Enhanced Scheme Evaluation Project (ESEP) Robert Harper On behalf of the ESEP team

Transcription

1 Enhanced Scheme Evaluation Project (ESEP) Robert Harper On behalf of the ESEP team

2 ESEP Team Project Leads: Robert Harper and John Lawrenson Co-applicants: David Edgar, Cecilia Fenerty, David Henson, Ian Murdoch, David Parkins, Steve Roberts, Paul Showman, Fiona Spencer, Matt Sutton and Heather Waterman Researchers: Evgenia Konstantakopoulou, Helen Baker, Paddy Gunn, Jo Marks, Cheryl Jones, Tom Mason

3 Evolving optometry role (and much else going on too...)

4 Background to ESEP College of Optometrists Call for proposals 2011 The College is seeking to identify a suitable research provider to undertake the development and delivery of a project to evaluate enhanced eye care services in the UK. Proposals are therefore invited from parties interested in such a project and with the experience and expertise to deliver high quality research outputs

5 ESEP key objectives Realist review of enhanced service schemes Enhanced (community) scheme case studies MECS (Lambeth and Lewisham ) and GRRS (Manchester) Clinical safety and effectiveness evaluation Health economic evaluation Stakeholder qualitative evaluation Other ESS (cataract, referral management)

6 The effectiveness of enhanced optometric services in the management of acute and chronic ophthalmic disease: a realist review of the literature.highlights: First systematic review to evaluate locally-commissioned ESS using community optometrists ESS can provide ophthalmic care commensurate with usual care ESS are well received by patients and other stakeholders Further work to establish cost-effectiveness and sustainability of schemes is required

7 MECS (Lambeth and Lewisham) Audit - high rates of ophthalmology referrals from GPs ~38% of acute ophthalmology referrals could be more appropriately managed in primary care Acute trusts failing 18 week targets High costs in dealing with low severity conditions - tariff ~ 144 for first appointment, ~ 84 for follow up

8 MECS (Lambeth and Lewisham) aims of service re-design Deliver greater proportion of ophthalmic care in community, improve Px experience, reduce waiting times Develop new access points to enable a broader spectrum of patients to access ophthalmology services Take advantage of optometrists clinical training and experience Promote cost-effective services Promote closer working relationships 1 o &2 o care

9 MECS

10 MECS 13 Optometric practices Guy s and St Thomas Hospital and King s College Hospital Local GPs Training and accreditation Specific requirements for clinical equipment: Slit lamp; Volk or similar lens; contact tonometer; visual field equipment capable of producing a plot; Amsler charts; diagnostic medication

11 Qualitative evaluation The most common reason for participation was to further professional development Lack of fit with the retail business model of optometry was key reason for non-participation Ophthalmologists involved in MECS widely acknowledged that the scheme would reduce unnecessary referrals & shorten Px waiting times GPs involved in MECS were very supportive

12 Reason for visit % of Px Red eye 37% Painful white eye 11% Flashes & floaters 10% Loss of vision 9% Headaches 5% Trauma 2% Diplopia <1% Other 25% n=2307 patients Swollen lid, lid lump 22% Watery eyes 20% Itchy eyes 10% FBS, sore, dry, gritty eyes 15%

13 Management % of Px Management of ocular pathology in practice 64% Discharge/no ocular pathology 11% Referral to King s College Hospital 10% Referral to Guy s and St Thomas s Hospital 7% Referral to other HES 1% Referral to GP 6%

14 Clinical safety Reference panel consensus following record card review of random sample of 220 (~10%) non-referrals - ~5% unacceptable Ophthalmologist review of HES referrals - 89% appropriately referred - 71% referred with the appropriate urgency - Those deemed referred with inappropriate urgency were all overcautious referrals

15 Patient satisfaction 100% satisfied with their visit 99% would recommend the scheme to a friend 95% reported confidence and trust in the Optometrist 90% satisfied with the location of the optometry practice

16 Cost consequences Preliminary results from the first nine months MECS indicate that first attendances from the GP to HES dropped by ~27% in Lambeth & Lewisham when compared to Southwark, a neighbouring borough without a MECS scheme

17 National Eye Care Services Steering Group (2002) MREH GRRS (2000) Objectives reduce number of FP glaucoma referrals to HES reduce waiting times between GP referral & glaucoma evaluation greater involvement of primary care sector GRRS

18 Early analysis of GRRS Referred Not Referred 41% 59% N=670

19 GRRS Referral criteria (2013) Single criteria IOP >30mmHg confirmed at a second visit. If IOP >35 mmhg then no confirmatory measurement is necessary Unequivocal pathological cupping at the optic nerve head. Abnormal neuroretinal rim configuration. Large cup, taking into account the overall size of the disc. Notched neuroretinal rim. The existence of a disc haemorrhage merits closer inspection for early nerve fibre loss. A >0.2 asymmetry of cup to disc ratio Visual field loss consistent with a diagnosis of glaucoma, confirmed at a second visit. If explained by other disc or retinal pathology to be referred as such and not through scheme. Combined criteria IOP, age and CCT criteria as per NICE treatment algorithm** IOP >21 mmhg plus an optic disc appearance suspicious of glaucoma or optic disc asymmetry Abnormal optic disc and corresponding visual field defect (IOP not raised) (no need for confirmatory measures). ** CCT >590 micrometres micrometres Additional criteria Optic disc change over time e.g. increase in cup size, change in the rim appearance, or the occurrence of a new haemorrhage Anterior segment signs of secondary glaucoma (eg pseudoexfoliation) with IOPs >22 mmhg on two occasions Suspected narrow-angle glaucoma (symptoms of subacute attacks or occludable angle and IOP >22 mmhg). <555 micrometres Any IOP (mmhg) >21-25 >25-29 >21-25 >25-29 >21-25 >25-29 >30 Referral No No No Refer if <60 Refer if <65 Refer if <80 Refer

20 Manchester GRRS 2013 Questions? New false positive rate? False negative rate? Stakeholder views? Patient satisfaction? Cost-effectiveness/cost-consequences?

21 Qualitative evaluation Optometrists recognise the need for additional training and viewed this favourably

22 Patient satisfaction 100% satisfied with their visit 94% reported confidence and trust in the Optometrist 92% satisfied with the location of the optometry practice

23 GRRS evaluation progress False negative study 64/200 recruited Outcomes (12 months since Oct 2014) 729 patients seen in GRRS 396 (54%) discharged 333 (46%) referred Referrals to date: 13% discharged, 50% monitored, 28% commenced on treatment, 9% DNA

24 Thanks for listening