Lei-Ai Lim MBBS, FRCOphth

Consultant Ophthalmologist

SPEAKER

Charles Bill BSc (Hons) MCOptom

PLYMOUTH OPTICIAN GLAUCOMA

MONITORING SCHEME (POGCS) AUDIT

BACKGROUND (GENERAL)

• Increase demand for age related chronic eye conditions e.g. glaucoma : Ageing population, increased optometric screening, increased public awareness ; Conditions requiring long term monitoring and care

• Numbers of ophthalmologists are not increasing in line with demand

• “A perfect storm of increased demand, caused by more eye disease in ageing population” Professor Carrie MacEwen, President of Royal College of Ophthalmologists for BBC’s Scrubbing Up

• Irreversible sight loss can occur in chronic eye disease like glaucoma from delayed follow up and timely intervention

• Absence of information to assess magnitude of problem: No targets for follow up patients (unlike 18week target for seeing new patients) , data not routinely gathered

• National Reporting and Learning System (NRLS) : 500 incidents of loss /deterioration of vision (130 severe harm, 350 moderate harm) from delays between 2011-2013

• National Study by RCOphth to identify patients who have come to harm due to hospital initiated delays for follow up appointments: (Not yet reported) Preliminary results: At least 20 per month suffer severe visual loss : age range 7 months -92 years; delays up to 4 years

BACKGROUND (GENERAL)

• The National Eye Health Epidemiological Model (NEHEM) projection by Office for National Statistics (ONS) :

• From 2010 to 2035, over 75 years population will rise by >80%, over 85 more than double

• Over next 10 years , glaucoma cases will rise by 22%, suspects by 10% and OHT by 9%

• NHS England: Way Forward Project 2015-2035:

• Different ways of working

• Referral Management ( Referral refinement)

• Pathway redesign

• Technology (Virtual Clinics)

• Multi-disciplinary Team working

• Moving care from HES into Community

BACKGROUND

• POGCS Scheme started 2008

• Monitoring stable glaucoma/ ocular hypertension and glaucoma suspects via local optometrists from Plymouth Hospitals

NHS Trust, Royal Eye Infirmary

• Accredited optometrists via an administrator within 6 months of referral from REI

• All patients have baseline tests :

• History

• IOP (GAT)

• Disc assessment (Volk- ideally with dilated pupils)

• Slit lamp assessment of anterior chamber

• Humphreys VF

BACKGROUND

• Definition of stability: For one year (At REI)

• No change in management

• No change in visual field

• No change in optic disc appearance (based on good quality photo)

• IOP within target

• No new symptoms attributable to progressive visual field deterioration

• Exclusion:

• Unstable glaucoma

• Field constriction to within less than 20 degrees from fixation wither field

• Significant other ocular pathology

REI

OHT

Stable Glaucoma

Glaucoma Suspects

Optometrist for baseline assessment 6

months

Unstable

Early repeat follow up

Stable (Annual review)

Suspect

Worse

AIM

• To audit 5% of current OHT/Stable Glaucoma/Glaucoma suspects seen in the POGCS n terms of

• Safety (IOP stability, Visual Field Stability)

• Compliance with monitoring protocol ( Investigations performed, Interval of screening)

METHODS

• Audit by independent ophthalmologist specialising in Glaucoma

• Patients reviewed within 3 months of last review by Scheme

• Record review : Visual fields, Disc photo, Record keeping

• IOP check and disc assessment at audit

• Proforma filled in for each patient seen

• Data entered onto and subsequently analysed on Excel

POCGS Audit, May 2015 Devon LOC

Peninsula Optometrist Community Glaucoma Scheme Patient Attendance Record - Audit Form

To be completed by the practice

Patient name:

Date of Birth: Date:

Practice: Name of monitoring Optometrist:

Ophthalmologist: Miss Lei-Ai Lim

Target IOP (mmHg): L: R:

Date of last follow-up: Date of digital photograph:

To be completed by Ophthalmologist

Right Eye Left Eye

Visual Field Stable Unstable

Visual Field Stable Unstable

Optic Nerve Head Stable Unstable

Optic Nerve Head Stable Unstable

IOP (Goldmann):

IOP (Goldmann):

Is this patient? Stable Unstable

Signature

Additional comments overleaf

Comments

Comments

mmHg

Time of applanation

mmHg

Time of applanation

Reviewed at appropriate intervals

Timely referral

Clear documentation

VF and photo as per protocol

GLAUCOMA QUALITY STANDARDS1,2

• Statement 5. People diagnosed with COAG, suspected COAG or with OHT are monitored at intervals according to their

risk of progressive loss of vision in accordance with NICE guidance

• Statement 8. People diagnosed with COAG, suspected COAG or with OHT have access to timely follow-up appointments

and specialist investigations at intervals in accordance with NICE guidance.

• Statement 9. Healthcare professionals involved in the care of a person with COAG, suspected COAG or with OHT have

appropriate documentation and records available at each clinical encounter in accordance with NICE guidance

• Statement 12. People with suspected COAG or with OHT who are not recommended for treatment and whose condition is

considered stable are discharged from formal monitoring with patient-held management plan

RESULTS

POCGS & NUMBER AUDITTED

• 10 Practices:

1. Noakes Habermehl & Kerr Callington : 26

2. Noakes Habermehl & Kerr Crownhil : 20

3. Angus McPhie : 13

4. Kingsbridge : 7

5. Nigel Gainey : 14

6. Boots Plymouth : 10

7. Specsavers Plymouth : 27

8. Newsome : 13

9. Leonard A Gibson Plymstock : 25

10. Andrew Keirl : 30

• Total 184/3360 = 5.5%

• From 13/05/2015- 19/01/2016

• Age

• Range 48-92

• Mean 72 SD 8.8

• Mode 67

• Median 72

• Sex

• Male 48% (88)

• Female 52% (97)

DEMOGRAPHICS

TREATED PATIENTS WITHIN THE SCHEME AUDITED

• 116 (63%) on Topical treatment

• 19 (10% ) had previous laser (SLT/ALT/PI)

• 13 (7%) had previous trabeculectomy

• Patients not on Topical treatment at time of audit : 55 ( 30%)

• Glaucoma Suspect 23 (41%)

• OHT 29 (53%)

• POAG 1 (2%)

• NTG 2 (4%)

0

5

10

15

20

25

30

35

40

45

1 2 3 4 5 6 7 8

Number of Patients Auditted at Year of Attendance

Number of Years of Attendance

RESULTS

Safety Parameters

Left Eye Right Eye

Total 11 8

Stable Overall 5 5

Unsure (lack of

documentation)

4 1

Unstable

(referred back

to REI)

2 2

Left Eye Right Eye

Total Eyes 184 182 (2 only

eyes)

No. without

Target IOP

4 4

Number of

eyes

180 178

Number

exceeding

Target

11 8

Percentage 6% 4%

1.WERE THE IOPS WITHIN TARGET?

Overall Breakdown of IOPs exceeding target

• Total 7 cases

• 5 were referred back to REI by Optometrist

• 1 arranged for repeat VF in 3 months

• 1 was recommended referral back to REI

• The unclassifiable visual fields were unreliably

performed visual fields, both were deemed overall

stable.

Left Eye Right Eye

Total Eyes 184 182

Stable 179(97.3%) 174 (95.6%)

Unstable 1 6

Unclassifiable 4 (2.1%) 2 (1%)

Percentage

Unstable

0.5% 3.2%

2.WERE THE VISUAL FIELDS STABLE?

Overall Breakdown of Unstable Visual Fields

• All of the Unclassifiable cases were where no photos

were available on the systemLEFT EYE RIGHT EYE

TOTAL 184 182

STABLE 159 (86%) 160 (88%)

UNSTABLE 2 (1%) 1 (0.5%)

UNCLASS. 23 (12.5%) 21 (11.5%)

3. WERE THE DISCS STABLE?

OVERALL

UNSTABLE PATIENTS

• 6 patients in total were unstable and recommended referral back to HES

• 5/6 initiated by optometrist

• 1/6 initiated by auditing ophthalmologist

• All had visual field progression, 2 of which had concurrent IOP outside of target range

• None referred back on basis of optic nerve head appearance

RESULTS

Compliance with Protocol/ Record Keeping

RECORD KEEPING

• Each visit generates an attendance form --- which triggers payment for the visit

• Different systems in different practices:

• Paper system/ Scanned : Hospital discharge, attendances and printed visual fields

• Photo viewing system: usually separate

• Every visit: IOP, Disc assessment (slit lamp), visual fields, Every 6 th visit photo

WERE PATIENTS REVIEWED

AT INTERVAL AS PER

PROTOCOL ?

Of 13 patients without complete documentation

at audit visit:

• 1 was lost to follow up for a period of time

and then returned

• Remaining 12 had incomplete

documentation: absent hospital referral

documentation, incomplete visual fields, no

first photos for comparison

• Some scanned documents were completely

illegible

YES93%

NO7%

Number

Disc photo 18 (67%)

Photo and visual fields 9 (33%)

WERE INVESTIGATIONS AS PER PROTOCOL

PATIENT RECORD KEEPING

CONCLUSION

• The range of number of years within the scheme was 1-8 years with adequate representation of patients audited over the

duration of the scheme.

• 94-96% of intraocular pressures were within target at review, 95-97% of visual fields were stable and 86-88% of discs

were deemed stable.

• Unstable patients were appropriately referred back to the hospital glaucoma service. (Low false negative)

• 93% of patients were reviewed at the intervals specified by the protocol

• 85% investigations carried out as per protocol

• 89% of records legible

• Patient feedback good

RECOMMENDATIONS

1. A universal patient records system across the practices, ideally an electronic patient record and pathway, which enable

virtual monitoring.

2. All patient information and investigations results should be available at every review, and transfer of records should be

facilitated when patients move between practices, should an electronic system not be adopted.

3. Better compliance with investigations schedule: in accordance with NICE guidance

4. Standardised optic nerve head imaging, and revision of imaging frequency.

5. Better clinical governance in place to audit practices at regular predetermined intervals, which would be aided by

electronic patients record.

6. ? Computer assisted automated visual field progression analysis : trigger for referral

7. Patients with angle closure appropriate for scheme

8. Glaucoma suspects: how long they should be kept in scheme: review set up for possible discharge

• From 2010 to 2035, the population

over 75 years of age will rise by >80%.

Those over 86 will more than double,

• Over the next 10 years glaucoma cases will rise by

22%, glaucoma suspects by 10% and OHT by 9%

THANK YOU FOR YOUR ATTENTION

REFERENCES

1. National Institute for Health and Care Excellence. Glaucoma quality standard. 2011; QS7. Available at:

http://guidance.nice.org.uk/QS7

2. National Institute for Health and Care Excellence. Diagnosis and management of chronic open angle glaucoma and ocular

hypertension (clinical guideline 85). 2009;CG85. Available at: http://guidance.nice.org.uk/CG85

3. Royal College of Ophthalmologists, The College of Optometrists. Commissioning better eye care: glaucoma. 2013;version

2. Available at : http://www.college-optometrists.org/en/utilities/document-summary.cfm/4B0BE038-E6B2-49B4-

B913529D58F2F038