Evaluation of a hospital-based integrated model of eye care for diabetic retinopathy assessment: a multimethod study

Implementation and scalability of shared care models for chronic eye disease: a realist assessment informed by health system stakeholders in Finland, the United Kingdom, and Australia

BACKGROUND/OBJECTIVES

Several health systems have implemented innovative models of care which share the management of patients with chronic eye diseases between ophthalmologists and optometrists. These models have demonstrated positive outcomes for health systems including increased access for patients, service efficiency and cost-savings. This study aims to understand factors which support successful implementation and scalability of these models of care.

SUBJECTS/METHODS

Semi-structured interviews were conducted with 21 key health system stakeholders (clinicians, managers, administrators, policy-makers) in Finland, United Kingdom and Australia between October 2018 and February 2020. Data were analyzed using a realist framework to identify the contexts, mechanisms of action, and outcomes of sustained and emerging shared care schemes.

RESULTS

Five key themes relating to successful implementation of shared care were identified as (1) clinician-led solutions, (2) redistributing teams, (3) building inter-disciplinary trust, (4) using evidence for buy-in, and (5) standardized care protocols. Scalability was found to be supported by (6) financial incentives, (7) integrated information systems, (8) local governance, and (9) a need for evidence of longer-term health and economic benefits.

CONCLUSIONS

The themes and program theories presented in this paper should be considered when testing and scaling shared eye care schemes to optimize benefits and promote sustainability.

The paediatric optometry alignment program - a model of interprofessional collaborative eyecare

CLINICAL RELEVANCE

Collaboration  between hospital-based ophthalmology and community-based optometry could pave the way to improve access to paediatric eyecare services.

BACKGROUND

The Paediatric Optometry Alignment Program (POAP) began in 2016 as a proof-of-concept pilot project that aimed to improve access to specialist paediatric ophthalmology services. If found to be effective at improving patient access, and the quality of care acceptable to patients and professionals then the strategic intent was to upscale the programme to  serve as a model for paediatric eye care in the community.

METHODS

Temporal observational trend analysis was used to review ophthalmology clinic appointment waitlists prior and post POAP pilot project commencement. Family satisfaction with post-discharge care was surveyed in a purposive sample of 30 patients.  Aligned optometrists in the program pilot (n = 97) were invited to complete an online survey (response rate 46%; n = 45).

RESULTS

The percentage of children waiting longer than clinically recommended fell from 72% to 36%. Sixty-seven percent  of surveyed families had attended a community optometrist as recommended, and all rated the optometry experience from good to excellent.  Participating optometrists reported high levels of satisfaction with involvement in the program, and increased confidence and involvement in paediatric eye care delivery. The need to improve formal transfer  of clinical information was identified.

CONCLUSION

Facilitated integrated care between community-based optometrists and a hospital-based ophthalmology department can improve access for tertiary care services, with high satisfaction for families and participating community-based optometrists.

Laser Treatment Modalities for Diabetic Retinopathy

Diabetes is a chronic progressive metabolic disorder that is caused by the body's inability to regulate blood glucose levels. If uncontrolled, it can lead to various complications. Among its various complications, long-term diabetes leads to diabetic retinopathy (DR). It is a disease involving blood vessels and the destruction of retinal nerves. It is usually classified into two types: proliferative diabetic retinopathy (PDR) and nonproliferative diabetic retinopathy (NPDR). It progresses and causes loss of vision. The leading cause of loss of vision is diabetic macular edema (DME). The argon laser is used as a modality in the management of PDR. There are various types of laser photocoagulation, such as peripheral retinal laser photocoagulation, focal macular laser photocoagulation, and grid photocoagulation. DR results in various adverse consequences such as vitreous hemorrhage, fibrosis, traction, detachment of the retina, and glaucoma. To assess DR, a detailed fundus examination with a slit lamp biomicroscope needs to be done. Seven-standard field stereoscopic-color fundus photography needs to be done for documentation and follow-up. Patients with diabetes mellitus (DM) type 1 have a greater risk of suffering from DR. Another major complication of the condition is DME, which is characterized by an increase in the permeability of vessels and the thickening of the central part of the retina along with the accumulation of hard exudates on the macula. This article discusses various laser therapy modalities for the treatment of DR, their types, mechanisms, and aims. Clinical features of DR include abnormal dilatation of capillaries, and outpouchings in the form of microaneurysm from the capillary wall are one of the earliest and most dangerous changes; later, non-perfusion of the retina occurs, which is associated with cotton wool spots and blot hemorrhages. In patients suffering from PDR and maculopathy, peripheral retinal laser photocoagulation is used as a mode of intervention.

Experiences of Patients With Diabetes Attending a Publicly Funded Eye Care Pathway in Western Sydney: A Qualitative Study

Diabetic retinopathy (DR) complications can be prevented with regular screening and timely access to an ophthalmologist for treatment. But there are patient and health system barriers that can impact access to DR services. This study aims to identify enablers and barriers for accessing public DR eye care services in a low socio-economic urban area of Australia. We conducted a qualitative study using semi-structured interviews for patients with diabetes aged 35 years and older attending public ophthalmology services. Interviews were analyzed to identify themes and subthemes; and the COM-B framework was used to interpret the complex behavioral mechanisms, including capability, opportunity, and motivation factors, to explain adherence to DR eye care. Three main themes and 7 sub-themes relating to patient experiences of DR care were derived. Patients were found to be passive actors in their DR eye care, but patients trusted clinicians and were determined to maintain their vision and quality of life. The barriers and facilitators of care related to the health system (service availability and recall–reminder systems) and patient experiences (choices, knowledge, and fear). The findings of this study will guide patient-centered initiatives to target and improve access to DR care. Strategies should focus on improving communication between eye care providers, and communication with patients to empower them to become more active players in healthcare decisions.