Transcript GLAUCOMA UPDATE Royal College Guidelines for Ocular

New Care Pathways in Glaucoma
Stephen A. Vernon DM FRCS FRCOphth DO
DEPARTMENT OF OPHTHALMOLOGY
UNIVERSITY HOSPITAL NOTTINGHAM UK
UK population by age - 2001
UK population by age 2001
5
4.5
4
no in millions
3.5
3
2.5
2
1.5
1
0.5
0
0-4
5.0-9.0
10.014.0
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
Age range
55-59
Age range
60-64
65-69
70-74
75=79
80-84
85-89
90+
BMES PREVALENCE OF POAG
12
Percentage
10
Observed
Expected
8
6
4
2
0
0
<60
2
60-69
70-79
80+
4
<60 60-69
70-79 >80
Age group
Age Group
Estimated numbers of glaucomas in UK by age
Nos of glaucoma in UK by age
70
60
No in
1000s
No in thousands
50
40
30
20
10
0
35-39
40-44
45-49
50-54
55-59
60-64
65-69
Age
Age
70-74
75=79
80-84
85-89
90+
Estimated numbers of glaucomas in UK by age
Nos of glaucoma in UK by age
70
60
No in
1000s
No in thousands
50
40
30
20
10
0
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75=79
80-84
85-89
Age
Age
Over 65s to increase by 20-25% by 2020
90+
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
• 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.
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
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
100
90
80
Percentage of referrals diagnosed as normal
at first SAV Glaucoma Clinic
70
60
50
40
30
20
10
0
Year 1988
Year 1993
Year 1997
Year 1999
100
90
Diagnostic breakdown
2000 – SAV clinic
%
80
70
Nearly 30% OHT and suspects
60
50
40
30
20
10
0
POAG
PXE
Narrow a Aphakic
OHT
Suspect
Uveitic
Pigment Juvenile Traumati
Others
Typical Eye department increase in
Outpatient visits
Total OP appointments (1000s)
60
55
50
45
40
35
30
25
20
1992
1994
1996
1998
Year
2000
2002
2004
New meds have lowered surgical rates
glaucoma surgery
4,500
4,000
3,500
cases
3,000
trabec
2,500
redo trabec
2,000
Molteno tube
cyclo-ablation
1,500
1,000
500
0
1994
1995
1996
1997
1998
year
1999
2000
2001
2002
2003
Increase in glaucoma medications prescribed 1995 - 2004
total
All Beta blockers
UK
data
by
month
Xalatan
Timolol
Cosopt
The glaucoma clinic snowball phenomenon
Workload calculation for UK ophthalmologists
• 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
• 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
• 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 …………..
Nos of glaucoma in UK by age
70
60
No in thousands
50
40
30
20
10
0
35-39
40-44
45-49
50-54
55-59
60-64
65-69
Age
70-74
75=79
80-84
85-89
90+
Total OP appointments (1000s)
60
55
50
45
40
35
30
25
20
1992
+
1994
1996
1998
Year
2000
2002
2004
Potential outcome
The new DOH Eyecare Pathways
Membership of DoH Working Party
• 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
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.
Problems considered – 2
4. 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.
6. Excluding progression in an established case may
be difficult
•
- often requires considerable expertise and skill.
Problems considered - 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)
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
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.
Potential Problems
1. 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
2. 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
3. Defining who has responsibility for the
patient.
4. Legal issues – prescribing rights for nonmedical 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
Pre-requisites for successful care
• Capacity
• Trainability
• Professionalism
Optometrists and OMPs are best suited to
provide care
Non-ophthalmologist care of glaucoma
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
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
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.
4
Community care of “straightforward” glaucoma cases by
OMPs and specialist optometrists is established.
5
The National Screening Committee considers chronic
glaucoma as a candidate for formal screening.
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.
4
Community care of “straightforward” glaucoma cases by
OMPs and specialist optometrists is established.
5
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
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
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
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
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
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
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
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 –
•
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 –
•
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 –
•
Goodwill between optometrists and ophthalmologists
•
Sufficient interest from optometrists
•
Time/money for training
•
Changes in regulations
•
IT development/funding
•
Enthusiasm of protagonists
Which Ocular Conditions could Optometrists manage or already do
manage? (Optometrist answers)
Serious Eye infections/Ulceration 1
38
Iritis 1
Keratitis
42
2
Diagnosed Glaucoma
2
56
2
52
57
9
3
34
60
24
Ocular Hypertension
48
32
Conjunctivits
14
14
38
41
Minor corneal abrasions
34
22
Dry Eye
62
21
20%
30%
40%
50%
60%
1
21
61
10%
11
26
Blepharitis/Lids
0%
15
70%
14
14
80%
90%
Already manage
Could manage with training
Could manage without training
Could not manage
2002 survey
1
0
1
100%
Capacity – WTE optometrists are increasing ---
and still are! - now stands at approx 7800
Could it really happen?
Workload calculations
Protocol requirements
Ophthalmologist time
Training, supervision, monitoring
Ophthalmologist motivation
Funding
Workload calculations
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?
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 –
•
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 –
•
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
Community
CO refers as suspect
Hospital
Patient attends SO
Comprehensive glaucoma examination + data on Eyetrack in Medisoft
Normal
suspect early glaucoma
No treatment
treatment
review
Satisfactory control
Yearly reviews
Suspects on no treatment and stable 5 years
Discharged to CO
Moderate to advanced glaucoma
Patient attends HES
x1 only
On HES advice
Poor control
Normal or low risk suspect
Usual HES care
The new Nottingham care pathway
• 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
• 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