Experiences with developing and implementing a virtual clinic for glaucoma care in an NHS setting

The value of virtual glaucoma clinics: a review

Virtual clinics are being utilised to tackle the growing demand for glaucoma healthcare. We conducted a literature search on 28 February 2023 using MEDLINE (PubMed), EMBASE and Web of Science databases. We searched for studies on virtual glaucoma clinics, published in the English language between 2000 and 2023. Studies suggest that virtual glaucoma clinics are a safe and effective alternative to traditional face-to-face clinics for patients with stable and early-to-moderate glaucoma. Patient satisfaction is high across all clinics surveyed. Satisfaction appears to be linked to good communication, trust and improved waiting times. The majority of healthcare professionals are also content with virtual glaucoma clinics. There are no dedicated cost-benefit analyses for virtual glaucoma clinics in the UK. However, virtual clinics in other specialties have reported significant cost savings.

Patient-reported outcome and experience measures (POEM) of a community-based glaucoma clinic in Cambridge, UK: an observational study

OBJECTIVES

Glaucoma care demand in UK hospitals has exploded in recent years. This has resulted in a push to community (shared, virtual, etc) care models to reduce the burden on hospital systems and on patients. The study aimed to ascertain patient's experiences around various aspects of their care delivered in community clinics.

DESIGN

Observational study.

SETTING

Glaucoma Community Clinic, Cambridge, UK.

PARTICIPANTS

Ninety-six consecutive patients (M:F 47:49, mean age 70±12 years), recruited from July to September 2022.

OUTCOME MEASURES

Patients completed a modified glaucoma patient-reported outcome and experience measure (POEM) regarding their clinic experience and perspective on their diagnosis, treatment and fear of blindness. Patient's thoughts of feeling safe under the community clinical team were gathered. Patient demographics including age, gender, postcodes and education history were used to find their corresponding Lower-Layer Super Output Areas and socioeconomic status.

RESULTS

Patients had positive perceptions of their clinic experience. Ninety-six per cent of patients reported that their experience of attending the community clinic was comfortable, and 93% (n=92) felt the experience was the same as expected from the hospital. Feeling safe under the clinician team produced a mean Visual Analogue Scale (VAS) score of 90 (SD 15) and feeling care was organised produced a mean VAS score of 87 (SD 17). Age, gender, disease characteristics and socioeconomic status had no influence on perceived experience. Patients aged <60 years had significantly lower understanding of their diagnosis compared with older groups (p=0.027, η2=0.076), as did suspect glaucoma patients when compared with primary open glaucoma patients (p=0.045, η2=0.085).

CONCLUSIONS

A large majority of patients expressed a positive experience, felt safe under the care of their clinical team and their care was well organised. Relatively younger patients (<60 years) and those with no confirmed diagnosis would likely benefit from more consultation time and educational materials to improve their understanding of glaucoma.

Glaucoma triage system: results of implementing a virtual clinic

PURPOSE

This study describes the virtual clinic triage system implementation process at Hospital Santa Maria-Centro Hospitalar Universitário Lisboa Norte (HSM-CHULN) and analyzes its results regarding healthcare outcomes for the patients and the system.

METHODS

A retrospective analysis was performed, comparing two cohorts (pre-virtual cohort; virtual triage cohort). Outcomes related to waiting time, number of hospital visits, decisions at first contact, and ancillary exam-based decisions were reported.

RESULTS

Two hundred and ninety-two charts were reviewed (pre-virtual cohort: 132; virtual cohort: 160). Mean waiting time between referral and the first medical contact with the glaucoma department decreased on average by 71.3 days (human contact: 286.6 days; virtual triage contact: 215.3 days). Triage system significantly decreased waiting time for glaucoma patients, with an average decrease of 326.8 days between referral and treatment decision. Triage staging allowed to label 107 (66.9; 95% confidence intervals (CI): 59.6%, 74.2%) as non-urgent; 30 (18.8%; 95% CI: 12.7%, 24.9%) as urgent, and 23 (14.3%; 95% CI: 8.9%, 19.7%) as immediate contact, with the scheduling of future appointments reflecting National Institute for Health and Care Excellence (NICE) guidelines in every patient. Moreover, the number of visits to perform the same exams and obtain the same clinical decisions was reduced by 63.6%.

CONCLUSION

Our virtual screening strategy significantly decreased waiting time, number of hospital visits, and increased chances of data-assisted clinical decision. While results can be further improved, this system can add value in an overburdened healthcare system, where triage systems with remote decision-making may be valuable tools in optimizing glaucoma care, even without allocation of extra resources.

An online glaucoma educational course for patients to facilitate remote learning and patient empowerment

In both face-to-face and teleophthalmology glaucoma clinics, there are significant time constraints and limited resources available to educate the patient and their carers regarding the glaucoma condition. Glaucoma patients are often not satisfied with the content and amount of information they receive and have demonstrated a substantial lack of knowledge regarding their condition. Innovative educational tools that facilitate accessible digital remote patient education can be a powerful adjunct to empower patients in becoming healthcare partners.We describe the development of a free, comprehensive, multimodal online glaucoma patient education course for adults with glaucoma, their family and friends and carers, with the aim of providing a readable resource to aid remote learning and understanding of the condition.The working group for the development of the course comprised of consultants, medical practitioners and education specialists and expert patients. Given the specialised nature of ophthalmology and glaucoma, certain aspects can be difficult to conceptualise, and, therefore, clear and adequate explanations of concepts are provided in the course using diagrams, flow charts, medical illustrations, images, videos, written text, analogies and quizzes.The course is available in a short and long version to suit different learning needs which take approximately 2 hours and 10 hours to complete respectively. The contents list allows course takers to find sections relevant to them and it can be taken anywhere, as long as there is Internet access.We invite you to share this resource with your patients and their families, friends and carers.

Three-year outcomes of an optometrist-led virtual clinic for new glaucoma referrals

INTRODUCTION

The purpose of this study was to describe and evaluate the outcomes of an optometrist-led virtual glaucoma clinic (VGC).

METHODS

New patients referred to the glaucoma service who were consultant triaged as 'low risk' were assessed virtually by specialist-trained optometrists in the VGC and either discharged or monitored for a period of 3 years. Ten percent of virtual case notes were audited by a glaucoma consultant to verify quality and generate learning objectives. Retrospective case-note review and analysis of all patients seen in the virtual clinic between 2014 and 2016 was undertaken to determine 3-year outcomes.

RESULTS

A total of 1710 new patients were seen in the clinic between 1 January 2014 and 31 December 2016. Of these, 1033 (60.4%) patients required no outpatient input in 3 years of follow-up. Additionally, 320 (18.7%) were discharged at the first visit, and the proportion of glaucoma suspect and ocular hypertension patients who converted to glaucoma was 12.1% and 5.8%, respectively. At 3 years, 95 patients had died, 159 were lost to follow-up, 576 were discharged and 371 were diagnosed with glaucoma at baseline or during the 3-year follow-up. The cumulative discharge proportion from the service at the end of 3 years was 82.6%. No patients required emergency eye treatment or sight-impairment registration, and of the 12 referred back to the clinic on discharge, only five required ongoing monitoring.

CONCLUSION

This optometrist-led VGC combined two aspects of novel service delivery to reduce the burden of glaucoma monitoring in outpatient departments and consolidate consultant contact to patients requiring more intervention. This model will be of value in units establishing virtual services and looking to expand the role of allied health professionals.

Impact of COVID-19 on glaucoma management: A review

Glaucoma is the leading cause of irreversible vision loss and the second leading cause of blindness worldwide. The rapid transmission of SARS-CoV-2virus compelled governments to concentrate their efforts on emergency units to treat the large number of cases that arose due to the Covid-19 outbreak. As a result, many chronically ill patients were left without access to medical care. The progression of glaucoma in previously diagnosed cases has been accelerated; due to this, some have lost their vision. Evaluation of Covid-19's effect on glaucoma treatment was one goal of this study. We used search phrases like "COVID-19," "telemedicine," and "glaucoma" to find published papers on COVID-19 and glaucoma. Artificial Intelligence (AI) may be the answer to the unanswered questions that arose due to this pandemic crisis. The benefits and drawbacks of AI in the context of teliglaucoma have been thoroughly examined. These AI-related ideas have been floating around for some time. We hope that Covid-19's enormous revisions will provide them with the motivation to move forward and significantly improve services. Despite the devastation the pandemic has caused, we are hopeful that eye care services will be better prepared and better equipped to avoid the loss of sight due to glaucoma in future.

The current use of glaucoma virtual clinics in Europe

Objectives

To assess and describe current utilisation, characteristics and perspectives on virtual glaucoma clinics (VGCs) amongst European glaucoma specialists.

Methods

Cross-sectional, anonymized, online questionnaire distributed to all European Glaucoma Society-registered specialists. Questions were stratified into five domains: Demographics, Questions about VGC use, Questions for non-VGC users, COVID-19 effects, and VGC advantages/disadvantages.

Results

30% of 169 participants currently use VGCs, with 53% based in the United Kingdom. Of those using VGCs, 85% reported higher patient acceptance compared to traditional care. The commonest virtual model was asynchronous remote monitoring (54%). Nurses (49%) and ophthalmic technicians (46%) were mostly responsible for data collection, with two-thirds using a mixture of professionals. Consultant ophthalmologists were the main decision-makers in 51% of VGCs. Preferred cohorts were: ocular hypertension (85%), glaucoma suspects (80%), early/moderate glaucoma in worse eye (68%), stable glaucoma irrespective of treatment (59%) and stable glaucoma on monotherapy (51%). Commonest investigations were: IOP (90%), BCVA (88%), visual field testing (85%) and OCT (78%), with 33 different combinations. Reasons for face-to-face referral included: visual field progression (80%), ‘above-target’ IOP (63%), and OCT progression (51%). Reasons for not using VGCs included: lack of experience (47%), adequate systems in place (42%), no appropriate staff (34%) and insufficient time/money (34%). 55% of non-VGC users are interested in their use with 38% currently considering future implementation. 83% stated VGC consultations have increased during the COVID-19 pandemic; 86% of all participants felt that the pandemic has highlighted the importance of VGCs.

Conclusions

A significant proportion of European glaucoma units are currently using VGCs, while others are considering implementation. Financial reimbursement and consensus guidelines are potentially crucial steps in VGC uptake.

Patients views on a new surveillance pathway involving allied non-medical staff for people with treated diabetic macular oedema and proliferative diabetic retinopathy

BACKGROUND/OBJECTIVE

To explore acceptability by patients and health care professionals of a new surveillance pathway for people with previously treated and stable diabetic macular oedema (DMO) and/or proliferative diabetic retinopathy (PDR).

SUBJECT/METHODS

Structured discussions in 10 focus groups with patients; two with ophthalmic photographers/graders, and one with ophthalmologists, held across the UK as part of a large diagnostic accuracy study (EMERALD).

RESULTS

The most prominent issues raised by patients concerned (i) expertise of the various professionals within clinic, (ii) quality of interactions with clinic professionals, especially the flow of information from professionals to patients, and (iii) wish to be treated holistically. Ophthalmologists suggested such issues could be best dealt with via a programme of patient education and tended to overlook deeper implications of patient concerns for the organisation of services.

CONCLUSION

For patients, the clinical service should not only include the identification and treatment of disease but also exchange of information, reassurance, and mitigation of anxiety. Alterations in the standard care pathway need to take account of such concerns and their implications, in addition to any assessments of 'efficiency' that may flow from changes in diagnostic technology, or the division of professional labour.

Telemedicine Service for Keratoconus Monitoring: Patient Satisfaction and Prospects for Further Expansion

Introduction: During the COVID-19 pandemic, keratoconus patient care moved from in-person clinics to virtual care. We surveyed patient satisfaction with the new virtual clinic model. Methods: We assessed the views of keratoconus patients enrolled in the novel virtual service between June 1 and July 31, 2020, in individual structured telephone interviews using Likert questions. Results: Of the 88 patients enrolled, the opinions of 69 patients could be evaluated (78.4%). Compared with previous in-person visits, mean waiting times for diagnostic examinations dropped from 43 (±32) min to 4 (±3) min (p < 0.001). The majority of patients (68; 99%) were satisfied or very satisfied with the overall service irrespective of the communication channel (telephone or video). A majority also indicated a desire to continue attending the virtual keratoconus clinic after the pandemic and supported the idea of decentralized sites for future diagnostic measurements. Discussion: A novel virtual service to monitor keratoconus progression was well received and was associated with shorter waiting times. There was a strong interest on the part of patients to further develop the virtual keratoconus clinic. Conclusions: This study demonstrates that keratoconus patients managed very well the conversion from in-person to virtual care. A solid majority of keratoconus patients also supported further expansion of the virtual consultations to a completely decentralized telemedicine model.

Physician Satisfaction With Virtual Ophthalmology Clinics During the COVID-19 Pandemic: A Tertiary Eye Care Center Experience

Background

In this study, we aimed to assess ophthalmologists’ experience with teleophthalmology during the coronavirus disease 2019 (COVID-19) pandemic in the central region of Saudi Arabia. In addition, we evaluated their satisfaction level and explored their satisfaction determinants.

Methodology

We conducted an online survey for ophthalmologists who participated in the virtual ophthalmology clinic during COVID-19 between November 2020 and September 2021. The survey was used to evaluate ophthalmologists’ experience with teleophthalmology during the pandemic. Ophthalmologists were asked to measure their satisfaction with equipment and technical issues, communication, and clinical assessment, and to provide an overall program evaluation. Data were analyzed via frequency measures (e.g., numbers, percentages, mean, and standard deviation).

Results

Out of the 113 ophthalmologists who were invited to participate in our study, 71 completed the survey. In total, 23 (32.4%) participants were general ophthalmologists, 15 (21.1%) were subspecialists in the cornea, 16 (22.5%) were subspecialists in glaucoma, one (1.4%) was a subspecialist in neuro-ophthalmology, seven (9.9%) were subspecialists in pediatric ophthalmology, eight (11.3%) were subspecialists in the retina, and one (1.4%) participant was a subspecialist in oculoplastic. Overall, 56.3% of the respondents were satisfied with teleophthalmology. Ophthalmologists who subspecialized in the retina demonstrated higher levels of satisfaction than other subspecialties. The most common challenge reported by ophthalmologists in the virtual consultation was the lack of adequate equipment to evaluate the patients (53.5%), followed by technical issues (43.7%) and the patients’ lack of experience in using virtual consultation services (38%). Overall satisfaction score was the highest among ophthalmologists who reported providing at least five video consultations before the survey.

Conclusions

The findings from our study suggest that the subspeciality of ophthalmologists and the number of video consultations conducted by ophthalmologists are important determinants in their level of satisfaction with teleophthalmology. The majority of the respondents were satisfied with the virtual clinic during the COVID-19 pandemic. The current pandemic could pave the way for the future use of telemedicine in ophthalmology if virtual eye examinations become standardized.

How glaucoma care changed for the better after the pandemic

PURPOSE OF REVIEW

The current article reviews enhancements to the delivery of glaucoma care that developed in response to the coronavirus disease 19 (COVID-19) pandemic and are likely to persist beyond its resolution.

RECENT FINDINGS

Literature from the review period (2020-2021) includes reports highlighting contributions of the ophthalmology community to global health during the pandemic. Glaucoma practices worldwide have instituted more robust infection control measures to mitigate severe acute respiratory syndrome coronavirus 2 transmission in the outpatient setting, and many of these modifications will endure in the post-COVID era. Operational adjustments have led to the provision of more efficient glaucoma care. A hybrid care model involving technician-based diagnostic testing and subsequent virtual consultation with a glaucoma specialist has evolved as a useful adjunct to traditional face-to-face encounters with patients.

SUMMARY

Glaucoma specialists, patients, and staff have adapted to a 'new normal' of glaucoma care delivery during the COVID-19 pandemic. Although innovation has propelled several improvements to glaucoma care during this global health crisis, significant barriers to more widespread implementation of teleglaucoma still exist. Whether, and in what capacity, the pandemic has permanently altered glaucoma practice patterns remains to be seen.

Patient Experience Survey in a Corneal Service Conducted by Remote Consultation

Introduction

An ophthalmic remote consultation clinic was implemented due to the COVID-19 pandemic for stable patients under the corneal service in a district general hospital in Cheshire, UK. Patients were reviewed either by video or telephone consultation. The purpose of this survey was to assess patient satisfaction with this service.

Methods

Consecutive patients who were seen by remote consultation between September 2020 and November 2020 were identified. Approval for the survey was gained from the hospital Patient Experience and Survey department. A telephone survey was conducted between 4 and 8 weeks after the initial patient appointment. Data were obtained for patient demographic information, appointment details and patient satisfaction with their appointment, including preference for subsequent appointments and open feedback.

Results

Eighty-four remote consultations were identified and 51 (60.7%) patients completed the survey: 48 (94.1%) reported satisfaction with their remote consultation; 36 (70.5%) reported satisfaction for a subsequent remote consultation; and 33 (64.7%) patients reported they preferred being seen remotely rather than face-to-face. Qualitative data on patients’ thoughts about the service could be categorised into 4 themes: satisfaction with the interaction and service, conveniency, lack of clinical examination and satisfaction with the service given the current pandemic circumstances.

Conclusion

This survey has shown that patients were satisfied with their remote consultation and the majority thought it was an acceptable method of consultation. This also allowed patients to continue being seen during a period of COVID-19 lockdown and reduce patient footfall through the hospital. Overall feedback indicated very high levels of patient satisfaction with this service.

Evaluation of a Telemedicine Model for Following Keratoconus Patients in the Era of COVID-19 Pandemic

Purpose: To evaluate the diagnostic accuracy and reliability of a telemedicine approach for detecting keratoconus patients' progression in the era of coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: A retrospective study, comparing the office and telemedicine evaluations in determining whether keratoconus patients were at risk of progression and indicated for further treatment of corneal crosslinking, was conducted. The clinic examination included best spectacle corrected visual acuity measurement and manifest refraction, full ophthalmic examination, and corneal topography, which provided with the gold-standard diagnosis. The remote assessment included two decisions of keratoconus progression or stability: the first evaluation after revealing patient demographics and topography images, and the second with the manifest refraction and clinical findings as documented in the outpatient clinic visit. Results: Two-hundred and four eyes of 102 keratoconus patients were included. There was an agreement of assessment between the in-person and the remote diagnostic decisions in 192 (94%) of the eyes. Among the remaining 12 eyes, a false-positive diagnosis was made in 8 (3.9%) eyes, whereas a false-negative diagnosis was made in 4 (1.9%) eyes. The remote assessment showed a sensitivity and specificity of 69% and 96%, respectively. In no case was remote diagnostic decision 2 different from remote decision 1. Conclusions: The telemedicine model yielded high specificity, but low sensitivity values, therefore, not suitable as an alternative for keratoconus patient follow-up (Clinical trial number TLV-0363-20).

Shared Care and Virtual Clinics for Glaucoma in a Hospital Setting

Glaucoma patients require lifelong management, and the prevalence of glaucoma is expected to increase, resulting in capacity problems in many hospital eye departments. New models of care delivery are needed to offer requisite capacity. This review evaluates two alternative schemes for glaucoma care within a hospital, i.e., shared care (SC) and virtual clinics (VCs), whereby non-medical staff are entrusted with more responsibilities, and compares these schemes with the “traditional” ophthalmologist-led outpatient service (standard care). A literature search was conducted in three large bibliographic databases (PubMed, Embase, and Trip), and the abstracts from the prior five annual meetings of the Association for Research in Vision and Ophthalmology were consulted. Twenty-nine were included in the review (14 on SC and 15 on VCs). Patients with low risk of vision loss were considered suitable for these approaches. Among the non-medical staff, optometrists were the most frequently involved. The quality of both schemes was good and improved with the non-medical staff being trained in glaucoma care. No evidence was found on patients feeling disadvantaged by the lack of a doctor visit. Both schemes increased the hospital’s efficiency. Both SC and VCs are promising approaches to tackle the upcoming capacity problems of hospital-based glaucoma care.

Characterising the nationwide burden and predictors of unkept outpatient appointments in the National Health Service in England: A cohort study using a machine learning approach

BACKGROUND

Unkept outpatient hospital appointments cost the National Health Service £1 billion each year. Given the associated costs and morbidity of unkept appointments, this is an issue requiring urgent attention. We aimed to determine rates of unkept outpatient clinic appointments across hospital trusts in the England. In addition, we aimed to examine the predictors of unkept outpatient clinic appointments across specialties at Imperial College Healthcare NHS Trust (ICHT). Our final aim was to train machine learning models to determine the effectiveness of a potential intervention in reducing unkept appointments.

METHODS AND FINDINGS

UK Hospital Episode Statistics outpatient data from 2016 to 2018 were used for this study. Machine learning models were trained to determine predictors of unkept appointments and their relative importance. These models were gradient boosting machines. In 2017-2018 there were approximately 85 million outpatient appointments, with an unkept appointment rate of 5.7%. Within ICHT, there were almost 1 million appointments, with an unkept appointment rate of 11.2%. Hepatology had the highest rate of unkept appointments (17%), and medical oncology had the lowest (6%). The most important predictors of unkept appointments included the recency (25%) and frequency (13%) of previous unkept appointments and age at appointment (10%). A sensitivity of 0.287 was calculated overall for specialties with at least 10,000 appointments in 2016-2017 (after data cleaning). This suggests that 28.7% of patients who do miss their appointment would be successfully targeted if the top 10% least likely to attend received an intervention. As a result, an intervention targeting the top 10% of likely non-attenders, in the full population of patients, would be able to capture 28.7% of unkept appointments if successful. Study limitations include that some unkept appointments may have been missed from the analysis because recording of unkept appointments is not mandatory in England. Furthermore, results here are based on a single trust in England, hence may not be generalisable to other locations.

CONCLUSIONS

Unkept appointments remain an ongoing concern for healthcare systems internationally. Using machine learning, we can identify those most likely to miss their appointment and implement more targeted interventions to reduce unkept appointment rates.

The Future Is Now: Incorporating Telemedicine into Glaucoma Care

Purpose of Review

The field of teleglaucoma has expanded rapidly in recent years with several large-scale teleglaucoma screening programs in existence throughout the world. Additionally, teleglaucoma programs for use in disease management are under study. The limited access to care that resulted from the COVID-19 pandemic highlighted the need for expansion of such programs. This article reviews the literature on teleglaucoma for screening and management of glaucoma, discussing considerations for incorporating teleglaucoma into clinical practice.

Recent Findings

Teleglaucoma screening reduces the rate of false-positive referrals and can accurately screen at-risk populations with accuracy similar to in-person screening. The use of teleglaucoma for the management of glaucoma shows promise for low-risk patients with early disease. Furthermore, teleglaucoma is cost-effective and reduces travel burden for patients resulting in high patient satisfaction.

Summary

Teleglaucoma offers potential for improving access to glaucoma care, reducing the burden on patients and health care systems.

Digital Transformation in Ophthalmic Clinical Care During the COVID-19 Pandemic

ABSTRACT

COVID-19 has placed unprecedented pressure on health systems globally, whereas simultaneously stimulating unprecedented levels of transformation. Here, we review digital adoption that has taken place during the pandemic to drive improvements in ophthalmic clinical care, with a specific focus on out-of-hospital triage and services, clinical assessment, patient management, and use of electronic health records. We show that although there have been some successes, shortcomings in technology infrastructure prepandemic became only more apparent and consequential as COVID-19 progressed. Through our review, we emphasize the need for clinicians to better grasp and harness key technology trends such as telecommunications and artificial intelligence, so that they can effectively and safely shape clinical practice using these tools going forward.

Multimodal imaging interpreted by graders to detect re-activation of diabetic eye disease in previously treated patients: the EMERALD diagnostic accuracy study

BACKGROUND

Owing to the increasing prevalence of diabetes, the workload related to diabetic macular oedema and proliferative diabetic retinopathy is rising, making it difficult for hospital eye services to meet demands.

OBJECTIVE

The objective was to evaluate the diagnostic performance, cost-effectiveness and acceptability of a new pathway using multimodal imaging interpreted by ophthalmic graders to detect reactivation of diabetic macular oedema/proliferative diabetic retinopathy in previously treated patients.

DESIGN

This was a prospective, case-referent, cross-sectional diagnostic study.

SETTING

The setting was ophthalmic clinics in 13 NHS hospitals.

PARTICIPANTS

Adults with type 1 or type 2 diabetes with previously successfully treated diabetic macular oedema/proliferative diabetic retinopathy in one/both eyes in whom, at the time of enrolment, diabetic macular oedema/proliferative diabetic retinopathy could be active or inactive.

METHODS

For the ophthalmic grader pathway, review of the spectral domain optical coherence tomography scans to detect diabetic macular oedema, and seven-field Early Treatment Diabetic Retinopathy Study/ultra-wide field fundus images to detect proliferative diabetic retinopathy, by trained ophthalmic graders. For the current standard care pathway (reference standard), ophthalmologists examined patients face to face by slit-lamp biomicroscopy for proliferative diabetic retinopathy and, in addition, spectral domain optical coherence tomography imaging for diabetic macular oedema.

OUTCOME MEASURES

The primary outcome measure was sensitivity of the ophthalmic grader pathway to detect active diabetic macular oedema/proliferative diabetic retinopathy. The secondary outcomes were specificity, agreement between pathways, cost-consequences, acceptability and the proportion of patients requiring subsequent ophthalmologist assessment, unable to undergo imaging and with inadequate quality images/indeterminate findings. It was assumed for the main analysis that all patients in whom graders diagnosed active disease or were 'unsure' or images were 'ungradable' required examination by an ophthalmologist.

RESULTS

Eligible participants with active and inactive diabetic macular oedema (152 and 120 participants, respectively) and active and inactive proliferative diabetic retinopathy (111 and 170 participants, respectively) were recruited. Under the main analysis, graders had a sensitivity of 97% (142/147) (95% confidence interval 92% to 99%) and specificity of 31% (35/113) (95% confidence interval 23% to 40%) to detect diabetic macular oedema. For proliferative diabetic retinopathy, graders had a similar sensitivity and specificity using seven-field Early Treatment Diabetic Retinopathy Study [sensitivity 85% (87/102), 95% confidence interval 77% to 91%; specificity 48% (77/160), 95% confidence interval 41% to 56%] or ultra-wide field imaging [sensitivity 83% (87/105), 95% confidence interval 75% to 89%; specificity 54% (86/160), 95% confidence interval 46% to 61%]. Participants attending focus groups expressed preference for face-to-face evaluations by ophthalmologists. In the ophthalmologists' absence, patients voiced the need for immediate feedback following grader's assessments, maintaining periodic evaluations by ophthalmologists. Graders and ophthalmologists were supportive of the new pathway. When compared with the reference standard (current standard pathway), the new grader pathway could save £1390 per 100 patients in the review of people with diabetic macular oedema and, depending on the imaging modality used, between £461 and £1189 per 100 patients in the review of people with proliferative diabetic retinopathy.

CONCLUSIONS

For people with diabetic macular oedema, the ophthalmic grader pathway appears safe and cost saving. The sensitivity of the new pathway to detect active proliferative diabetic retinopathy was lower, but may still be considered acceptable for patients with proliferative diabetic retinopathy previously treated with laser. Suggestions from focus group discussions should be taken into consideration if the new pathway is introduced to ensure its acceptability to users.

LIMITATIONS

Lack of fundus fluorescein angiography to confirm diagnosis of active proliferative diabetic retinopathy.

FUTURE WORK

Could refinement of the new pathway increase its sensitivity to detect proliferative diabetic retinopathy? Could artificial intelligence be used for automated reading of images in this previously treated population?

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10856638 and ClinicalTrials.gov NCT03490318.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology AssessmentVol. 25, No. 32. See the NIHR Journals Library website for further project information.

Digital technology, tele-medicine and artificial intelligence in ophthalmology: A global perspective

The simultaneous maturation of multiple digital and telecommunications technologies in 2020 has created an unprecedented opportunity for ophthalmology to adapt to new models of care using tele-health supported by digital innovations. These digital innovations include artificial intelligence (AI), 5th generation (5G) telecommunication networks and the Internet of Things (IoT), creating an inter-dependent ecosystem offering opportunities to develop new models of eye care addressing the challenges of COVID-19 and beyond. Ophthalmology has thrived in some of these areas partly due to its many image-based investigations. Tele-health and AI provide synchronous solutions to challenges facing ophthalmologists and healthcare providers worldwide. This article reviews how countries across the world have utilised these digital innovations to tackle diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration, glaucoma, refractive error correction, cataract and other anterior segment disorders. The review summarises the digital strategies that countries are developing and discusses technologies that may increasingly enter the clinical workflow and processes of ophthalmologists. Furthermore as countries around the world have initiated a series of escalating containment and mitigation measures during the COVID-19 pandemic, the delivery of eye care services globally has been significantly impacted. As ophthalmic services adapt and form a "new normal", the rapid adoption of some of telehealth and digital innovation during the pandemic is also discussed. Finally, challenges for validation and clinical implementation are considered, as well as recommendations on future directions.

Outcomes of an Asynchronous Virtual Glaucoma Clinic in Monitoring Patients at Low Risk of Glaucoma Progression in Singapore

PURPOSE

To assess the implementation outcomes of a new asynchronous virtual clinic, the Glaucoma Observation Clinic (GLOC), at the Singapore National Eye Center, in monitoring patients at low risk for glaucoma progression.

METHODS

Patients with low risk of glaucoma progression were followed up at GLOC. Visual acuity, intraocular pressure, and visual field testing or optic nerve head imaging were assessed by nurses and technicians, with virtual review of data by an ophthalmologist separately. The implementation outcomes were defined as patient satisfaction, assessed by a nurse-administered questionnaire; the rate of referrals back to the glaucoma outpatient department; the patients' journey time (minutes); the time taken for the specialist review (minutes), and the per capita manpower cost compared with current glaucoma outpatient model.

RESULTS

A total of 377 patients were included, with the majority being glaucoma disc suspects (n = 250, 66.4%) and primary angle closure suspects (n = 54, 14.3%). Most patients (more than 90%) reported being satisfied, and only 7.7% (n = 29) were referred back to the specialist outpatient glaucoma clinic due to possible glaucoma progression. Compared with the glaucoma outpatient clinic, the average journey time in GLOC was 50% less (59.3 mins vs 132 mins), the average time for a specialist review was 3 times faster (5.8 mins vs 19.5 mins), and the per capita manpower cost of GLOC was halved ($20.07 vs $39.78).

CONCLUSIONS

GLOC is a time-efficient, cost-saving, and sustainable model of care for managing patients with low risk of glaucoma progression. It was well received by patients and freed up the conventional clinic to treat patients with complex needs.

Impact and Challenges of Integrating Artificial Intelligence and Telemedicine into Clinical Ophthalmology

ABSTRACT

Aging populations and worsening burden of chronic, treatable disease is increasingly creating a global shortfall in ophthalmic care provision. Remote and automated systems carry the promise to expand the scale and potential of health care interventions, and reduce strain on health care services through safe, personalized, efficient, and cost-effective services. However, significant challenges remain. Forward planning in service design is paramount to safeguard patient safety, trust in digital services, data privacy, medico-legal implications, and digital exclusion. We explore the impact and challenges facing patients and clinicians in integrating AI and telemedicine into ophthalmic care-and how these may influence its direction.

Acceptability of Telegenetics for Families with Genetic Eye Diseases

Healthcare providers around the world have implemented remote routine consultations to minimise disruption during the COVID-19 pandemic. Virtual clinics are particularly suitable for patients with genetic eye diseases as they rely on detailed histories with genetic counselling. During April-June 2019, the opinion of carers of children with inherited eye disorders attending the ocular genetics service at Moorfields Eye Hospital NHS Foundation Trust (MEH) were canvassed. Sixty-five percent of families (n = 35/54) preferred to have investigations carried out locally rather than travel to MEH, with 64% opting for a virtual consultation to interpret the results. The most popular mode of remote contact was via telephone (14/31), with video call being least preferred (8/31). Hence, 54 families who had received a telephone consultation mid-pandemic (November 2020-January 2021) were contacted to re-evaluate the acceptability of telegenetics using the Clinical Genetics Satisfaction Indicator and Telemedicine Satisfaction Questionnaire. Overall, 50 carers participated (response rate 93%); 58% of participants found teleconsultations acceptable and 54% agreed they increased their access to care, but 67.5% preferred to be seen in person. Patient satisfaction was high with 90% strongly agreeing/agreeing they shared and received all necessary information. Ocular genetics is well-suited for remote service delivery, ideally alternated with face-to-face consultations.

Implementing the new normal in ophthalmology care beyond COVID-19

The COVID-19 pandemic has altered the clinical landscape immeasurably. The need to physical distance requires rethinking how we deliver ophthalmic care. Within healthcare, we will need to focus our resources on the five T's: Utilising technology, multidisciplinary clinical teams with wide professional talents need to work efficiently to reduce patient contact time. With regular testing, this will allow us to reduce the risk further. We also must acknowledge the explosion of different modalities to train our future ophthalmologists and the global challenges and advantages that these bring. Finally, we must not forget the psychological impact that this pandemic will have on ophthalmologists and ancillary staff, and need to have robust mechanisms for support.

A virtual-clinic pathway for patients referred from a national diabetes eye screening programme reduces service demands whilst maintaining quality of care

Aim

To evaluate the potential of an integrated virtual medical retina clinic in secondary care for diabetic patients screened and referred by the UK National Diabetic Eye Screening Program (DESP).

Methods

This retrospective cohort study included diabetic patients referred by the DESP to either a virtual or a traditional doctor’s appointment (face-to-face, F2F) at the Moorfields Eye Hospital NHS Foundation Trust (London, UK) between January 2015 and December 2018. The primary outcome was the proportion of patients that qualified for a virtual-clinic appointment according to hospital guidance. Secondary outcomes included the rate of attendance, mean time from DESP referral to initial hospital appointment, mean time-to-discharge and -to-treatment of either panretinal photocoagulation or intravitreal injection of anti-vascular endothelial growth factor.

Results

We included 12,563 patients in this study. While 8833 patients (70.7%) would have qualified for a virtual appointment according to local triage guidance, only 2306 (18.4%) were referred to a virtual consultation due to capacity constraints. For routine referrals, mean time to the first hospital appointment was 66.9 days with a standard deviation of ±35.9 and 80.9 ± 44.4 days for a virtual and a F2F consultation, respectively. The mean time from referral to discharge to community was 71.7 ± 30.8 and 86.3 ± 37.0 days for a virtual and a F2F consultation, respectively. We did not observe a statistically significant difference in the mean time-to-treatment in the sub-cohort that required intravitreal therapy for maculopathy (virtual clinics: 220.7 ± 84.8; F2F: 178.0 days ± 80.7; p value > 0.05). Moreover, we observed a non-inferior attendance rate in virtual as compared to F2F clinics.

Conclusion

A significant proportion of diabetic patients referred to a F2F clinic could initially be managed in a virtual clinic. Increasing the adoption of virtual clinics in the management of diabetic patients that do not need long-term management or monitoring in secondary services may help alleviate service demands without diminishing quality of clinical care. Collectively, our analyses suggest that virtual consultations are a faster and clinically appropriate alternative for a substantial proportion of diabetic patients.

Evaluation of a New Model of Care for People with Complications of Diabetic Retinopathy: The EMERALD Study

Purpose

The increasing diabetes prevalence and advent of new treatments for its major visual-threatening complications (diabetic macular edema [DME] and proliferative diabetic retinopathy [PDR]), which require frequent life-long follow-up, have increased hospital demands markedly. Subsequent delays in patient's evaluation and treatment are causing sight loss. Strategies to increase capacity are needed urgently. The retinopathy (EMERALD) study tested diagnostic accuracy, acceptability, and costs of a new health care pathway for people with previously treated DME or PDR.

Design

Prospective, multicenter, case-referent, cross-sectional, diagnostic accuracy study undertaken in 13 hospitals in the United Kingdom.

Participants

Adults with type 1 or 2 diabetes previously successfully treated DME or PDR who, at the time of enrollment, had active or inactive disease.

Methods

A new health care pathway entailing multimodal imaging (spectral-domain OCT for DME, and 7-field Early Treatment Diabetic Retinopathy Study [ETDRS] and ultra-widefield [UWF] fundus images for PDR) interpreted by trained nonmedical staff (ophthalmic graders) to detect reactivation of disease was compared with the current standard care (face-to-face examination by ophthalmologists).

Main Outcome Measures

Primary outcome: sensitivity of the new pathway. Secondary outcomes: specificity; agreement between pathways; costs; acceptability; proportions requiring subsequent ophthalmologist assessment, unable to undergo imaging, and with inadequate images or indeterminate findings.

Results

The new pathway showed sensitivity of 97% (95% confidence interval [CI], 92%–99%) and specificity of 31% (95% CI, 23%–40%) to detect DME. For PDR, sensitivity and specificity using 7-field ETDRS images (85% [95% CI, 77%–91%] and 48% [95% CI, 41%–56%], respectively) or UWF images (83% [95% CI, 75%–89%] and 54% [95% CI, 46%–61%], respectively) were comparable. For detection of high-risk PDR, sensitivity and specificity were higher when using UWF images (87% [95% CI, 78%–93%] and 49% [95% CI, 42%–56%], respectively, for UWF versus 80% [95% CI, 69–88%] and 40% [95% CI, 34%–47%], respectively, for 7-field ETDRS images). Participants preferred ophthalmologists’ assessments; in their absence, they preferred immediate feedback by graders, maintaining periodic ophthalmologist evaluations. When compared with the current standard of care, the new pathway could save £1390 per 100 DME visits and between £461 and £1189 per 100 PDR visits.

Conclusions

The new pathway has acceptable sensitivity and would release resources. Users’ suggestions should guide implementation.

Glaucoma Community Care: Does Ongoing Shared Care Work?

Purpose:

We assessed a novel, public, vertical integrated care model for glaucoma management in the community.

Methods:

This study was a retrospective, longitudinal study of 266 patients diagnosed or suspected of glaucoma. Patients were stratified to either ongoing ophthalmology-led (n = 81) or optometry-led shared care (n = 185). Demographics and clinical characteristics, including the re-referral rate and timeliness of follow up were analysed.

Results:

Just under half (565/1224, 46%) of all follow up consultations over the total study period of 45 months were seen in optometry-led care, with a re-referral rate to ophthalmology of 21%. Treated patients showed a median intraocular pressure reduction of 20% and a median time delay of just two days between the actual and recommended review period.

Conclusions:

Shared care provides an effective option for managing the ongoing care burden in chronic stable glaucoma cases at low risk of vision loss.

What is the best way to measure intraocular pressure (IOP) in a virtual clinic?

BACKGROUND

Patients with ocular hypertension (OHT) and glaucoma are increasingly reviewed in virtual clinics. As the clinician is not present during the patient's visit it is important that measurements obtained are reliable. The aim of this study was to examine agreement between Goldmann Applanation Tonometry (GAT) intraocular pressure (IOP) measurements (obtained by ophthalmologists and ophthalmic nurses) and a newer automated tonometer-the Ocular Response Analyzer (ORA).

METHODS

A prospective study was conducted including 116 eyes of 116 patients with glaucoma and OHT. All subjects had GAT IOP obtained by a nurse and ophthalmologist and ORA IOP by a technician. The order of testing was randomised and previous measurements were masked. Agreement was examined using Bland-Altman plots and 95% limits of agreement (LoA). Intraclass correlation coefficients (ICC) of repeat GAT and ORA measurements were calculated.

RESULTS

Patients had a mean age of 70 ± 13 years. The 95% LoA between ophthalmologist (mean: 14.6 ± 4.3 mmHg) and nurse (mean: 15.0 ± 4.0 mmHg) GAT measurements was ±5.21 mmHg, whereas the 95% LoA between repeat ORA IOPg (mean: 13.8 ± 4.7 mmHg) was ±2.52 mmHg. There was no proportional bias. The ICC was 0.972 for repeat IOPg compared with 0.863 for repeat GAT.

CONCLUSIONS

There was only moderate agreement between GAT IOP measurements obtained by nurses working in the virtual clinic and ophthalmologists. Agreement between ORA IOP and ophthalmologists' GAT IOP was better and ORA produced more repeatable measurements, providing evidence it may be a more reliable tool for IOP assessment in virtual clinics.

Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition

Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.

Telemedicine for Glaucoma: Guidelines and Recommendations

Background: Glaucoma is the leading cause of irreversible blindness worldwide. Access to glaucoma specialists is challenging and likely to become more difficult as the population ages. Introduction: Using telemedicine for glaucoma (teleglaucoma) has the potential to increase access to glaucoma care by improving efficiency and decreasing the need for long-distance travel for patients. Results: Teleglaucoma programs can be used for screening, diagnostic consultation, and long-term treatment monitoring. Key components of teleglaucoma programs include patient history, equipment, intraocular pressure measurement, pachymetry, anterior chamber imaging/gonioscopy, fundus photography, retinal nerve fiber layer imaging, medical record and imaging software, and skilled personnel. Discussion: Teleglaucoma has tremendous potential to improve patient access to high-quality cost-effective glaucoma care. Conclusions: We have reviewed some special considerations needed to address the complexity of providing guideline-concordant glaucoma care.

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.

Is ultra wide-field retinal imaging alone appropriate for retinal angioma screening in lower risk subjects attending Von Hippel-Lindau (VHL) clinics?

Purpose: To determine if non-mydriatic ultra wide-angle digital retinal imaging alone is effective for screening subjects considered to be at 50% or lower risk for developing retinal angiomas.Methods: Digital records and retinal images of subjects attending a regional Von-Hippel-Lindau disease multi-disciplinary clinic over a 12 month period were reviewed. Individuals were stratified for risk of developing retinal angiomas on the basis of age, clinical features and genetic risk. The image quality and necessity for subsequent mydriatic fundoscopy were assessed.Results: Eighty subjects from 55 pedigrees attended the VHL clinic over 12 months. Of these, 44 (55%) were considered to be at lower risk for retinal angiomatosis: 34 (77%) because they had reached at least 30 years of age without developing an angioma, 16 with a presenting solitary tumour of the type associated with VHL but no identifiable gene mutation, and 12 with a family history giving them a 50% risk of carrying a gene mutation. Eighteen patients fulfilled two low risk criteria. All were able to comply with imaging but poor image quality (limited view of the inferior retinal far-periphery) required subsequent dilated fundoscopy in five (6%) eyes of three patients.Conclusions: Non-mydriatic ultra wide-field retinal imaging enabled satisfactory assessment in over 95% of lower-risk VHL subjects. Virtual clinics or remote imaging of lower-risk subjects may improve both the efficiency and flexibility in the provision of multi-disciplinary VHL services and the patient experience.

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.

Tele-glaucoma versus clinical evaluation: The New Jersey Health Foundation Prospective Clinical Study

INTRODUCTION

Glaucoma, the second most common cause of blindness, is normally detected in clinic. With technological improvements, tele-glaucoma exams can identify these changes off-site. The quality of tele-glaucoma exams needs to be compared with that of traditional exams. This study's purpose was to validate the tele-glaucoma programme, which allows a physician comprehensive access to patients' data, by comparing results to clinical examinations.

METHODS

A prospective study of 107 subjects evaluated in clinic and then tele-glaucoma stations, which consisted of non-mydriatic fundus photography, puff-tonometry, auto-refraction and Optical Coherence Tomography (OCT). The OCT captured central corneal thickness, angle anatomy, cup-to-disc ratio (CDR), retinal nerve fibre layer distribution and posterior-pole ganglion cell complex data.

RESULTS

Intraocular pressure (IOP) comparisons between clinical and tele-glaucoma exams had strong positive Pearson correlation coefficients (0.8248 OD, 0.8672 OS). Strong positive correlations were seen for CDR (0.7835 OD, 0.8082 OS) as well as diagnosis (glaucoma, no glaucoma or glaucoma suspect). A moderate positive correlation was seen for return to clinic time (RTC). Tele-glaucoma had an average lower RTC (2.7 vs 3.9 months). Tele-glaucoma was more likely to elicit a non-glaucomatous diagnosis not found in clinic vs a diagnosis found only in clinic (18% vs 5% of subjects).

DISCUSSION

Tele-glaucoma allows for detecting glaucoma remotely. These advancements alleviate patient difficulties with obtaining adequate glaucoma screenings and helps ophthalmologists triage patients with more severe pathology. Our study indicates that our tele-glaucoma protocol is comparable to a clinical exam in its ability to detect glaucoma. Further studies will be needed for off-site testing and transferring data separately for analysis.

Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland

INTRODUCTION

The Trauma Assessment Clinic [TAC], also referred to as Virtual Fracture Clinic, offers a novel care pathway for patients and is being increasingly utilised across the Irish and UK health care systems. The provision of safe, patient centred, efficient and cost-effective treatment via a multidisciplinary team [MDT] approach is the primary focus of TAC. The Trauma and Orthopaedic unit at Tullamore Hospital was the first centre to introduce a TAC in Ireland and this overview outlines the experiences of this pilot.

METHODS AND PATIENTS

Patients arriving to the Emergency Department with injuries that were TAC appropriate were treated as per a recognised protocol. They were given information regarding their injury and a removable splint or cast and told to expect a follow up phone call from the orthopaedic team. Within 24 h the patient's clinical notes and x-rays were assessed by the TAC MDT and patients were called immediately to be advised as to their planned treatment.

RESULTS

To date the TAC pilot in Tullamore Hospital has reviewed 2704 patients. 35% of patients were discharged at the TAC review stage, 27% were referred to an appropriate clinic (e.g. Shoulder injuries referred to an upper limb specialist) or a general trauma follow-up clinic, and 38% were referred onto physiotherapy services local and community based for follow-up. A survey of patients reviewed in the TAC revealed that 97% of respondents agreed or strongly agreed that they were satisfied with their recovery. The cost of each TAC consultation was €28 versus €129 for a traditional fracture clinic appointment.

CONCLUSION

Our experience of the TAC is that it provides a very safe, patient focused and cost-effective means of delivering trauma care. It provides a more streamlined and improved patient journey in select patients with certain fracture patterns, allowing for patient empowerment without compromising clinical care and marries current available technology with up to date best clinical practice.

Feasibility of simple machine learning approaches to support detection of non-glaucomatous visual fields in future automated glaucoma clinics

OBJECTIVES

To assess the performance of feed-forward back-propagation artificial neural networks (ANNs) in detecting field defects caused by pituitary disease from among a glaucomatous population.

METHODS

24-2 Humphrey Visual Field reports were gathered from 121 pituitary patients and 907 glaucomatous patients. Optical character recognition was used to extract the threshold values from PDF reports. Left and right eye visual fields were coupled for each patient in an array to create bilateral field representations. ANNs were created to detect chiasmal field defects. We also assessed the ability of ANNs to identify a single pituitary field among 907 glaucomatous distractors.

RESULTS

Mean field thresholds across all locations were lower for pituitary patients (20.3 dB, SD = 5.2 dB) than for glaucoma patients (24.4 dB, SD = 5.0 dB) indicating a greater degree of field loss (p < 0.0001) in the pituitary group. However, substantial overlap between the groups meant that mean bilateral field loss was not a reliable indicator of aetiology. Representative ANNs showed good performance in the discrimination task with sensitivity and specificity routinely above 95%. Where a single pituitary field was hidden among 907 glaucomatous fields, it had one of the five highest indexes of suspicion on 91% of 2420 ANNs.

CONCLUSIONS

Traditional artificial neural networks perform well at detecting chiasmal field defects among a glaucoma cohort by inspecting bilateral field representations. Increasing automation of care means we will need robust methods of automatically diagnosing and managing disease. This work shows that machine learning can perform a useful role in diagnostic oversight in highly automated glaucoma clinics, enhancing patient safety.

Clinical Outcomes of a Hospital-Based Teleophthalmology Service: What Happens to Patients in a Virtual Clinic?

PURPOSE

Demographic changes as well as increasing referral rates from national screening services put pressure on available ophthalmologic resources in the United Kingdom. To improve resource allocation, virtual medical retina clinics were introduced in 2016 in Moorfields Eye Hospital, South Division. The scope of this work was to assess clinical outcomes of patients followed up in a virtual clinic setting.

DESIGN

Retrospective database study.

PARTICIPANTS

Patients booked for a consecutive appointment in our virtual medical retina clinic.

METHODS

Seven hundred twenty-eight patients booked for their second virtual clinic appointment in a tertiary eye care referral center between November 2016 and July 2018 were identified retrospectively from our electronic health records and patient administration systems. Information about disease grade and clinical and visual outcomes was assessed.

MAIN OUTCOME MEASURES

Clinical outcome of the virtual clinic visit, including virtual follow-up, urgent referral to face-to-face clinic, or discharge.

RESULTS

Seven hundred twelve of 728 patients received a clinical outcome. Four hundred ninety-seven patients (70%) were eligible for further virtual follow-up after the second virtual clinic visit, whereas 15% each (107 and 108 patients) were either discharged or referred to a face-to-face clinic. In total, 661 patients attended their appointments in person and were reviewed by trained staff. Seventeen patients were referred for urgent treatment and 8 patients were not suitable for virtual follow-up. In 542 (82%) of all patients, diabetic retinopathy was the most common diagnosis.

CONCLUSIONS

This study reports clinical outcomes of a virtual model of care for medical retina clinics that imply safety of patient care in this clinic setting. This clinic format optimizes the use of already available resources and increases the skills of our existing workforce while maintaining high-quality clinical standards.

Expanding the role of medical retina virtual clinics using multimodal ultra-widefield and optical coherence tomography imaging

Background

An increasingly elderly population with a corresponding increase in ophthalmic conditions has led to increased pressure on hospital eye services (HES). In this study, we evaluated the use of a medical retina virtual clinic (MRVC), which has expanded into assessing all new medical retina referrals, where the need for urgent treatment was not clear.

Methods

Retrospective analysis of all new patients who were seen in the MRVC between April 2016 and May 2018. Pro forma sheets were used in the MRVC to record the patient history, visual acuity, and type of imaging required. Two consultants reviewed the completed pro formas and images and provided a final diagnosis and management plan. These results and reasons for face-to-face (F2F) clinic appointment requests were analyzed.

Results

Six hundred ten new referrals were enrolled in the virtual clinic. The most common diagnosis was diabetic eye disease (59.9%). In the virtual clinic 44.1% were followed up, 28.1% were discharged, and 27.8% were booked an F2F clinic appointment (urgent/routine). The main reason for F2F clinic was to offer treatment. Urgent F2F appointments took place on average 11.9 days after virtual clinic attendance. In only two cases was the image quality felt to be inadequate to assess the retina.

Conclusions

MRVC is an effective way of triaging medical retina referrals to allow those patients needing treatment to be seen promptly in the medical retinal service. The use of multimodal ultra-widefield and optical coherence tomography imaging allows assessment of a wide range of retinal pathologies and is a promising solution to alleviate the burden on HES.

A simulation tool for better management of retinal services

Background

Advances in the management of retinal diseases have been fast-paced as new treatments become available, resulting in increasing numbers of patients receiving treatment in hospital retinal services. These patients require frequent and long-term follow-up and repeated treatments, resulting in increased pressure on clinical workloads. Due to limited clinic capacity, many National Health Service (NHS) clinics are failing to maintain recommended follow-up intervals for patients receiving care. As such, clear and robust, long term retinal service models are required to assess and respond to the needs of local populations, both currently and in the future.

Methods

A discrete event simulation (DES) tool was developed to facilitate the improvement of retinal services by identifying efficiencies and cost savings within the pathway of care. For a mid-size hospital in England serving a population of over 500,000, we used 36 months of patient level data in conjunction with statistical forecasting and simulation to predict the impact of making changes within the service.

Results

A simulation of increased demand and a potential solution of the ‘Treat and Extend’ (T&E) regimen which is reported to result in better outcomes, in combination with virtual clinics which improve quality, effectiveness and productivity and thus increase capacity is presented. Without the virtual clinic, where T&E is implemented along with the current service, we notice a sharp increase in the number of follow-ups, number of Anti-VEGF injections, and utilisation of resources. In the case of combining T&E with virtual clinics, there is a negligible (almost 0%) impact on utilisation of resources.

Conclusions

Expansion of services to accommodate increasing number of patients seen and treated in retinal services is feasible with service re-organisation. It is inevitable that some form of initial investment is required to implement service expansion through T&E and virtual clinics. However, modelling with DES indicates that such investment is outweighed by cost reductions in the long term as more patients receive optimal treatment and retain vision with better outcomes. The model also shows that the service will experience an average of 10% increase in surplus capacity.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3560-5) contains supplementary material, which is available to authorized users.

Electronic referrals for virtual fracture clinic service using the National Integrated Medical Imaging System (NIMIS)

INTRODUCTION

Virtual fracture clinics (VFC) are now prevalent across many orthopaedic services in the UK and Ireland. The management of a variety of musculoskeletal injuries using the VFC model has been demonstrated to be safe, cost-effective and associated with high levels of patient satisfaction. Referrals were made available through the National Integrated Medical Imaging System (NIMIS). NIMIS allows for electronic movement of patient images throughout the Irish health service.

METHODS

A retrospective review of 157 orthopaedic fracture referrals from a regional hospital was performed. The referrals were received during a 6-week period between May 2016 and June 2016. Each of these referrals was sent electronically. These referrals were reviewed each day by a consultant-led multi-disciplinary team.

RESULTS

Thirty (93%) patients agreed or strongly agreed that they received adequate information in relation to the VFC when they attended the emergency department (ED). All patients except for one either agreed or strongly agreed that they were satisfied with their recovery (97%). Fifteen parents advised us that they would have had to take time off to attend fracture clinic with their child. Two patients attended their general practitioner (GP) or ED to seek further pain relief following their injuries. Only one patient reported a poor clinical outcome. Nine (28%) patients reported that they would have preferred a face-to-face appointment rather than being treated by the VFC.

CONCLUSION

Virtual review of orthopaedic trauma patients results in satisfactory patient outcomes. Clinical outcomes were acceptable with minimal additional medical attention required following injury. Electronic transfer of information allows for the virtual service to operate from sites long distances from the primary orthopaedic centre. The NIMIS is a safe and confidential means of collaborating with other institutions and has huge potential in the areas of trauma care delivery, clinical conferencing and other image-based disciplines.

The "National Integrated Medical Imaging System" [NIMIS]-friend, not nimesis!

INTRODUCTION

The "National Integrated Medical Imaging System" or NIMIS went live in 2011 and allows the movement of patient radiology imaging throughout the Irish health system. At the time of its launch, NIMIS was not only going to allow the filmless passage of patient radiology imaging but it was also envisaged that it would act as a medical image archive. The aim of this study was to assess the awareness and use of non-consultant hospital doctors and hospital consultants with regard to this medical image archive/referral function of NIMIS.

METHODS

A survey was carried out on 50 doctors across all specialities and grades at Tullamore Hospital looking at different aspects of the use of NIMIS.

RESULTS

Ninety-four percent of respondents use NIMIS on a daily basis and 6% use it on a weekly basis. The primary reason for using NIMIS was found to be "Viewing and Ordering Imaging" in 92% of those surveyed with 8% stating it was "Viewing imaging/reports". Ninety-eight percent surveyed said they had never used NIMIS to send a referral form or clinical photograph and 82% were not aware of this potential function. The majority of those surveyed stated that they either agreed or strongly agreed NIMIS is user-friendly.

CONCLUSION

NIMIS allows the safe and confidential flow of patient images and clinical information in the Irish health system. It could provide definite potential in the areas of clinical conferencing, multidisciplinary meetings and remote patient assessment along with collaborative research and education.

Analysing barriers to service improvement using a multi-level theory of innovation: the case of glaucoma outpatient clinics

The development and implementation of innovation by healthcare providers is understood as a multi-determinant and multi-level process. Theories at different analytical levels (i.e. micro and organisational) are needed to capture the processes that influence innovation by providers. This article combines a micro theory of innovation, actor-network theory, with organisational level processes using the 'resource based view of the firm'. It examines the influence of, and interplay between, innovation-seeking teams (micro) and underlying organisational capabilities (meso) during innovation processes. We used ethnographic methods to study service innovations in relation to ophthalmology services run by a specialist English NHS Trust at multiple locations. Operational research techniques were used to support the ethnographic methods by mapping the care process in the existing and redesigned clinics. Deficiencies in organisational capabilities for supporting innovation were identified, including manager-clinician relations and organisation-wide resources. The article concludes that actor-network theory can be combined with the resource-based view to highlight the influence of organisational capabilities on the management of innovation. Equally, actor-network theory helps to address the lack of theory in the resource-based view on the micro practices of implementing change.

Acceptability and use of glaucoma virtual clinics in the UK: a national survey of clinical leads

Objective

The purpose of this paper is to describe the findings of a national survey that aimed to estimate the proportion of Hospital Eye Service (HES) units using glaucoma virtual clinics, to determine how these services differ and to gauge clinicians’ views and opinions on the safety and acceptability of this model of care compared with usual care.

Methods and analysis

This 12-question survey was disseminated nationally to 92 clinical lead consultant ophthalmologists using SurveyMonkey.

Results

The response rate was 45.7%. There were 21 out of the total 42 respondents (50.0%) who were based at an NHS Trust where glaucoma virtual clinics were already being used and a further 9 (21.4%) were planning to establish one. Clinical leads largely rated efficiency and patient safety to be at least equivalent to usual care (92.9%) and 81.0% perceived glaucoma virtual clinics to be acceptable to patients. The main reasons for not running glaucoma virtual clinics were insufficient staff (71.4%) and inadequate space (47.6%). The majority of those running virtual clinics used this model of care for ‘lower risk’ patients such as ocular hypertensives (90.5%) and glaucoma suspects.

Conclusion

Glaucoma virtual clinics are employed by a large proportion of HES units, with many seeking to develop such services. Clinical leads largely rate efficiency, patient safety and the perception of patient acceptability to be at least equivalent to usual care.

Example of monitoring measurements in a virtual eye clinic using ‘big data’

Aim

To assess the equivalence of measurement outcomes between patients attending a standard glaucoma care service, where patients see an ophthalmologist in a face-to-face setting, and a glaucoma monitoring service (GMS).

Methods

The average mean deviation (MD) measurement on the visual field (VF) test for 250 patients attending a GMS were compared with a ‘big data’ repository of patients attending a standard glaucoma care service (reference database). In addition, the speed of VF progression between GMS patients and reference database patients was compared. Reference database patients were used to create expected outcomes that GMS patients could be compared with. For GMS patients falling outside of the expected limits, further analysis was carried out on the clinical management decisions for these patients.

Results

The average MD of patients in the GMS ranged from +1.6dB to −18.9dB between two consecutive appointments at the clinic. In the first analysis, 12 (4.8%; 95% CI 2.5% to 8.2%) GMS patients scored outside the 90% expected values based on the reference database. In the second analysis, 1.9% (95% CI 0.4% to 5.4%) GMS patients had VF changes outside of the expected 90% limits.

Conclusions

Using ‘big data’ collected in the standard glaucoma care service, we found that patients attending a GMS have equivalent outcomes on the VF test. Our findings provide support for the implementation of virtual healthcare delivery in the hospital eye service.

Developing standards for the development of glaucoma virtual clinics using a modified Delphi approach

Purpose

To obtain consensus opinion for the development of a standards framework for the development and implementation of virtual clinics for glaucoma monitoring in the UK using a modified Delphi methodology.

Methods

A modified Delphi technique was used that involved sampling members of the UK Glaucoma and Eire Society (UKEGS). The first round scored the strength of agreement to a series of standards statements using a 9-point Likert scale. The revised standards were subjected to a second round of scoring and free-text comment. The final standards were discussed and agreed by an expert panel consisting of seven glaucoma subspecialists from across the UK. A version of the standards was submitted to external stakeholders for a 3-month consultation.

Results

There was a 44% response rate of UKEGS members to rounds 1 and 2, consisting largely of consultant ophthalmologists with a specialist interest in glaucoma. The final version of the standards document was validated by stakeholder consultation and contains four sections pertaining to the patient groups, testing methods, staffing requirements and governance structure of NHS secondary care glaucoma virtual clinic models.

Conclusions

Use of a modified Delphi approach has provided consensus agreement for the standards required for the development of virtual clinics to monitor glaucoma in the UK. It is anticipated that this document will be useful as a guide for those implementing this model of service delivery.

Prospective evaluation of a virtual urology outpatient clinic

BACKGROUND

Outpatient department (OPD) clinics account for a significant proportion of healthcare expenditure. We report on a pilot study of a virtual outpatient clinic (VC) for urology patients as an alternative to a general urology clinic review.

AIMS

The study aims to assess the safety and cost-effectiveness of a virtual clinic as an alternative to general OPD review.

METHODS

A prospective study performed between March 2015 and December 2015 investigated the effectiveness of a VC in our institution. Eligible patients were recruited from general urology outpatient visits, from medical team members and from general practitioners (GP). Data recorded on each VC review included patient demographics, indication for referral to VC, outcome of VC and method of communication with the patient and their GP after the VC.

RESULTS

Three hundred eighty-five patients were registered for the VC. Indications for referral included review of imaging results (n = 136), doctor or patient query (n = 112) and review of laboratory results (n = 67). Outcomes after VC review included general OPD follow-up (n = 134), discharge from urology care (n = 39), referral for urological intervention (n = 29) and referral for radiological investigation (n = 23). VC review prevented 217 OPD clinic visits, saved €17,360 and provided a failsafe mechanism for reviewing investigation results. Two patients booked for OPD review following VC review did not receive appointments.

CONCLUSIONS

Virtual clinic is a safe and cost-effective alternative to general OPD review in appropriately selected patients.

A technician-delivered 'virtual clinic' for triaging low-risk glaucoma referrals

PurposeThe purpose of this study is to describe the outcomes of a technician-delivered glaucoma referral triaging service with 'virtual review' of resultant data by a consultant ophthalmologist.Patients and methodsThe Glaucoma Screening Clinic reviewed new optometrist or GP-initiated glaucoma suspect referrals into a specialist ophthalmic hospital. Patients underwent testing by three ophthalmic technicians in a dedicated clinical facility. Data were reviewed at a different time and date by a consultant glaucoma ophthalmologist. Approximately 10% of discharged patients were reviewed in a face-to-face consultant-led clinic to examine the false-negative rate of the service.ResultsBetween 1 March 2014 and 31 March 2016, 1380 patients were seen in the clinic. The number of patients discharged following consultant virtual review was 855 (62%). The positive predictive value of onward referrals was 84%. Three of the 82 patients brought back for face-to-face review were deemed to require treatment, equating to negative predictive value of 96%.ConclusionsOur technician-delivered glaucoma referral triaging clinic incorporates consultant 'virtual review' to provide a service model that significantly reduces the number of onward referrals into the glaucoma outpatient department. This model may be an alternative to departments where there are difficulties in implementing optometrist-led community-based referral refinement schemes.