3. What data did we require
• Identify the problem areas
• Identify the current referral pathways
• Identify the stakeholders in OPC
• Identify the barriers to entry for these
stakeholders (optometrists)
4. 1st Outpatient appointments ORH
34,699
15,739
54,396
13,175
16,642
22,636
390
16,991
4,942
43,524
Trauma & Orthopaedics
Ear, nose and throat (ENT)
Opthhamology
Clinical haemotology
Cardiology
Dermatology
Rheumatology
Paediatrics
Obstetrics
Gynaecology
The NHS Information Centre, Hospital Episode Statistics for England. Outpatient statistics, 2010-11
Activity in English NHS Hospitals and English NHS commissioned activity in the independent sector.
Please see the HESonline website (http://www.hesonline.nhs.uk) for information on outpatients data quality.
5. Breakdown in 1st Outpatient
appointments by type
Unfortunately Hospital Episode Statistics (HES) data are worthless for understanding N:F
ratios according to disease category because in 97% of OPD hospital visits disease is
unspecified (RCOphthal)
30%
20%20%
15%
15%
Glaucoma
Cataract
AMD and other
Anterior segment
Casualty
6. What data did we require
• Identify the problem areas
• Identify the current referral pathways
• Identify the stakeholders in PCO
• Identify the barriers to entry for these
stakeholders
7. Optometrist referrals (GOS18)
Disorders of lens
Primary open angle glaucoma
suspect
Diabetic retinopathy
Age related macular degeneration
Visual disturbances and other
disorders of eye and adnexa
Other disorders of retina
Disorders of the cornea
Disorders of eyelid, lacrimal system
and orbit
Disorders of vitreous body and
globe
Retinal vascular occlusions
BV/Refraction/Acc
Retinal detachments and breaks
Davey CJ, Green C & Elliott DB. Assessment of referrals to the hospital eye service by
optometrists and GPs in Bradford
and Airedale. Ophthalmic Physiol Opt 2011, 31, 23–28. doi: 10.1111/j.1475-1313.2010.00797.
8. GP referrals
Davey CJ, Green C & Elliott DB. Assessment of referrals to the hospital eye service by
optometrists and GPs in Bradford
and Airedale. Ophthalmic Physiol Opt 2011, 31, 23–28. doi: 10.1111/j.1475-1313.2010.00797.
Disorders of eyelid, lacrimal system and orbit 52 (46)
Visual disturbances and other disorders of eye and
adnexa 21 (18)
Disorders of conjunctiva 10 (9)
Disorders of the cornea 2 (2)
Disorders of vitreous, globe, sclera, optic nerve,visual
pathway, iris, ciliary body, retinal breaks and other
disorders of retina
Disorders of lens 12 (11)
BV/Refraction/Acc
Age related macular degeneration 4 (4)
9. SELF REFERRAL
Eye Casualty only
GENERAL MEDICAL
PRACTITIONER
self-referral
A&E (including Minor
Injuries Units and
Walk In Centres)
Specialist Nurse
(Secondary Care)
Optometrist
Number of Outpatient Eye Casualty activities in OUH during Apr11 to Nov11
10. Optometrist referrals
Disorders of lens
Primary open angle glaucoma
suspect
Diabetic retinopathy
Age related macular degeneration
Visual disturbances and other
disorders of eye and adnexa
Other disorders of retina
Disorders of the cornea
Disorders of eyelid, lacrimal system
and orbit
Disorders of vitreous body and
globe
Retinal vascular occlusions
BV/Refraction/Acc
Retinal detachments and breaks
Davey CJ, Green C & Elliott DB. Assessment of referrals to the hospital eye service by
optometrists and GPs in Bradford
and Airedale. Ophthalmic Physiol Opt 2011, 31, 23–28. doi: 10.1111/j.1475-1313.2010.00797.
11. So where were Optometrists good and where was there room for
improvement?
• Cataract Less than 7% were not listed for surgery
• Diabetes Will be a much smaller % due to ODESS although this
remains a slight issue with a few Optometrists
• AMD Oxford has Direct referral pathways for wet AMD
• Glaucoma This study was done pre – NICE
A 10 year prospective study of glaucoma referrals to the Oxford Eye Hospital by
optometrists found that glaucoma was confirmed in 20% and ocular hypertension in
around 30% of the patients referred; over 40%
of patients referred for glaucoma were found not to have the condition (Bowling et
al., 2005)
A separate study in Oxford showed the following results:
• 2003 52% false positives
• 2004 46% false positives
• 2005 47% false positives
40% False Positives pre-NICE 2009
Are we worse than the rest of the England
An analysis of patients discharged from a hospital-based glaucoma case-finding clinic over a 3-year period
Nicola J. Salmon1, H. P. Terry2, Andrew D. Farmery3 and John F. Salmon4 1Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland, 2Department of Optometry,
Oxford Eye Hospital, Oxford, UK, 3Nuffield Department of Anaesthetics, and 4Nuffield Department of
Ophthalmology, University of Oxford, Oxford, UK
12. Where do the false positive come
from?
Optometrists account for 95% of all Glaucoma referrals
Optic Disc Assessment,
41.90%
IOP, 36.30%
Visual Fields, 19.50%
Other , 2.30%
An analysis of patients discharged from a hospital-based glaucoma case-finding clinic over a 3-year period
Nicola J. Salmon1, H. P. Terry2, Andrew D. Farmery3 and John F. Salmon4 1Faculty of Medicine, University of Edinburgh, Edinburgh, Scotland, 2Department of Optometry,
Oxford Eye Hospital, Oxford, UK, 3Nuffield Department of Anaesthetics, and 4Nuffield Department of
Ophthalmology, University of Oxford, Oxford, UK
13. How can we reduce the false positives?
1. Studies have shown that the correlation
between decision making on visual fields
between Ophthalmologists and Optometrists to
be nearly 90%...........yet almost all referrals are
based on a single visual field plot and no
repeats.
2. Repeating pressures using Goldmann can
deflect a large proportion of high IOP’s found
with NCT.
3. Almost 50% of all referrals are based on a
single abnormal finding
14. What data did we require
• Identify the problem areas
• Identify the current referral pathways
• Identify the stakeholders in OPC
• Identify the barriers to entry for these
stakeholders
16. 0
10
20
30
40
50
60
Percentage
What are the barriers for Optometrists?
Barriers perceived by UK-based community
optometrists to the detection of primary open
angle glaucoma
Joy Myint1, David F. Edgar1, Aachal Kotecha1,2, Ian E. Murdoch3 and John
G. Lawrenson
17. LOCSU – Referral Refinement
• Level 1a Goldmann Applanation Tonometry
– If IOP >21 mmHg at GOS or private sight test, Optometrist carries out Goldmann
applanation tonometry and repeats on a separate occasion if necessary
• Level 1b Visual Field Refinement
– If suspicious visual field at GOS or private sight test, optometrist carries out
repeat measurement on a separate occasion
• Level 2 OHT Monitoring
– Patients who are diagnosed by secondary care (or specialist practitioner) as
having OHT which does not require treatment will be referred for monitoring in
the community at intervals specified by NICE
– Costs based on 25 minute assessments with optometrist
18. Audit
Data is key to success
Participati
ng
37%Non-
participati
ng
63%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Deflected at Test A
Deflected at Test B
Contractors signed up to LES Deflection by Optometrist
£0
£5,000
£10,000
£15,000
£20,000
£25,000
Fees Paid Software
costs
HES Spend Base Costs Savings
Made
Costs
0%
10%
20%
30%
40%
50%
60%
70%
Deflected at First Deflected at repeat
Total Deflection
19. 6 month audit
• Slow Uptake by Optometrists
• Deflection comparable with other UK
schemes.
• Individual Optometrist deflections similar
–No outliers but to early to know.
• The need for feedback from the HES to
close the loop( how many are OHT)
• What happens next year OHT???
20. LOCSU – Referral Refinement
• Level 1a Goldmann Applanation Tonometry
– If IOP >21 mmHg at GOS or private sight test, Optometrist carries out Goldmann
applanation tonometry and repeats on a separate occasion if necessary
• Level 1b Visual Field Refinement
– If suspicious visual field at GOS or private sight test, optometrist carries out
repeat measurement on a separate occasion
• Level 2 OHT Monitoring
– Patients who are diagnosed by secondary care (or specialist practitioner) as
having OHT which does not require treatment will be referred for monitoring in
the community at intervals specified by NICE
21. IOP/OHT…. What else?
Community Care
IOP/OHT referral refinement
Diabetic Retinopathy
Hospital Care
Stable Glaucoma monitoring (Consultant lead clinic)
Cataract pre and post operative care
Low Vision Services
Children's Eye Care Services
Acute / Eye Casualty
Possibilities
Cataract Direct referral
Children's eye care services
PEARS/ACES/CORRS
Patients with Learning Disabilities
22. GP referrals (40%)
Davey CJ, Green C & Elliott DB. Assessment of referrals to the hospital eye service by
optometrists and GPs in Bradford
and Airedale. Ophthalmic Physiol Opt 2011, 31, 23–28. doi: 10.1111/j.1475-1313.2010.00797.
Disorders of eyelid, lacrimal system and orbit 52 (46)
Visual disturbances and other disorders of eye and
adnexa 21 (18)
Disorders of conjunctiva 10 (9)
Disorders of the cornea 2 (2)
Disorders of vitreous, globe, sclera, optic nerve,visual
pathway, iris, ciliary body, retinal breaks and other
disorders of retina
Disorders of lens 12 (11)
BV/Refraction/Acc
Age related macular degeneration 4 (4)
23. SELF REFERRAL
Eye Casualty only
GENERAL MEDICAL
PRACTITIONER
self-referral
A&E (including Minor
Injuries Units and
Walk In Centres)
Specialist Nurse
(Secondary Care)
Optometrist
Number of Outpatient Eye Casualty activities in OUH during Apr11 to Nov11
24. One week Audit of Nurse lead Clinic at ORH in 2010
Allergic Conjunctivitis
Blepharitis
Corneal Abrasion
Corneal/Subtarsal FB
Dry Eyes
Episcleritis
Herpes Zoster No Eye Involvement
Posterior Vitreous Detachment
Sub Conj Haemorrhage If Spontaneous
Trichiasis
Subtarsal FB
Bacterial Conjunctivitis
Marginal Keratitis
Sjogren's Syndrome
Recurrent Corneal Erosion
Corneal Epithelial Defect
Concreation
Conjunctivitis
Other
26. “There is a ‘high-brow’ type of optician who takes a keen delight in delving into
subjects which are absolutely outside the scope of his work. Considerable play is
often made with afflictions, other than pathological conditions of the eye or arising
therefrom, of which doctors themselves know little and the optician a great deal
less…
…..Some opticians seek to heighten the illusion of being pseudo medical men by
resorting to the use of white coats, ‘hospitally smelling’ lens cleaning solutions and
similar means.
…..The more the optician is encroaching on medical ground the more he is
endangering his position. The medical side is being rightly perturbed and
unnecessarily antagonised by the optician interfering with matters which are not his own”.
Brumer 1942
Historical perspective
Changing Perspectives
0 20 40 60 80 100
Gp's
Ophthalmologists
Yes
No
Current Perspective
Seeking views of stakeholders: medical practitioners
In principle, do you believe that UK optometrists could use ocular therapeutic drugs, provided suitable training were given?
27. • I believe there is a huge opportunity for the
stakeholders of OPC to work together to
provide an invaluable service to the
community.
• Thank you!
