Patient Referral Pathways

Michael Austin Consultant Ophthalmologist, ABMU Health BoardRachel WhitehallAssistant Director of Planned Care, NHS Wales

Overview

• Diabetic retinopathy• Glaucoma• Unscheduled eye care• ‘wet’ AMD• Cataract• (Children) • (Everything else…)

• Clinical prioritisation & ‘routine new referrals’• Electronic referrals…

http://howis.wales.nhs.uk/deliveryandsupportunit

Sobering thought 1…New patient demand…

is double new patient ‘Dr.’ slots

w/c 30th December 2013

Audit of new patient referrals: Observations

• A pattern emerges…• Not much from GPs (and mainly low priority)• Cataracts & glaucoma largest groups• Many general-type cases• But… other routes of entry for…

– Children/ diabetic retinopathy/ surgical retina– ‘wet’ AMD

Diabetic retinopathy

• DRSSW• 2003 WG initiative• 2006 fully operational and…

– 1.2 million eyes– 29,000 screen positive and referred to HES

• No longer No. 1 cause of sight loss – in working age group– Liew G et al http://bmjopen.bmj.com/content/4/2/e004015.full

Glaucoma

• WECS-EHEW– Fuller clinical data set

• Optic disc stereo biomicroscopy (dilated)• Threshold perimetry • Applanation tonometry (GAT, PAT)

– Better clinical decision making

All Wales Glaucoma Care PathwayGetting referrals right

Patient

Focus On Ophthalmology: Glaucoma – DRAFT 3.3Diagnostics

Referral Form to reflect Guidelines –

NICE

Optometrist

GP

Public Awareness:RNI B Campaign/s e.g.

Glaucoma Week

NICE links

Consultant led MDT

(inc virtual clinic)

Long term monitoring

No abnormality detected

SOS route

Goldmann ApplanationVisual fields as appropriateCorneal thickness disc: slit lamp +/ - dilation

Goldmann Applanation+/ - Visual fields (Humphrey)Corneal thickness disc: slit lamp +/- dilationHRT & digital disc image

Monitor

Referral with refinement / investigations

Community Eye Care Assessment and Treatment

CentreODTC

DU glaucoma audits 2014

• 100% of referrals are direct from optometrists– Except for 2 units (30%, 89%)

• WECS forms largely incomplete (63% average)– But in one HB only 21% were incomplete…

• 6 ODTCs up and running (variable extent)– One HB has 10,000 ODTC appointments per year

• ALL new & approaching half of follow-ups– Poor accommodation– Only 4 virtual clinics

Virtual clinics: Patient satisfaction

• 135 VC patients sent questionnaire• 63% response rate• Mean satisfaction score 4.5 / 5

– Across whole of QUOTE PREM tool• 95% correctly identified glaucoma diagnosis• 96% found the information useful• No inferiority compared with ‘Dr’ clinic

ABMUHB audit data on file

New referrals – VC diagnosisMay – July 2013 Neath Port Talbot N = 56

Glaucoma 6 (‘Dr’ clinic next visit)

NOT Glaucoma 10 (& discharged back to optometrist)

G Suspect – disc 24 (& NICE reviews)

OHT 16 (& NICE reviews +/- treatment)

PDS 1

Narrow angle 6 (‘Dr’ clinic +/- iridotomy)

(Treatment via VC 5)

So how is it going now in my practice?

Not much Dr input required

Unscheduled Eye Care Pathway

Unscheduled eye care

• Many routes into pathway• WECS optometrist = a good place to start

– (rather than GP)– 80% retained

• BUT… red flags = RACE via local triage system– Significant trauma– Sudden visual loss– Sudden onset diplopia

“Red Flags”“Red Flags”

Need to be seen “now”

But not many of them

Other unscheduled eye care

• Won’t die / go blind today…– Significant morbidity possible– And pain

• So… not “Eye Casualty” … but…• R.A.C.E.

– Rapid Access Clinic for Eyes– See patients according to clinical need– Within 1 - 7 daysDU Audits: By and large, patients in RACE needed to be there…

Unscheduled Eye Care Pathway

TRIAGE !

‘wet’ AMD

‘wet’ AMD

• DU audits confirm…• Appropriate referrals• Increasing uptake of standard referral form• MDT working evolving• Issues

– Accommodation, staffing, nurse injectors• Other indications for intravitreal therapy

– Diabetic retinopathy– Retinal vein occlusion

Wales Cataract Pathway

Wales Cataract Pathway:Ophthalmologist input

Swansea Cataract referrals January 2013

• N = 70• VA between 6/12 and 6/60 41• Comorbity = “No” 47• Both of above…

– …& ‘no special refractive issues’, so…• “Direct Access” suitable 32 (46%)

Swansea Cataract referrals January 2013

• “Cataracts Direct” unsuitable 38 (54%)

• Additional reason for referral 4• VA > 6/12

23*• VA < 6/60 5• Fellow eye no cataract & ametropia > 3DS 6• Comorbity = “Yes” 8• Incomplete data 13• THESE NEED SOME OPHTHALMOLOGIST ‘CHAIR TIME’ PRIOR TO CONSENT

(* … more likely to decline offer of surgery following discussion of risk vs benefit)

Direct access patients survey

• Patients having cataract surgery in 2012• Postop • Direct access route• 50 patients’ details from DSU records• Less duplicates• N = 47• Replies = 40 (85%)

Q8. Are you pleased with the result of your cataract operation(s) ?

• YES 38• NO 0 (no response = 2)

Q9. Knowing what you know now… would you go through the experience of a cataract operation with us again?

• YES 38• NO 0 (no response = 2)

47 questionnaires to Direct Access patients, 40 replies (85%)

Q10. Thinking about the visit to the Singleton Hospital Day Surgery Unit preassessment clinic BEFORE the operation (the one where you

were seen by a nurse to discuss the operation and sign the yellow consent form) ...

SA A NSO D SD

A I felt put at ease by the nurse I saw 29 6 1 0 0B I was able to express any concerns 23 9 4 0 0C I felt comfortable to ask questions 27 8 1 0 0D I was given explanations that were helpful 25 10 1 0 0E I was treated with respect and my opinion

was regarded as important 26 8 2 0 0F I had a good enough understanding to go

ahead with the operation 27 8 1 0 0G Overall my experience at the preop cataract

clinic was positive 29 7 0 0 0

Clinical prioritisation & ‘routine new referrals’

Wales Eye Care Plan:• Revise targets for ophthalmology to

incorporate measures for all patients (new and follow-up) that are based on clinical need and risk of irreversible sight loss.

• ‘New Measures” project• BCU & ABMU

• Condition codes• Priority codes P1, P2, P3

– (see next slides)• Patient-specific time to appointment

– New and follow-up patients– Evidence based & audited– Reporting “slippage” as % of intended interval– Instruction in event of CNA/ DNA/ ‘HCNA’

Priority 1

• Patients who may suffer serious irreversible harm from delayed appointments – e.g. wet AMD, diabetic retinopathy – progressing glaucoma– tumour surveillance patients – post-operative patients

Priority 2

• Patients who may suffer reversible harm from delayed appointments– e.g. cataract

Priority 3• Patients who may be inconvenienced or suffer

mild reversible consequences from delayed appointments – e.g. dry eyes, blepharitis, adnexal cysts

Electronic referrals

• OpenEyes EPR• An Eye Care Plan required action• Key trail- blazers installed by April 2015• Health care technology fund grant• Connectivity for community optometry

– NOT a license to swamp consultants’ email– Ground rules required…

Sobering thought 2…90% of FUNB is P1

• N= 156 survey in Singleton adult clinics– Glaucoma pathway patients 68– Diabetic retinopathy 39– Tumours 7– Neuro-ophthalmology 9– 'other miscellaneous P1' 15

• P2 = 11• P3 = 6

"If I had a magic wand"

• EPR to support virtual clinic / shared care• Independent prescribing • Peer support in community optometry• ODTC access for patients throughout Wales• Applanation tonometry & corneal pachymetry