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GlaucomaImplementing NICE guidance

Slide set updated May 2011

NICE clinical guideline 85

What this presentation covers

Background

Scope

Key priorities for implementation

Costs and savings

Discussion

Find out more

NICE Quality standard

Background

• Chronic open angle glaucoma (COAG) is a common and potentially blinding condition, and is usually asymptomatic until advanced

• Ocular hypertension (OHT) is a major risk factor for developing COAG

• Approximately 10% of UK blindness registrations are attributed to glaucoma

• By implementing this guideline more people will be prevented from going blind

Scope

The diagnosis and management of people with COAG and OHT in community, primary care, secondary care outpatient and day treatment services and tertiary care specialist services for people in the following groups:

• adults (18 and older) with a diagnosis of COAG or OHT

• people with chronic open angle glaucoma or ocular hypertension associated with pseudoexfoliation or pigment dispersion

• people who have a higher prevalence of glaucoma and may have worse clinical outcomes

Key priorities for implementation

Diagnosis

At diagnosis offer all people who have COAG, who are suspected of having COAG or who have OHT all of the following tests:

•intraocular pressure (IOP) measurement using Goldmann applanation tonometry (slit lamp mounted)

•central corneal thickness (CCT) measurement

•peripheral anterior chamber configuration and depth assessments using gonioscopy

•visual field measurement using standard automated perimetry (central thresholding test)

•optic nerve assessment, with dilatation, using stereoscopicslit lamp biomicroscopy with fundus examination

Diagnosis

Ensure that all of the following are made available at each clinical episode to all healthcare professionals involved in aperson’s care:

records of all previous tests and images relevant to COAG and OHT assessment

records of past medical history which could affect drug choice

current systemic and topical medication

glaucoma medication record

drug allergies and intolerances

Monitoring

Monitor at regular intervals people with OHT or suspected COAG recommended to receive medication (see ‘Treatment for people with OHT or suspected COAG’), according to their risk of conversion to COAG (see next slide)

Monitoring intervals for peoplewith OHT/suspected COAG

recommended to receive medication

Clinical assessment Monitoring intervals (months)

IOP at targeta

Risk of conversion to COAGb Outcomec IOP aloned

IOP, optic nerve head and visual field

Yes LowNo change in treatment plan Not applicable 12 to 24

Yes HighNo change in treatment plan Not applicable 6 to 12

No Low

Review target IOP or change treatment plan 1 to 4 6 to 12

No High

Review target IOP or change treatment plan 1 to 4 4 to 6

Monitor at regular intervals people with COAG according to their risk of progression to sight loss (see next slide)

Monitoring

Monitoring intervals for people with COAG

Clinical assessment Monitoring intervals (months)

IOP at targeta Progressionb Outcomec IOP aloned

IOP, optic nerve head and visual field

Yes Noe

No change in treatment plan

Not applicable 6 to 12

Yes Yes

Review target IOP and change treatment plan 1 to 4 2 to 6

Yes UncertainNo change in treatment plan

Not applicable 2 to 6

No Noe

Review target IOP or change treatment plan 1 to 4 6 to 12

No Yes/uncertainChange treatment plan 1 to 2 2 to 6

Treatment for people withOHT or suspected COAG

Offer people with OHT or suspected COAG with high IOP treatment based on estimated risk of conversion to COAG using IOP, CCT and age (see next slide)

Treatment for people with OHT or suspected COAG

CCTMore than 590 micrometres

555–590 micrometres

Less than 555 micrometres Any

Untreated IOP (mmHg) > 21 to 25 > 25 to 32 > 21 to 25

>25 to 32 > 21 to 25 > 25 to 32 > 32

Age (years)a Any Any Any

Treat until 60

Treat until 65

Treat until 80 Any

TreatmentNo

treatmentNo

treatmentNo

treatment BBb PGA PGA PGA

BB: betablockerPGA: prostaglandin analogue

Treatment for peoplewith COAG

• Offer people newly diagnosed with early or moderate COAG, and at risk of significant visual loss in their lifetime, treatment with a prostaglandin analogue

• Offer surgery with pharmacological augmentation (mitomycin C [MMC] or 5-fluorouracil [5-FU]) as indicated to people with COAG who are at risk of progressing to sight loss despite treatment. Offer them information on the risks and benefits associated with surgery

Organisation of care

• Refer people with suspected optic nerve damage or repeatable visual field defect, or both, to a consultant ophthalmologist for consideration of a definitive diagnosis and formulation of a management plan

• People with a diagnosis of OHT, suspected COAG or COAG should be monitored and treated by a trained healthcare professional who has all of the following:

– a specialist qualification (when not working under the supervision of a consultant ophthalmologist)

– relevant experience

– ability to detect a change in clinical status

Provision of information

Offer people the opportunity to discuss their diagnosis, prognosis and treatment, and provide them with relevant information in an accessible format at initial and subsequent visits

Costs and savings per 100,000 population

Recommendations with significant costs Costs (£ per year)

Monitoring and treatment of people with OHT or suspected COAG 20,820

Surgery for people who have COAG progression despite treatment 3808

Estimated incremental cost of implementation 24,628

Potential resource shift as a result of implementation

Potential resource shift (£ per year)

Demand pressures reduced in hospital eye service from potential resource shift to community –14,661

Estimated cost of shifting services to the community 14,661

Costs and potentialresource shift

Recommendations in the following areas may result in additional costs depending on local circumstances:

• more regular monitoring and treatment of people with OHT or suspected COAG

• surgery for people who have COAG progression despite treatment as a result of improved sequential data

• potential resource shift from hospital eye services to community (where appropriate) as a result of increased monitoring of people with OHT and suspected COAG

Discussion

• How effective are local diagnostic services?

• What changes might we need to make to achieve the monitoring intervals for each patient group?

• What are the options that local commissioners might consider for delivering this guideline?

• How are patient information needs currently met?

Find out more

Visit www.nice.org.uk/CG85 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•NICE Pathway•costing report and template•audit support•commissioning guide•online educational tool

Glaucoma Quality Standard can be found atwww.nice.org.uk/guidance/qualitystandards/glaucoma/Home.jsp

NICE Quality Standard

Glaucoma

www.nice.org.uk/guidance/qualitystandards/glaucoma/Home.jsp

Quality standards

A quality standard is a set of specific, concise statements that:

•act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment and prevention

•are derived from the best available evidence such as NICE guidance or other NHS evidence accredited sources and produced collaboratively with the NHS and social care, along with their partners and service users.

Glaucoma quality standard

The glaucoma quality standard consists of 12 statements that describe the care for people with chronic open angle glaucoma (COAG), suspected COAG or ocular hypertension (OHT).

Desired outcomes are to:

•enhance the quality of life for people with COAG

•ensure people have a positive experience of care

•treat and care for people in a safe environment

•contribute to a reduction in Certificate of Visual Impairment registration rates for glaucoma.

Quality statement 1- Referral

People are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects COAG. There are local agreements in place for referral refinement.

Quality measureProcess:a) Proportion of people in whom an optometrist or other healthcareprofessional suspects COAG who undergo further assessmentwith referral refinement.b) Proportion of people who undergo referral refinement who aresubsequently referred on to a consultant ophthalmologist fordefinitive diagnosis because COAG is suspected.

Quality statement 2 - Referral

People with elevated IOP alone are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG. There are agreements in place for repeat measures.

Quality measureProcess:a) Proportion of people with elevation of IOP alone, who arereferred for repeat measures to an appropriately qualifiedhealthcare professional.b) Proportion of people with confirmed elevation of IOP alone, whoare referred to an appropriately qualified healthcare professionalfor further assessment on the basis of perceived risk ofprogression to COAG.

Quality statement 3 - Diagnosis

People referred for definitive diagnosis in the context of possible COAG or with OHT receive all relevant tests in accordance with NICE guidance.

Quality measureProcess:Proportion of people referred for definitive diagnosis inthe context of possible COAG or with OHT who attend andreceive all relevant tests in accordance with NICE guidance.

Quality statement 4 – Diagnosis and management plan

People with COAG, suspected COAG or with OHT are diagnosed and have a management plan formulated by a suitably trained healthcare professional with competencies and experience in accordance with NICE guidance.

Quality measureProcess:a) Proportion of people with COAG, suspected COAG or with OHTwho are diagnosed by a suitably trained healthcare professionalwith competencies and experience in the relevant condition inaccordance with NICE guidance.b) Proportion of people with COAG, suspected COAG or with OHTwho have a management plan formulated by a healthcareprofessional with competencies and experience in the relevantcondition in accordance with NICE guidance.

Quality statement 5 - Monitoring

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.

Quality measureProcess:Proportion of people with COAG, suspected COAG orwith OHT who are monitored at intervals according to their risk ofprogressive loss of vision in accordance with NICE guidance.

Quality statement 6 - Management

People with suspected COAG or with OHT are managed based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance.

Quality measureProcess:a) Proportion of people diagnosed with suspected COAG or withOHT who are assessed for treatment eligibility based on estimatedrisk of conversion to COAG and progression to visual impairmentusing IOP, CCT and age.b) Proportion of people diagnosed with suspected COAG or withOHT who are eligible for treatment based on estimated risk ofconversion to COAG and progression to visual impairment usingIOP, CCT and age, who are managed in accordance with NICEguidance.

Quality statement 6 – Management cont.

People with suspected COAG or with OHT are managed based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance.

Quality measureProcess:c) Proportion of people diagnosed with suspected COAG or withOHT at low risk of progressing to visual impairment who receiveno treatment in accordance with NICE guidance.

Quality statement 7 – Stopping treatment

People with COAG, suspected COAG or with OHT have a regular review of management options with their healthcare professional, taking into account comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment.

Quality measureProcess:a) Proportion of people with COAG, suspected COAG or with OHTwho have a regular review of management options with theirhealthcare professional taking into account comorbidity and otherchanged circumstances.b) Proportion of people with COAG, suspected COAG or with OHTat low risk of progressing to visual impairment who have adiscussion of the benefits and risks of stopping treatment.

Quality statement 8 – Service capacity

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. Sufficient capacity is put in place to provide this service, and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed.

Quality measureProcess:a) Proportion of people with COAG, suspected COAG or with OHTwho have access to timely follow-up appointments and specialistinvestigations at appropriate intervals in accordance with NICEguidance.b) Proportion of people with COAG, suspected COAG or withOHT, whose appointment has been cancelled, delayed or missedwho have their clinical priority assessed.

Quality statement 8 – Service capacity cont.

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. Sufficient capacity is put in place to provide this service, and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed.

Quality measureProcess:c) Proportion of people with COAG, suspected COAG or with OHTwhose cancelled, delayed or missed appointment is rescheduledwithin an appropriate time interval.

Quality statement 9 - Documentation

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.

Quality measureProcess:Proportion of people with chronic open angle glaucoma(COAG), suspected COAG or with ocular hypertension (OHT)whose documentation and records are available to healthcareprofessionals at each clinical encounter.

Quality statement 10 - Surgery

People with COAG who are progressing to loss of vision despite treatment or who present with advanced visual loss are offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated and information on the risks and benefits associated with surgery.

Quality measureProcess:a) Proportion of people with COAG who are progressing to loss ofvision despite treatment or who present with advanced visual losswho are offered surgery with pharmacological augmentation (forexample, MMC or 5FU) as indicated.b) Proportion of people with COAG offered surgery because theyare progressing to loss of vision despite treatment or who presentwith advanced visual loss, who receive information on the risksand benefits associated with surgery.

Quality statement 11 - Information

People with COAG, suspected COAG or with OHT are given the opportunity to discuss their diagnosis, prognosis and management, and are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.

Quality measureProcess:Proportion of people with COAG, suspected COAG orwith OHT who are given the opportunity to discuss their diagnosis,prognosis and management and who are provided with relevantand accessible information and advice at initial and subsequentvisits in accordance with NICE guidance.

Quality statement 12 - Discharge

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 a patient-held management plan.

Quality measureProcess:Proportion of people with suspected COAG or with OHTwho are not recommended for treatment and whose condition isconsidered stable who are discharged from formal monitoring with apatient-held management plan.

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