Patient Referral Pathways Michael Austin Consultant Ophthalmologist, ABMU Health Board Rachel Whitehall Assistant Director of Planned Care, NHS Wales
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