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Carmichael J, Abdi S, Balaskas K, Costanza E, Blandford A. The effectiveness of interventions for optometric referrals into the hospital eye service: A review. Ophthalmic Physiol Opt 2023; 43:1510-1523. [PMID: 37632154 PMCID: PMC10947293 DOI: 10.1111/opo.13219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
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.
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Affiliation(s)
- Josie Carmichael
- University College London Interaction Centre (UCLIC), UCLLondonUK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCLInstitute of OphthalmologyLondonUK
| | - Sarah Abdi
- University College London Interaction Centre (UCLIC), UCLLondonUK
| | - Konstantinos Balaskas
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCLInstitute of OphthalmologyLondonUK
| | - Enrico Costanza
- University College London Interaction Centre (UCLIC), UCLLondonUK
| | - Ann Blandford
- University College London Interaction Centre (UCLIC), UCLLondonUK
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Goodman L, Hamm L, Tousignant B, Black J, Misra S, Woodburn S, Keay L, Harwood M, Gordon I, Evans JR, Ramke J. Primary eye health services for older adults as a component of universal health coverage: a scoping review of evidence from high income countries. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 35:100560. [PMID: 37424679 PMCID: PMC10326716 DOI: 10.1016/j.lanwpc.2022.100560] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
In pursuit of Universal Health Coverage (UHC) for eye health, countries must strengthen services for older adults, who experience the highest prevalence of eye conditions. This scoping review narratively summarised (i) primary eye health services for older adults in eleven high-income countries/territories (from government websites), and (ii) the evidence that eye health services reduced vision impairment and/or provided UHC (access, quality, equity, or financial protection) (from a systematic literature search). We identified 76 services, commonly comprehensive eye examinations ± refractive error correction. Of 102 included publications reporting UHC outcomes, there was no evidence to support vision screening in the absence of follow-up care. Included studies tended to report the UHC dimensions of access (n=70), equity (n=47), and/or quality (n=39), and rarely reported financial protection (n=5). Insufficient access for population subgroups was common; several examples of horizontal and vertical integration of eye health services within the health system were described. Funding This work was funded by Blind Low Vision New Zealand for Eye Health Aotearoa.
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Affiliation(s)
- Lucy Goodman
- School of Optometry & Vision Science, Faculty of Medicine and Health Sciences, The University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Lisa Hamm
- School of Optometry & Vision Science, Faculty of Medicine and Health Sciences, The University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Benoit Tousignant
- School of Optometry, Université de Montréal, 3774 Jean-Brillant, Montreal, Quebec H3T1P1, Canada
- School of Public Health, Université de Montréal, 3774 Jean-Brillant, Montreal, Quebec H3T1P1, Canada
| | - Joanna Black
- School of Optometry & Vision Science, Faculty of Medicine and Health Sciences, The University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Stuti Misra
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, 85 Park Road, Grafton 1023, Auckland, New Zealand
| | - Sophie Woodburn
- Specsavers Queenstown, 12 Hawthorne Drive, Frankton, Queenstown 9300, New Zealand
| | - Lisa Keay
- School of Optometry and Vision Science, UNSW Sydney, Rupert Myers Building (M15), Southern Dr, Kensington, NSW 2052, Australia
- The George Institute for Global Health, UNSW Sydney, Level 5/1 King St, Newtown NSW 2042, Australia
| | - Matire Harwood
- Department of General Practice & Primary Health Care, School of Population Health, University of Auckland, 28 Park Ave, Grafton Auckland 1023, New Zealand
| | - Iris Gordon
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
| | - Jennifer R. Evans
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
- Centre for Public Health, Institute of Clinical Science, Block A, Royal Victoria Hospital, Queen's University Belfast BT12 6BA, United Kingdom
| | - Jacqueline Ramke
- School of Optometry & Vision Science, Faculty of Medicine and Health Sciences, The University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
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Performance of a Glaucoma Screening Program Compared With Opportunistic Detection in China. J Glaucoma 2023; 32:80-84. [PMID: 36223297 DOI: 10.1097/ijg.0000000000002125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 08/16/2022] [Indexed: 01/26/2023]
Abstract
PRCIS Health examination center-based screening provide a good supplement to clinic-based glaucoma care by detecting early-stage glaucoma, especially those with normal intraocular pressure (IOP) and less visual impairment. PURPOSE Opportunistic glaucoma screening for early case identification is of great value in the prevention of severe visual impairment, however, novel, low-cost models are needed. We aimed to determine whether health examination center-based glaucoma screening identifies diseases earlier than outpatient cases in China. MATERIALS AND METHODS In this case-control study, 76 patients with primary glaucoma identified from a health examination center-based glaucoma screening program and 272 consecutive outpatient cases at the same hospital were enrolled from March 21 to September 30, 2016. Demographic characteristics, best-corrected visual acuity, IOP, mean deviation (MD), and pattern standard deviation (PSD) on Humphrey visual field testing in the better-seeing eye were compared between groups. RESULTS Screening-detected glaucoma patients had significantly lower IOP (18.3±4.2 mm Hg) than out-patient cases (26.7±12.6 mm Hg, P <0.001). Most (71.1%) of the screening-detected patients had IOP<21 mm Hg compared with 37.1% in the clinic group ( P <0.001). Seventy-five patients (98.7%) in the screening group were diagnosed as primary open angle glaucoma, compared with 44.1% in the clinic group ( P <0.001). Screening-detected patients had significantly less visual impairment than the clinic group (6.6% vs. 38.6%, P <0.05). Mean MD (-4.4±5.0 dB) and PSD (4.4±3.6 dB) for the screening group were superior to the clinic group (MD: -16.5±10.5 dB, P <0.001; PSD: 6.5±3.7 dB, P <0.001). CONCLUSION The glaucoma screening program was effective at detecting early disease, especially normal tension glaucoma and supplemented opportunistic detection of glaucoma.
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Aboelkhir HAB, Elomri A, ElMekkawy TY, Kerbache L, Elakkad MS, Al-Ansari A, Aboumarzouk OM, El Omri A. A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16952. [PMID: 36554837 PMCID: PMC9778793 DOI: 10.3390/ijerph192416952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process. METHODS A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis. RESULTS A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified. CONCLUSIONS Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
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Affiliation(s)
| | - Adel Elomri
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Tarek Y. ElMekkawy
- Department of Mechanical and Industrial Engineering, College of Engineering, Qatar University, Doha 2713, Qatar
| | - Laoucine Kerbache
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Mohamed S. Elakkad
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Abdulla Al-Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, QU-Health, Qatar University, Doha 2713, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Abdelfatteh El Omri
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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Wang H, Kalloniatis M. Response to re: clinical outcomes of the Centre for Eye Health: an intra-professional optometry-led collaborative eye care clinic in Australia. Clin Exp Optom 2021; 105:669-670. [PMID: 34751103 DOI: 10.1080/08164622.2021.1992250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Henrietta Wang
- Centre for Eye Health, and School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Michael Kalloniatis
- Centre for Eye Health, and School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
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Landgren K, Peters D. A prospective study on effectiveness of elevated intraocular pressure as a criterion for glaucoma referrals by optometric practitioners in Sweden. Acta Ophthalmol 2021; 99:e1098-e1105. [PMID: 33423398 PMCID: PMC8596777 DOI: 10.1111/aos.14764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 12/10/2020] [Accepted: 12/20/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE To evaluate the outcome of referrals for suspected glaucoma based on elevated intraocular pressure (IOP) made by optometric practitioners in Sweden. METHODS This prospective study included 95 individuals referred to the Skåne University Hospital Malmö, Sweden, during 2019, by optometric practitioners, based on elevated IOP. Positive outcome was defined as a diagnosis of glaucoma, or a diagnosis of suspected glaucoma. Referral accuracy was analysed. Positive predictive values (PPV) of different hypothetical IOP and age thresholds were calculated. RESULTS In 34% (95% CI: 24-43%) of the referrals, no eye disease was found. Intraocular pressure (IOP) was the only referral criterion in 77% (73/95). The PPV was 35% (95% CI: 25-45%) for all referrals, 27% (95% CI: 16-38%) for IOP-only referrals and 59% (95% CI: 36-82%) for referrals including additional findings. In IOP-only referrals, no definite diagnosis of glaucoma was made in any patients <45 years of age. Applying a theoretical age limit of ≥45 years with a hypothetical IOP limit of ≥25 mmHg in patients 45-69 years and of ≥22 mmHg in patients ≥70 years increased the PPV to 42% (95% CI: 27-57%). IOP-only referrals would have been reduced by 27% without missing any glaucoma cases. CONCLUSION The overall predictive value of the referrals was poor. Glaucoma resources would have been used more effectively by increasing the required age for IOP-only referrals to ≥45 years in combination with different IOP thresholds for certain age groups.
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Affiliation(s)
- Karin Landgren
- Department of Ophthalmology Skåne University Hospital Malmö‐Lund Sweden
| | - Dorothea Peters
- Department of Ophthalmology Skåne University Hospital Malmö‐Lund Sweden
- Department of Clinical Sciences in Malmö Ophthalmology Lund University Malmö Sweden
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Barrett C, O'brien C, Butler JS, Loughman J. Barriers to glaucoma case finding as perceived by optometrists in Ireland. Clin Exp Optom 2021; 101:90-99. [DOI: 10.1111/cxo.12573] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/22/2017] [Accepted: 05/01/2017] [Indexed: 11/29/2022] Open
Affiliation(s)
- Catriona Barrett
- School of Physics and Clinical and Optometric Sciences, Dublin Institute of Technology, Dublin, Ireland,
| | - Colm O'brien
- Mater Misericordiae University Hospital, Dublin, Ireland,
| | - John S Butler
- School of Mathematical Sciences, Dublin Institute of Technology, Dublin, Ireland,
| | - James Loughman
- School of Physics and Clinical and Optometric Sciences, Dublin Institute of Technology, Dublin, Ireland,
- African Vision Research Institute, University of KwaZulu Natal, Durban, South Africa,
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Ophthalmic nurse practitioner assessment of glaucoma: evaluating agreement within an initiative to enhance capacity in glaucoma clinics. Eye (Lond) 2021; 35:3258-3265. [PMID: 33495567 PMCID: PMC7832419 DOI: 10.1038/s41433-021-01394-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 12/04/2020] [Accepted: 01/05/2021] [Indexed: 11/08/2022] Open
Abstract
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.
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Desai P, Parkins D, Richmond Z. A catalyst for change. Eye (Lond) 2020; 35:1037-1040. [PMID: 32929183 PMCID: PMC7488641 DOI: 10.1038/s41433-020-01176-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Parul Desai
- Public Health and Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK.
| | - David Parkins
- Kings College Hospital NHS Foundation Trust, Frognal Avenue, Sidcup, Kent, DA14 6LT, UK
| | - Zoe Richmond
- Local Optical Committee Support Unit, LOCSU, 2 Woodbridge Street, London, EC1R ODG, UK
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Project Panopia: cost-effective model for glaucoma referral refinement from community optometrists without the need for repeat testing. Eye (Lond) 2020; 35:1056-1060. [PMID: 32839559 PMCID: PMC8115041 DOI: 10.1038/s41433-020-01133-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/21/2020] [Accepted: 08/05/2020] [Indexed: 11/16/2022] Open
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Optometrist referrals to an emergency ophthalmology department: a retrospective review to identify current practise and development of shared care working strategies, in England. Eye (Lond) 2020; 35:1340-1346. [PMID: 32601501 DOI: 10.1038/s41433-020-1049-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 06/08/2020] [Accepted: 06/16/2020] [Indexed: 11/09/2022] Open
Abstract
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.
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Care pathways for glaucoma detection and monitoring in the UK. Eye (Lond) 2019; 34:89-102. [PMID: 31700149 DOI: 10.1038/s41433-019-0667-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/11/2019] [Accepted: 10/11/2019] [Indexed: 11/08/2022] Open
Abstract
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.
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Forbes H, Sutton M, Edgar DF, Lawrenson J, Spencer AF, Fenerty C, Harper R. Impact of the Manchester Glaucoma Enhanced Referral Scheme on NHS costs. BMJ Open Ophthalmol 2019; 4:e000278. [PMID: 31673631 PMCID: PMC6797377 DOI: 10.1136/bmjophth-2019-000278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 07/23/2019] [Accepted: 08/23/2019] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Hannah Forbes
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - David F Edgar
- Division of Optometry and Visual Science, City, University of London, London, UK
| | - John Lawrenson
- Division of Optometry and Visual Science, City, University of London, London, UK
| | - Anne Fiona Spencer
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
| | - Cecilia Fenerty
- Glaucoma, Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
| | - Robert Harper
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
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Barrett C, Loughman J. Expanding the traditional role of optometry: Current practice patterns and attitudes to enhanced glaucoma services in Ireland. JOURNAL OF OPTOMETRY 2018; 11:252-261. [PMID: 29650469 PMCID: PMC6147747 DOI: 10.1016/j.optom.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 02/05/2018] [Accepted: 02/11/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE To investigate current diagnostic equipment availability and usage for glaucoma case-finding within community optometric practice, and to explore optometrists' attitudes towards an enhanced scope of clinical practice. METHODS An anonymous survey was developed, validated, and distributed to all optometrists in Ireland. RESULTS 199 optometrists (27% of registrants) responded to the survey. 87% had access to the traditional triad of tests necessary to conduct adequate glaucoma case finding. Standard automated perimetry was the most commonly absent (13%) of the three essential screening tests. 64% of respondents indicated that monocular direct ophthalmoscopy was their first choice technique for fundus examination. 47% of respondents had access to contact applanation tonometry, though just 14% used it as first choice during routine eye examinations. Among the 73 participants with access to both contact and non-contact tonometry (NCT), 80.8%, used NCT preferentially. The significant majority (98%) indicated an interest in enhanced glaucoma services with 57% agreeing that postgraduate training was an essential prerequisite to any increase in scope of practice. CONCLUSION Irish optometrists are well equipped with the traditional tests used in glaucoma detection. However, implementation of enhanced referral schemes or glaucoma monitoring or management services would require equipment upgrades and associated training in at least half of the surveyed practices. There is strong interest in furthering optometric professional development and expanding the traditional role boundaries of optometrists, incorporating further education as an essential prerequisite to an enhanced scope of practice.
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Affiliation(s)
- Catriona Barrett
- Dublin Institute of Technology, 19A Lower Kevin Street, Dublin 8, Ireland; DIT Centre for Eye Research Ireland, Environmental Sustainability and Health Institute, Dublin, Ireland.
| | - James Loughman
- Dublin Institute of Technology, 19A Lower Kevin Street, Dublin 8, Ireland; DIT Centre for Eye Research Ireland, Environmental Sustainability and Health Institute, Dublin, Ireland; African Vision Research Institute, University of KwaZulu Natal, South Africa
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Baker H, Ratnarajan G, Harper RA, Edgar DF, Lawrenson JG. Effectiveness of UK optometric enhanced eye care services: a realist review of the literature. Ophthalmic Physiol Opt 2017; 36:545-57. [PMID: 27580754 DOI: 10.1111/opo.12312] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 06/09/2016] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Helen Baker
- Division of Optometry and Visual Science, City University London, London, UK.,UCL Institute of Ophthalmology, London, UK
| | - Gokulan Ratnarajan
- UCL Institute of Ophthalmology, London, UK.,Corneo-Plastic Unit, Queen Victoria Hospital, East Grinstead, UK.,Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, UK
| | - Robert A Harper
- Manchester Academic Health Sciences Centre, Manchester Royal Eye Hospital, Manchester, UK
| | - David F Edgar
- Division of Optometry and Visual Science, City University London, London, UK
| | - John G Lawrenson
- Division of Optometry and Visual Science, City University London, London, UK
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A technician-delivered 'virtual clinic' for triaging low-risk glaucoma referrals. Eye (Lond) 2017; 31:899-905. [PMID: 28211881 DOI: 10.1038/eye.2017.9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/26/2016] [Indexed: 11/08/2022] Open
Abstract
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.
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Chambers D, Booth A, Baxter SK, Johnson M, Dickinson KC, Goyder EC. Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04350] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BackgroundCurrent NHS policy favours the expansion of diagnostic testing services in community and primary care settings.ObjectivesOur objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.Review methodsWe performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.ResultsWe identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.ConclusionsIn the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.LimitationsWe have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.Future workThere is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan K Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Maxine Johnson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katherine C Dickinson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth C Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Abstract
OBJECTIVES To explore views of all stakeholders (patients, optometrists, general practitioners (GPs), commissioners and ophthalmologists) regarding the operation of community-based enhanced optometric services. DESIGN Qualitative study using mixed methods (patient satisfaction surveys, semi-structured telephone interviews and optometrist focus groups). SETTING A minor eye conditions scheme (MECS) and glaucoma referral refinement scheme (GRRS) provided by accredited community optometrists. PARTICIPANTS 189 patients, 25 community optometrists, 4 glaucoma specialist hospital optometrists (GRRS), 5 ophthalmologists, 6 GPs (MECS), 4 commissioners. RESULTS Overall, 99% (GRRS) and 100% (MECS) patients were satisfied with their optometrists' examination. The vast majority rated the following as 'very good'; examination duration, optometrists' listening skills, explanations of tests and management, patient involvement in decision-making, treating the patient with care and concern. 99% of MECS patients would recommend the service. Manchester optometrists were enthusiastic about GRRS, feeling fortunate to practise in a 'pro-optometry' area. No major negatives were reported, although both schemes were limited to patients resident within certain postcode areas, and some inappropriate GP referrals occurred (MECS). Communication with hospitals was praised in GRRS but was variable, depending on hospital (MECS). Training for both schemes was valuable and appropriate but should be ongoing. MECS GPs were very supportive, reporting the scheme would reduce secondary care referral numbers, although some MECS patients were referred back to GPs for medication. Ophthalmologists (MECS and GRRS) expressed very positive views and widely acknowledged that these new care pathways would reduce unnecessary referrals and shorten patient waiting times. Commissioners felt both schemes met or exceeded expectations in terms of quality of care, allowing patients to be seen quicker and more efficiently. CONCLUSIONS Locally commissioned schemes can be a positive experience for all involved. With appropriate training, clear referral pathways and good communication, community optometrists can offer high-quality services that are highly acceptable to patients, health professionals and commissioners.
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Affiliation(s)
- H Baker
- Division of Optometry and Visual Science, City, University of London, London, UK
- UCL (University College London), Institute of Ophthalmology, London, UK
| | - R A Harper
- Manchester Academic Health Sciences Centre, Manchester Royal Eye Hospital, Manchester, UK
| | - D F Edgar
- Division of Optometry and Visual Science, City, University of London, London, UK
| | - J G Lawrenson
- Division of Optometry and Visual Science, City, University of London, London, UK
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Azuara-Blanco A, Banister K, Boachie C, McMeekin P, Gray J, Burr J, Bourne R, Garway-Heath D, Batterbury M, Hernández R, McPherson G, Ramsay C, Cook J. Automated imaging technologies for the diagnosis of glaucoma: a comparative diagnostic study for the evaluation of the diagnostic accuracy, performance as triage tests and cost-effectiveness (GATE study). Health Technol Assess 2016; 20:1-168. [PMID: 26822760 DOI: 10.3310/hta20080] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many glaucoma referrals from the community to hospital eye services are unnecessary. Imaging technologies can potentially be useful to triage this population. OBJECTIVES To assess the diagnostic performance and cost-effectiveness of imaging technologies as triage tests for identifying people with glaucoma. DESIGN Within-patient comparative diagnostic accuracy study. Markov economic model comparing the cost-effectiveness of a triage test with usual care. SETTING Secondary care. PARTICIPANTS Adults referred from the community to hospital eye services for possible glaucoma. INTERVENTIONS Heidelberg Retinal Tomography (HRT), including two diagnostic algorithms, glaucoma probability score (HRT-GPS) and Moorfields regression analysis (HRT-MRA); scanning laser polarimetry [glaucoma diagnostics (GDx)]; and optical coherence tomography (OCT). The reference standard was clinical examination by a consultant ophthalmologist with glaucoma expertise including visual field testing and intraocular pressure (IOP) measurement. MAIN OUTCOME MEASURES (1) Diagnostic performance of imaging, using data from the eye with most severe disease. (2) Composite triage test performance (imaging test, IOP measurement and visual acuity measurement), using data from both eyes, in correctly identifying clinical management decisions, that is 'discharge' or 'do not discharge'. Outcome measures were sensitivity, specificity and incremental cost per quality-adjusted life-year (QALY). RESULTS Data from 943 of 955 participants were included in the analysis. The average age was 60.5 years (standard deviation 13.8 years) and 51.1% were females. Glaucoma was diagnosed by the clinician in at least one eye in 16.8% of participants; 37.9% of participants were discharged after the first visit. Regarding diagnosing glaucoma, HRT-MRA had the highest sensitivity [87.0%, 95% confidence interval (CI) 80.2% to 92.1%] but the lowest specificity (63.9%, 95% CI 60.2% to 67.4%) and GDx had the lowest sensitivity (35.1%, 95% CI 27.0% to 43.8%) but the highest specificity (97.2%, 95% CI 95.6% to 98.3%). HRT-GPS had sensitivity of 81.5% (95% CI 73.9% to 87.6%) and specificity of 67.7% (95% CI 64.2% to 71.2%) and OCT had sensitivity of 76.9% (95% CI 69.2% to 83.4%) and specificity of 78.5% (95% CI 75.4% to 81.4%). Regarding triage accuracy, triage using HRT-GPS had the highest sensitivity (86.0%, 95% CI 82.8% to 88.7%) but the lowest specificity (39.1%, 95% CI 34.0% to 44.5%), GDx had the lowest sensitivity (64.7%, 95% CI 60.7% to 68.7%) but the highest specificity (53.6%, 95% CI 48.2% to 58.9%). Introducing a composite triage station into the referral pathway to identify appropriate referrals was cost-effective. All triage strategies resulted in a cost reduction compared with standard care (consultant-led diagnosis) but with an associated reduction in effectiveness. GDx was the least costly and least effective strategy. OCT and HRT-GPS were not cost-effective. Compared with GDx, the cost per QALY gained for HRT-MRA is £22,904. The cost per QALY gained with current practice is £156,985 compared with HRT-MRA. Large savings could be made by implementing HRT-MRA but some benefit to patients will be forgone. The results were sensitive to the triage costs. CONCLUSIONS Automated imaging can be effective to aid glaucoma diagnosis among individuals referred from the community to hospital eye services. A model of care using a triage composite test appears to be cost-effective. FUTURE WORK There are uncertainties about glaucoma progression under routine care and the cost of providing health care. The acceptability of implementing a triage test needs to be explored. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Katie Banister
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Charles Boachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Peter McMeekin
- Health Economics Group, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Gray
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Jennifer Burr
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Rupert Bourne
- Vision and Eye Research Unit, Postgraduate Institute, Anglia Ruskin University, Cambridge, UK
| | - David Garway-Heath
- National Institute of Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK.,University College London Institute of Ophthalmology, London, UK
| | - Mark Batterbury
- St Paul's Eye Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Gladys McPherson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jonathan Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Bowen M, Edgar DF, Hancock B, Haque S, Shah R, Buchanan S, Iliffe S, Maskell S, Pickett J, Taylor JP, O’Leary N. The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross-sectional study of people aged 60–89 years with dementia and qualitative exploration of individual, carer and professional perspectives. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04210] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BackgroundThe prevalence of visual impairment (VI) and dementia increases with age and these conditions may coexist, but few UK data exist on VI among people with dementia.ObjectivesTo measure the prevalence of eye conditions causing VI in people with dementia and to identify/describe reasons for underdetection or inappropriate management.DesignStage 1 – cross-sectional prevalence study. Stage 2 – qualitative research exploring participant, carer and professional perspectives of eye care.SettingStage 1 – 20 NHS sites in six English regions. Stage 2 – six English regions.ParticipantsStage 1 – 708 participants with dementia (aged 60–89 years): 389 lived in the community (group 1) and 319 lived in care homes (group 2). Stage 2 – 119 participants.InterventionsStage 1 gathered eye examination data following domiciliary sight tests complying with General Ophthalmic Services requirements and professional guidelines. Cognitive impairment was assessed using the Standardised Mini-Mental State Examination (sMMSE) test, and functional ability and behaviour were assessed using the Bristol Activities of Daily Living Scale and Cambridge Behavioural Inventory – Revised. Stage 2 involved individual interviews (36 people with dementia and 11 care workers); and separate focus groups (34 optometrists; 38 family and professional carers).Main outcome measures.VI defined by visual acuity (VA) worse than 6/12 or worse than 6/18 measured before and after refraction.ResultsStage 1 – when participants wore their current spectacles, VI prevalence was 32.5% [95% confidence interval (CI) 28.7% to 36.5%] and 16.3% (95% CI 13.5% to 19.6%) for commonly used criteria for VI of VA worse than 6/12 and 6/18, respectively. Of those with VI, 44% (VA < 6/12) and 47% (VA < 6/18) were correctable with new spectacles. Almost 50% of remaining uncorrectable VI (VA < 6/12) was associated with cataract, and was, therefore, potentially remediable, and one-third was associated with macular degeneration. Uncorrected/undercorrected VI prevalence (VA < 6/12) was significantly higher in participants in care homes (odds ratio 2.19, 95% CI 1.30 to 3.73;p < 0.01) when adjusted for age, sex and sMMSE score. VA could not be measured in 2.6% of group 1 and 34.2% of group 2 participants (p < 0.01). The main eye examination elements (excluding visual fields) could be performed in > 80% of participants. There was no evidence that the management of VI in people with dementia differed from that in older people in general. Exploratory analysis suggested significant deficits in some vision-related aspects of function and behaviour in participants with VI. Stage 2 key messages – carers and care workers underestimated how much can be achieved in an eye examination. People with dementia and carers were unaware of domiciliary sight test availability. Improved communication is needed between optometrists and carers; optometrists should be informed of the person’s dementia. Tailoring eye examinations to individual needs includes allowing extra time. Optometrists wanted training and guidance about dementia. Correcting VI may improve the quality of life of people with dementia but should be weighed against the risks and burdens of undergoing examinations and cataract surgery on an individual basis.LimitationsSampling bias is possible owing to quota-sampling and response bias.ConclusionsThe prevalence of VI is disproportionately higher in people with dementia living in care homes. Almost 50% of presenting VI is correctable with spectacles, and more with cataract surgery. Areas for future research are the development of an eye-care pathway for people with dementia; assessment of the benefits of early cataract surgery; and research into the feasibility of specialist optometrists for older people.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Michael Bowen
- Research Department, College of Optometrists, London, UK
| | - David F Edgar
- Division of Optometry and Visual Science, City University London, London, UK
| | | | - Sayeed Haque
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Rakhee Shah
- Research Department, College of Optometrists, London, UK
- The Outside Clinic, Swindon, UK
| | - Sarah Buchanan
- Research Department, Thomas Pocklington Trust, London, UK
| | - Steve Iliffe
- Department of Primary Care and Population Health, University College London, London, UK
| | - Susan Maskell
- Public and participant involvement representative, Alzheimer’s Society Research Network, London, UK
| | - James Pickett
- Research Department, Alzheimer’s Society, London, UK
| | - John-Paul Taylor
- Institute for Neuroscience, Newcastle University, Newcastle upon Tyne, UK
- Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Neil O’Leary
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Republic of Ireland
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Davey CJ, Scally AJ, Green C, Mitchell ES, Elliott DB. Factors influencing accuracy of referral and the likelihood of false positive referral by optometrists in Bradford, United Kingdom. JOURNAL OF OPTOMETRY 2016; 9:158-65. [PMID: 26614021 PMCID: PMC4911451 DOI: 10.1016/j.optom.2015.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/12/2015] [Accepted: 10/12/2015] [Indexed: 05/16/2023]
Abstract
AIMS Levels of false positive referral to ophthalmology departments can be high. This study aimed to evaluate commonality between false positive referrals in order to find the factors which may influence referral accuracy. METHODS In 2007/08, a sample of 431 new Ophthalmology referrals from the catchment area of Bradford Royal Infirmary were retrospectively analysed. RESULTS The proportion of false positive referrals generated by optometrists decreases with experience at a rate of 6.2% per year since registration (p<0.0001). Community services which involved further investigation done by the optometrist before directly referring to the hospital were 2.7 times less likely to refer false positively than other referral formats (p=0.007). Male optometrists were about half as likely to generate a false positive referral than females (OR=0.51, p=0.008) and as multiple/corporate practices in the Bradford area employ less experienced and more female staff, independent practices generate about half the number of false positive referrals (OR=0.52, p=0.005). CONCLUSIONS Clinician experience has the greatest effect on referral accuracy although there is also a significant effect of gender with women tending to refer more false positives. This may be due to a different approach to patient care and possibly a greater sensitivity to litigation. The improved accuracy of community services (which often refer directly after further investigation) supports further growth of these schemes.
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Affiliation(s)
| | - Andrew J Scally
- School of Health Studies, University of Bradford, Bradford, UK
| | - Clare Green
- Bradford Teaching Hospitals Foundation Trust, Bradford Royal Infirmary, Bradford, UK
| | - Edwin S Mitchell
- Shipley Ophthalmic Assessment Programme, Windhill Green Medical Centre, Shipley, UK
| | - David B Elliott
- Bradford School of Optometry and Vision Science, University of Bradford, Bradford, UK
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El-Assal K, Foulds J, Dobson S, Sanders R. A comparative study of glaucoma referrals in Southeast Scotland: effect of the new general ophthalmic service contract, Eyecare integration pilot programme and NICE guidelines. BMC Ophthalmol 2015; 15:172. [PMID: 26643710 PMCID: PMC4672504 DOI: 10.1186/s12886-015-0161-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 12/02/2015] [Indexed: 08/08/2023] Open
Abstract
Background Glaucoma is a progressive disease responsible for the second commonest cause of blindness in the UK. Identifying appropriate patients for hospital care remains an ongoing challenge for all UK hospital glaucoma services. The purpose of our study is to evaluate accuracy and outcome of community optometry referrals before and after implementation of the new general ophthalmic service contract in 2006, the Eyecare Integration Programme pilot in 2008 and the effect of NICE guidelines in glaucoma in 2009, over a 12-year period Methods A retrospective case analysis using a glaucoma electronic patient record was performed encompassing two six-year periods, 2000–2006 (Group A), and 2007–2012 (Group B). Results One thousand six hundred twenty-two new patients’ records were analysed. Waiting times reduced from 12.3 to 9.4 weeks. Significantly more patients kept first appointment (p = 0.0002) in group B. Glaucoma symptoms were significantly more in group A (p <0.0001) and only three patients lost Snellen’ visual acuity before appointment in group B compared to 12 in group A. Documentation of intraocular pressure was made in 74.1 % of Group A and 75.9 % of Group B, optic disc appearance in 85.4 % of Group A, and 93 % of Group B and visual fields in 84.4 % of Group A and 81.3 % of Group B. Significantly less normal (p < 0,0001), more glaucoma suspects (p < 0.0001), more open angle glaucoma (p = 0.0006) and fewer other conditions (p = 0.0024) were present in group B, compared to group A. Conclusion Patients were referred earlier with shorter waiting times for hospital appointments with the new Scottish general ophthalmic service and Eyecare Integration Programme. Additionally there were fewer false positive referrals with more diagnosis of glaucomatous disease. We discuss the benefits of these national screening and referral pathways together with their limitations and further refinements.
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Affiliation(s)
- Karim El-Assal
- Department of Ophthalmology, Queen Margaret Hospital, Whitefield Road, KY12 0SU, Dunfermline, Fife, UK.
| | | | - Stuart Dobson
- Medical Informatics, Queen Margaret Hospital, Dunfermline, Fife, UK
| | - Roshini Sanders
- Department of Ophthalmology, Queen Margaret Hospital, Whitefield Road, KY12 0SU, Dunfermline, Fife, UK
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Ratnarajan G, Kean J, French K, Parker M, Bourne R. The false negative rate and the role for virtual review in a nationally evaluated glaucoma referral refinement scheme. Ophthalmic Physiol Opt 2015; 35:577-81. [DOI: 10.1111/opo.12224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 05/27/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Gokulan Ratnarajan
- Vision and Eye Research Unit; Anglia Ruskin University; Cambridge UK
- UCL Institute of Ophthalmology; University of London; London UK
- Oxford Eye Hospital; John Radcliffe Hospital; Oxford UK
| | - Jane Kean
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital; Huntingdon UK
| | - Karen French
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital; Huntingdon UK
| | - Mike Parker
- Postgraduate Medical Institute; Anglia Ruskin University; Cambridge UK
| | - Rupert Bourne
- Vision and Eye Research Unit; Anglia Ruskin University; Cambridge UK
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital; Huntingdon UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology; London UK
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Dabasia PL, Edgar DF, Garway-Heath DF, Lawrenson JG. A survey of current and anticipated use of standard and specialist equipment by UK optometrists. Ophthalmic Physiol Opt 2015; 34:592-613. [PMID: 25160893 DOI: 10.1111/opo.12150] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 07/22/2014] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Priya L Dabasia
- Centre for Public Health Research, School of Health Sciences, City University London, London, UK
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Boodhna T, Crabb DP. Disease severity in newly diagnosed glaucoma patients with visual field loss: trends from more than a decade of data. Ophthalmic Physiol Opt 2014; 35:225-30. [PMID: 25545852 DOI: 10.1111/opo.12187] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 11/29/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Large archives of visual field (VF) records from automated perimetry are used to examine severity of vision loss at diagnosis in glaucoma patients over a 13 year period in England. METHODS A total of 473 252 Humphrey VFs recorded at four regionally different glaucoma clinics in England were retrospectively examined. Patients were required to have a Humphrey mean deviation (MD) outside 95% normative limits in at least one eye and had at least two visits to the glaucoma clinic in a study period between the start of 1999 and the end of 2011. No other clinical data was considered. MD of the worse eye at the first hospital visit was used as an estimate of vision loss for a patient at diagnosis; proportion of patients categorised as having 'early' (better than -6 dB) or 'advanced' (worse than -12 dB) VF loss were also calculated. Simple linear regression of MD against the date of first visit was used to estimate changes in vision loss at diagnosis over time. RESULTS Median age, at the time of diagnosis, of the 25 521 patients included in the analysis was 67 (interquartile range 55-76) years. Average level of glaucoma vision loss at diagnosis, in those patients presenting to secondary care with a VF defect, improved by an average 0.11 dB per year over the study period (95% confidence interval: 0.08-0.13 dB per year; p < 0.0001). Percentage of patients with 'advanced' VF loss in at least one eye at diagnosis changed from 30% (1999-2001) to 21% in (2009-2011) (p < 0.0001). CONCLUSIONS Severity of vision loss at the point of glaucoma detection, in those patients diagnosed with a VF defect, is improving over time in England. Nevertheless, the improvement is modest and large numbers of patients still present at glaucoma clinics with significant vision loss in at least one eye. Large scale digital VF data can be used to help monitor and audit health service delivery of glaucoma.
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Affiliation(s)
- Trishal Boodhna
- Optometry and Visual Science, School of Health Sciences, City University London, London, UK
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Jamous KF, Kalloniatis M, Hennessy MP, Agar A, Hayen A, Zangerl B. Clinical model assisting with the collaborative care of glaucoma patients and suspects. Clin Exp Ophthalmol 2014; 43:308-19. [PMID: 25362898 DOI: 10.1111/ceo.12466] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 10/23/2014] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Khalid F Jamous
- Centre for Eye Health, UNSW Australia, Sydney, New South Wales, Australia.,School of Optometry and Vision Science, UNSW Australia, Sydney, New South Wales, Australia.,Department of Ophthalmology, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Michael Kalloniatis
- Centre for Eye Health, UNSW Australia, Sydney, New South Wales, Australia.,School of Optometry and Vision Science, UNSW Australia, Sydney, New South Wales, Australia
| | - Michael P Hennessy
- Ophthalmology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Ashish Agar
- Ophthalmology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Andrew Hayen
- School of Public Health and Community Medicine, UNSW Australia, Sydney, New South Wales, Australia
| | - Barbara Zangerl
- Centre for Eye Health, UNSW Australia, Sydney, New South Wales, Australia.,School of Optometry and Vision Science, UNSW Australia, Sydney, New South Wales, Australia
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Roberts HW, Rughani K, Syam P, Dhingra S, Ramirez-Florez S. The Peterborough Scheme for Community Specialist Optometrists in Glaucoma: Results of 4 Years of a Two-Tiered Community-Based Assessment and Follow-up Service. Curr Eye Res 2014; 40:690-6. [DOI: 10.3109/02713683.2014.957326] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kotecha A, Turner S, Vasilakis C, Utley M, Fulop N, Azuara-Blanco A, Foster PJ. Improving care and increasing efficiency-challenges in the care of chronic eye diseases. Eye (Lond) 2014; 28:779-83. [PMID: 25008575 PMCID: PMC4094808 DOI: 10.1038/eye.2014.135] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- A Kotecha
- NIHR Biomedical Research Centre, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - S Turner
- Department of Applied Health Research, University College London, London, UK
| | - C Vasilakis
- IDO Group, School of Management, University of Bath, Bath, UK
| | - M Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - N Fulop
- Department of Applied Health Research, University College London, London, UK
| | - A Azuara-Blanco
- Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - P J Foster
- NIHR Biomedical Research Centre, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
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Konstantakopoulou E, Harper RA, Edgar DF, Lawrenson JG. A qualitative study of stakeholder views regarding participation in locally commissioned enhanced optometric services. BMJ Open 2014; 4:e004781. [PMID: 24875489 PMCID: PMC4039782 DOI: 10.1136/bmjopen-2013-004781] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore the views of optometrists, general practitioners (GPs) and ophthalmologists regarding the development and organisation of community-based enhanced optometric services. DESIGN Qualitative study using free-text questionnaires and telephone interviews. SETTING A minor eye conditions scheme (MECS) and a glaucoma referral refinement scheme (GRRS) are based on accredited community optometry practices. PARTICIPANTS 41 optometrists, 6 ophthalmologists and 25 GPs. RESULTS The most common reason given by optometrists for participation in enhanced schemes was to further their professional development; however, as providers of 'for-profit' healthcare, it was clear that participants had also considered the impact of the schemes on their business. Lack of fit with the 'retail' business model of optometry was a frequently given reason for non-participation. The methods used for training and accreditation were generally thought to be appropriate, and participating optometrists welcomed the opportunities for ongoing training. The ophthalmologists involved in the MECS and GRRS expressed very positive views regarding the schemes and widely acknowledged that the new care pathways would reduce unnecessary referrals and shorten patient waiting times. GPs involved in the MECS were also very supportive. They felt that the scheme provided an 'expert' local opinion that could potentially reduce the number of secondary care referrals. CONCLUSIONS The results of this study demonstrated strong stakeholder support for the development of community-based enhanced optometric services. Although optometrists welcomed the opportunity to develop their professional skills and knowledge, enhanced schemes must also provide a sufficient financial incentive so as not to compromise the profitability of their business.
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Affiliation(s)
- E Konstantakopoulou
- Centre for Public Health Research, School of Health Sciences, City University London, London, UK
| | - R A Harper
- Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - D F Edgar
- Centre for Public Health Research, School of Health Sciences, City University London, London, UK
| | - J G Lawrenson
- Centre for Public Health Research, School of Health Sciences, City University London, London, UK
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White A, Goldberg I. Guidelines for the collaborative care of glaucoma patients and suspects by ophthalmologists and optometrists in Australia. Clin Exp Ophthalmol 2014; 42:107-17. [DOI: 10.1111/ceo.12270] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 10/26/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew White
- Save Sight Institute and Westmead Millennium Institute; University of Sydney; Westmead Hospital; Westmead New South Wales Australia
- Discipline of Ophthalmology; University of Sydney; Sydney New South Wales Australia
| | - Ivan Goldberg
- Discipline of Ophthalmology; University of Sydney; Sydney New South Wales Australia
- Glaucoma Unit; Sydney Eye Hospital; Sydney New South Wales Australia
- Eye Associates; Sydney New South Wales Australia
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Affiliation(s)
- Waseem Qureshi
- Ophthalmology Department; North Middlesex University Hospital Trust; London; UK
| | - Raal Obikpo
- Ophthalmology Department; North Middlesex University Hospital Trust; London; UK
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Ratnarajan G, Newsom W, French K, Kean J, Chang L, Parker M, Garway-Heath DF, Bourne RRA. The impact of glaucoma referral refinement criteria on referral to, and first-visit discharge rates from, the hospital eye service: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways project. Ophthalmic Physiol Opt 2013; 33:183-9. [DOI: 10.1111/opo.12029] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/03/2013] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Karen French
- Huntingdon Glaucoma Diagnostic & Research Centre; Hinchingbrooke Hospital; Huntingdon; UK
| | - Jane Kean
- Huntingdon Glaucoma Diagnostic & Research Centre; Hinchingbrooke Hospital; Huntingdon; UK
| | | | - Mike Parker
- Postgraduate Medical Institute; Anglia Ruskin University; Cambridge; UK
| | - David F Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology; London; UK
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Ratnarajan G, Newsom W, Vernon SA, Fenerty C, Henson D, Spencer F, Wang Y, Harper R, McNaught A, Collins L, Parker M, Lawrenson J, Hudson R, Khaw PT, Wormald R, Garway-Heath D, Bourne R. 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. BMJ Open 2013; 3:bmjopen-2013-002715. [PMID: 23878172 PMCID: PMC3717451 DOI: 10.1136/bmjopen-2013-002715] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Gokulan Ratnarajan
- The North East, North Central London and Essex Health Innovation & Education Cluster
- Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK
- UCL Institute of Ophthalmology, London, UK
| | - Wendy Newsom
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, Huntingdon, UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | | | - Cecilia Fenerty
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - David Henson
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Fiona Spencer
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Yanfang Wang
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Robert Harper
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Andrew McNaught
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Lisa Collins
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Mike Parker
- Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK
| | - John Lawrenson
- Division of Optometry and Visual Science, City University London, London, UK
| | - Robyn Hudson
- The North East, North Central London and Essex Health Innovation & Education Cluster
| | - Peng Tee Khaw
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Richard Wormald
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Rupert Bourne
- The North East, North Central London and Essex Health Innovation & Education Cluster
- Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, Huntingdon, UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
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Blakeney S. NICE and joint-College guidelines on the referral of glaucoma suspects. Ophthalmic Physiol Opt 2012; 33:67. [PMID: 23252857 DOI: 10.1111/opo.12011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kotecha A, Clarke J. Authors' reply. Ophthalmic Physiol Opt 2012; 33:68-9. [PMID: 23252859 DOI: 10.1111/opo.12014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- John Lawrenson
- Division of Optometry and Visual Science; City University; London; UK
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Khan S, Clarke J, Kotecha A. Comparison of optometrist glaucoma referrals against published guidelines. Ophthalmic Physiol Opt 2012; 32:472-7. [PMID: 23009293 DOI: 10.1111/j.1475-1313.2012.00943.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Accepted: 08/20/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine if community optometrists follow published guidelines for referral of patients with suspect glaucoma to the hospital eye service. METHODS A retrospective audit of new optometrist-initiated referrals to the Glaucoma Service at Moorfields Eye Hospital, London was performed. Clinical data from referral letters recorded included evidence of intraocular pressure (IOP) measurement and tonometer used. Referral letter information was compared to 2009 guidelines published jointly by the College of Optometrists and Royal College of Ophthalmologists on referring glaucoma suspect patients. RESULTS A total of 289 new patients were seen in the Glaucoma Service over a 6 week period from 4th January 2011; a 100% hospital record retrieval rate was obtained. Of these, 114 (39%) were optometrists initiated referrals. Optometrist letters were available for 105 patients. IOP measurements were recorded in 102 (97%); most practitioners used non-contact tonometry (NCT; n = 69; 68%). Practitioners recorded <4 NCT readings per eye (4 readings: n = 3, 4%; 3 readings: n = 42, 61%; 2 readings: n = 6, 9%; 1 reading: n = 18, 26%). Seventy-seven patients (73%) reported with raised IOP as the main referral reason; of these, 33 (43%) were referred with raised IOP in isolation. NCT was the instrument used in the majority of these raised IOP cases (n = 56; 73%). In cases where raised IOP in isolation was the referral reason, 24 (73%) were recorded using NCT; 10 (30%) provided repeat IOP measurement data in the letter. One hundred and two (97%) referred patients attended the hospital appointment. Thirty (29%) were deemed not to have glaucoma, with the remainder diagnosed with ocular hypertension (n = 25; 25%), glaucoma suspect/glaucoma (n = 35, 34%) or narrow angles requiring intervention (n = 12, 12%). Thirty of the 33 patients referred with raised IOP in isolation attended their hospital visit. Ten (33%) of these patients were subsequently discharged. Six (20%) patients had IOP within normal limits when measured with applanation tonometry; all of these patients were kept within the service. CONCLUSIONS Community optometrists using NCT for measurement should be reminded of the guidelines on number of readings to take and also the value of repeating NCT measures when appropriate. This may help to increase the accuracy of glaucoma suspect referrals to hospital eye service.
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Affiliation(s)
- Sheema Khan
- NIHR Biomedical Research Centre for Ophthalmology, UCL Institute of Ophthalmology and Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Parkins DJ, Edgar DF. College guidelines for examining patients at risk from glaucoma. Ophthalmic Physiol Opt 2012; 32:164. [DOI: 10.1111/j.1475-1313.2012.00895.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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