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Presentation about data collection for eye services in Oxfordshire

Presentation about data collection for eye services in Oxfordshire

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Enhanced services Enhanced services Presentation Transcript

  • 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
  • What data did we require • Identify the problem areas • Identify the current referral pathways • Identify the stakeholders in PCO • Identify the barriers to entry for these stakeholders
  • Optometrist referrals (GOS18) Disorders of lens Primary open angle glaucoma suspect Diabetic retinopathy Age related macular degeneration Visual disturbances and other disorders of eye and adnexa Other disorders of retina Disorders of the cornea Disorders of eyelid, lacrimal system and orbit Disorders of vitreous body and globe Retinal 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 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. Disorders of eyelid, lacrimal system and orbit 52 (46) Visual disturbances and other disorders of eye and adnexa 21 (18) Disorders of conjunctiva 10 (9) Disorders of the cornea 2 (2) Disorders of vitreous, globe, sclera, optic nerve,visual pathway, iris, ciliary body, retinal breaks and other disorders of retina Disorders of lens 12 (11) BV/Refraction/Acc Age related macular degeneration 4 (4)
  • SELF REFERRAL Eye Casualty only GENERAL MEDICAL PRACTITIONER self-referral A&E (including Minor Injuries Units and Walk 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 glaucoma suspect Diabetic retinopathy Age related macular degeneration Visual disturbances and other disorders of eye and adnexa Other disorders of retina Disorders of the cornea Disorders of eyelid, lacrimal system and orbit Disorders of vitreous body and globe Retinal 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.
  • 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 • 2004 46% false positives • 2005 47% 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
  • 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
  • Stakeholders OMP's Optometrists Ophthalmologists General Practioners OMP's Optometrists Ophthalmologists General Practioners
  • 0 10 20 30 40 50 60 Percentage 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 Participati ng 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 Software costs HES Spend Base Costs Savings Made 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%) 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. Disorders of eyelid, lacrimal system and orbit 52 (46) Visual disturbances and other disorders of eye and adnexa 21 (18) Disorders of conjunctiva 10 (9) Disorders of the cornea 2 (2) Disorders of vitreous, globe, sclera, optic nerve,visual pathway, iris, ciliary body, retinal breaks and other disorders of retina Disorders of lens 12 (11) BV/Refraction/Acc Age related macular degeneration 4 (4)
  • SELF REFERRAL Eye Casualty only GENERAL MEDICAL PRACTITIONER self-referral A&E (including Minor Injuries Units and Walk 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 Ophthalmologists Yes 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!