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New Care Pathways in Glaucoma Stephen A. Vernon DM FRCS FRCOphth DO DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY HOSPITAL NOTTINGHAM UK.

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Presentation on theme: "New Care Pathways in Glaucoma Stephen A. Vernon DM FRCS FRCOphth DO DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY HOSPITAL NOTTINGHAM UK."— Presentation transcript:

1 New Care Pathways in Glaucoma Stephen A. Vernon DM FRCS FRCOphth DO DEPARTMENT OF OPHTHALMOLOGY UNIVERSITY HOSPITAL NOTTINGHAM UK

2 UK population by age Age range

3 BMES PREVALENCE OF POAG 80 Age Group

4 Estimated numbers of glaucomas in UK by age Age No in 1000s

5 Estimated numbers of glaucomas in UK by age Age No in 1000s Over 65s to increase by 20-25% by 2020

6 No disease Clear cut disease disease Ageing increases size of grey area Overlaps depend on definitions Grey area A model of onset of a slowly progressive degenerative disease

7 Factors driving change in glaucoma Elderly population increasingElderly population increasing More cases detected (esp NTG)More cases detected (esp NTG) Low ratio of ophthalmol. : patients in UKLow ratio of ophthalmol. : patients in UK Increasing specialisation and investigationsIncreasing specialisation and investigations Changes in training reduces clinic staffChanges in training reduces clinic staff Drive for low target pressures – more visitsDrive for low target pressures – more visits Medical management options greater - more visitsMedical management options greater - more visits Demand for “patient centred care” – patient choice, C&BDemand for “patient centred care” – patient choice, C&B New targets for first OPD visits lead to bow-wave of follow up patientsNew targets for first OPD visits lead to bow-wave of follow up patients Desire of PCT to save moneyDesire of PCT to save money Payment by resultsPayment by results The Optometrists lobby.The Optometrists lobby.

8 Demographic details of presenting patients Past (1980) 63% via optometrists Mean age 70.6 Mean IOP 31.7mmHg 33% late 10% reg blind few false positives

9 Demographic details of presenting patients Present 98% via optometrists Mean age reducing Mean IOP reducing fewer present late rare to register blind at presentation false positive referrals a problem

10 Percentage of referrals diagnosed as normal at first SAV Glaucoma Clinic

11 Diagnostic breakdown 2000 – SAV clinic % Nearly 30% OHT and suspects Nearly 30% OHT and suspects

12 Typical Eye department increase in Outpatient visits

13 New meds have lowered surgical rates

14 Increase in glaucoma medications prescribed total All Beta blockers Xalatan Timolol Cosopt UK data by month

15 The glaucoma clinic snowball phenomenon

16 Workload calculation for UK ophthalmologists 380,000 glaucoma patients in UK380,000 glaucoma patients in UK 540 patients per consultant540 patients per consultant Average 2.5 visits/yrAverage 2.5 visits/yr 1600 visits/yr1600 visits/yr 3 clinics available3 clinics available 533 visits per clinic for 42 weeks533 visits per clinic for 42 weeks 13 glaucoma pts/clinic (if all diagnosed)13 glaucoma pts/clinic (if all diagnosed)

17 Workload calculation for UK ophthalmologists 13 glaucoma pts/clinic (if all diagnosed)13 glaucoma pts/clinic (if all diagnosed) 50% diagnosed50% diagnosed But 200 suspect referrals/yr + review suspects/OHTBut 200 suspect referrals/yr + review suspects/OHT –6 per clinic 12.5 glaucoma related patients every clinic12.5 glaucoma related patients every clinic If all consultants “do” glaucoma If all consultants “do” glaucoma Glaucoma accounts for only 25% of OPD visits Glaucoma accounts for only 25% of OPD visits

18 The current “English” care pathway Suspects “detected” by optometristsSuspects “detected” by optometrists Referred to GP by letter (GOS18)Referred to GP by letter (GOS18) GP sends letter + GOS18? to patient choice co-ordinating centreGP sends letter + GOS18? to patient choice co-ordinating centre Patient rings centre to choose secondary providerPatient rings centre to choose secondary provider Choice centre sends letter to secondary providerChoice centre sends letter to secondary provider Letter vetted by ophthalmologistLetter vetted by ophthalmologist Patient sent appointment(s) for clinic CaB is changing thisPatient sent appointment(s) for clinic CaB is changing this Diagnosis glaucoma, suspect or normal (1/3 each)Diagnosis glaucoma, suspect or normal (1/3 each) HES manages glaucomas and most suspectsHES manages glaucomas and most suspects But …………..

19 +

20 Potential outcome SS HES

21 The new DOH Eyecare Pathways

22 Membership of DoH Working Party Stephen Vernon (R C Ophth Nottingham) ChairStephen Vernon (R C Ophth Nottingham) Chair Nicholas Astbury (R C Ophth Norwich)Nicholas Astbury (R C Ophth Norwich) Mike Nelson (R C Ophth Sheffield)Mike Nelson (R C Ophth Sheffield) Jane Futrille (GOC)Jane Futrille (GOC) Trevor Warburton (AOP)Trevor Warburton (AOP) Steve Taylor (FODO)Steve Taylor (FODO) Michael Banes (Coll Optom)Michael Banes (Coll Optom) Chris Packford (Assn Disp Optom)Chris Packford (Assn Disp Optom) Tim Smith (RCGPs)Tim Smith (RCGPs) The late John Keast-Butler (BMA)The late John Keast-Butler (BMA)

23 Problems considered 1.Suspect glaucoma accounts for 16-20% of new referrals to the HES and an even larger number of return visits (25-30%). 2.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.

24 Problems considered – 2 4.Incorrect perceptions - glaucoma causes a rapid progression to blindness- glaucoma causes a rapid progression to blindness - early diagnosis is essential to prevent this in most or all cases.- early diagnosis is essential to prevent this in most or all cases. 5.Other conditions commonly co-exist with glaucoma, particularly in the elderly. 6.Excluding progression in an established case may be difficult - often requires considerable expertise and skill.- often requires considerable expertise and skill.

25 Problems considered 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.

26 Current position (Jan 2003) 4 strategies to relieve HES pressures 1. Reduce the number of referrals to the HES (e.g. the Manchester Super-optometrist in the community scheme) 2. Increase the capacity within the HES (e.g. the Nottingham and Bristol in-house optometrist schemes) 3. Reduce the number of glaucoma patients seen in the HES (various UK shared care projects) 4. Initiative clinics/change of job plan

27 Primary objective - Convert patients from secondary to primary care Potential advantages 1.Reduces workload for secondary care – allows reduced waiting times for other ophthalmic conditions. 2.Increase in patient quality of life (reduced travel, cost, waiting times etc.). 3.Cost minimising analysis may be positive for primary care. 4.Increases potential for implementation of National Protocols.

28 Potential Problems Potential Problems 1.Previous studies failed to indicate potential value of shared care in the community more expensivemore expensive relatively low percentage of glaucoma patients suitablerelatively low percentage of glaucoma patients suitable high “referral-back” rate to HEShigh “referral-back” rate to HES 2.Current skill level in primary care insufficient who would train/do the trainingwho would train/do the training do the trainers and/or trainees have the time/desire to train?do the trainers and/or trainees have the time/desire to train?

29 Potential Problems -2 Potential Problems -2 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.

30 Glaucoma care in the Community Pre-requisites for successful care CapacityCapacity TrainabilityTrainability ProfessionalismProfessionalism Optometrists and OMPs are best suited to provide care Optometrists and OMPs are best suited to provide care

31 Non-ophthalmologist care of glaucoma Two strategies Train all optometrists to minimum levelTrain all optometrists to minimum level Train some optometrists to higher levelTrain some optometrists to higher level Principle of the “Specialist Optometrist” Principle of the “Specialist Optometrist” (OMPs could also assume similar role) (OMPs could also assume similar role)

32 Non-HES care of glaucoma Operational principles Open to all optometrists and OMPsOpen to all optometrists and OMPs Accreditation and revalidation systemAccreditation and revalidation system Audit and clinical governance safeguardsAudit and clinical governance safeguards Referring optometrists work to referral guidelines/protocolsReferring optometrists work to referral guidelines/protocols

33 Main WP Recommendations 1 Community optometrists are encouraged to conform to College guidelines for referral of glaucoma suspects. 2 HES services are encouraged to utilise optometrists to assist in glaucoma care within the HES. 3 Community refinement of optometric referrals is established utilising OMPs and specialist optometrists. 4Community care of “straightforward” glaucoma cases by OMPs and specialist optometrists is established. 5The National Screening Committee considers chronic glaucoma as a candidate for formal screening.

34 Main WP Recommendations 1 Community optometrists are encouraged to conform to College guidelines for referral of glaucoma suspects. 2 HES services are encouraged to utilise optometrists to assist in glaucoma care within the HES. 3 Community refinement of optometric referrals is established utilising OMPs and specialist optometrists. 4Community care of “straightforward” glaucoma cases by OMPs and specialist optometrists is established. 5The National Screening Committee considers chronic glaucoma as a candidate for formal screening. First 3 deemed priorities, fourth requires legislation changes

35 The 5 Care Pathways 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

36 The 5 Care Pathways 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

37 The 5 Care Pathways 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

38 The 5 Care Pathways 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

39 The 5 Care Pathways 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

40 The 5 Care Pathways 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

41 Important features of new care pathways IT link continues to involve UK based Ophthalmologists Evidence based protocol driven care Readily auditable Will provide evidence base for changes in practice

42

43 At what stage is the DoH process – Bids for funds to pilot pathways invited (Sept 03)Bids for funds to pilot pathways invited (Sept 03) Approx 40 received (Early Oct 03)Approx 40 received (Early Oct 03) Short-listing completed (End Oct 03)Short-listing completed (End Oct 03) 4 accepted for funding4 accepted for funding Pilots June 04 – May 06Pilots June 04 – May 06 DoH roadshows April/May 04DoH roadshows April/May 04 Pilots report early 2007Pilots report early 2007 –NECSSG first report on website

44 Pathways are dependant on – Goodwill between optometrists and ophthalmologistsGoodwill between optometrists and ophthalmologists Sufficient interest from optometristsSufficient interest from optometrists Time/money for trainingTime/money for training Changes in regulationsChanges in regulations IT development/fundingIT development/funding Enthusiasm of protagonistsEnthusiasm of protagonists

45 Pathways are dependant on – Goodwill between optometrists and ophthalmologistsGoodwill between optometrists and ophthalmologists Sufficient interest from optometristsSufficient interest from optometrists Time/money for trainingTime/money for training Changes in regulationsChanges in regulations IT development/fundingIT development/funding Enthusiasm of protagonistsEnthusiasm of protagonists

46 2002 survey

47 Capacity – WTE optometrists are increasing --- and still are! - now stands at approx 7800

48 Could it really happen? Workload calculations Protocol requirements Ophthalmologist time Training, supervision, monitoring Ophthalmologist motivation Funding

49 Workload calculations referrals for suspect glaucoma per year Referral refinement requires 53 WTE OSIReferral refinement requires 53 WTE OSI ? 250 community optoms to be trained? 250 community optoms to be trained Should reduce referrals by 50%Should reduce referrals by 50% If community manages straightforward glaucomas – 820,000 patient visits in community per year would require additional 50 WTE optoms would require additional 50 WTE optoms

50 Is it happening? Multiple “pilots” running as schemes (Nottm “in house” + OHT in community projects) Clinical competencies being defined RCO diplomas proving popular

51 Shared care schemes in England – National Survey May-Nov 2006 (Vernon S.A. et al)National Survey May-Nov 2006 (Vernon S.A. et al) 131 eye departments131 eye departments 76 with shared care scheme (58%)76 with shared care scheme (58%) 61 in house only, 9 community, 6 both61 in house only, 9 community, 6 both Community - optometrists 87%, GPSIs 13%.Community - optometrists 87%, GPSIs 13%. In house - nurses 61%, Optoms 27%, orthoptists 25%In house - nurses 61%, Optoms 27%, orthoptists 25%

52 Nottingham OHT in the community project – Approx 200 new patients Approx 200 new patients % non-attendance rate in first year1.5% non-attendance rate in first year High success rate dependant in good administratorHigh success rate dependant in good administrator 6% re-referral rate per year6% re-referral rate per year

53 Care Pathway Diagram for NGCCS CO refers as suspect Patient attends SO suspect early glaucoma Moderate to advanced glaucoma Normal Yearly reviews Patient attends HES treatment Discharged to CO review Comprehensive glaucoma examination + data on Eyetrack in Medisoft No treatment Satisfactory control Usual HES care Normal or low risk suspect Poor control x1 only Suspects on no treatment and stable 5 years On HES advice Hospital Community

54 The new Nottingham care pathway Suspects “detected” by community optometristsSuspects “detected” by community optometrists Referred to Specialist Optometrist (choice) GP + PCT informedReferred to Specialist Optometrist (choice) GP + PCT informed Patient rings SpO for appointmentPatient rings SpO for appointment Patient attends SpO for full assessment and management planPatient attends SpO for full assessment and management plan If for treatment, SpO gives “prescription” to patient who takes to GPIf for treatment, SpO gives “prescription” to patient who takes to GP SpO reviews patient and manages accordingly (protocol driven)SpO reviews patient and manages accordingly (protocol driven) Ophthalmologist checks decision(s) via Eyetrack in MedisoftOphthalmologist checks decision(s) via Eyetrack in Medisoft SpO manages most glaucomas and all suspectsSpO manages most glaucomas and all suspects Data “on file” for main HES unit if attends HESData “on file” for main HES unit if attends HES

55 Conclusions Shared care facilitates glaucoma pathway developmentShared care facilitates glaucoma pathway development Evidence based protocols can be run within pathwaysEvidence based protocols can be run within pathways Shared care schemes in most departmentsShared care schemes in most departments –but mainly “in house” Payment by results may influence DoH proposalsPayment by results may influence DoH proposals IT crucial for long-term successIT crucial for long-term success Optometrists and ophthalmologists need to work togetherOptometrists and ophthalmologists need to work together

56 Thank you for your attention Stephen A. Vernon


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