Enhanced services

Ophthalmic Primary Care Involving Community Optometrists and Local Enhanced Services

Paul Jewitt

What data did we require

• Identify the problem areas

• Identify the current referral pathways

• Identify the stakeholders in OPC

• Identify the barriers to entry for these

stakeholders (optometrists)

1st Outpatient appointments ORH

34,699

15,739

54,396

13,175 16,642

22,636

390

16,991

4,942

43,524

Trauma & Orthopaedics

Ear, nose and throat (ENT)

Opthhamology

Clinical haemotology

Cardiology

Dermatology

Rheumatology

Paediatrics

Obstetrics

Gynaecology

The NHS Information Centre, Hospital Episode Statistics for England. Outpatient statistics, 2010-11

Activity in English NHS Hospitals and English NHS commissioned activity in the independent sector.

Please see the HESonline website (http://www.hesonline.nhs.uk) for information on outpatients data quality.

Breakdown in 1st Outpatient

appointments by type Unfortunately Hospital Episode Statistics (HES) data are worthless for understanding N:F

ratios according to disease category because in 97% of OPD hospital visits disease is

unspecified (RCOphthal)

30%

20% 20%

15%

15%

Glaucoma

Cataract

AMD and other

Anterior segment

Casualty




• Identify the stakeholders in PCO


stakeholders

Optometrist referrals (GOS18) Disorders of lens

Primary open angle glaucomasuspectDiabetic retinopathy

Age related macular degeneration

Visual disturbances and otherdisorders of eye and adnexaOther disorders of retina

Disorders of the cornea

Disorders of eyelid, lacrimal systemand orbitDisorders of vitreous body andglobeRetinal vascular occlusions

BV/Refraction/Acc

Retinal detachments and breaks

Davey CJ, Green C & Elliott DB. Assessment of referrals to the hospital eye service by

optometrists and GPs in Bradford

and Airedale. Ophthalmic Physiol Opt 2011, 31, 23–28. doi: 10.1111/j.1475-1313.2010.00797.

GP referrals




Disorders of eyelid, lacrimal system and orbit 52 (46)

Visual disturbances and other disorders of eye andadnexa 21 (18)

Disorders of conjunctiva 10 (9)

Disorders of the cornea 2 (2)

Disorders of vitreous, globe, sclera, optic nerve,visualpathway, iris, ciliary body, retinal breaks and otherdisorders of retina

Disorders of lens 12 (11)

BV/Refraction/Acc

Age related macular degeneration 4 (4)

SELF REFERRAL Eye Casualty only

GENERAL MEDICALPRACTITIONER

self-referral

A&E (including MinorInjuries Units andWalk In Centres)Specialist Nurse(Secondary Care)

Optometrist

Number of Outpatient Eye Casualty activities in OUH during Apr11 to Nov11

Optometrist referrals Disorders of lens

Primary open angle glaucomasuspectDiabetic retinopathy

Age related macular degeneration

Visual disturbances and otherdisorders of eye and adnexaOther disorders of retina

Disorders of the cornea

Disorders of eyelid, lacrimal systemand orbitDisorders of vitreous body andglobeRetinal vascular occlusions

BV/Refraction/Acc

Retinal detachments and breaks




So where were Optometrists good and where was there room for

improvement?

• Cataract Less than 7% were not listed for surgery

• Diabetes Will be a much smaller % due to ODESS although this

remains a slight issue with a few Optometrists

• AMD Oxford has Direct referral pathways for wet AMD

• Glaucoma This study was done pre – NICE

A 10 year prospective study of glaucoma referrals to the Oxford Eye Hospital by

optometrists found that glaucoma was confirmed in 20% and ocular hypertension in

around 30% of the patients referred; over 40%

of patients referred for glaucoma were found not to have the condition (Bowling et

al., 2005)

A separate study in Oxford showed the following results:

• 2003 52% false positives



40% False Positives pre-NICE 2009

Are we worse than the rest of the England An analysis of patients discharged from a hospital-based glaucoma case-finding clinic over a 3-year period

Nicola J. Salmon1, H. P. Terry2, Andrew D. Farmery3 and John F. Salmon4 1Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland, 2Department of Optometry,

Oxford Eye Hospital, Oxford, UK, 3Nuffield Department of Anaesthetics, and 4Nuffield Department of

Ophthalmology, University of Oxford, Oxford, UK

Where do the false positive come

from? Optometrists account for 95% of all Glaucoma referrals

Optic Disc Assessment, 41.90%

IOP, 36.30%

Visual Fields, 19.50%

Other , 2.30%

An analysis of patients discharged from a hospital-based glaucoma case-finding clinic over a 3-year period

Nicola J. Salmon1, H. P. Terry2, Andrew D. Farmery3 and John F. Salmon4 1Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland, 2Department of Optometry,

Oxford Eye Hospital, Oxford, UK, 3Nuffield Department of Anaesthetics, and 4Nuffield Department of

Ophthalmology, University of Oxford, Oxford, UK

How can we reduce the false positives?

1. Studies have shown that the correlation

between decision making on visual fields

between Ophthalmologists and Optometrists to

be nearly 90%...........yet almost all referrals are

based on a single visual field plot and no

repeats.

2. Repeating pressures using Goldmann can

deflect a large proportion of high IOP’s found

with NCT.

3. Almost 50% of all referrals are based on a

single abnormal finding




• Identify the stakeholders in OPC


stakeholders

Stakeholders

OMP's

Optometrists Ophthalmologists

General Practioners

OMP's

Optometrists

Ophthalmologists

GeneralPractioners

0

10

20

30

40

50

60

Perc

en

tag

e

What are the barriers for Optometrists?

Barriers perceived by UK-based community

optometrists to the detection of primary open

angle glaucoma Joy Myint1, David F. Edgar1, Aachal Kotecha1,2, Ian E. Murdoch3 and John

G. Lawrenson

LOCSU – Referral Refinement

• Level 1a Goldmann Applanation Tonometry

– If IOP >21 mmHg at GOS or private sight test, Optometrist carries out Goldmann

applanation tonometry and repeats on a separate occasion if necessary

• Level 1b Visual Field Refinement

– If suspicious visual field at GOS or private sight test, optometrist carries out repeat measurement on a separate occasion

• Level 2 OHT Monitoring

– Patients who are diagnosed by secondary care (or specialist practitioner) as having OHT which does not require treatment will be referred for monitoring in the community at intervals specified by NICE

– Costs based on 25 minute assessments with optometrist

Audit Data is key to success

Participating

37% Non-participati

ng 63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Deflected at Test A

Deflected at Test B

Contractors signed up to LES Deflection by Optometrist

£0

£5,000

£10,000

£15,000

£20,000

£25,000

Fees Paid Softwarecosts

HES Spend Base Costs SavingsMade

Costs

0%

10%

20%

30%

40%

50%

60%

70%

Deflected at First Deflected at repeat

Total Deflection

6 month audit

• Slow Uptake by Optometrists

• Deflection comparable with other UK schemes.

• Individual Optometrist deflections similar

– No outliers but to early to know.

• The need for feedback from the HES to close the loop( how many are OHT)

• What happens next year OHT???

LOCSU – Referral Refinement

• Level 1a Goldmann Applanation Tonometry

– If IOP >21 mmHg at GOS or private sight test, Optometrist carries out Goldmann

applanation tonometry and repeats on a separate occasion if necessary

• Level 1b Visual Field Refinement

– If suspicious visual field at GOS or private sight test, optometrist carries out repeat measurement on a separate occasion

• Level 2 OHT Monitoring

– Patients who are diagnosed by secondary care (or specialist practitioner) as having OHT which does not require treatment will be referred for monitoring in the community at intervals specified by NICE

IOP/OHT…. What else? Community Care

IOP/OHT referral refinement

Diabetic Retinopathy

Hospital Care Stable Glaucoma monitoring (Consultant lead clinic)

Cataract pre and post operative care

Low Vision Services

Children's Eye Care Services

Acute / Eye Casualty

Possibilities Cataract Direct referral

Children's eye care services

PEARS/ACES/CORRS

Patients with Learning Disabilities

GP referrals (40%)




Disorders of eyelid, lacrimal system and orbit 52 (46)

Visual disturbances and other disorders of eye andadnexa 21 (18)

Disorders of conjunctiva 10 (9)

Disorders of the cornea 2 (2)

Disorders of vitreous, globe, sclera, optic nerve,visualpathway, iris, ciliary body, retinal breaks and otherdisorders of retina

Disorders of lens 12 (11)

BV/Refraction/Acc

Age related macular degeneration 4 (4)

SELF REFERRAL Eye Casualty only

GENERAL MEDICALPRACTITIONER

self-referral

A&E (including MinorInjuries Units andWalk In Centres)Specialist Nurse(Secondary Care)

Optometrist

Number of Outpatient Eye Casualty activities in OUH during Apr11 to Nov11

One week Audit of Nurse lead Clinic at ORH in 2010

Allergic Conjunctivitis

Blepharitis

Corneal Abrasion

Corneal/Subtarsal FB

Dry Eyes

Episcleritis

Herpes Zoster No Eye Involvement

Posterior Vitreous Detachment

Sub Conj Haemorrhage If Spontaneous

Trichiasis

Subtarsal FB

Bacterial Conjunctivitis

Marginal Keratitis

Sjogren's Syndrome

Recurrent Corneal Erosion

Corneal Epithelial Defect

Concreation

Conjunctivitis

Other

Optometrist with Independent Prescribing

“There is a ‘high-brow’ type of optician who takes a keen delight in delving into

subjects which are absolutely outside the scope of his work. Considerable play is

often made with afflictions, other than pathological conditions of the eye or arising

therefrom, of which doctors themselves know little and the optician a great deal

less…

…..Some opticians seek to heighten the illusion of being pseudo medical men by

resorting to the use of white coats, ‘hospitally smelling’ lens cleaning solutions and

similar means.

…..The more the optician is encroaching on medical ground the more he is

endangering his position. The medical side is being rightly perturbed and

unnecessarily antagonised by the optician interfering with matters which are not his own”.

Brumer 1942

Historical perspective

Changing Perspectives

0 20 40 60 80 100

Gp's

OphthalmologistsYes

No

Current Perspective

Seeking views of stakeholders: medical practitioners

In principle, do you believe that UK optometrists could use ocular therapeutic drugs, provided suitable training were given?

• I believe there is a huge opportunity for the

stakeholders of OPC to work together to

provide an invaluable service to the

community.

• Thank you!

Health & Medicine

Enhanced services