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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patterns of attendances to the hospital emergency eye care service: a multicentre study in England

BACKGROUND/OBJECTIVES

To characterise the patterns of presentation and diagnostic frequencies in Hospital Emergency Eye Care Services (HEECS) across 13 hospitals in England.

METHODS

Retrospective, cross-sectional, observational multi-centre (n = 13) study to assess HEECS attendances over a 28-day study period. Data derived included: number of consecutive attendances, patient demographics and diagnoses. Age and gender variations, the impact of day of the week on attendance patterns, diagnostic frequencies and estimates of the annual incidence and attendance rates were evaluated.

RESULTS

A total of 17,667 patient (mean ± standard deviation age = 49.6 ± 21.8 years) attendances were identified with an estimated HEECS annual new attendance rate of 31.0 per 1,000 population. Significantly more females (53%) than males (47%) attended HEECS (p < 0.001). Female attendances were 13% higher in those ≥50 years of age. Weekends were associated with a significant reduction in attendances compared to weekdays (χ2 = 6.94, p < 0.001). Among weekdays, Mondays and Fridays were associated with significantly higher attendances compared with midweek (χ2 = 2.20, p = 0.032). Presenting pathologies involving the external eye, cornea and conjunctiva accounted for 28.6% of the caseload.

CONCLUSION

This is the largest multicentre study assessing attendance patterns in HEECS in England. We have, for the first time, observed a "weekend effect" in relation to attendance to HEECS. Differences in health-seeking behaviour and lack of awareness of HEECS weekend services may be partly attributed to the differences observed. Our findings, along with the type of presentations, have the potential to guide commissioners with future planning of HEECS.

Protocol for a qualitative study to explore acceptability, barriers and facilitators of the implementation of new teleophthalmology technologies between community optometry practices and hospital eye services

INTRODUCTION

Novel teleophthalmology technologies have the potential to reduce unnecessary and inaccurate referrals between community optometry practices and hospital eye services and as a result improve patients' access to appropriate and timely eye care. However, little is known about the acceptability and facilitators and barriers to the implementations of these technologies in real life.

METHODS AND ANALYSIS

A theoretically informed, qualitative study will explore patients' and healthcare professionals' perspectives on teleophthalmology and Artificial Intelligence Decision Support System models of care. A combination of situated observations in community optometry practices and hospital eye services, semistructured qualitative interviews with patients and healthcare professionals and self-audiorecordings of healthcare professionals will be conducted. Participants will be purposively selected from 4 to 5 hospital eye services and 6-8 affiliated community optometry practices. The aim will be to recruit 30-36 patients and 30 healthcare professionals from hospital eye services and community optometry practices. All interviews will be audiorecorded, with participants' permission, and transcribed verbatim. Data from interviews, observations and self-audiorecordings will be analysed thematically and will be informed by normalisation process theory and an inductive approach.

ETHICS AND DISSEMINATION

Ethical approval has been received from London-Bromley research ethics committee. Findings will be reported through academic journals and conferences in ophthalmology, health services research, management studies and human-computer interaction.

Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease (HERMES): a Cluster Randomised Superiority Trial with a linked Diagnostic Accuracy Study-HERMES study report 1-study protocol

INTRODUCTION

Recent years have witnessed an upsurge of demand in eye care services in the UK. With a large proportion of patients referred to Hospital Eye Services (HES) for diagnostics and disease management, the referral process results in unnecessary referrals from erroneous diagnoses and delays in access to appropriate treatment. A potential solution is a teleophthalmology digital referral pathway linking community optometry and HES.

METHODS AND ANALYSIS

The HERMES study (Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease: a cluster randomised superiority trial with a linked diagnostic accuracy study) is a cluster randomised clinical trial for evaluating the effectiveness of a teleophthalmology referral pathway between community optometry and HES for retinal diseases. Nested within HERMES is a diagnostic accuracy study, which assesses the accuracy of an artificial intelligence (AI) decision support system (DSS) for automated diagnosis and referral recommendation. A postimplementation, observational substudy, a within-trial economic evaluation and discrete choice experiment will assess the feasibility of implementation of both digital technologies within a real-life setting. Patients with a suspicion of retinal disease, undergoing eye examination and optical coherence tomography (OCT) scans, will be recruited across 24 optometry practices in the UK. Optometry practices will be randomised to standard care or teleophthalmology. The primary outcome is the proportion of false-positive referrals (unnecessary HES visits) in the current referral pathway compared with the teleophthalmology referral pathway. OCT scans will be interpreted by the AI DSS, which provides a diagnosis and referral decision and the primary outcome for the AI diagnostic study is diagnostic accuracy of the referral decision made by the Moorfields-DeepMind AI system. Secondary outcomes relate to inappropriate referral rate, cost-effectiveness analyses and human-computer interaction (HCI) analyses.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the London-Bromley Research Ethics Committee (REC 20/LO/1299). Findings will be reported through academic journals in ophthalmology, health services research and HCI.

TRIAL REGISTRATION NUMBER

ISRCTN18106677 (protocol V.1.1).

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Analysis of UK eye casualty presentations

CLINICAL RELEVANCE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical outcomes of the Centre for Eye Health: an intra-professional optometry-led collaborative eye care clinic in Australia

Clinical relevance: This novel clinical model is the first of its kind in Australia and was designed to help reduce unnecessary referrals into overburdened public systems by utilising pre-existing community-based resources.Background: The Centre for Eye Health (CFEH) is an intra-professional optometry-led care clinic offering an alternative pathway to traditional ophthalmology-based pathways (public hospital clinics or private practices) for 'at-risk' patients requiring ocular imaging, diagnostic and management services. This study evaluates the CFEH integrated eye-care model in the identification of chronic eye diseases within the community.Methods: A retrospective random clinical audit of over 750 medical records of patients referred to the CFEH between July 2016 and June 2019 was conducted. Demographics of patients, referral type, final diagnosis and recommended management plans were extracted from this subset. Clinic key performance indicators (referral turnaround time, and net cost per patient appointment) were also extracted.Results: Of the 755 referrals associated with the audited records, 77.4% resulted in the identification of patients with or at-risk of developing eye diseases with 73.5% of this cohort requiring ongoing monitoring at CFEH or referral to ophthalmology. Although the CFEH model is not designed to diagnose or manage acute conditions, 1.5% of patients in this pathway required same day ophthalmological or medical intervention. The cost per patient was equivalent to hospital eye departments costs.Conclusion: This integrated care pathway has the potential to reduce unnecessary referrals from optometrists to hospital ophthalmological service by offering a safe and effective alternate pathway. The majority of patients seen within this pathway were able to be monitored within optometry-led services. This is a unique clinical model utilising inter-professional referrals within optometry which has the potential to reduce preventable blindness within the community through the early detection of eye diseases.

Referrals from community optometrists to the hospital eye service in England

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Method

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

Results

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

Conclusions

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