Lecturer, School of Optometry and the Vision Institute, Cardiff University.

Transcription

1 Evaluation of the Primary Eyecare Acute Referral Scheme (PEARS) and the Welsh Eye Health Examination (WEHE)

2 Evaluation of the Primary Eyecare Acute Referral Scheme (PEARS) and the Welsh Eye Health Examination (WEHE) NJL Sheen Lecturer, School of Optometry and the Vision Institute, Cardiff University. JM Wild D Fone CJ Phillips JM Sparrow JS Pointer Professor of Clinical Vision Sciences, School of Optometry and the Vision Institute, Cardiff University Professor of Health Sciences Research, Centre for Health Sciences Research, Cardiff University Professor of Health Economics, Institute for Health Research, Swansea University Consultant Ophthalmologist, Bristol Eye Hospital Optometrist, Rushden, Northamptonshire Professor D Fone would like to acknowledge the support of Margaret Webber in the GIS Drivetime analysis ii

3 TABLE OF CONTENTS EXECUTIVE SUMMARY...1 INTRODUCTION...1 PRIMARY OBJECTIVES...1 SECONDARY OBJECTIVES....2 METHODOLOGY...2 SPECIFIC OUTCOMES...3 Optometric aspects...3 Hospital Eye Service (HES) aspects...4 Patient aspects...5 Cost implications...6 CONCLUSIONS...7 RECOMMENDATIONS...7 CHAPTER 1 BACKGROUND AND METHODOLOGY OF THE EVALUATION...11 INTRODUCTION...11 BACKGROUND...12 Primary Eyecare Acute Referral Scheme...13 Welsh Eye Health Examination...13 Primary Objectives...15 Secondary Objectives...15 METHODOLOGY...16 Optometric record card...16 Information sheet and patient consent form...16 Transmission of record card...16 Data entry...16 Database...18 Retrieval of notes at the Hospital Eye Service...18 Retrieval of records from the GP...18 Telephone interview...19 Equity of Access...19 Health economics evaluation...19 CHAPTER 2: OPTOMETRIC MANAGEMENT OF PATIENTS ATTENDING FOR A PEARS OR WEHE...21 INTRODUCTION...21 iii

4 METHODS...21 RESULTS...22 Patient presentation...22 Optometric management...23 Patients referred by the GP to the optometrist...23 Self-referrals in PEARS...24 Symptoms of patients presenting for a PEARS examination...24 Referrals to the HES for glaucoma...24 Retrieval of information from the GP...24 DISCUSSION...26 CONCLUSIONS...28 CHAPTER 3: REFERRALS FROM OPTOMETRISTS TO THE HOSPITAL EYE SERVICE (HES)...29 INTRODUCTION...29 METHODS...30 RESULTS...31 Symptoms of patients referred to HES...32 Optometric management resulting in referral to the HES...38 Optometric diagnosis resulting in referral to the HES...40 Referrals for glaucoma...41 Other glaucoma-related referrals...41 Referrals for Age-Related Macular Degeneration (AMD)...42 DISCUSSION...42 CONCLUSIONS...45 CHAPTER 4 TELEPHONE INTERVIEW OF PATIENTS...47 INTRODUCTION...47 METHODS...47 Telephone interview...47 Appropriateness of patient management by optometrists...48 Patient Satisfaction...49 Socio-economic classification of patients...49 RESULTS...50 Appropriateness of patient management by optometrists...50 Patient satisfaction...51 Population characteristics and socio-economic classification...52 DISCUSSION...53 CONCLUSIONS...55 CHAPTER 5: EQUITY OF ACCESS...56 INTRODUCTION...56 METHODS...57 iv

5 RESULTS...57 DISCUSSION...67 CONCLUSIONS...68 CHAPTER 6 ECONOMIC IMPLICATIONS...69 INTRODUCTION...69 METHODS...69 GP consultations avoided...70 RESULTS...72 Costs associated with PEARS/WEHE...72 Costs resulting from inappropriate patient management and unnecessary referrals...73 Costs avoided from reasonable patient management and reduced utilisation...73 CONCLUSIONS...76 REFERENCES...77 APPENDIX A..81 APPENDIX B..83 APPENDIX C..85 APPENDIX D..86 APPENDIX E..89 v

6 FIGURES AND TABLES Figure 1.1. Flow diagram of the methodology used for the evaluation.17 Table 2.1. The reason for the PEARS or WEHE examination in the 6432 patients. 23 Figure 2.1: Outcome of 6432 patients examined under the auspices of the PEARS and WEHE.25 Table 2.2: Primary symptom and outcome of the 4881 patients presenting for a PEARS examination Table 3.1. The number and type of presenting symptom (as categorized in Appendix D) of the 392 sampled patients referred to the HES and the management outcome within the HES...35 Figure 3.1. The presenting symptoms for the 392 sampled patients referred to the HES...36 Table 3.2. The number and type of presenting symptom (condensed from that in Table 3.1) of the 392 sampled patients referred to the HES and the management outcome within the HES...37 Table 3.3 The appropriateness of the optometric management decision, stratified by location of ocular disorder, of the patients referred to the HES as a result of the PEARS examination (n=344/392).39 Table 3.4 The appropriateness of the optometric management decision, stratified by location of ocular disorder, of the patients referred to the HES as a result of the WEHE (n=48/392)...40 Table 3.5: Classification of glaucoma referrals to the HES...41 Figure 5.1: The regional distribution of patients attending for a WEHE/PEARS examination...58 vi

7 Figure 5.2: The distribution of PEARS and WEHE optometrists in North Wales...59 Figure 5.3: The distribution of PEARS and WEHE optometrists in South Wales Figure 5.4: The distribution of PEARS and WEHE optometrists in West and Mid- Wales.. 61 Table 5.1: Distance travelled by patients to reach a WEHE/PEARS optometrist (Drivetime) in Wales...63 Table 5.2 : Distance travelled by patients to reach a WEHE/PEARS optometrist (Drivetime) by rurality - (ONS 2005)...63 Table 5.3: Distance travelled by patients to reach a WEHE/PEARS optometrist (Drivetime) by Townsend fifth of deprivation (1 is most deprived, 5 least deprived) Table 5.4: Time taken by patients to reach a WEHE/PEARS optometrist (Drivetime)...64 Table 5.5: Time taken by patients to reach a WEHE/PEARS optometrist (Drivetime) by rurality - (ONS 2005)...65 Table 5.6: Time taken by patients to reach a WEHE/PEARS optometrist (Drivetime) by Townsend fifth of deprivation Figure 5.5: Histogram of travel time in minutes (Drivetime) to a WEHE/PEARS optometrist for all patients in Wales Table 6.1 (overleaf). Data sources in relation to the costs incurred, potential additional costs resulting from inappropriate patient management, and costs avoided as a result of fewer GP consultations and hospital outpatient attendances and benefits gained...71 Table 6.2: Costs associated with PEARS and WEHE.75 vii

8 EXECUTIVE SUMMARY INTRODUCTION The PEARS and WEHE schemes are part of an all encompassing Welsh Eye Care Initiative (WECI). The two schemes are intended, respectively, to facilitate the early assessment of acute ocular conditions and to case-find ocular disease in at-risk individuals. Both types of eye examinations are undertaken by PEARS/WEHE accredited optometrists. To be accredited for the PEARS and WEHE schemes, optometrists must pass a theoretical module and pass a practical component. The aim of PEARS is to maintain as many patients as possible in the primary care setting, thus avoiding unnecessary referrals to the Hospital Eye Service (HES). The WEHE is intended to facilitate the detection of eye disease in the early stages, before significant visual loss occurs, thereby reducing the burden on the HES and other health care sectors. PRIMARY OBJECTIVES The primary objectives for the evaluation of the PEARS and WEHE schemes were: To determine the number of PEARS and WEHE patients examined by accredited optometrists. To determine the number of PEARS and WEHE patients managed and referred by accredited optometrists. To determine if the patient management decisions by accredited optometrists were reasonable to ophthalmology, based upon the information available to the optometrist. 1

9 To determine if the diagnoses of the eye conditions referred to the HES by accredited optometrists were reasonable to ophthalmology, based upon the information available to the optometrist. To determine the distribution of accredited optometrists and the geographical equity of access to them. To determine if patients who have received a PEARS and WEHE eye examination are satisfied with the service provided by the accredited optometrist. To assess the economic impact of the PEARS and WEHE schemes. SECONDARY OBJECTIVES The secondary objectives for the evaluation of the PEARS and WEHE schemes were: To determine which symptoms and signs were referred to the HES by accredited optometrists. To determine the number and types of eye conditions referred by accredited optometrists. To determine the socio-economic background of patients attending for a PEARS or WEHE examination. METHODOLOGY 6432 successive record cards (from 274 optometrists) were utilised during the period of the evaluation (from 04/04/06 to 21/12/06). 76% of the 6432 cases were for the PEARS scheme and 24% were for the WEHE. The mean age of patients was 57.2 years (SD 18.6). 2

10 289 randomly selected patients from the 6432 patients underwent a telephone interview within one week of attending an accredited optometrist. Of these 289 patients, 119 (41%) exhibited persisting symptoms and therefore received a further telephone interview approximately one month later. The hospital notes of 596 consecutive referrals were requested from 877 referrals to the HES (covering all 11 main HES Departments in Wales) during a four month period (from 4/08/06 and 21/12/06). Of these 596 consecutive referrals, the notes of 392 were available for assessment and were accessed and the relevant information extracted. One optometrist and one ophthalmologist, both practicing in England and independent of the PEARS and WEHE, then evaluated whether the optometric management and the optometric diagnosis of these patients were appropriate. In each case, the ophthalmologist was the final arbiter. SPECIFIC OUTCOMES Optometric aspects Referral route to the optometrist 1576 (24.5%) of all referrals to the PEARS and WEHE were from the General Practitioner (GP). A further 3692 (57.4%) of patients were self-referred. 589 patients (9.2%) were eligible for a WEHE because of a risk of eye disease by reasons of race or family history. Only in 19 (0.3%) cases were patients eligible for a WEHE due to race alone. The remaining 556 (8.6%) patients were eligible for a WEHE due to deafness, uni-ocularity, retinitis pigmentosa, a sibling of a patient with inherited eye disease or referral from the Diabetic Retinopathy Screening Service of Wales. Optometric management Out of the 6432 patients presenting for a PEARS or WEHE examination, 4243 (66%) were managed by optometrists (i.e. not referred to the HES or GP). 3

11 1171 (18%) patients were referred to the HES following examination by an accredited optometrist. The remaining 16% (1018) of patients were referred to the GP. The majority of patients referred by the GP to PEARS and WEHE accredited optometrists were managed within optometric practice or discharged at the first visit 940 (60%). Patients requiring additional examination after being managed by their optometrist 3 (1%) of 289 patients interviewed by telephone, that had been either discharged by their optometrist or managed by their optometrist, had to seek medical attention for their ocular problem. Number of referrals to HES with suspect glaucoma 129 patients were referred to the HES with suspected glaucoma (2.4% of the PEARS and WEHE patients over 40 years of age). Hospital Eye Service (HES) aspects 1171 (18%) of the 6423 patients were referred to the HES. The hospital notes of 392 patients were perused to establish the outcome of these referrals. Symptoms of patients referred to the HES Of the 392 patients, the most common presenting symptoms resulting in referral to the HES were uni-ocular irritated/painful red eye (62 cases, 16%), and flashes and floaters without visual loss (50 cases, 13%). 4

12 Optometric management resulting in referral to the HES 295 (75%) of the 392 management decisions were deemed to be appropriate. 49 (51%) of the 97 inappropriate management decisions were due to posterior vitreous detachment (PVD). Optometric diagnosis resulting in referral to the HES 284 (72%) of the 392 conditions were deemed to be correctly diagnosed. Corneal disorders (16%) were the most common reason for referral, followed by optic nerve head disorders (including glaucoma) (16%), vitreous (15%), macular (12%), other retina (12%) and lens (11%) disorders. Uncomplicated PVD accounted for 13% of the total number of sampled referrals seen by ophthalmologists. Asymptomatic patients referred to the HES 41 patients referred to the HES were asymptomatic. Of these, 33 were retained within the HES and 8 patients were discharged. Of the 33 patients, 23 (6% of referrals assessed) had been referred with suspected glaucoma; of these, the majority (19 cases) were retained within the HES. Patient aspects Patient satisfaction with the service Of the 289 patients interviewed by telephone within one week of their PEARS or WEHE examination, 94.8% were very satisfied and 5.2% fairly satisfied with the optometric service. The level of satisfaction was independent of deprivation (Welsh Index Multiple Deprivation, WIMD classification), age, gender, occupational status (NSSEC3 classification), and whether the patient normally paid for an eye examination. 5

13 Travel to the optometrist Of the 289 patients interviewed by telephone, the mean journey time to the optometrist was 13.0 minutes (SD 11.0). The longest journey time was 1.5 hours. Most patients (66%) travelled by car to reach their optometrist. Based upon the postcodes of the 6432 patients, 87.3% had to travel less than 5 miles to a PEARS/WEHE accredited optometrist. In Mid and West Wales, combined, this proportion was 78.6%. In areas with the sparsest populations (defined by ONS Census 2001), such as Powys and Ceredigion, the average distance travelled to a PEARS/WEHE accredited optometrist was 6.1 and 5.8 miles, respectively. Across all of Wales, 84.9% of patients travelled less than 10 minutes to reach a WEHE PEARS/WEHE accredited optometrist. In Mid and West Wales the proportion was 74.9%. The corresponding figures for Powys and Ceredigion were 13 and 12 minutes, respectively. Patients residing in the most deprived areas (determined by Townsend fifth of deprivation) did not have to travel any further to a PEARS/WEHE accredited optometrist than those living in the least deprived areas. Cost implications The model for the costing of the PEARS/WEHE scheme was based upon: (a) the PEARS/WEHE fees to optometrists incurred for the 6432 cases; (b) the assumption that the 3692 self-referring patients into the PEARS did not consult a GP prior to self-referral (GP consultation costed at 22.00); (c) the 1576 PEARS patients managed within optometric practice (thereby saving HES consultations costed at per outpatient consultation, not including procedures); and (d) the costs of inappropriate optometric management (ranging between 27,853 and 19,823, depending upon the scenario). The calculated total expenditure was approximately 244,000 and the resource utilisation avoided (i.e. the savings on unnecessary HES and GP 6

14 consultations) was approximately 191,000. The net cost of the 6423 WEHE/PEARS examinations over the eight month period of the Evaluation was therefore approximately 77,000, or a cost of approximately 12 per PEARS/WEHE examination. CONCLUSIONS The evaluation showed that PEARS/WEHE accredited optometrists managed the majority of patients and made acceptable clinical judgements in their management. Adjustments in training and the setting of protocols for specific eye conditions could potentially enhance the clinical decision making by optometrists and decrease referrals to the HES. PEARS and WEHE examinations provided high levels of patient satisfaction. Patient equity of access to the service was good within all geographic areas of Wales. The cost of the PEARS and WEHE examinations is relatively low when the clinical benefits, coupled with ease of patient accessibility to these schemes, are considered. RECOMMENDATIONS The PEARS and WEHE schemes should continue. As a means of providing primary eye health care to patients, the PEARS and WEHE schemes are relatively cost efficient, exhibit very high levels of patient satisfaction and the vast majority of optometrists operating within the schemes satisfy the required professional clinical standards. A relatively large number of referrals from accredited optometrists to the HES were for symptoms of flashes and/or floaters in the presence 7

15 of an apparently normal retina. In all but three cases, these patients exhibited a PVD and, once seen at the HES, were discharged with advice from the ophthalmologist about the symptoms associated with a retinal detachment. Further training on the identification and management of PVDs would reduce unnecessary referrals. Agreement from ophthalmologists and optometrists, at a local level if necessary, as to which patients can reasonably be managed by the optometrist would reduce these types of referrals and would provide further cost savings. Four percent of the sampled HES referrals were patients with marginal keratitis. This condition is often referred to the HES as bacterial keratitis. Further training on the identification and management of marginal keratitis would enable optometrists to make reasonable referrals when presented with this condition. Again, inter-professional agreement, with standardised protocols, should be established on the referral route for this condition. Marginal keratitis is, invariably, accompanied by blepharitis which accredited optometrists are able to manage. With the prospect of future prescribing rights for optometrists, marginal keratitis is a commonly presenting condition that is readily amenable to in-practice treatment by a suitably qualified optometrist. The PEARS is well known and appears to be readily accepted by both the public and professionals, alike. However, there is less awareness and an apparent under-utilisation of the WEHE. As a consequence, it should be re-formatted and marketed to the public and to health professionals. A further category for the WEHE should be introduced to allow practitioners to undertake further examinations, if clinically necessary, on a separate patient visit e.g. a patient suspected of having open angle glaucoma may require a repeat visual field examination and a repeat assessment of their intra-ocular pressure for diagnostic clarification. A suggested name for this category would be Additional 8

16 clinically necessary examinations. Such repeat examinations would reduce the number of false-positive referrals to the HES leading to further cost savings. A small number of optometrists identified during the evaluation evidently require further experience and training to ensure that they meet the necessary professional clinical standards. This is a sensitive professional issue but is essential to maintain the integrity of the PEARS and WEHE and to prevent potential impaired fitness to practice cases in the future. Re-evaluation for all PEARS and WEHE accredited optometrists should occur on a 3-year cycle. This is essential to maintain the level of professional standards. The WEHE does not appear to be taken-up by ethnic groups which are at-risk of developing sight-threatening eye diseases. These ethnic communities need to be specifically targeted with a publicity campaign in conjunction with the local general practitioner and optometry practices in those regions where the ethnic communities reside. A combined claim form and record card should be introduced to facilitate regular audit of the PEARS and WEHE schemes. The single form would include reason for examination and management tick boxes, as well as optometrist, patient and practice details. The details would be kept by the Business Service Centres (BSCs) or by the Local Health Board (LHB) in Carmarthen. At present, details of claims for PEARS and WEHE are not in a standardised format, which makes audit of finances difficult. The Referred by GP category should only be available in the PEARS scheme. It should be removed from the WEHE forms to avoid confusion and make future evaluations easier. 9

17 . Within the WEHE claim form is a category of examination Risk of eye disease for reasons of race or family history. This category of examination could be subject to various interpretations and has the potential for misuse. Consequently, stringent guidelines for this category should be introduced and enforced. 10

18 CHAPTER 1 BACKGROUND AND METHODOLOGY OF THE EVALUATION INTRODUCTION Over the last 5-10 years, government policy has altered the provision of primary eye care. Whereas previous providers of primary eye care comprised GPs and optometrists, the provision is now disseminated across the community such that it may, theoretically, be delivered by any service possessing the following attributes: first contact, accessibility, continuity, longitudinally, comprehensiveness, coordination, equity and accountability (Riad et al 2003). A community-based ophthalmic team involved in prevention and treatment of eye disease is considered to provide a total model of ophthalmic care. However, ophthalmologists due to their restricted numbers and expanding workloads cannot provide such a service, alone (Blach 2001). The necessary model of prevention and treatment would include optometrists, orthoptists and associated personnel working closely with ophthalmologists. These approaches were referred to in several Department of Health reports in 2004 and 2005 in which ophthalmology was highlighted as a speciality where outpatient attendances could be safely and effectively managed in the community. The principle of the PEARS is to mange minor eye conditions safely and effectively in optometric community practice. The need to create holistic approaches to healthcare, with the formation of partnerships and improvements in access to high-quality services across all sections of the NHS in Wales, was detailed in the Designed for Life strategy published by the Welsh Assembly Government in More recently, the Welsh Assembly Government has resolved that Referral Management Centres (RMCs) should be established in Wales. It is intended that the RMCs will channel referrals to the most appropriate care-pathways, ultimately improving the quality of referrals to the secondary care sectors (NLIAH 2006). The PEARS and WEHE schemes are consistent with the primary care model favoured by the Welsh Assembly Government. Firstly, both schemes provide a first-point of contact and apparent accessibility and equity for patients in Wales. Secondly, PEARS provides a model for reducing referrals to the 11

19 hospital sector by managing patients in the community. Thirdly, WEHE provides a mechanism for case-finding for ocular disease in at-risk individuals, thereby reducing the burden on other health care sectors. However, there is no evidence, as yet, to assert these claims. This report describes the evaluation of the PEARS and WEHE schemes which determined if the process provided a high quality service and equity of access and investigated the financial and clinical accountability of the schemes. Recent proposals from the Department of Health and the Medicines & Healthcare Products Regulatory Agency pave the way for optometrists to have full independent prescribing rights and, therefore, an expanded role in Primary Care. This evaluation provides an insight into two existing schemes where optometrists have an extended Primary Care role. BACKGROUND The PEARS scheme was introduced, on a local basis, in the Vale of Glamorgan in 2000 and was funded from a non-recurring Primary Care Development Fund budget. In 2002, the Welsh Assembly Government introduced and financed WEHE for selected categories of patients in Wales. Six months later, the PEARS was expanded to include the whole of Wales and was also financed by the Welsh Assembly Government. The PEARS and WEHE are part of the all encompassing Welsh Eyecare Initiative. The PEARS and WEHE schemes are intended, respectively, to facilitate the early assessment of acute ocular conditions and to case-find ocular disease in at-risk individuals. Both types of eye examinations are undertaken by PEARS/WEHE accredited optometrists. Optometrists must be accredited to perform both types of examination; they cannot provide just one type of examination. To be accredited for PEARS and WEHE schemes, optometrists have to pass a theoretical module and a practical assessment. Every practice registered with the PEARS and WEHE schemes is required to have a semi-automated or automated perimeter, a Volk or similar lens for binocular indirect ophthalmoscopy and a contact applanation tonometer. The 12

20 PEARS and WEHE are different from a routine optometric examination in that the examinations concentrate upon the health of the eye. The PEARS and WEHE examination is at no cost to the patient. The Primary Eyecare Acute Referral Scheme The purpose of the PEARS examination is to address the needs of a patient presenting with an acute eye condition i.e. ocular symptoms which would require urgent, if not immediate, attention. The aim of PEARS is to maintain as many patients as possible in the primary care setting, thus avoiding unnecessary referrals to the HES. The patient can self-refer for a PEARS examination or may be referred by their General Practitioner (GP). General Practitioners traditionally manage acute eye problems but optometrists are well placed within the community to provide primary eye health care, quickly and effectively. Additionally, GPs face an ever increasing burden on their resources and manage acute eye problems without having access to the full range of diagnostic equipment. PEARS and WEHE accredited optometrists possess a full range of such equipment in their practices. The Welsh Eye Health Examination The WEHE enables optometrists to case-find patients who are either at risk of developing eye disease or who are hearing impaired and would find the consequences of losing their sight particularly difficult. Early detection of eye disease in these groups is particularly important as such patients are frequently asymptomatic. The following groups of patients are entitled to a WEHE: Uni-ocular patients i.e. patients who would be significantly impaired if they lost vision in their better eye. 13

21 Patients who are profoundly hearing impaired these patients require sight to lip-read. Patients with retinitis pigmentosa or siblings of patients with inherited eye disease. Patients whose family origins are Black African, Black Caribbean, Indian, Pakistani or Bangladeshi. Patients at risk of eye disease by reason of race or family history. Patients may self-refer or be referred by their GP for the WEHE. The WEHE is intended to facilitate the detection of eye disease in the early stages, before significant visual loss occurs, thereby reducing the burden on the HES and other health and social care sectors. The perceived advantages of the PEARS and WEHE are: Ophthalmologists should receive fewer referrals from optometrists as more patients will be managed within the primary care sector. Patients have improved access to diagnostic eye care service. Ophthalmologists should eventually receive a better quality of referral from optometrists registered with PEARS/WEHE since these optometrists will have gained more experience of managing acute eye problems. Fewer demands should be made upon GPs time and resources in primary eye care. Multi-professional collaboration and alliances should occur between GPs and optometrists. Optometrists should be able to operate at the top-end of their skills, leading to increased job satisfaction. 14

22 Primary Objectives The primary objectives for the evaluation of the PEARS and WEHE schemes were: To determine the number of PEARS and WEHE patients seen by accredited optometrists (Chapter 2). To determine the number of PEARS and WEHE patients managed and referred by accredited optometrists (Chapter 2). To determine if the patient management decisions by accredited optometrists were reasonable to ophthalmology, based upon the information available to the optometrist (Chapter 3). To determine if the diagnoses of the eye conditions referred to the HES by accredited optometrists were reasonable to ophthalmology, based upon the information available to the optometrist (Chapter 3). To determine the distribution of accredited optometrists and the geographical equity of access (Chapter 5). To determine if patients who have received a PEARS or WEHE examination were satisfied with the service provided by their optometrist (Chapter 4). To assess the economic impact of the PEARS and WEHE (Chapter 6). Secondary objectives The secondary objectives for the evaluation of the PEARS and WEHE schemes were: To determine the types of symptoms and signs referred to the HES by accredited optometrists (Chapter 3). To determine the number and types of eye conditions referred by accredited optometrists (Chapter 3). To determine the socio-economic background of patients attending for a PEARS or WEHE examination (Chapter 5). 15

23 METHODOLOGY The evaluation of the PEARS and WEHE was undertaken on a cohort of patients consecutively presenting to the two schemes between April 4th 2006 and December 17 th A flow diagram of the methodology is shown in Figure 1.1. Optometric record card Every optometrist accredited to the PEARS and WEHE schemes recorded their examination findings on a standardized record card especially designed for the evaluation (Appendix A) thereby permitting relevant data to be extracted. The record card was available both in paper and electronic format and had been approved by Optometry Wales. Information sheet and patient consent form Each patient received an information sheet describing the study (Appendix B). At the end of the PEARS or WEHE examination each patient was given the opportunity to sign a consent form permitting access to their relevant medical records (Appendix C). This procedure was in accordance with the Multi- Centre Research Ethics committee (MREC for Wales). Transmission of the record card Following receipt of informed consent, the optometrist either faxed the written record card and consent form to Carmarthen LHB, or ed an electronic version of the record card and faxed the signed consent form to Carmarthen LHB, on the same day as the examination. Data entry At the processing centre in Carmarthen LHB, the information contained within the record card was manually entered by operators onto a password-protected and encrypted custom-designed Access database. The LHB had a secure storage area. Access was used a platform to enable consistency with other NHS software. 16

24 Figure 1.1. Flow diagram of the methodology used for the evaluation 17

25 The Access software utilised drop down lists, where appropriate, to create transcripts of the information on the record card. A standard flat-bed scanner was used to capture visual field print-outs and drawings. These were transferred into the database using a scanning function incorporated into the custom designed software. Database The Access database was custom designed to enable easy-of-use data entry combined with the functionality of data analysis and cross-linkage through the Microsoft Access interface. Patient record cards were assigned a unique patient identification code. Data was extracted from the Access database using the Access query writing function. Descriptive analysis was performed using Excel and SPSS for Windows. Retrieval of notes at the Hospital Eye Service If the patient was referred by their optometrist to the HES, arrangements were made with the appropriate Trust staff (clinical director, ophthalmologist, medical records, audit, research and development) of each HES unit to view the patient s HES case notes. The notes were scrutinised to establish: the date the patient was seen, the ophthalmological diagnosis, and the management outcome. The details of the HES units and corresponding numbers of patients and the categorisation of the extracted variables are detailed in Chapter 3. Retrieval of records from the GP A letter was sent to the GP if a patient was referred to the GP for investigation (e.g. blood pressure measurement); if the patient was rereferred to the GP because the optometrist had found a negative ocular finding (e.g. headache without apparent ocular cause); or if the optometrist referred the patient to the GP for the purposes of providing ocular medication for co-management. 18

26 The letter explained the purpose of the evaluation and contained a selfcompletion form and a stamped addressed envelope for return. The form compromised the following tick boxes: whether the GP found the patient to have a medical condition that required treatment or follow-up; and whether the GP found that there was no condition that required treatment or a followup. One letter only was sent to a GP practice even if there was more than one referral to the same GP practice. Details of the procedures are given Chapter 2 Telephone interview A randomly selected sample of patients was chosen for a telephone interview within a week of undergoing their PEARS or WEHE. The questions asked at interview are included as Appendix E. Details of the interview procedures are given in Chapter 4. Patients manifesting persisting symptoms at the first telephone interview were asked if they could be contacted for a follow-up interview one month later to establish if their symptoms had resolved. Therefore, each randomly selected patient was subjected to a maximum of two telephone interviews. Health economics evaluation The economic impact of PEARS and WEHE was assessed primarily from an NHS perspective but also included consideration of patient issues. Costs associated with the PEARS and WEHE examinations in terms of the optometrist time, equipment and materials and cost of the ophthalmological first outpatient visit were ascertained. Costs resulting from unreasonable patient management and unnecessary referrals were calculated and balanced against the calculated costs saved from reasonable patient management and reduced utilisation. Details are given in Chapter 6. Equity of access Postcodes of each patient s place of residence provided the necessary information required for a GIS analysis to determine the equity of access to 19

27 an accredited optometrist. A population based geographic analysis determined the proportion of the adult population that resided more than 10, 20, 30 and 60 minutes drive time from an accredited optometrist, stratified by deprivation and rurality. All geographic analyses were carried out using MapInfo and Drive time software. 20

28 CHAPTER 2: OPTOMETRIC MANAGEMENT OF PATIENTS ATTENDING FOR A PEARS OR WEHE INTRODUCTION Approximately 70% of the optometrists in Wales are accredited for the PEARS and WEHE. However, the number and demographics of patients examined under the PEARS and WEHE schemes is unknown. The outcome of the PEARS and WEHE is also unknown. However, a limited audit of the PEARS scheme (Arbuthnot 2005) found that approximately 80% of 500 patients examined by 15 WECI accredited optometrists under the PEARS scheme were managed in the community with the remaining 20% of patients being referred to the HES. Of the 420 patients managed in the community, 70% were managed solely by the optometrist and 30% were managed by the optometrist in conjunction with the GP. The PEARS and WEHE potentially may reduce referrals to the HES by enabling GPs to refer patients to PEARS/WEHE accredited optometrists in the first instance and permitting optometrists to manage minor eye disorders. A previous study (Featherstone et al 1992) indicated that many GPs were unhappy managing some cases of anterior segment eye disease. The lack of specialist equipment in GP surgeries may also hamper attempts to manage some eye diseases effectively. The first two primary objectives of the evaluation were: to determine the number of number of PEARS and WEHE patients examined by accredited optometrists and to determine the numbers of PEARS and WEHE patients managed and referred by accredited optometrists. METHODS The method for the extraction of the appropriate information from the optometric record card is detailed in Chapter 1. 21

29 RESULTS The optometric records of 6432 patients were entered into the database. All patients were included in the analysis. A total of 274 PEARS and WEHE accredited optometrists returned the 6432 record cards representing 80% of accredited optometrists. The mean number of record cards per optometrist was 23.0 (SD 14.7, median 19, range 1-113). The mean age of the cohort was 57.2 years (SD 18.6). The cohort comprised 3751 female (58%) and 2681 (42%) male patients. A flow diagram detailing the reason for patient presentation and outcomes of the PEARS and WEHE examinations is shown in Figure 2.1. Patient presentation The majority of referrals (57%) were self-referrals due to an acute eye problem (Figure 2.1 and Table 2.1) and referrals from the GP (25%). Only 19 patients (0.3%) presented because of eligibility for a WEHE due to a reason of race, alone. 22

30 Reason for PEARS/WEHE examination Number Percentage Self-referred because of an acute eye % problem (PEARS only) Referred from GP (PEARS AND WEHE) % Risk factor due to race or family history 589 9% (WEHE only) Risk factor: sibling of patient with inherited eye 429 7% disease (WEHE only) Uni-ocularity (WEHE only) 92 1% Hearing impairment (WEHE only) 23 >1% Risk factor: race only (WEHE only) 19 >1% Retinitis Pigmentosa (WEHE only) 11 >1% Referred from DRSSW 1 >1% Table 2.1. The reason for the PEARS or WEHE examination in the 6432 patients. Optometric management Of the 6432 patients presenting for a PEARS or WEHE examination, 4243 (66%) were managed in practice or were discharged at the first visit (i.e. not referred to the HES or to the GP). A total of 1171 (18%) were referred to the HES. The remaining 1018 (16%) patients were referred to the GP. Of those patients referred to the GP, 415 (7%) were co-managed (i.e. for ocular medical therapy prescribed by the GP) and 603 (9%) were referred for systemic investigation. Patients referred by the GP to the optometrist The number of patients referred by GPs to PEARS and WEHE accredited optometrists was 1576 (24.5% of the 6432 patients). The majority of these, 940 (60%), were managed within optometric practice or discharged at the first visit. However, 365 (23%) patients were referred back to the GP and 261 (17%) were referred onwards to the HES. Of the patients referred back to the 23

31 GP, 101 patients (6%) were co-managed (i.e. referred to the GP for ocular medical therapy prescribed by the GP) and 264 (17%) were referred for systemic investigation. Self-referrals to PEARS Of the 3692 patients self-referring for an acute eye problem, 1003 (27%) were discharged at the first visit, 1326 (36%) were managed in practice, 802 (22%) were referred to the HES and 561 (15%) were referred to the GP. Symptoms of patients presenting for a PEARS examination The symptoms reported by the 4881 patients presenting for a PEARS examination are shown in Table 2.2. The most common symptom was a unilateral red eye. The large number of unclassified symptoms is due to two reasons. Firstly, it was not clear from the record card what the presenting symptoms were and, secondly, the symptoms could not be described by any one category. Referrals to the HES for glaucoma A total of 129 patients were referred from the PEARS and WEHE examinations to the HES for suspected glaucoma. Retrieval of information from the GP Three hundred and twenty one letters were sent to GP practices. Only 5 responses were received. 24

32 6432 record patients cards Other self - referral % WEHE % Referred by GP % Self referral % PEARS % Referred by GP % % Discharged % managed in practice % Referred % Discharged % managed in practice % Referred % HES % GP % HES % GP Figure 2.1: Outcome of 6432 patients examined under the auspices of the PEARS and WEHE 25

33 Symptom reported Referred to HES Managed in practice or discharged Referred to GP Total number Acute vision loss Chronic vision loss Distorted vision Diplopia Headaches Unilateral red eye Bilateral red eye Discomfort/ Irritation Ocular discharge, only Unusual lid appearance Flashes +/ floaters Floaters, only Trauma Unclassified Table 2.2. Primary symptom and outcome of the 4881 patients presenting for a PEARS examination. DISCUSSION Many more patients were examined under the PEARS, compared to the WEHE scheme. The WEHE contributed less than one fifth of the overall number of examinations carried out over the evaluation period. This suggests that patients in Wales who fall into a WEHE category are not aware of the WEHE scheme or, less likely, that PEARS/WEHE accredited optometrists do 26

34 not offer such patients a WEHE examination when these patients enter their practice. A renewed advertising campaign targeting these at-risk groups of patients is warranted to increase the numbers attending for a WEHE examination. Self-referring patients constituted the majority of the PEARS examinations. It not known whether these patients specifically requested a PEARS examination or if the patients attended the optometrist for an eye problem without being aware of the PEARS scheme and were subsequently examined under the auspices of PEARS. Optometrists referred just over one-third of patients that presented for either a PEARS or a WEHE examination. This indicates that two-thirds of patients examined by optometrists are deemed to have an eye condition that is not serious enough to warrant referral. This figure is less than the 80% found in the small-scale audit of 15 PEARS accredited optometrists in the Vale of Glamorgan (Arbuthnot 2005) but suggests that the expansion of PEARS and WEHE across Wales has maintained a similar pattern of management. The figure also indicates that optometrists felt confident to manage within practice a majority of the patients. The validity of this approach was determined using the patient interview (see Chapter 4). There were less referrals following a WEHE than following a PEARS examination. This would be expected as the WEHE is a case-finding examination in at-risk patients. Most patients self-referred for a PEARS examination. Approximately one quarter of patients were referred by the GP. However, what cannot be determined is whether GPs are simply using the PEARS and WEHE schemes as another level of triage for eye conditions that they may have been previously discharged, managed within GP practice, or referred to the HES. It is conceivable that GPs may have referred such patients to the HES if the PEARS scheme was not in existence. However, only 17% of the patients 27

35 referred by the GP to the optometrist were then referred onwards to the HES. Assuming a correct diagnostic and management strategy by the optometrist for all the patients referred by the GP, the cost-saving from avoidance of unnecessary HES appointments is potentially considerable. This is an important consideration, which requires further investigation to ensure optimal cost efficiency of the PEARS and WEHE schemes, and will be discussed in Chapter 6. It is also dependent upon the validity and accuracy of the optometric decision making strategy (see Chapter 4). In addition, the quality of life issues in terms of benefit to the patient from such unnecessary attendance at the HES is likely to be of great benefit to patients. Referrals from the optometrist to the GP could not be analysed to determine if the referrals involved a systemic abnormality. Such analysis would have provided information on the ability of optometrists to case-find systemic disease. Patients attending for PEARS predominantly presented with symptoms of red or irritated eyes. Furthermore, the majority of these patients were not referred to the HES. In the past, optometrists have always managed a proportion of these patients in practice; however, the PEARS scheme formalises and legitimises this approach. CONCLUSIONS Approximately three-times as many patients attended for a PEARS examination than for a WEHE examination. One-third of patients attending for a PEARS or WEHE examination were referred to the HES or to the GP. Unilateral red eye was the commonest symptom in patients attending for a PEARS examination. 28

36 CHAPTER 3: REFERRALS FROM OPTOMETRISTS TO THE HOSPITAL EYE SERVICE INTRODUCTION The HES traditionally provides first-line treatment for simple to sightthreatening eye conditions (Claoué et al 1997). If minor eye conditions were managed in the community, the burden on the HES would be reduced. Previous studies have concentrated on assessing optometric referrals for particular conditions, such as glaucoma (Bell and O Brien 1997, Bowling et al 2005, Patel et al 2006, Vernon 1998), or upon optometric referrals to the GP before direct referral to the HES was instigated (Perkins 1990). Other studies have investigated referral patterns of optometrists but have not considered the outcome of these referrals (Hobley et al 1992, Port and Pope 1988). There are few studies describing the outcome of optometric referrals to the HES (Harrison et al 1988, Pooley and Frost 1999). The primary objectives for the evaluation of the optometric referrals to the HES were twofold. Firstly, to determine if the patient management decision by the accredited optometrists was reasonable to ophthalmology, based upon the information available to the optometrist. Secondly, to determine if the diagnoses of the eye condition referred to the HES by accredited optometrists was reasonable to ophthalmology based upon the information available to the optometrist. The secondary objectives for the evaluation of the optometric referrals to the HES were twofold. Firstly, to determine the symptoms and signs necessitating referral to the HES. Secondly, to determine the types and number referred by accredited optometrists. 29

37 METHODS The optometric record card was used to assess the information available to the optometrist at the time of the PEARS or WEHE examination and to establish the symptoms. The symptoms were coded by category (Appendix D Part 1). Red eye and unusual lid appearance, because they are evident to the patients, themselves, are strictly defined as signs, but were included as symptoms. Asymptomatic patients were categorised according to the condition indicated in the optometric referral and as sight threatening or, if non-sight threatening, on the location of the condition (Harrison et al 1988), see Appendix D - Part 2. Referrals to the HES from the optometrist were perused and traced to the relevant HES within Wales. The HES records were then scrutinised to establish the date the patient attended for examination within the HES, the ophthalmological diagnosis and the ophthalmological management outcome (patient discharged without treatment; patient discharged with chloramphenicol drops only; discharged with other treatment or retained within the HES). The referrals to the HES were analysed according to the initial symptoms and to the subsequent management in the HES. The analysis was structured in this way because the levels of agreement when defining the appropriateness, per se, of primary care referrals are poor (Thom et al, 2004). In addition, a comparison between the reason for optometric referral and the ophthalmological diagnosis is subject to differences in training and in the job requirements between the two professions. Choosing to concentrate on the management outcome of referred patients provides a feasible, acceptable and reliable measure of referral quality (Campbell et al, 2005). Nevertheless, the patient management decisions and diagnoses by accredited optometrists were assessed to determine if they were reasonable, based upon the information available to the optometrist at the time of the patient visit, to provide a measure of optometric referral effectiveness. 30

38 The management outcome and diagnosis was derived from inspection of the letter from the ophthalmologist to the GP contained within the hospital notes or, if this was unavailable, from perusal of the hospital notes themselves. Whenever possible, the follow-up notes were inspected to establish if the original ophthalmological diagnosis was upheld. The coding for the ophthalmological diagnosis and the location of eye disorder was based upon a condensed form of the International Statistical Classification of Diseases and Related Health Problems (WHO, 2007). A panel of three optometrists (NJS, JMW and JSP) and one ophthalmologist (JMS) evaluated whether the optometric management and the optometric diagnosis of the referrals were appropriate. The optometric management and diagnosis were differentiated since an optometrist, for example, could have correctly diagnosed a minor ocular disorder but could then have referred the minor disorder as an emergency thereby rendering the management as inappropriate. Conversely, an optometrist may have incorrectly diagnosed an unusual ocular disorder but recognised that it required ophthalmological intervention and, therefore, had correctly managed the patient. One of the three optometrists (JSP) and the ophthalmologist (JMS) practiced in England and were independent of the PEARS and WEHE. The remaining two optometrists had transcribed the information from the HES record cards and facilitated discussion of each case. Where there was uncertainty, the ophthalmologist was the final arbiter in the decision making process. RESULTS A total of 1171 patients were referred to the HES during the 8 month period of the evaluation 04/04/06 to 21/12/06. Of these referrals, 997 patients had been examined under the auspices of the PEARS and 174 patients under the auspices of WEHE. A total of 261 patients had originally been referred by their GP to the optometrist before being referred by the optometrist on to the HES. 31