Glaucoma 7 - Referral Filtering Pathway Flashcards
why do we have GLAUCOMA REFERRAL FILTERING AND CO-MANAGEMENT BY OPTOMETRISTS?
-increased burden on NHS services (ophthlamology outpatients)
-shortage of Ophthalmologists
-ageing population= greater glauc load
how much does Glaucoma account for eye outpatient attendances in UK
25%
how do we increase Diagnostic accuracy of optometrists’ referrals for suspect glaucoma
by repeating and refining measurements
what has been put into place to minimise unecessary HES referrals?
“Two-tier” testing increases specificity by reducing false positives of case detection by reducing false positives = repeating and refining measurement
what factors are monitored on the Glaucoma scheme?
- demographic factors:population growth, life expectancy and ageing
- other factors: targets, requirements for training/supervision, guidelines
what have been some challenges of the Glaucoma scheme?
- px safety issues
- 7million apts (2014-15)
- 20 patients a month unnecessarily losing sight as a result of delays-increasing figure due to covid
which country in the EU has the least qualified Ophthalmologists
the UK (Can be due to stricter rules on qualifying)
is there a good potential for Optometry in glauc shared care?
yes as:
-Large profession *~14,000 and growing!
-Extended role interest- community and Hospital presence
-Post-graduate specialist training- Glaucoma, IP etc
-Economics- it is cost effective
what is the difference between england and scotland eye services?
scotland= 2006-more enhanced services, NHS covers all eyetests
(Optoms are required to do more though)
according to Tuck 1991; Tuck and Crick 1991, which medical professionals initiate most referrals and what three tests are conducted prior to the referral process?
Optometrists initiate most referrals;
- Optic disc; always
- IOP; 1/2 to 2/3 of patients >40yrs
- VF; <10% of patients >40yrs
what test specifically were results (inc false positives) variable between practitioners when referring suspect glauc px?
visual fields
what are the names of two Glaucoma referral refinement schemes?
-DoH National Eye Care Services Steering Group (2002)
-MREH glaucoma referral refinement scheme – GERS (2000)
what were the three objectives of the two Glaucoma referral refinement schemes?
- reduce number of false positive glaucoma referrals to HES
- reduce waiting times between GP referral & glaucoma evaluation
- greater involvement of primary care sector
how has the Manchester GRR Scheme (now termed enhanced case finding service (GERS) been refined from the old to newer pathway?
involvement of accredited community optometrist- can be asked to include gonioscopy
state some advantages of the Manchester GERS PATHWAY
- reduced waiting times (Seen within 2 wks by accredited optom)
- reduced number of false positives AND false negatives
- px seen in primary care esp if slow growth + good prognosis
- increased capacity in HES
how have referrals in Scotland improved after the new GOS contract?
- Decrease in false positive referrals
- ↑ number of referrals with info on GAT
- ↑ number of referrals with info on dilated exam
- ↑ number of referrals with info on repeat VF
- Training provided and undertaken since
what is included in the referral guidelines for glauc?
- High IOPS
- Age
- CCT
What are some of the key tests stated to do before referring in the 2017 referral guidance of Glaucoma?
- visual fields
- iops using goldmann
- disc assessment
- gonioscopy or VH
According to the 2017 referral guidance of Glaucoma, can we refer based solely on non-contact tonometry?
nope
what is the IOP threshold for referral using goldmann?
24mm/hg or above- repeated IOPS at different time of day is recommended though
can we refer suspect COAG who have previously been sent to HES?
No, unless any changes have been noticed since the previous referral
Are Glaucoma Repeat measures, enhanced case finding, referral refinement, glaucoma co-management services all the same thing?
No:
- Referral filtering (refinement/enhanced case finding/repeat measurement services) = BEFORE px are referred
- Co-management services = px who have ALREADY been referred as suspect glu or OHT
what is the definition of shared care schemes?
Sharing of clinical management responsibilities between two or more health care professionals in HES or community
what was found in the RCT of Bristol Shared care glauc study between HES and community optoms?
*there was a low eligibility (only 2780 participants) due to inclusion criteria
- equally reliable
- outcomes comparable
- High patient satisfaction for HES and community optometrists
- Costs lower in HES
what is an example of a shared care model (used by GERS)
stable (maybe suspect) patients are monitored by community optometrists in practice, and return/referred to the ophthalmologist in the Hospital Eye Service (HES) if their condition worsens
in what eye condition was shared care first used and what else is it used in now?
first used in diab retionpathy, extended into
-OHT/open angle glauc
-LV
-Cataract
advs of shared care schemes
- improve the quality and equality of patient care
- Reduces pressure on outpatient waiting lists
- Reduced waiting times
- May save money - but costs of scheme doesnt make this a strong one
- Patients may prefer to visit community optometrist rather than hospital
- Greater integration of primary and secondary care
- Multidisciplinary co-operation
which healthcare professional would see a px with medical glaucoma?
ophthalmologist only or optometrist under opthalmologist guidance
which healthcare professional would see a px with ‘Complex’ glaucoma
ophthalmologist
what are 5 way a patient can get their glaucoma prescription?
- requested from the GP
- Optometric Supplementary Prescribing Formulary
- Optometric Independent Prescribing Formulary
- Patient Group Directive
- written by a medical colleague
which clinic has the highest amount of supervision?
glaucoma
what training and accreditation is available for optometrists to take part in these schemes?
- College of Optometrists ‘new’ Higher Qualifications
- Certificate/Higher Certificate/Diploma in Glaucoma
- Independent Prescribing GOC & Specialty Registration
- Local Optical Support Unit (LOCSU) Pathway
case studies at end
case studies at end
The definition of “shared care” can mean different things to different people, what are three examples of what it can mean?
- data collection only
- data collection and decision making by protocol
- data collection and decision making on there professional opinion
