A nurse-led ocular oncology clinic in Liverpool: results of a 6-month trial

Integrating Nurse-Led Interventions in Ophthalmology Care: A Systematic Review

BACKGROUND

Nurse-led interventions in ophthalmology care can enhance the overall patient experience while optimizing health care system efficiency.

PURPOSE

The purpose of this study was to investigate the impact of nurse-led interventions in ophthalmology care.

METHODS

A comprehensive search was conducted across multiple databases for articles published from 2000 to 2023. Randomized controlled trials, quasi-experimental, and observational studies were included. Quality assessments were performed using the Cochrane Risk of Bias tool or Newcastle-Ottawa Scale, based on study design.

RESULTS

Nineteen studies were included. Nurse-led interventions positively impacted patient outcomes, improved efficiency and resource utilization, enhanced patient satisfaction and adherence, maintained safety and efficacy, and demonstrated notable diagnostic accuracy. Included studies originated from different countries and employed diverse methodologies, offering a global perspective on nurse-led interventions in ophthalmology care.

CONCLUSION

The findings advocate for the integration of nurse-led strategies in routine practice to realize equitable, efficient, and patient-centered eye care.

Evaluation of a nurse-led glaucoma assessment clinic for non-complex patients

AIMS AND OBJECTIVES

The purpose of this study was to assess the safety, feasibility and effectiveness of a nurse-led glaucoma assessment clinic service.

BACKGROUND

Glaucoma is a group of serious, irreversible optic neuropathies that progressively damage the optic nerve resulting in blindness. Over 64.3 million people globally are affected by glaucoma with numbers projected to increase to 111.8 million by 2040. Glaucoma is a major public health concern that requires the development of innovative models of care to meet current and future health care demands.

METHODS/DESIGN

A mixed method design was used to evaluate the assessment of non-complex glaucoma patients attending a new nurse-led clinic. Under an ophthalmologist's supervision, the glaucoma nurse completed 100 hof clinical training and assessment to ensure they were competent in completing and interpreting the required glaucoma assessment protocols. Interrater reliability between the glaucoma nurse and ophthalmology doctor was undertaken. Glaucoma patient waitlist appointment data were also compared before and after the introduction of the nurse-led clinics. This study adhered to the SQUIRE checklist for the reporting of excellence with quality improvement projects.

PATIENT CONTRIBUTION

Patients contributed to the evaluation of this new nurse-led service by providing follow-up feedback on their experience.

RESULTS

Agreement between clinicians for appropriate follow-up appointment times was high with 93% (n = 315) agreement achieved. Furthermore in 297 (87.5%) cases, both clinicians agreed on the patient being referred to the doctor for follow-up review. Glaucoma consultations were shown to increase from 3,115 appointments in 2019/20 to 3,504 appointments in 2020/21 after the introduction of the nurse-led clinic. The nurse-led clinics accounted for 14.5% (n = 512) of clinic appointments.

CONCLUSIONS

The introduction of the nurse-led glaucoma assessment clinic service allowed patients to be reviewed safely, efficiently and satisfactorily. This new service subsequently allowed for more complex glaucoma patients to be seen by the ophthalmologists.

RELEVANCE TO CLINICAL PRACTICE

Findings revealed that suitably trained glaucoma nurses are able to clinically assess and safely monitor stable non-complex glaucoma patients. Highlights the need for appropriate investment in clinical training and supervision to ensure that glaucoma assessment nurses are adequately prepared to undertake this new practice role.

Cost Analysis of Orthoptist-Led Neurofibromatosis Type 1 Screening Clinics

Purpose

To conduct a costing study comparing orthoptist-led with consultant-led clinics screening for optic pathway gliomas (OPGs) in children with neurofibromatosis Type 1 (NF1) attending the Royal Children's Hospital (RCH), Melbourne.

Methods

Patients with NF1 examined in the orthoptist-led NF1 screening clinic and/or consultant-led clinics during the study period were identified. The workflow management software Q-Flow 6® provided data documenting patient's time spent with the orthoptist, nurse, and ophthalmologist. Time points were converted into minutes and multiplied by the cost-per-minute for each profession. A bottom-up micro-costing approach was used to estimate appointment level costs. Bootstrap simulations with 1000 replications were used to estimate 95% confidence intervals (CIs) for the difference in mean appointment time and cost between clinics.

Results

Data for 130 consultant-led clinic appointments and 234 orthoptist-led clinic appointments were extracted for analysis. The mean time per appointment for the consultant-led clinic was 45.11 minutes, and the mean time per appointment for the orthoptist-led clinic was 25.85 minutes. The mean cost per appointment for the consultant-led clinic was A $84.15 (GBP £39.60) compared to the orthoptist-led clinic at A $20.40 (GBP £9.60). This represents a mean reduction of 19.25 minutes per appointment (95% CI, -24.85 to -13.66) and a mean reduction of A $63.75 (GBP £30.00) per appointment (95% CI, (A $-75.40 to $-52.10 [GBP £ -35.48 to £ -24.52]).

Conclusion

An orthoptist-led clinic screening for OPGs in patients with NF1 can be a more cost-efficient model of care for ophthalmic screening in this patient group.

Pilot study of a nurse-led adult lacrimal clinic at a tertiary ophthalmic centre

This article provides the reader with an outline of the anatomy and physiology of the lacrimal system and illustrates how a variety of pathologies within this system can result in the development of a watery eye. It describes the role of the nurse consultant in the diagnosis and management of patients with watery eye in the lacrimal clinic, and how the training programme for the development of such skills was implemented. Following training, within the realms of an established pilot study, the nurse consultant began to implement her skills in a newly established nurse-led lacrimal clinic. Patients seen in the lacrimal clinic would previously have been assessed and managed by a doctor. To confirm the accuracy of this approach, an audit was undertaken comparing the nurse-led diagnosis and management plans with that of an oculoplastic doctor. In addition, patient waiting times in the clinic and patient satisfaction were assessed, as important indicators of quality of care.

Real-world outcomes of allied health professional-led clinic model for assessing and monitoring ocular melanocytic lesions

BACKGROUND

Naevomelanocytic lesions comprise an increasing workload in ophthalmic secondary care and, although largely benign, carry high risk of mortality in case of malignant transformation. Previous studies highlight the theoretical strength of virtual models in monitoring such lesions and the role of allied health professionals (AHPs). We aim to describe and validate a "real-world" functional clinical model utilising these particular resources.

METHODS

New and existing follow-up patients from November 2016 to June 2019 with melanocytic lesions of the uveal tract and conjunctiva were directed into an optometrist-led, consultant-supported, clinic. Diagnostic tests included colour photography, autofluorescence, enhanced-depth imaging and ultrasound biomicroscopy. New patients were examined face-to-face initially, then virtually on subsequent visits. Suspicious lesions were referred to the consultant, with tertiary oncology referrals made as necessary. Clinical concordance between optometrist and consultant, patient satisfaction and outcomes of second opinion requests were audited.

RESULTS

Eight hundred and twenty-five patient episodes were encountered: 419 new and 406 follow-up. Between July 1st and August 31st 2018, 72 cases were audited. There was 98.6% concordance between AHP and consultant for diagnosis and management. Referral for consultant second opinion was requested in 18(2%) clinical encounters, with 4(0.5%) referred on to the oncology centre, of which 3 received treatment. Of 65 patients responding to a patient satisfaction survey, 100% were satisfied with their experience and 95% were happy to continue monitoring by the AHP.

CONCLUSION

With robust training and assessment, AHP-led service models are a highly efficient in busy units, without compromising patient safety.

Uveal melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults. UMs are usually initiated by a mutation in GNAQ or GNA11, unlike cutaneous melanomas, which usually harbour a BRAF or NRAS mutation. The annual incidence in Europe and the USA is ~6 per million population per year. Risk factors include fair skin, light-coloured eyes, congenital ocular melanocytosis, ocular melanocytoma and the BAP1-tumour predisposition syndrome. Ocular treatment aims at preserving the eye and useful vision and, if possible, preventing metastases. Enucleation has largely been superseded by various forms of radiotherapy, phototherapy and local tumour resection, often administered in combination. Ocular outcomes are best with small tumours not extending close to the optic disc and/or fovea. Almost 50% of patients develop metastatic disease, which usually involves the liver, and is usually fatal within 1 year. Although UM metastases are less responsive than cutaneous melanoma to chemotherapy or immune checkpoint inhibitors, encouraging results have been reported with partial hepatectomy for solitary metastases, with percutaneous hepatic perfusion with melphalan or with tebentafusp. Better insight into tumour immunology and metabolism may lead to new treatments.

Patient-reported Outcomes and Quality of Life After Treatment of Choroidal Melanoma: A Comparison of Enucleation Versus Radiotherapy in 1596 Patients

PURPOSE

To test the hypothesis that patients treated with radiotherapy for choroidal melanoma enjoy better quality of life (QoL) than patients who have undergone enucleation.

METHODS

In this nonrandomized study, patients with choroidal melanoma treated at the Royal Liverpool University Hospital, Liverpool, UK, were invited to complete QoL questionnaires approximately 6 months postoperatively and then on each anniversary of their primary treatment. These instruments consisted of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-OPT30 questionnaire, Hospital Anxiety & Depression Scale, and the Functional Assessment of Cancer Treatment questionnaire. Patient-reported outcomes were correlated with demographics, ocular treatment, social factors, presenting tumor and ocular status, self-reported general health, marital status, and employment status.

RESULTS

The 1596 patients were treated with radiotherapy (72.3%) or enucleation (27.7%). Enucleation was associated with male sex (χ², P = .004), older age (t test, P < .001), larger tumor diameter (t test, P < .001), monosomy 3 (χ², P < .001), depression (linear regression, 95% confidence interval [CI], .17 to 1.01), and reduced physical and functional well-being (linear regression, 95% CI, -1.14 to -0.12 and -1.96 to -0.47), respectively. Poor QoL was attributed to the ocular disease by 21% and 20% of enucleated and irradiated patients, respectively (χ², P = .938).

CONCLUSIONS

Patient-reported outcomes and QoL were worse in patients who had undergone primary enucleation for choroidal melanoma. These outcomes may partly have been caused by factors predisposing to enucleation rather than enucleation itself, because enucleated patients tended to be older, with more advanced disease at presentation, and a worse prognosis for survival. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Patient satisfaction with nurse-led chronic kidney disease clinics: A multicentre evaluation

BACKGROUND

There is growing international evidence that nurse-led chronic kidney disease (CKD) clinics provide a comprehensive approach to achieving clinical targets effective in slowing the progression of CKD. Across Queensland, Australia, these clinics have been established in many renal outpatient departments although patient satisfaction with these clinics is unknown.

OBJECTIVES

To measure patient satisfaction levels with CKD nurse-led clinics.

METHOD

This was a cross-sectional study undertaken at five clinics located in metropolitan, regional and remote hospitals in Queensland. Participants were >18 years of age (no upper age limit) with CKD (non-dialysis) who attended CKD nurse-led clinics over a six month period (N = 873). They completed the Nurse Practitioner Patient Satisfaction questionnaire which was modified for CKD.

RESULTS

The response rate was 64.3 % (n = 561); half of the respondents were male (55.5 %), there was a median age range of 71-80 years (43.5 %) and most respondents were pensioners or retired (84.2 %). While the majority reported that they were highly satisfied with the quality of care provided by the nurse (83.8 %), we detected differences in some aspects of satisfaction between genders, age groups and familiarity with the nurse. Overall, patients' comments were highly positive with a few improvements to the service being suggested; these related to car-parking, providing more practical support, and having accessible locations.

CONCLUSION

In an era of person-centred care, it is important to measure patient satisfaction using appropriate and standardised questionnaires. Our results highlight that, to improve services, communication strategies should be optimised in nurse-led clinics.

Personalized treatment of uveal melanoma

Personalized treatment of uveal melanoma involves the tailoring of all aspects of care to the condition, needs, wishes, and fears of the patient, taking account of the individual's circumstances. When selecting between radiotherapy, surgical resection, and phototherapy, or when deciding how best to combine these different therapeutic modalities, it is necessary to understand the patients utilities, with respect to tumour control, visual conservation, and preservation of the eye, so as to prioritize outcomes accordingly. For example, such considerations would influence the width of the safety margins when administering radiotherapy, according to whether the patient considers it more important to conserve vision or to guarantee tumour control. With 'suspicious naevi', the choice between observation, immediate treatment, and biopsy is complicated by the lack of adequate survival data on which to base rational decisions, making it necessary for both patient and doctor to accept uncertainty. Personalized care should involve close relatives, as appropriate. It must also adapt to changes in the patient's needs over time. Such personalized care demands the ability to respond to such needs and the sensitivity to identify these requirements in the first place. Personalized treatment enhances not only the patient's satisfaction but also the 'job satisfaction' of all members of the multidisciplinary team, improving quality of care.

Progress in the management of patients with uveal melanoma. The 2012 Ashton Lecture

Uveal melanomas are diverse in their clinical features and behaviour. More than 90% involve the choroid, the remainder being confined to the ciliary body and iris. Most patients experience visual loss and more than a third require enucleation, in some cases because of pain. Diagnosis is based on slit-lamp biomicroscopy and/or ophthalmoscopy, with ultrasonography, autofluorescence photography, and/or biopsy in selected cases. Conservation of the eye with useful vision has improved with advances in brachytherapy, proton beam radiotherapy, endoresection, exoresection, transpupillary thermotherapy, and photodynamic therapy. Despite ocular treatment, almost 50% of patients develop metastatic disease, which occurs almost exclusively in patients whose tumour shows chromosome 3 loss and/or class 2 gene expression profile. When the tumour shows such lethal genetic changes, the survival time depends on the anatomical stage and the histological grade of malignancy. Prognostication has improved as a result of progress in multivariate analysis including all the major risk factors. Screening for metastases is more sensitive as a consequence of advances in liver scanning with magnetic resonance imaging and other methods. More patients with metastases are living longer, benefiting from therapies such as: partial hepatectomy; radiofrequency ablation; ipilumumab immunotherapy; selective internal radiotherapy; intra-hepatic chemotherapy, possibly with isolated liver perfusion; and systemic chemotherapy. There is scope for improvement in the detection of uveal melanoma so as to maximise any opportunities for conserving the eye and vision, as well as preventing metastatic spread. Patient management has been enhanced by the formation of multidisciplinary teams in specialised ocular oncology centres.