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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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2
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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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3
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Harvey K, Edgar DF, Agarwal R, Benwell MJ, Evans BJ. Referrals from community optometrists in England and their replies: A mixed methods study. Ophthalmic Physiol Opt 2022; 42:454-470. [PMID: 35106831 DOI: 10.1111/opo.12948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Community optometrists, through routine eye examinations, identify patients with disease or ocular abnormalities requiring referral to the Hospital Eye Service. In many cases no reply to the referral letter is received, resulting in some patients being re-referred unnecessarily, potentially increasing the number of other patients who lose sight whilst on hospital waiting lists. This study investigated, qualitatively and quantitatively, factors influencing optometric referrals and replies. METHODS The three-phase, sequential mixed methods study started with a literature review and qualitative phase, interviewing stakeholders to identify issues for exploration in subsequent phases. The second, quantitative phase, undertook documentary analysis of 349 patient referral records from three optometric practice modalities (domiciliary, independently owned, and corporate chain) in England. A final qualitative phase obtained views from stakeholders to explore unexplained findings from the first two phases. RESULTS Phase 1 identified communication, financial, professional and technological issues for further exploration. In Phase 2, the referral rate was 22.2% for domiciliary provider, 2.1% for independent practice and 2.5% for the corporate chain, with the variation most likely explained by patient age and associated ophthalmic disease, illness and disability. The referral reply rate was 5.7% for domiciliary provider, 25.0% for independent practice and 4.9% for the corporate chain. The community optometrist remained unaware of the outcome of their referral in 72.8% of cases. Qualitative analyses indicate the main factors influencing referral reply rates are technology, the General Medical Practitioner, community optometrists' utility to and utility of the National Health Service and patient mobilisation. CONCLUSIONS The low referral reply rate creates a break in the feedback loop required to raise the standard of referrals and avoid unnecessary re-referral. Of the factors identified that influence referral reply rates, technology is key in view of the increasing use of online referral platforms. Feedback to the referring optometrist should be embedded in such systems.
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Affiliation(s)
- Krystynne Harvey
- School of Health and Social Care, London South Bank University, London, UK.,Institute of Optometry, London, UK
| | - David F Edgar
- Division of Optometry and Visual Sciences, School of Health Sciences, City, University of London, London, UK
| | - Rishi Agarwal
- School of Health and Social Care, London South Bank University, London, UK.,Institute of Optometry, London, UK
| | - Martin J Benwell
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Bruce Jw Evans
- School of Health and Social Care, London South Bank University, London, UK.,Institute of Optometry, London, UK.,Division of Optometry and Visual Sciences, School of Health Sciences, City, University of London, London, UK
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Harper RA, Edgar DF, Lawrenson JG. Methodological challenges and opportunities in evaluating clinical safety in primary eyecare services. Ophthalmic Physiol Opt 2022; 42:658-659. [DOI: 10.1111/opo.12954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Robert A Harper
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre Manchester University NHS Foundation Trust Manchester Manchester UK
- Division of Pharmacy and Optometry Faculty of Biology, Medicine and Health School of Health Sciences University of Manchester Manchester UK
| | - David F Edgar
- Division of Optometry and Visual Sciences School of Health Sciences, City University of London London UK
| | - John G Lawrenson
- Division of Optometry and Visual Sciences School of Health Sciences, City University of London London UK
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5
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Williams E, Craven W, Wilson H, Dhawahir-Scala F, Jinkinson M, Newman WD, Harper RA. Reassurance on false negatives in the Manchester COVID19 Urgent Eyecare Service (CUES). Eye (Lond) 2022; 36:12-14. [PMID: 34584233 PMCID: PMC8477717 DOI: 10.1038/s41433-021-01774-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/20/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- Emma Williams
- grid.498924.aManchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
| | - Wendy Craven
- Primary Eyecare Service, 2.3 Waulk Mill, Manchester, UK
| | - Helen Wilson
- grid.498924.aManchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
| | - Felipe Dhawahir-Scala
- grid.498924.aManchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
| | - Matthew Jinkinson
- Primary Eyecare Service, 2.3 Waulk Mill, Manchester, UK ,Greater Manchester Eye Health Network, Health & Social Care Partnership, Manchester, UK
| | - William D. Newman
- grid.498924.aManchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
| | - Robert A. Harper
- grid.498924.aManchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK ,grid.5379.80000000121662407Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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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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7
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Hanumunthadu D, Adan K, Tinkler K, Balaskas K, Hamilton R, Nicholson L. Outcomes following implementation of a high-volume medical retina virtual clinic utilising a diagnostic hub during COVID-19. Eye (Lond) 2021; 36:627-633. [PMID: 33824508 PMCID: PMC8023775 DOI: 10.1038/s41433-021-01510-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/05/2021] [Accepted: 03/10/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To describe the clinical outcomes following implementation of a high-volume medical retina virtual clinic utilising a diagnostic hub. METHODS Retrospective consecutive case-series of all patients attending the medical retina virtual clinics at Moorfields Eye Hospital (City Road) for 6 weeks from September 21, 2020. RESULTS In 6 weeks, 1006 patients attended the medical retina virtual clinics, which included an appointment in the diagnostic hub followed by an assessment asynchronously the following working day. The vast majority of patients were follow-up attendances (969, 96.3%) with much fewer new patient attendances (37, 3.7%). The most common diagnoses made overall were diabetic retinopathy (457, 45.4%), age-related macular degeneration (208, 20.7%) and retinal vein occlusion (80, 8.0%). The majority of patient (643, 63.9%) outcomes were follow-up in the medical retina virtual clinics including 313 (31.1%) with OCT-only pathway and 330 (32.8%) with OCT and widefield fundus imaging. Routine follow-up requested after virtual assessment included 320 (31.8%) with a 3-4 month review and 267 (26.5%) with a 6 months assessment. Only 62 patients (6.2%) were asked to return for face-to-face assessment within 2 weeks. CONCLUSIONS We describe a new high-volume medical retina virtual clinic utilising a diagnostic hub in which more than 1000 patients were seen and assessed asynchronously. Most patients were assessed as suitable for routine follow-up in this virtual pathway and only a small proportion required urgent reviews (within 2 weeks). In the COVID-19 era, this form of high-volume virtual clinic has the potential to review patients efficiently and safely.
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Affiliation(s)
| | - Khadra Adan
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Kerry Tinkler
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Robin Hamilton
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Luke Nicholson
- Moorfields Eye Hospital NHS Foundation Trust, London, UK.
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8
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Conway MP, Forristal MT, Treacy MP, Duignan ES. Investigating the Role of Optometrists in Teleophthalmology and the Implications of Increasing Access to Advanced Imaging Techniques and Digital Referral: A Systematic Search and Review. Telemed J E Health 2020; 27:974-981. [PMID: 33275866 DOI: 10.1089/tmj.2020.0284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: The objective of this systematic search and review was to investigate the role of optometrists in teleophthalmology and digital referral. We examine the implications of the optometric communities' increasing access to advanced imaging, such as optical coherence tomography (OCT), in ophthalmic telemedicine schemes. Methods: A systematic search was conducted, using PubMed and Embase, in April of 2019. Eight hundred eight (n = 808) texts were retrieved and 99 articles were deemed eligible for full-text review. Twenty-six (n = 26) studies were included in the qualitative synthesis. All studies involved optometrists as principal service providers. Results: Findings demonstrate that optometrist-facilitated teleophthalmology results in consistent reductions in hospital referrals and waiting times, as well as high patient satisfaction. Optometrists are identified as crucial to the success of many projects and their access to advanced imaging technology is observed to position optometry practices as the most convenient location to establish a teleophthalmology program. OCT imaging demonstrated the potential to increase diagnostic accuracy and is increasingly prevalent in optometry practice. The importance of additional training for optometrists participating in teleophthalmology schemes is highlighted, as is the need for appropriate remuneration for those involved. Conclusion: The role of community-based ophthalmic care in reducing demands on hospital eye services (HES) is highlighted by our results, demonstrating that optometrist-facilitated teleophthalmology can dramatically reduce referrals and streamline care. In addition, the increasing prevalence of OCT in optometric practice represents an underutilized resource for HES.
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9
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Jindal A, Ctori I, Fidalgo B, Dabasia P, Balaskas K, Lawrenson JG. Impact of optical coherence tomography on diagnostic decision-making by UK community optometrists: a clinical vignette study. Ophthalmic Physiol Opt 2019; 39:205-215. [PMID: 30994199 PMCID: PMC6849707 DOI: 10.1111/opo.12613] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/13/2019] [Indexed: 11/30/2022]
Abstract
Purpose In recent years, there has been widespread investment in imaging technologies by community optometrists in the UK, most notably optical coherence tomography (OCT). The aim of the current study was to determine the value of OCT in the diagnosis of posterior segment diseases in a representative sample of community optometrists using a clinical vignette methodology. Methods A group of community optometrists (n = 50) initially completed a standardised training package on OCT interpretation followed by a computer‐based assessment featuring 52 clinical vignettes, containing images of healthy (n = 8) or glaucomatous (n = 18) discs or healthy (n = 8) or diseased (n = 18) fundi. Each vignette featured either a single fundus/disc photographic image, or a combination of a fundus/disc image with the corresponding OCT scan. An expert panel confirmed that the fundus images presented alone and those in combination with OCT data were of a similar level of difficulty and that the cases were typical of those seen in primary care. For each case, the optometrist selected their diagnosis from a pull‐down list and reported their confidence in their decision using a 10‐point Likert scale. Pairwise comparisons of the fundus image alone and fundus image/OCT combination were made for both diagnostic performance and confidence. Results The mean percentage of correct diagnoses using fundus imaging alone was 62% (95% CI 59–64%) and for the combination of fundus image/OCT was 80% (95% CI 77–82%). The mean false negative rate with fundus alone was 27% reducing to 13% with the OCT combination. Median confidence scores for fundus imaging alone was 8.0 (IQR 7.0–8.0) and 8.3 (IQR 8.0–9.0) for the combination. Improvements in performance and confidence were statistically significant (p < 0.001). Conclusion The results from this vignette study suggests that OCT improves optometrists’ diagnostic performance compared to fundus observation alone. These initial results suggest that OCT provides valuable additional data that could augment case‐finding for glaucoma and retinal disease; however, further research is needed to assess its diagnostic performance in a routine clinical practice setting.
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Affiliation(s)
- Anish Jindal
- Division of Optometry and Visual Science, City University of London, London, UK
| | - Irene Ctori
- Division of Optometry and Visual Science, City University of London, London, UK
| | - Bruno Fidalgo
- Division of Optometry and Visual Science, City University of London, London, UK
| | - Priya Dabasia
- Division of Optometry and Visual Science, City University of London, London, UK
| | | | - John G Lawrenson
- Division of Optometry and Visual Science, City University of London, London, UK
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10
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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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11
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Phu J, Hennessy MP, Spargo M, Dance S, Kalloniatis M. A collaborative care pathway for patients with suspected angle closure glaucoma spectrum disease. Clin Exp Optom 2019; 103:212-219. [PMID: 31119793 DOI: 10.1111/cxo.12923] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/01/2019] [Accepted: 04/15/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Currently, no specific collaborative care pathway exists that distinguishes open angle glaucoma from narrow angle or angle closure disease. This study evaluates a newly developed referral and collaborative care pathway specifically for patients with angle closure spectrum disease. METHODS The medical records of consecutive patients referred to the Centre for Eye Health for glaucoma assessment were examined, six months before (Pre Suite) and after (Post Suite) the introduction of a novel referral pathway for anterior chamber angle assessment (Angle Suite). Patient demographic and clinical data, the referral letter and practitioner characteristics were extracted. RESULTS Angle Suite (n = 77) patients had an appointment much sooner compared to Pre (n = 383) and Post Suite (n = 425) patients (p < 0.0001). Following the introduction of Angle Suites, there was a reduction of incidental angle closure disease found in routine, non-angle closure glaucoma assessment. Onward referral was required by 36.4 per cent of patients referred for suspected angle closure disease, while the rest could be discharged back into the community (13.0 per cent) or reviewed at the Centre for Eye Health (50.6 per cent). Multinomial logistic regression found that the presence of an angle description in the referral letter improved the true positive rate for angle closure disease (p < 0.0001). CONCLUSIONS The clinical pathway may reduce the number of incidental angle closure patients and improved the timeliness of appropriate clinical care delivered to a subset of patients who may benefit from prompt medical attention. This pathway provides an opportunity for appropriately staffed and equipped collaborative care clinics to reduce the burden on tertiary level ophthalmic facilities.
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Affiliation(s)
- Jack Phu
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,School of Optometry and Vision Science, The University of New South Wales, Kensington, New South Wales, Australia
| | - Michael P Hennessy
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,Department of Ophthalmology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Matthew Spargo
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,Department of Ophthalmology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Samuel Dance
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,Department of Ophthalmology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Michael Kalloniatis
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,School of Optometry and Vision Science, The University of New South Wales, Kensington, New South Wales, Australia
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12
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Annoh R, Patel S, Beck D, Ellis H, Dhillon B, Sanders R. Digital ophthalmology in Scotland: benefits to patient care and education. Clin Ophthalmol 2019; 13:277-286. [PMID: 30799914 PMCID: PMC6371934 DOI: 10.2147/opth.s185186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Tackling visual impairment remains an important public health issue. Due to limited resources and the increasing demand on hospital eye services (HES), delivery of quality eye care within the community is essential. Training of clinical ophthalmic specialists and allied health-care professionals in the detection and management of common eye conditions can thus help to reduce the burden of eye disease and improve prognostic outcomes. Digital imaging has become a useful tool in facilitating eye-care delivery in both the community and hospital setting. In the last decade, the advent of electronic image exchange via a centralized referral unit in Scotland has revolutionized screening for ophthalmic disease, referrals, and shared care between community and HES clinicians. A government-led initiative known as the Scottish Eyecare Integration Project introduced electronic transfer of digital images within referrals from community optometrists to HES, which greatly reduced outpatient waiting times and improved patient satisfaction. The catalogue of live clinical information and digital images that resulted from the project led to the creation of a virtual learning platform through the University of Edinburgh. Participating professionals involved in eye care have interactive discussions about common eye conditions by sharing digital images of cases and investigations on a global online platform. This has received worldwide attention and inspired the creation of other university courses, e-learning platforms in eye-health education, and shared-care schemes in the screening of eye disease. We show that digital ophthalmology plays a vital role in the integration of community and HES partnership in delivery of patient care and in facilitating eye-health education to a global audience.
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Affiliation(s)
| | - Sirjhun Patel
- Ophthalmology Department, Ninewells Hospital, Dundee, UK
| | - Daniel Beck
- Princess Alexandra Eye Pavilion, Edinburgh, UK,
| | - Heather Ellis
- Ophthalmology Department, Lauriston Building, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | - Bal Dhillon
- Princess Alexandra Eye Pavilion, Edinburgh, UK,
- University of Edinburgh, Edinburgh, UK
| | - Roshini Sanders
- University of Edinburgh, Edinburgh, UK
- Queen Margaret Hospital, Dunfermline, UK
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13
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Gunn PJG, Marks JR, Konstantakopoulou E, Edgar DF, Lawrenson JG, Roberts SA, Spencer AF, Fenerty CH, Harper RA. Clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme. Br J Ophthalmol 2018; 103:1066-1071. [PMID: 30309913 PMCID: PMC6678050 DOI: 10.1136/bjophthalmol-2018-312385] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/24/2018] [Accepted: 08/18/2018] [Indexed: 11/26/2022]
Abstract
Background Glaucoma referral filtering schemes have operated in the UK for many years. However, there is a paucity of data on the false-negative (FN) rate. This study evaluated the clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme (GERS), estimating both the false-positive (FP) and FN rates. Method Outcome data were collected for patients newly referred through GERS and assessed in ‘usual-care’ clinics to determine the FP rate (referred patients subsequently discharged at their first visit). For the FN rate, glaucoma suspects deemed not requiring referral following GERS assessment were invited to attend for a ‘reference standard’ examination including all elements of assessment recommended by National Institute for Health and Care Excellence (NICE) by a glaucoma specialist optometrist. A separate 33 cases comprising randomly selected referred and non-referred cases were reviewed independently by two glaucoma specialist consultant ophthalmologists to validate the reference standard assessment. Results 1404 patients were evaluated in GERS during the study period; 651 (46.3%) were referred to the Hospital Eye Service (HES) and 753 (53.6%) were discharged. The FP rate in 307 assessable patients referred to the HES was 15.5%. This study reviewed 131 (17.4%) of those patients not referred to the HES through the GERS scheme; 117 (89.3%) were confirmed as not requiring hospital follow-up; 14 (10.7%) required follow-up, including 5 (3.8%) offered treatment. Only one patient (0.8%) in this sample met the GERS referral criteria and was not referred (true FN). There were no cases of missed glaucoma or non-glaucomatous pathology identified within our sample. Conclusion The Manchester GERS is an effective glaucoma filtering scheme with a low FP and FN rate.
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Affiliation(s)
- Patrick J G Gunn
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK .,Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Joanne R Marks
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
| | - Evgenia Konstantakopoulou
- Division of Optometry and Visual Science, Centre for Applied Vision Research, University of London, London, UK.,NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - David F Edgar
- Division of Optometry and Visual Science, Centre for Applied Vision Research, University of London, London, UK
| | - John G Lawrenson
- Division of Optometry and Visual Science, Centre for Applied Vision Research, University of London, London, UK
| | - Stephen A Roberts
- Centre for Biostatistics School of Health Sciences, University of Manchester, Manchester, UK
| | - Anne F Spencer
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
| | - Cecilia H Fenerty
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK
| | - Robert A Harper
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, UK.,Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Division of Optometry and Visual Science, Centre for Applied Vision Research, University of London, London, UK
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14
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Barrett C, O'Brien C, Loughman J. Glaucoma referral refinement in Ireland: managing the sensitivity-specificity paradox in optometric practice. Ophthalmic Physiol Opt 2018; 38:400-410. [PMID: 29492992 DOI: 10.1111/opo.12446] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/24/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Glaucoma referral refinement (GRR) has proven a successful demand management strategy for glaucoma suspect cases in the United Kingdom (UK). A GRR clinic was established in Dublin, Ireland to investigate the clinical viability of this pathway outside the UK's National Health Service (NHS) structures, and away from the influence of National Institute for Clinical Excellence (NICE) guidance. METHODS Glaucoma suspect patients were recruited into the scheme following referral from community optometrists in the greater Dublin area. The GRR exam protocol was designed in consultation with the participating ophthalmology department. The refinement scheme optometrist, trained through apprenticeship style experience at a hospital outpatient clinic, made a tentative management decision after carrying out the GRR exam. The final management decision was made in a 'virtual clinic' by a glaucoma specialist consultant ophthalmologist. RESULTS Two hundred and twenty-five glaucoma suspect patients were seen in the scheme. After their first GRR visit, 28% were discharged back to their own optometrist, 42% were monitored in the GRR clinic, and 30% were referred to ophthalmology. After this monitoring cohort were further assessed, a total of 38% of the patients seen within the scheme required referral to ophthalmology. Sixteen percent of the total participant group (n = 225) were lost to follow up. Cohen's κ was used to determine the level of agreement between the scheme optometrist and ophthalmologist. There was substantial agreement, with κ = 0.63 for the first visit management decisions (n = 225). Agreement increased for subsequent monitoring visits with κ = 0.85 for second visits (n = 65), and κ = 0.69 for all management decisions within the scheme (n = 301). We received management outcomes for 44 of the 86 patients referred to ophthalmology. Of these 44, 57% received medical treatment for glaucoma, 34% were monitored without treatment, 2% were discharged, and 7% had comorbidities that were assessed and managed. CONCLUSION Of the patients seen within the scheme, 62% did not require referral onward to ophthalmology, thus releasing the significant majority of hospital clinic slots that would previously have been required to examine such patients. The high level of inter-professional decision agreement likely reflects the benefits of pre-scheme apprenticeship style training and ongoing hospital clinic participation by the scheme optometrist. The rate of loss to follow up compares favourably with ophthalmology led, hospital based, glaucoma clinics. Nevertheless, the losses indicate that patient education remains a key priority for future planning.
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Affiliation(s)
- Catriona Barrett
- Department of Optometry, Dublin Institute of Technology (DIT), Dublin, Ireland.,DIT Centre for Eye Research Ireland, Environmental Sustainability and Health Institute, Dublin, Ireland
| | - Colm O'Brien
- Department of Ophthalmology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - James Loughman
- Department of Optometry, Dublin Institute of Technology (DIT), Dublin, Ireland.,DIT Centre for Eye Research Ireland, Environmental Sustainability and Health Institute, Dublin, Ireland.,African Vision Research Institute, University of KwaZulu Natal, Durban, South Africa
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15
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Sim DA, Mitry D, Alexander P, Mapani A, Goverdhan S, Aslam T, Tufail A, Egan CA, Keane PA. The Evolution of Teleophthalmology Programs in the United Kingdom: Beyond Diabetic Retinopathy Screening. J Diabetes Sci Technol 2016; 10:308-17. [PMID: 26830492 PMCID: PMC4773982 DOI: 10.1177/1932296816629983] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Modern ophthalmic practice in the United Kingdom is faced by the challenges of an aging population, increasing prevalence of systemic pathologies with ophthalmic manifestations, and emergent treatments that are revolutionary but dependent on timely monitoring and diagnosis. This represents a huge strain not only on diagnostic services but also outpatient management and surveillance capacity. There is an urgent need for newer means of managing this surge in demand and the socioeconomic burden it places on the health care system. Concurrently, there have been exponential increases in computing power, expansions in the strength and ubiquity of communications technologies, and developments in imaging capabilities. Advances in imaging have been not only in terms of resolution, but also in terms of anatomical coverage, allowing new inferences to be made. In spite of this, image analysis techniques are still currently superseded by expert ophthalmologist interpretation. Teleophthalmology is therefore currently perfectly placed to face this urgent and immediate challenge of provision of optimal and expert care to remote and multiple patients over widespread geographical areas. This article reviews teleophthalmology programs currently deployed in the United Kingdom, focusing on diabetic eye care but also discussing glaucoma, emergency eye care, and other retinal diseases. We examined current programs and levels of evidence for their utility, and explored the relationships between screening, teleophthalmology, disease detection, and monitoring before discussing aspects of health economics pertinent to diabetic eye care. The use of teleophthalmology presents an immense opportunity to manage the steadily increasing demand for eye care, but challenges remain in the delivery of practical, viable, and clinically proven solutions.
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Affiliation(s)
- Dawn A Sim
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK Moorfields South, Croydon University Hospital, London, UK Moorfields South, St George's Hospital, London, UK University College London, Institute of Ophthalmology, London, UK
| | - Danny Mitry
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Philip Alexander
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Adam Mapani
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Srini Goverdhan
- University of Southampton, Southampton Eye Unit, Southampton, UK
| | - Tariq Aslam
- Manchester University, Manchester Royal Eye Hospital, Manchester, UK
| | - Adnan Tufail
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK University College London, Institute of Ophthalmology, London, UK
| | - Catherine A Egan
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK Moorfields South, St George's Hospital, London, UK University College London, Institute of Ophthalmology, London, UK
| | - Pearse A Keane
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK University College London, Institute of Ophthalmology, London, UK
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