Auditing a repeat readings service: Optometrist Dharmesh Patel explores the effectiveness of an intraocular pressure glaucoma repeat readings service operating in parts of Cheshire.
The glaucoma repeat readings service was launched in central and eastern Cheshire PCT (as it was then known) in 2010. Its introduction was in response to the well-known NICE guidance (1) which was published in April 2009.
The aim of a glaucoma repeat readings pathway is to reduce false positive referrals to the hospital eye service, easing patient anxiety and increasing capacity within the over-burdened hospital glaucoma clinics. This should provide a more cost-effective service, with a greater number of patients managed within the primary care setting.
The pathway allows accredited optometrists to repeat diagnostic tests in order to confirm the risk of disease, thus improving the accuracy of referrals and deflecting unnecessary referrals.
The first two Quality Statements of the NICE Quality Standards for glaucoma recommend local agreements for referral refinement and repeat measurements.
The particularly interesting part of this service was that the PCT decided, after discussion with the LOC, to include repeats of visual fields, in addition to an intraocular pressure (IOP) repeat readings service. This gave an opportunity to determine the effectiveness of adding repeat visual fields to an IOP repeat measure service.
The service was therefore split into the following two parts:
* IOP repeat measurement
* Visual field repeat assessment.
In the IOP part of the service, patients who are identified as having pressures above 21mmHg and no other signs of glaucoma following a GOS or private sight test have Goldmann applanation tonometry or Perkins tonometry repeated straight away.
Patients with a raised pressure of >21mmHg after measurement by applanation tonometry are then referred to secondary care that is there is only one repeat IOP reading.
In the visual fields part of the service, patients who are identified as having suspicious visual fields following a GOS or private sight test will have visual fields repeated on a separate occasion.
If pressure is above 21mmHg in either eye and there is a suspicious visual field defect, then the pressure should be repeated initially with applanation tonometry (ideally immediately following the sight test). If the IOP is consistently above 21mmHg, then the patient is referred for raised IOP as per the NICE guidelines. However, if the pressure reading on Goldmann/Perkins is 21mmHg or less, then the patient is asked to return on a different day for repeat visual fields and the visual field pathway is followed.
This service falls within core competencies for optometrists and thus there was no need for formal accreditation to take part in the service. However, the LOC was aware that many optometrists may not have performed contact tonometry for some considerable time. Consequently, two optional training packages were made available for those who wanted a refresher in any of the techniques involved: distance learning lectures/ videos on glaucoma which were provided by LOCSU and WOPEC at Cardiff University, and a workshop on Goldmann use and calibration. These were run at a couple of locations.
Data collated by LOCSU (2) from services in Stockport (3), Bexley (4) and North of Tyne (5) show that a reduction in referrals for raised IOP of at least 74% can be expected following implementation of an IOP repeat readings service provided by community optometrists. There is little, or no, data from community services on the effectiveness of repeating visual fields, so this will provide a benchmark. It was felt that a deflection rate of around 50% would be cost effective.
This service was a paper-based service and all referrals and payment claims were processed and managed by a central administrator on behalf of the PCT.
A total of 622 patients were seen by the service within the 12-month period of 2012 (January-December). Of these 622 patients, 457 (73.5%) required IOP repeats and 141 (22.5%) needed repeats of visual fields. Only 24 patients (4%) needed to have both.
Of the patients who underwent repeats pressure measurement, only 190 (42%) were referred onto secondary care--which equates to a deflection rate of 58% (Figure 1).
Of the 141 patients who had visual fields repeated, only 38 patients (27%) were referred onto secondary care (Figure 2)--a deflection rate of 73%. Overall, 228 patients (37%) from this glaucoma repeat readings service were referred to secondary care, resulting in an overall deflection rate of 63% for the service.
This audit shows that there is significant benefit in adding visual field repeats to support IOP repeat measures. The deflection rates from repeating visual fields exceeded expectations. The lack of audit data in this area in the past has meant that many commissioners have not had the confidence to commission this part of the service. This audit provides evidence for the added benefit of this.
When this service is compared with others across England, the overall deflection rate from repeating IOP readings appears, superficially, to be lower than the expected figure of around 74%. However, detailed analysis of the figures shows that the first repeat typically deflects around 60% and the second repeat a further 15-20%, so the difference is likely to be due to the fact that this Cheshire service has a single repeat on detection of a raised intraocular pressure, while the comparative audited services mentioned above carry out a second repeat on a separate occasion.
Looking at the various elements of this service and what could be improved further, the main enhancement would be the introduction of a second repeat measure of the IOP on a separate occasion where the first repeat was greater than 21mmHg. Evidence from other services suggests that the second repeat deflects almost half of the remaining patients so this would further increase the number of patients deflected from referral to secondary care with raised intra ocular pressures and this is currently under active consideration locally.
Additionally, the introduction of an IT platform will significantly reduce the administrations while streamlining the service and making future analysis and audit a routine matter. It took the administrator a great deal of time and effort to collate this data in a format useful for audit. Going forward, the commissioner has decided to adopt the Webstar IT platform for the electronic recording of the repeat reading episodes. This will allow detailed audit analysis to be made much more quickly and easily, while streamlining the referral process and generating invoices.
This audit shows that a service which funds repeat IOP and visual fields by community optometrists is an effective service which reduces referrals to secondary care and benefits the patient.
(1.) NICE CG85: Glaucoma: Diagnosis and management of chronic open angle glaucoma and Ocular Hypertension in April 2009.
(2.) LOCSU Glaucoma Repeat Readings Pathway
(3.) Repeating pressures--an electronic reporting system. T J Warburton. OT, September 17 2010
(4.) Comparison of the effectiveness of two enhanced glaucoma referral schemes David J Parkins and David F Edgar. Ophthalmic & Physiological Optics 31 (2011) 343-352
(5.) Local audit data, NHS North of Tyne.
Dharmesh Patel is an independent optometrist, LOCSU optical lead and a WOPEC lead assessor.
Figure 1 The outcomes of repeating IOP readings (Introcular pressure referral refinement) Deflected 58.42% Referred 41.58% Note: Table made from pie chart. Figure 2 The outcomes of repeating visual fields Deflected 73% Referred 27% Note: Table made from bar graph.
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|Date:||Jun 28, 2013|
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