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Stephen A. Vernon DM FRCS FRCOphth DO. New Care Pathways in Glaucoma. DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY HOSPITAL NOTTINGHAM UK. UK population by age - 2001. Age range. BMES PREVALENCE OF POAG. <60 60-69 70-79 >80. Age Group. Estimated numbers of glaucomas in UK by age.

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New care pathways in glaucoma

Stephen A. Vernon DM FRCS FRCOphth DO

New Care Pathways in Glaucoma

DEPARTMENT OF OPHTHALMOLOGY

UNIVERSITY HOSPITAL NOTTINGHAM UK



BMES PREVALENCE OF POAG

<60 60-69 70-79 >80

Age Group



Estimated numbers of glaucomas in UK by age

No in 1000s

Age

Over 65s to increase by 20-25% by 2020


A model of onset of a slowly progressive degenerative disease

Clear cut

disease

No disease

Grey area

Ageing increases size of grey area

Overlaps depend on definitions


Factors driving change in glaucoma

Elderly population increasing disease

More cases detected (esp NTG)

Low ratio of ophthalmol. : patients in UK

Increasing specialisation and investigations

Changes in training reduces clinic staff

Drive for low target pressures – more visits

Medical management options greater - more visits

Demand for “patient centred care” – patient choice, C&B

New targets for first OPD visits lead to bow-wave of follow up patients

Desire of PCT to save money

Payment by results

The Optometrists lobby.

Factors driving change in glaucoma


Demographic details of presenting patients disease

Past (1980)

63% via optometrists

Mean age 70.6

Mean IOP 31.7mmHg

33% late

10% reg blind

few false positives


Demographic details of presenting patients disease

Present

98% via optometrists

Mean age reducing

Mean IOP reducing

fewer present late

rare to register blind at presentation

false positive referrals a problem


Percentage of referrals diagnosed as normal disease

at first SAV Glaucoma Clinic


Diagnostic breakdown disease

2000 – SAV clinic

%

Nearly 30% OHT and suspects




Increase in glaucoma medications prescribed 1995 - 2004 disease

total

UK data

by month

All Beta blockers

Xalatan

Timolol

Cosopt



Workload calculation for UK ophthalmologists disease

380,000 glaucoma patients in UK

540 patients per consultant

Average 2.5 visits/yr

1600 visits/yr

3 clinics available

533 visits per clinic for 42 weeks

13 glaucoma pts/clinic (if all diagnosed)


Workload calculation for UK ophthalmologists disease

13 glaucoma pts/clinic (if all diagnosed)

50% diagnosed

But 200 suspect referrals/yr + review suspects/OHT

6 per clinic

12.5 glaucoma related patients every clinic

If all consultants “do” glaucoma

Glaucoma accounts for only 25% of OPD visits


The current “English” care pathway disease

Suspects “detected” by optometrists

Referred to GP by letter (GOS18)

GP sends letter + GOS18? to patient choice co-ordinating centre

Patient rings centre to choose secondary provider

Choice centre sends letter to secondary provider

Letter vetted by ophthalmologist

Patient sent appointment(s) for clinic CaB is changing this

Diagnosis glaucoma, suspect or normal (1/3 each)

HES manages glaucomas and most suspects

But …………..


+ disease


Potential outcome disease

SS HES



Membership of DoH Working Party disease

Stephen Vernon (R C Ophth Nottingham) Chair

Nicholas Astbury (R C Ophth Norwich)

Mike Nelson (R C Ophth Sheffield)

Jane Futrille (GOC)

Trevor Warburton (AOP)

Steve Taylor (FODO)

Michael Banes (Coll Optom)

Chris Packford (Assn Disp Optom)

Tim Smith (RCGPs)

The late John Keast-Butler (BMA)


Problems considered disease

Suspect glaucoma accounts for 16-20% of new referrals to the HES and an even larger number of return visits (25-30%).

Increased referrals are likely as population ages.

3. Early glaucoma is not easy to diagnose or to exclude with certainty. This leads to “defensive” continued observation in the HES.


Problems considered disease– 2

Incorrect perceptions

- glaucoma causes a rapid progression to blindness

- early diagnosis is essential to prevent this in most or all cases.

5. Other conditions commonly co-exist with glaucoma, particularly in the elderly.

Excluding progression in an established case may be difficult

- often requires considerable expertise and skill.


Problems considered disease - 3

7. Not all patients with glaucoma require treatment on diagnosis and some never do.

8. Treatment may have side effects which can be life threatening.

9. The quality of data in referrals from community optometrists is highly variable.


Current position (Jan 2003) disease

4 strategies to relieve HES pressures

Reduce the number of referrals to the HES (e.g. the Manchester Super-optometrist in the community scheme)

Increase the capacity within the HES (e.g. the Nottingham and Bristol in-house optometrist schemes)

Reduce the number of glaucoma patients seen in the HES (various UK shared care projects)

Initiative clinics/change of job plan


Primary objective - disease

Convert patients from secondary to primary care

Potential advantages

Reduces workload for secondary care – allows reduced waiting times for other ophthalmic conditions.

Increase in patient quality of life (reduced travel, cost, waiting times etc.).

Cost minimising analysis may be positive for primary care.

4. Increases potential for implementation of National Protocols.


Potential Problems disease

Previous studies failed to indicate potential value of shared care in the community

more expensive

relatively low percentage of glaucoma patients suitable

high “referral-back” rate to HES

Current skill level in primary care insufficient

who would train/do the training

do the trainers and/or trainees have the time/desire to train?


Potential Problems -2 disease

3. Defining who has responsibility for the patient.

4. Legal issues – prescribing rights for non-medical staff will be essential if they are to manage all but low risk OHT and suspects.

5. IT, audit and clinical governance/confidentiality issues.


Glaucoma care in the Community disease

Pre-requisites for successful care

Capacity

Trainability

Professionalism

Optometrists and OMPs are best suited to provide care


Non-ophthalmologist care of glaucoma disease

Two strategies

Train all optometrists to minimum level

Train some optometrists to higher level

Principle of the “Specialist Optometrist”

(OMPs could also assume similar role)


Non-HES care of glaucoma disease

Operational principles

Open to all optometrists and OMPs

Accreditation and revalidation system

Audit and clinical governance safeguards

Referring optometrists work to referral guidelines/protocols


Main WP Recommendations disease

1Community optometrists are encouraged to conform to College guidelines for referral of glaucoma suspects.

2HES services are encouraged to utilise optometrists to assist in glaucoma care within the HES.

3Community refinement of optometric referrals is established utilising OMPs and specialist optometrists.

Community care of “straightforward” glaucoma cases by OMPs and specialist optometrists is established.

The National Screening Committee considers chronic glaucoma as a candidate for formal screening.


Main WP Recommendations disease

1Community optometrists are encouraged to conform to College guidelines for referral of glaucoma suspects.

2HES services are encouraged to utilise optometrists to assist in glaucoma care within the HES.

3Community refinement of optometric referrals is established utilising OMPs and specialist optometrists.

Community care of “straightforward” glaucoma cases by OMPs and specialist optometrists is established.

The National Screening Committee considers chronic glaucoma as a candidate for formal screening.

First 3 deemed priorities, fourth requires legislation changes


The 5 Care Pathways disease

Care Pathway 1

Ocular Hypertension

Care Pathway 2

Glaucoma without other eye disease

Care Pathway 3

Glaucoma suspect on discs and/or fields

Care Pathway 4

Glaucoma in presence of other significant eye disease

Care Pathway 5

Refinement of community optometric referrals


The 5 Care Pathways disease

Care Pathway 1

Ocular Hypertension

Patient maintained in primary care following confirmation

Yearly monitoring by SpO + or – treatment on protocol

(IOPs, fields, discs)

SpO has responsibility


The 5 Care Pathways disease

Care Pathway 2

Glaucoma without other eye disease

If not “advanced” – remains in primary care

Care shared between SpO and HES via IT link

SpO decision following protocol – HES intervenes only if necessary

Monitored by SpO following protocol

If “advanced” – refer to HES

HES has responsibility in pathway 2


The 5 Care Pathways disease

Care Pathway 3

Glaucoma suspect on discs and/or fields

Monitor by SpO yearly

HES opinion (via IT link or appnt) if SpO considers possible

neuro cause for field loss

SpO Converts to other pathway as appropriate

SpO has responsibility unless HES involved


The 5 Care Pathways disease

Care Pathway 4

Glaucoma in presence of other significant eye disease

SpO refers patient to HES

HES may convert to pathway 2 if SpO agrees

HES has responsibility


The 5 Care Pathways disease

Care Pathway 5

Refinement of community optometric referrals

SpO refers all but normals and very low risk suspects (inc OHT) to HES

(SpO, as in all pathways, performs full exam

inc pachymetry, imaging, fields etc)

SpO has responsibility


Important features of new care pathways disease

IT link continues to involve UK based Ophthalmologists

Evidence based protocol driven care

Readily auditable

Will provide evidence base for changes in practice


At what stage is the DoH process – disease

Bids for funds to pilot pathways invited (Sept 03)

Approx 40 received (Early Oct 03)

Short-listing completed (End Oct 03)

4 accepted for funding

Pilots June 04 – May 06

DoH roadshows April/May 04

Pilots report early 2007

NECSSG first report on website

www.modern.nhs.uk


Pathways are dependant on – disease

Goodwill between optometrists and ophthalmologists

Sufficient interest from optometrists

Time/money for training

Changes in regulations

IT development/funding

Enthusiasm of protagonists


Pathways are dependant on – disease

Goodwill between optometrists and ophthalmologists

Sufficient interest from optometrists

Time/money for training

Changes in regulations

IT development/funding

Enthusiasm of protagonists


2002 survey disease


Capacity – diseaseWTE optometrists are increasing ---

and still are! - now stands at approx 7800


Could it really happen? disease

Workload calculations

Protocol requirements

Ophthalmologist time

Training, supervision, monitoring

Ophthalmologist motivation

Funding


Workload calculations disease

172000 referrals for suspect glaucoma per year

Referral refinement requires 53 WTE OSI

? 250 community optoms to be trained

Should reduce referrals by 50%

If community manages straightforward glaucomas – 820,000 patient visits in community per year

would require additional 50 WTE optoms


Is it happening? disease

Multiple “pilots” running as schemes

(Nottm “in house” + OHT in community projects)

Clinical competencies being defined

RCO diplomas proving popular


Shared care schemes in England – disease

National Survey May-Nov 2006 (Vernon S.A. et al)

131 eye departments

76 with shared care scheme (58%)

61 in house only, 9 community, 6 both

Community - optometrists 87%, GPSIs 13%.

In house - nurses 61%, Optoms 27%, orthoptists 25%


Nottingham OHT in the community project – disease

Approx 200 new patients 2003-6

1.5% non-attendance rate in first year

High success rate dependant in good administrator

6% re-referral rate per year


Care Pathway Diagram for NGCCS disease

Community

CO refers as suspect

Hospital

Patient attends SO

Comprehensive glaucoma examination + data on Eyetrack in Medisoft

Normal

suspect

early glaucoma

Moderate to advanced glaucoma

No treatment

treatment

Patient attends HES

review

x1only

On HES advice

Satisfactory control

Poor control

Usual HES care

Yearly reviews

Normal or low risk suspect

Suspects on no treatment and stable 5 years

Discharged to CO


The new Nottingham care pathway disease

Suspects “detected” by community optometrists

Referred to Specialist Optometrist (choice) GP + PCT informed

Patient rings SpO for appointment

Patient attends SpO for full assessment and management plan

If for treatment, SpO gives “prescription” to patient who takes to GP

SpO reviews patient and manages accordingly (protocol driven)

Ophthalmologist checks decision(s) via Eyetrack in Medisoft

SpO manages most glaucomas and all suspects

Data “on file” for main HES unit if attends HES


Conclusions disease

Shared care facilitates glaucoma pathway development

Evidence based protocols can be run within pathways

Shared care schemes in most departments

but mainly “in house”

Payment by results may influence DoH proposals

IT crucial for long-term success

Optometrists and ophthalmologists need to work together


Thank you for your attention

Stephen A. Vernon disease

Thank you for your attention


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