the patient presented to the EHEW scheme. The pathway for patients to be sent from the emergency department to an EHEW optometrist does not appear to delay presentation to an ophthalmologist thereafter. Further promotion of the EHEW service is needed to change patient behaviours and reduce avoidable attendance to overstretched emergency departments.

A needs assessment for a minor eye condition service within Leeds, Bradford and Airedale, UK

Background

There are a number of limitations to the present primary eye care system in the UK. Patients with minor eye conditions typically either have to present to their local hospital or GP, or face a charge when visiting eye care professionals (optometrists). Some areas of the UK have commissioned enhanced community services to alleviate this problem; however, many areas have not. The present study is a needs assessment of three areas (Leeds, Airedale and Bradford) without a Minor Eye Conditions Service (MECS), with the aim of determining whether such a service is clinically or economically viable.

Method

A pro forma was developed for optometrists and practice staff to complete when a patient presented whose reason for attending was due to symptoms indicative of a problem that could not be optically corrected. This form captured the reason for visit, whether the patient was seen, the consultation funding, the outcome and where the patient would have presented to if the optometrists could not have seen them. Optometrists were invited to participate via Local Optical Committees. Results were submitted via a Google form or a Microsoft Excel document and were analysed in Microsoft Excel.

Results

Seventy-five percent of patients were managed in optometric practice. Nine and 16% of patients required subsequent referral to their General Practitioner or hospital ophthalmology department, respectively. Should they not have been seen, 34% of patients would have presented to accident and emergency departments and 59% to their general practitioner. 53% of patients paid privately for the optometrist appointment, 28% of patients received a free examination either through use of General Ophthalmic Service sight tests (9%) or optometrist good will (19%) and 19% of patients did not receive a consultation and were redirected to other providers (e.g. pharmacy, accident and emergency or General Practitioner). 88% of patients were satisfied with the level of service. Cost-analyses revealed a theoretical cost saving of £3198 to the NHS across our sample for the study period, indicating cost effectiveness.

Conclusions

This assessment demonstrates that a minor eye condition service in the local areas would be economically and clinically viable and well received by patients.

Is there scope for expanding the optometrist's scope of practice in Singapore? - A survey of optometrists, opticians in Singapore

PURPOSE

In Singapore, optometrists' roles are limited compared to their counterparts elsewhere. The purpose of the survey is to investigate optometrists' current roles, views on extended roles, self-reported primary eye care knowledge, needs for continuing professional education (CPE) and views on suitable modes for CPE.

METHODS

Members of the Optometrist and Optician Board (OOB) were invited via email to take part in an anonymous online survey. The survey questions covered the following areas: current scope of practice, self-rated primary eye care knowledge, confidence in screening, co-managing minor eye conditions, CPE and referral behavior.

RESULTS

A total of 230 optometrists completed the survey (response rate 30%). Their current roles were limited to diagnostic refraction (92%), colour vision assessment (65%), contact lens fitting and dispensing (62%) amongst others. The average self-rated score for primary eye care knowledge was 8.2 ± 1.4; score range 1-10 (1-Very poor, 10-Excellent). Self-rated confidence scores for screening for cataract, diabetic retinopathy, chronic glaucoma and age-related macular degeneration were 2.7 ± 1.5, 3.7 ± 1.9, 4.0 ± 1.9 and 3.8 ± 1.8, respectively. 71% of the optometrists felt that they should undertake regular CPE to improve their primary eye care knowledge. Blended learning (eLearning and traditional face-to-face lectures) (46.1%) was the most preferred mode for CPE delivery.

CONCLUSION

Optometrists in Singapore represent a skilled underutilized primary eye care provider. Though their self-reported primary eye care knowledge is high, their confidence in screening and co-managing chronic eye conditions is low. Enabling them for extended primary eye care role would require further training.

SIGNIFICANCE

Singapore ageing population has led to greater eye care demands. Task-shifting from ophthalmologists to optometrists has been proposed in the literature to handle this growing care demands. At this juncture, this study provides evidence based answers to issues revolving around optometrists' readiness for a role expansion in Singapore.

Clinical safety of a minor eye conditions scheme in England delivered by community optometrists

OBJECTIVE

The aim of this study was to monitor the activity and evaluate the clinical safety of a minor eye conditions scheme (MECS) conducted by accredited community optometrists in Lambeth and Lewisham, London.

METHODS AND ANALYSIS

Optometrists underwent an accredited training programme, including attendance at hospital eye services (HES) clinics. Patients who satisfied certain inclusion criteria were referred to accredited MECS optometrists by their general practitioners (GPs) or could self-refer. Data were extracted from clinical records. A sample of MECS clinical records was graded to assess the quality of the MECS optometrists' clinical management decisions. Referrals to the HES were assessed by the collaborating ophthalmologists and feedback was provided.

RESULTS

A total of 2123 patients (mean age 47 years) were seen over 12 months. Two-thirds of the patients (67.3%) were referred by their GP. The most common reasons for patients needing a MECS assessment were 'red eye' (36.7% of patients), 'painful white eye' (11.1%), 'flashes and floaters' (10.2%); 8.7% of patients had a follow-up appointment. Of the patients seen, 75.1% were retained in the community, 5.7% were referred to their GP and 18.9% were referred to the HES. Of the HES referrals, 49.1% were routine, 22.6% urgent and 28.3% emergency. Of the records reviewed, 94.5% were rated as appropriately managed; 89.2% of the HES referrals were considered appropriate.

CONCLUSION

The findings of this study indicate that optometrists are in a good position to work very safely within the remits of the scheme and to assess risk.

Retrospective economic analysis of the transfer of services from hospitals to the community: an application to an enhanced eye care service

OBJECTIVE

This research aims to evaluate the wider health system effects of the introduction of an intermediate-tier service for eye care.

SETTING

This research employs the Minor Eye Conditions Scheme (MECS), an intermediate-tier eye care service introduced in two London boroughs, Lewisham and Lambeth, in April 2013.

DESIGN

Retrospective difference-in-differences analysis comparing changes over time in service use and costs between April 2011 and October 2014 in two commissioning areas that introduced an intermediate-tier service programme with changes in a neighbouring area that did not introduce the programme.

DATA SOURCES

MECS audit data; unit costs for MECS visits; volumes of first and follow-up outpatient attendances to hospital ophthalmology; the national schedule of reference costs.

MAIN OUTCOME MEASURES

Volumes and costs of patients treated.

RESULTS

In one intervention area (Lewisham), general practitioner (GP) referrals to hospital ophthalmology decreased differentially by 75.2% (95% CI -0.918% to -0.587%) for first attendances, and by 40.3% for follow-ups (95% CI -0.489% to -0.316%). GP referrals to hospital ophthalmology decreased differentially by 30.2% (95% CI -0.468% to -0.137%) for first attendances in the other intervention area (Lambeth). Costs increased by 3.1% in the comparison area between 2011/2012 and 2013/2014. Over the same period, costs increased by less (2.5%) in one intervention area and fell by 13.8% in the other intervention area.

CONCLUSIONS

Intermediate-tier services based in the community could potentially reduce volumes of patients referred to hospitals by GPs and provide replacement services at lower unit costs.