Comparing costs of monitoring glaucoma patients: hospital ophthalmologists versus community optometrists

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.

Evaluating the cost and wait-times of a task-sharing model of care for diabetic eye care: a case study from Australia

OBJECTIVES

To determine whether a collaborative model of care that uses task-sharing for the management of low-risk diabetic retinopathy, Community Eye Care (C-EYE-C), can improve access to care and better use resources, compared with hospital-based care.

DESIGN

Retrospective audit of medical and financial records to compare two models of care.

SETTING

A large, urban tertiary Australian publicly funded hospital.

INTERVENTION

C-EYE-C is a collaborative care model, involving community-based optometrist assessment and 'virtual review' by ophthalmologists to manage low-risk patients. The C-EYE-C model of care was implemented from January to October 2017.

PARTICIPANTS

New low-risk patient referrals with diabetes received at a tertiary hospital ophthalmology unit.

PRIMARY AND SECONDARY OUTCOMES

Historical standard hospital care was compared with C-EYE-C for attendance, wait-times, outcomes and costs. Clinical concordance between the optometrist and ophthalmologist diagnosis and management was assessed using weighted kappa statistic.

RESULTS

There were 133 new low-risk referrals, managed in standard hospital care (n=68) and C-EYE-C (n=65). Attendance rates were similar between the models of care (72.1% hospital vs 67.7% C-EYE-C, p=0.71). C-EYE-C had shorter appointment wait-time (53 vs 118 days, p<0.01). In the C-EYE-C model of care, 68.2% of patients did not require hospital appointments and costs were 43% less than hospital care. There was substantial agreement between optometrists and ophthalmologists for diagnosis (κ=0.64, CI 0.47-0.81) and management (κ=0.66, CI 0.45-0.87).

CONCLUSION

This Australian study showed that collaborative eye care resulted in reduced patient waiting times and considerable cost-savings, while maintaining a high standard of patient care compared with traditional hospital-based care in the management of low-risk hospital referrals with diabetic eye disease. The improved access and reduced costs were largely the result of better task allocation through greater utilisation of primary eye care professionals to provide services for low-risk patients. Better resource use may free up further resources for other eye care services.

Impact of referral refinement on management of glaucoma suspects in Australia

BACKGROUND

In ageing populations, the prevalence of chronic diseases such as glaucoma is projected to increase, placing additional demands on limited health-care resources. In the UK, the demand for secondary care in hospital eye clinics was inflated by high rates of false positive glaucoma referrals. Collaborative care models incorporating referral refinement, whereby glaucoma suspect referrals are triaged by suitably trained optometrists through further testing, can potentially reduce false positive referrals. This study examined the impact of a referral refinement model on the accuracy of glaucoma referrals in Australia.

METHODS

Optometrist-initiated glaucoma suspect referrals to the Glaucoma Management Clinic (Sydney, Australia) were prospectively recruited. Glaucoma suspect referrals arising from two pathways were eligible for inclusion, either directly from a community optometrist (standard care) or following comprehensive assessment at the Centre for Eye Health (referral refinement). Main outcome measures were the positive predictive value and false positive rate of referrals. The impact of referral letter content on management outcomes was also investigated.

RESULTS

Of 464 referrals received between March 2015 and June 2018, 252 were for treatment of naïve glaucoma suspects and eligible for inclusion. Following ophthalmological assessment, 45.6 per cent (n = 115/252) were prescribed treatment for open angle glaucoma or ocular hypertension. Positive predictive value of community optometry referrals was 33.8 per cent (n = 25/74) and 50.6 per cent (n = 90/178) following referral refinement. The first visit discharge (false positive) rate was 26 per cent (n = 19/74) for community referrals compared to four per cent (n = 8/178) with referral refinement. Positive predictive value increased with the number of abnormal clinical examination findings associated with referral (χ² test, p < 0.0001). The number of abnormal findings reported in referrals was significantly higher with referral refinement compared to without (n = 1.9 versus 1.5, t-test, p < 0.0001).

CONCLUSION

Referral refinement can improve the diagnostic accuracy of optometry-initiated referrals for glaucoma suspects in Australia, thereby decreasing unnecessary referrals to hospital and other secondary clinics.

Care pathways for glaucoma detection and monitoring in the UK

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.

Improving Patient Access and Reducing Costs for Glaucoma with Integrated Hospital and Community Care: A Case Study from Australia

Introduction:

Glaucoma, a chronic eye disease requires regular monitoring and treatment to prevent vision-loss. In Australia, most public ophthalmology departments are overburdened. Community Eye Care is a ‘collaborative’ care model, involving community-based optometrist assessment and ‘virtual review’ by ophthalmologists to manage low-risk patients. C-EYE-C was implemented at one Australian hospital. This study aims to determine whether C-EYE-C improves access to care and better utilises resources, compared to hospital-based care.

Methods:

A clinical and financial audit was conducted to compare access to care and health system costs for hospital care and C-EYE-C. Attendance, wait-time, patient outcomes, and the average cost per encounter were calculated. A weighted kappa assessed agreement between the optometrist and ophthalmologist decisions.

Results:

There were 503 low-risk referrals, hospital (n = 182) and C-EYE-C (n = 321). C-EYE-C had higher attendance (81.6% vs 68.7%, p = 0.001); and shorter appointment wait-time (89 vs 386 days, p < 0.001). Following C-EYE-C, 57% of patients avoided hospital; with 39% requiring glaucoma management. C-EYE-C costs were 22% less than hospital care. There was substantial agreement between optometrists and ophthalmologist for diagnosis (k = 0.69, CI 0.61–0.76) and management (k = 0.66, CI 0.57–0.74).

Discussion:

C-EYE-C showed higher attendance, and reduced wait-times and health system costs.

Conclusions:

Upscale of the C-EYE-C model should be considered to further improve capacity of public eye services in Australia.

A systematic review of teleophthalmological studies in Europe

A systematic review of the recent literature regarding a series of ocular diseases involved in European telemedicine projects was performed based on the PubMed, Google Scholar and Springer databases in June 2017. Literature review returned 44 eligible studies; among them, emergency ophthalmology, diabetic retinopathy, glaucoma, age-related macular disease, cataract and retinopathy of prematurity. The majority of studies indicate teleophthalmology as a valid, reliable and cost-efficient method for care-provision in ophthalmology patients which delivers comparable outcomes to the traditional examination methods.

Effectiveness of UK optometric enhanced eye care services: a realist review of the literature

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.

Shared Care in Monitoring Stable Glaucoma Patients: A Randomized Controlled Trial

PURPOSE

Comparing the quality of care provided by a hospital-based shared care glaucoma follow-up unit with care as usual.

PATIENTS AND METHODS

This randomized controlled trial included stable glaucoma patients and patients at risk for developing glaucoma. Patients in the Usual Care group (n=410) were seen by glaucoma specialists. In the glaucoma follow-up unit group (n=405), patients visited the glaucoma follow-up unit twice followed by a visit to a glaucoma specialist. The main outcome measures were: compliance to the working protocol by glaucoma follow-up unit employees; difference in intraocular pressure between baseline and at ≥18 months; and patient satisfaction.

RESULTS

Glaucoma follow-up unit employees closely adhered to the working protocol for the measurement of intraocular pressure, visual acuity and GDx (≥97.5% of all visits). Humphrey Field Analyzer examinations were not performed as frequently as prescribed by the working protocol, but more often than in the Usual Care group. In a small minority of patients that required back-referral, the protocol was disregarded, notably when criteria were only slightly exceeded. There was no statistically significant difference in changes in intraocular pressure between the 2 treatment groups (P=0.854). Patients were slightly more satisfied with the glaucoma follow-up unit employees than with the glaucoma specialists (scores: 8.56 vs. 8.40; P=0.006).

CONCLUSIONS

In general, the hospital-based shared care glaucoma follow-up closely observed its working protocol and patients preferred it slightly over the usual care provided by medical doctors. The glaucoma follow-up unit operated satisfactorily and might serve as a model for shared care strategies elsewhere.

An economic comparison of hospital-based and community-based glaucoma clinics

INTRODUCTION

We have established one model for community care of glaucoma clinic patients. Community optometrists received training and accreditation in glaucoma care. Once qualified they alternated between running half day glaucoma clinics in their own High Street practices and assisting in a hospital-based glaucoma clinic session. This paper reports the cost of this model.

METHODS

Micro-costing was undertaken for the hospital clinic. A consensus meeting was held to agree costs for community clinics involving all optometrists in the project along with representatives of the multiple chain optometry practices who had participated. Costs to patients both indirect and direct were calculated following structured interviews of 197 patients attending hospital clinics and 194 attending community clinics.

RESULTS

The estimated cost per patient attendance to the hospital clinic was £63.91 and the estimated cost per attendance to the community clinic was £145.62. For patients the combined direct and indirect cost to attend the hospital clinic was £6.15 and the cost to attend the community clinic £5.91.

DISCUSSION

The principal reason for the higher cost in the community clinic was higher overhead costs in the community. Re-referral to the hospital system only occurred for 9% of patients and was not a large contribution to the increased cost. Time requested to next appointment was similar for the two clinics. Sensitivity analysis shows a strong effect of increasing patients seen per clinic. It would, however, require 25 patients to be seen per clinician per day in the community in order to make the costs comparable.

Cost-effectiveness of monitoring glaucoma patients in shared care: an economic evaluation alongside a randomized controlled trial

Background

Population aging increases the number of glaucoma patients which leads to higher workloads of glaucoma specialists. If stable glaucoma patients were monitored by optometrists and ophthalmic technicians in a glaucoma follow-up unit (GFU) rather than by glaucoma specialists, the specialists' workload and waiting lists might be reduced.

We compared costs and quality of care at the GFU with those of usual care by glaucoma specialists in the Rotterdam Eye Hospital (REH) in a 30-month randomized clinical trial. Because quality of care turned out to be similar, we focus here on the costs.

Methods

Stable glaucoma patients were randomized between the GFU and the glaucoma specialist group. Costs per patient year were calculated from four perspectives: those of patients, the Rotterdam Eye Hospital (REH), Dutch healthcare system, and society. The outcome measures were: compliance to the protocol; patient satisfaction; stability according to the practitioner; mean difference in IOP; results of the examinations; and number of treatment changes.

Results

Baseline characteristics (such as age, intraocular pressure and target pressure) were comparable between the GFU group (n = 410) and the glaucoma specialist group (n = 405).

Despite a higher number of visits per year, mean hospital costs per patient year were lower in the GFU group (€139 vs. €161). Patients' time and travel costs were similar. Healthcare costs were significantly lower for the GFU group (€230 vs. €251), as were societal costs (€310 vs. €339) (p < 0.01). Bootstrap-, sensitivity- and scenario-analyses showed that the costs were robust when varying hospital policy and the duration of visits and tests.

Conclusion

We conclude that this GFU is cost-effective and deserves to be considered for implementation in other hospitals.

Hospital-based glaucoma clinics: what are the costs to patients?

AIM

To investigate the costs to patients attending hospital-based glaucoma clinics.

METHODS

A patient-based costs questionnaire was developed and completed for patients attending six ophthalmology units across London (Ealing General Hospital, St Georges Hospital, Mile End Hospital, Upney Centre Barking, St Ann's Hospital and the Royal London Hospital). The questionnaire considered age, sex, ethnicity as well as patient-based costs, opportunity costs, and companion costs. All patients visiting for review or appointments were approached non-selectively. A total of 100 patients were sampled from each unit.

RESULTS

The mean age of the full sample was 69.6 years (SD 12.6), with little variation between sites (68.5-71.8 years). There was an almost equal sex distribution (male (298 (50.6%)). There was no major difference in occupational distribution between sites. The majority of people came to hospital by bus (40%) or car (26%). Female patients went slightly more by cab or car, whereas male patients went slightly more by foot or train. There was some variability in transport method by site. The data showed that the Royal London hospital had the highest mean cost per visit (pound16.20), whereas St Georges had the lowest (pound12.90). Upney had the second highest mean cost per visit (pound15.20), whereas Ealing and St Ann's had similar mean costs of (pound13.25) and (pound13), respectively. Travel costs accounted for about one-fifth of the total patient's costs. For all glaucoma clinics, total societal costs were higher than the sum of patients' costs because of the high frequency of companions. A surprising finding was that two-thirds of the population (392 or 66.6%) reported no qualification-considerably higher than the national census statistics for the same population.

CONCLUSIONS

To our knowledge this paper presents direct and indirect patient costs in attending hospital glaucoma units for the first time. It highlights the significance of opportunity costs when considering health-care interventions as they amount to a third or more of the total costs of patient attendances to clinics.

Managing 'suspicious glaucomatous discs' identified during digital-photography-based diabetic retinopathy screening

PURPOSE

An audit to demonstrate the outcome of patients identified with suspicious glaucomatous discs within a digital-photography-based diabetic retinopathy screening programme.

METHODS

Primary care based digital photographic screening was performed utilising mydriasis and two-field digital photography for all patients with diabetes. Patients identified with discs suspicious of glaucomatous optic neuropathy (GON) were initially referred to an accredited community-based optometrist for further assessment. Some patients were then referred to secondary care where appropriate.

RESULTS

From 1st April 2002 to 31st March 2003 a total of 3868 patients were screened for diabetic retinopathy. This audit revealed that 55 subjects were identified by retinal screeners as having discs suspicious of glaucoma. A total of 29 were already under glaucoma clinic review. A total of 23/26 remaining were referred for an assessment by an accredited optometrist. Of these 13 were normal, 6 were referred to secondary care and 4 failed to attend. The three remaining were referred directly to secondary care.

CONCLUSIONS

All nine referrals to secondary care were deemed appropriate by a glaucoma specialist. This suggests that the system described does not lead to over-referral of suspicious discs - although the issue of how many glaucomatous discs are missed during screening (false negatives) will only be answered in the longer term.

Optometrist prescribing of therapeutic agents: findings of the AESOP survey

Throughout the USA and in some parts of Australia and Canada, licensed optometrists may prescribe therapeutic agents for certain eye conditions. However, this role is not currently available to European optometrists. The extension of prescribing rights to new professional groups was the subject of a UK government-commissioned review, which cited optometrists as potential candidates. A recent literature review found limited evidence to assess the appropriateness of eye care delivered by different health care providers. To inform the UK decision, we therefore conducted a national postal survey to explore how optometric practice might change with the introduction of therapeutic prescribing. The Anonymous Enquiry of the Scope for Optometrist Prescribing (AESOP), was sent to a random 10% sample of registered optometrists. Over 80% of respondents indicated that optometrists should be able to train as therapeutic prescribers. Most respondents were willing to undergo training, periodic re-accreditation and continuing education, as well to participate in simple professional audit of their prescribing. Respondents anticipated that referrals to general practitioners (GPs) would be reduced by nearly 40% and to ophthalmologists via a GP by nearly 20%. Optometrist participation could increase patient access to therapeutic ocular care by between 29% and 50%. Authorising UK optometrists to prescribe therapeutically for eye diseases would appear to make good use of their existing skills and improve patient access to eye care, while relieving pressures upon other healthcare providers. Tentative economic analysis suggests that the introduction of independent optometrist prescribing may be cost neutral. However, adequate comparative research on the performance of optometrists as prescribers is needed and the issue of reimbursement will require careful consideration.

Resource use and costs of patients with glaucoma or ocular hypertension: a one-year study based on retrospective chart review in the Netherlands

PURPOSE

To estimate resource use and costs associated with the diagnosis and treatment of glaucoma and ocular hypertension in the Netherlands in 1996 and to determine how costs differed between patients, diagnoses, and hospitals.

PATIENTS AND METHODS

Patient characteristics and glaucoma-related resource use were collected for 500 patients with glaucoma or ocular hypertension from the medical records of 10 hospitals. Costs were calculated by multiplying the health care resource use of each patient with actual unit costs. Multiple least-squares regression was used to analyze the relationship between costs and patient characteristics, diagnosis, and type of hospital (general or academic).

RESULTS

The mean annual frequency of visits to the ophthalmologist for patients with ocular hypertension and glaucoma was 2.43 and 3.74, respectively, and the mean cost per patient was $280 and $559, respectively. The mean cost of patients with glaucoma who had no changes in medication therapy was $347 and increased to $1,765 in patients with more than three adjustments in medication therapy. Outpatient visits to the ophthalmologist and medication contributed most to total costs. Regression analysis showed that costs were significantly related to intraocular pressure, diagnosis, severe excavation of the optic nerve head, and type of hospital.

CONCLUSIONS

The costs of patients with glaucoma were twice as high as the costs of patients with ocular hypertension. Aside from diagnosis, differences in costs between patients could partly be explained by baseline patient characteristics. Patients in academic hospitals had more severe glaucoma and treatment was considerably more expensive than for patients in nonacademic hospitals.

The Bristol shared care glaucoma study: outcome at follow up at 2 years

AIM

To examine the outcome of care for patients with glaucoma followed up by the hospital eye service compared with those followed up by community optometrists.

METHODS

A randomised study with patients allocated to follow up by the hospital eye service or community optometrists was carried out in the former county of Avon in south west England. 403 patients with established or suspected primary open angle glaucoma attending Bristol Eye Hospital and meeting defined inclusion and exclusion criteria were studied. The mean number of missed points on visual field testing in the better eye (using a "better/worse" eye analysis) in each group were measured. The visual field was measured using the Henson semiautomated central field analyser (CFA 3000). Measurements were made by the research team on all patients at baseline before randomisation and again 2 years after randomisation. The mean number of missed points on visual field testing in the worse eye, mean intraocular pressure (mm Hg), and cup disc ratio using a "better/worse" eye analysis in each group at 2 years were also measured. Measurements were made by the research team on all patients at baseline before randomisation and again 2 years after randomisation. An analysis of covariance comparing method of follow up taking into account baseline measurements of outcome variables was carried out. Additional control was considered for age, sex, diagnostic group (glaucoma suspect/established primary open angle glaucoma), and treatment (any/none).

RESULTS

From examination of patient notes, 2780 patients with established or suspected glaucoma were identified. Of these, 752 (27.1%) fulfilled the entry criteria. For hospital and community follow up group respectively, mean number of missed points on visual field testing at 2 year follow up for better eye was 7.9 points and 6.8 points; for the worse eye 20.2 points and 18.4 points. Similarly, intraocular pressure was 19.3 mm Hg and 19.3 mm Hg (better eye), and 19.1 mm Hg and 19.0 mm Hg (worse eye); cup disc ratio at 2 year follow up was 0.72 and 0.72 (better eye), and 0.74 and 0.74 for hospital and community follow up group respectively. No significant differences in any of the key visual variables were found between the two groups before or after adjusting for baseline values and age, sex, treatment, and type of glaucoma.

CONCLUSIONS

It is feasible to set and run shared care schemes for a proportion of patients with suspected and established glaucoma using community optometrists. After 2 years (a relatively short time in the life of a patient with glaucoma), there were no marked or statistically significant differences in outcome between patients followed up in the hospital eye service or by community optometrists. Decisions to implement such schemes need to be based on careful consideration of the costs of such schemes and local circumstances, including geographical access and the current organisation of glaucoma care within the hospital eye service.

The Bristol Shared Care Glaucoma Study: reliability of community optometric and hospital eye service test measures

BACKGROUND/AIMS

Primary open angle glaucoma patients and glaucoma suspects make up a considerable proportion of outpatient ophthalmological attendances and require lifelong review. Community optometrists can be suitably trained for assessment of glaucoma. This randomised controlled trial aims to assess the ability of community optometrists in the monitoring of this group of patients.

METHODS

Measures of cup to disc ratio, visual field score, and intraocular pressure were taken by community optometrists, the hospital eye service and a research clinic reference "gold" standard in 405 stable glaucoma patients and ocular hypertensives. Agreement between and within the three centres was assessed using mean differences and intraclass correlation coefficients. Tolerance limits for a change in status at the level of individual pairs of measurements were also calculated.

RESULTS

Compared with a research clinic reference standard, measurements made by community optometrists and those made in the routine hospital eye service were similar. Mean measurement differences and variability were similar across all three groups compared for each of the test variables (IOP, cup to disc ratio, and visual field). Overall, the visual field was found to be the most reliable measurement and the cup to disc ratio the least.

CONCLUSIONS

Trained community optometrists are able to make reliable measurements of the factors important in the assessment of glaucoma patients and glaucoma suspects. This clinical ability should allow those optometrists with appropriate training to play a role in the monitoring of suitable patients.