Quickfire Audits Sourced and facilitated by Trevor Warburton Barbara Ryan
Referral Refinement Service in Shipley Stewart Mitchell SOAP Shipley Ophthalmic Assessment Programme Dr Stewart Mitchell, Dr Mark Hurst, Dr John Bibby Ophthalmic Triage Optometrist led but GP practice based Service Established in 1996 Fund Holding GP Aims Financial Savings Prioritise Referrals Reduce Referrals to secondary Care IOP 16.5% Fields/Discs 16% Lids/Lashes Orbit 15% Retina; 13.5% Blurred Vision 9% Data from 1001 Patients episodes (50% of clinic time) Feb 2009 to August 2013 Corneal/Anterior Chamber, 4.50% AMD, 5% Flashers Floaters, 6.50% Blurred Vision, 9% Other, 7% Corneal/Anterior Chamber 4.5% Flashers/Floaters 6.5% Cataract 6% AMD 5% Other 7% IOP, 16.50% Fields/Discs, 16% *To see patients within 2 weeks of referral.* Retinal, 13.50% Lids/Lashes/Orbit, 16% SOAP Clinical Decision & Primary Diagnosis HES Feedback, Costs, Issues No Referral 684 68% Routine 197 20% Urgent 38 4% DNA 82 8% Lids/Lashes/Orbit 17.5% Retinal 14% PVD 8% Cataract 8% IOP 42% Fields 27% Blurred Vision 8% Retinal 7% Cataract 2% Other 14% 2002 64% 2002 27% 2002 9% Glaucoma 7% AMD 6.5% Anterior eye 6% IOP 5% Other 11% 31 replies (yes only 31!) 28 agreed with SOAP Referral 3 Disagreed/Referral not necessary. 2 weeks became 12 weeks Optometrists on sessional basis. 3 currently allowing 18 patient episodes per week. Any competent Optometrist? PEARS training. Assumptions 108 Ophthalmology 68 SOAP No SOAP 99252 With SOAP 87872 Saving 11380 SOAP On a ROPE? Due to limitations in what it can offer i.e no OCT. Or off the ROPE? Cost effective, rapid triage service for GP referrals that need an Ophthalmic opinion.
Post-op Cataract Outcomes Wendy Newsom Community Optometrist Postop Cataract Assessment A summary of 5 cycles of audit data from a shared care cataract pathway in Cambridgeshire Mrs Wendy Newsom Background/Methods 2001- community based optometrist dilated pre-op assessment and direct referral 2005- community based optometrist routine 1 month post-op assessment 2006- Medisoft EPR introduced: allows continuous audit of ALL patients undergoing cataract surgery 1 month post-op data collected for all patients undergoing cataract surgery from July 2006 to June 2011 2011- Patient satisfaction survey conducted Objectives Results Is community optometrist post-op cataract assessment safe? Does the patient attend for post-op assessment? Does the hospital received post-op data for audit and consultant revalidation purposes? Do the outcomes compare well with national standards? LOCAL, NATIONAL AND INTERNATIONAL STANDARDS (National Dataset 2009, Auckland Cataract study 2004) 7220 cataract operations Av age 74.9 years (75.4 years) 36.2% had documented co-morbidity (29.5%) 88% had their post-op assessment by their community optometrist (post-op refractive data collected) (62.5%) 92.4% of all patients we seen post-op (VA data collected) (73.3%) BC VA 6/12 or better = 90.5% (91%) 6/6 or better = 51.3% (45.9%) Refractive deviation from predicted +/- 1.00 D 92% (97%) +/- 0.50D 64.2% (58.4%) Figure in red = standard measured against Patient satisfaction/additional data Discussion Patient satisfaction survey 2011 Questions relating to every stage of the pathway 98.7% Satisfied or very satisfied with the overall pathway (2008-2011) Only 1 in 4500 patients cancelled on the day of surgery because they did not want surgery Intra-op and post-op complications all lower than Royal College Guidance and national standards Patients do go and see their community optometrist for post-op assessment Community optometrist post-op feedback > feedback than published standards for conventional pathways Outcomes/complications compare very well with national standards: No reduction in quality of surgical outcomes in a shared care cataract pathway Patient satisfaction with the pathway is very high
Glaucoma Repeat Readings in Cheshire Rupesh Bagdai 300 250 200 150 100 50 0 267 190 141 33 24 IOP's Visual Fields IOP's & Visual Fields 5 deflected referred
Optometrist training affects glaucoma referral outcomes Sarah Farrell Outcomes from referrals to the glaucoma clinic for raised IOP and narrow anterior angles: A three year audit cycle National Optical Conference 2013 2009-10: Glaucoma teaching evenings (4): lectures on optic disc evaluation, visual fields and Van Herick delivered to community optometrists May 2010: Pilot cataract shared care scheme launched: 6 accredited community optometrists July 2011: Glaucoma referral quality audit: results presented to community optometrists May September 2012: Cataract shared care scheme roll out: 100% practice participation. November 2012: Glaucoma teaching evening: optic disc lecture and practical session with stereo disc examination IOP referral outcomes % false positive % OHT % with angle closure diagnosis Positive predictive value for glaucoma (ppv) Narrow angle referral outcomes % false positive Positive predictive value for narrow angles (ppv) 42% 1-48% 2 31% 1 11% 1 0.04 1 30% 1 0.55 1 Referrals for raised IOP (<28mmHg) and referrals for narrow anterior angles identified from triaging database All optometrist referrals from 2010, 2011 and 2012 included Those without a clinic visit excluded from data (DNA/Cancelled) Data collected by one hospital optometrist retrospectively viewing Medisoft EPR. Diagnosis of the highest order recorded 2010 2011 2012 Total new glaucoma referrals 566 691 1065 IOP referrals (<28mmHg) 183 (32.3%) 238 (34.4%) 295 (27.7%) Narrow angle referrals 48 (8.5%) 77 (11.1%) 148 (13.9%) 1 Previous Moorfields at Bedford audit: Comparison of outcomes between high risk and low risk glaucoma referrals (2011) 2 False-positive glaucoma hospital referrals without compromising quality of care? The community and hospital allied network glaucoma evaluation scheme (CHANGES). Bourne RRA, French KA, Chang L et al. Eye 2010; 24: 881 887. Outcomes from IOP referrals 2010 2011 2012 Total IOP referrals audited (minus exclusions) 176 237 259 False positive 59 (33.5%) 102 (43.0%) 112 (43.2%) Ocular hypertension 69 (39.2%) 75 (31.67%) 87 (33.59%) Angle closure diagnosis 22 (12.5%) 26 (11.0%) 24 (9.3%) ppv for glaucoma 0.03 0.04 0.03 ppv for OHT 0.39 0.32 0.34 Outcomes from narrow angle referrals 2010 2011 2012 Total narrow angle referrals audited (minus exclusions) 44 77 129 Angle closure diagnosis 30 (68.2%) 42 (54.5%) 96 (74.4%) False positive 10 (22.7%) 23 (29.9%) 25 (19.4%) ppv for angle closure 0.68 0.55 0.74 Referrals for raised IOP fail to detect narrow anterior angles in a small but significant proportion of patients. Van Herick training can reduce this effect (12.5% in 2010-9.3% in 2012 = 26% reduction) Referrals for narrow anterior angles are very good predictors of angle closure. Community optometrists become more accurate at predicting angle closure following practical Van Herick training (ppv increased from 0.55 in 2011-0.74 in 2012) 3 College of Optometrists Guideline D03.07 Examining patients at risk from glaucoma
Professional Fee Structures for Community Optometry Neelam Patel Professional Fee Structures for Community Services Neelam Patel 1,2, Shehzad A. Naroo 1 & Nicholas Rumney 2 1. School of Life and Health Science, Aston University, Birmingham, B4 7ET 2. BBR Optometry Ltd, Hereford, HR1 2PR Practice Based Audit UK Practice Business Model: Service costs recouped from product sales, such as spectacles. Do community services perform equally in generating product sales? 12 month audit (May 2012 to April 2013) Independent practice based in Hereford 12 services 2 NHS sight test (General Ophthalmic Sight test) 5 Private services 5 community services Key Performance Indicators Service uptake Profitability Spectacle conversion rate Average transaction value (ATV) Aims and Methods Service Uptake Service Profitability Results Conversion Rate Pre Cataract Assessment Post Cataract Assessment Glaucoma Referral Refinement GP Eye Referral Low Vision Assessment CL Aftercare 2609 spectacle sales Results NHS sight test 25.00 Soft/RGP CL Exam Private U25 Exam Private services 20.00 Private Eye Exam Enhanced services Other 15.00 NHS Extended Exam Child GOS sight test 16% 10.00 GOS sight test 25% 5.00 6% 0.00 0% 10% 20% 30% 40% 50% 60% 5.00 Average Dispense Value 10.00 400 GOS sight test 53% 15.00 20.00 350 300 Child GOS sight test NHS Extended Exam Private Eye Exam Total Appointments: 8902 25.00 250 200 Private U25 Exam Soft/RGP CL Exam CL Aftercare 150 Low Vision Assessment 100 GP Eye Referral Glaucoma Referral Refinement 50 Post Cataract Assessment 0 Pre Cataract Assessment Service Uptake Profitability Conversion Rate Average Transaction Value NHS sight test High Low High Moderate Private services High Moderate Moderate High Community services Low Low Low Moderate Conclusions Community services do not perform well in the traditional business model Low service uptake Do not generate product sales by volume or value If service uptake increases, these services will be unsustainable Alternative business No reliance on spectacle sales Appropriate fees for the true cost of service delivery
Optometry referrals to Ophthalmology via GPs Susan Parker Aims of Audit Audit of GP referrals to Ophthalmology Susan Parker Clinical Lead for Eyecare NHS Stockport CCG 4 weeks referrals from 8 GP practices (224) Was referral to secondary care necessary Was the urgency and route safe Was the quality of optometrist referrals good (56% originated from optom) Was there potential to see some patients in a primary care setting Number of referrals Reason for Referral 45 40 35 30 25 20 15 10 5 0 from GP from optom Optometrist Referral Quality Unfortunately the GOS18 is too faint to send a copy to yourselves 58% of referrals had a complete set of information 72% were handwritten, 24% of which were illegible when scanned When optoms asked for urgent referral GPs referred routinely (wetamd, F & F) Reason for referral Outcomes 20% could have been seen in a PEARS type scheme. In 2012/13 the CCG procured a Minor Eye Conditions Primary Care Service 16% were on the wrong pathway. All local clinicians reminded of LES and urgent routes GOS Contractors and optometrists urged to provide time and facilities to type referrals.
Minot Eye Conditions in Stockport Matthew Jinkinson Background MINOR EYE CONDITIONS SERVICE (MECS) HALF TERM REPORT (QUICKFIRE AUDIT) Matthew Jinkinson Stockport LOC & Director GM Primary Eyecare Ltd to ease pressure on HES Urgency clinic after audit of referrals into the urgency clinic Patients could enter the service via referral from GP, Pharmacy, A&E, Out of Hours service or Self-referral To include anterior segment minor conditions, loss of vision, recent onset loss of visual field, recent onset diplopia and flashes & floaters. Patients to be seen at either 24 (Urgent) or 48 hour (Routine) intervals dependant on presenting symptoms. Fee to practice to be 50 per episode. 42 43 Activity & Effectiveness Six monthly activity report (30 th Sept 2013): Type of appointment Number of episodes Percentage % Routine (48 hours) 580 39.92% Urgent (24 hours) 873 60.08% Grand Total 1453 100% Clinical Effectiveness: Number of episodes Percentage % Discharge 1046 72.09% Urgent referral to HES 157 10.82% Follow up 102 7.03% Routine referral to HES 66 4.55% Routine referral to GP 80 5.51% (not for onward referral) Grand Total 1451 100% 44 Most common outcomes Outcomes 1 st No sign of RD, holes or tears (with Sx of Flashes & Floaters) 2 nd Dry eye (aqueous/evaporative/dry eye/tear duct) 3 rd Blepharitis 4 th Bacterial Conjunctivitis 45 79.12% of patients are managed exclusively within the service. 99.76% of patients were Very Satisfied or Satisfied with the service. 23 out of 38 practices participate. If the current activity continues the MECS service will bring 150,000 in to the local optometric economy in Year 1. 46