Download Nick Sheen - Health in Wales

Evaluation of the Primary Eyecare
Acute Referral Scheme (PEARS) and
the Welsh Eye Health Examination
(WEHE).
EXECUTIVE SUMMARY OF A REPORT COMMISSIONED BY
THE WELSH ASSEMBLY GOVERNMENT
Dr NJL Sheen Lecturer in the School of Optometry and Vision Sciences, Cardiff University
Prof D Fone Professor of Health Sciences Research, Department of Primary Care
and Public Health, School of Medicine, Cardiff University
Prof CJ Phillips Professor of Health Economics, Swansea University
Mr JM Sparrow Consultant Ophthalmologist, Bristol Eye Hospital
Dr JS Pointer Optometrist in practice, Northamptonshire
Prof JM Wild Professor in the School of Optometry and Vision Sciences, Cardiff University
INTRODUCTION
The Primary Eyecare Acute Referral Scheme (PEARS) and the Welsh Eye Health
Examination (WEHE) schemes are part of an all encompassing Welsh Eye Care
Initiative (WECI). The PEARS and WEHE schemes are intended, respectively, to
facilitate the early assessment of acute ocular conditions and to case-find ocular
disease in at-risk individuals. Both types of eye examinations are undertaken by
PEARS/WEHE accredited optometrists. To be accredited for the PEARS and WEHE
schemes, optometrists must pass a theoretical module and pass a practical
component.
The aim of PEARS is to maintain as many patients as possible in the primary care
setting, thus avoiding unnecessary referrals to the Hospital Eye Service (HES).
The WEHE is intended to facilitate the detection of eye disease in the early stages,
before significant visual loss occurs, thereby reducing the burden on the HES and
other health care sectors.
PRIMARY OBJECTIVES
The primary objectives for the evaluation of the PEARS and WEHE schemes were:
•
To determine the number of PEARS and WEHE patients examined by
accredited optometrists.
•
To determine the number of PEARS and WEHE patients managed and
referred by accredited optometrists.
•
To determine if the patient management decisions by accredited optometrists
were reasonable to ophthalmology, based upon the information available to the
optometrist.
•
To determine if the diagnoses of the eye conditions referred to the HES by
accredited optometrists were reasonable to ophthalmology, based upon the
information available to the optometrist.
•
To determine the distribution of accredited optometrists and the geographical
equity of access to them.
•
To determine if patients who have received a PEARS and WEHE eye examination
are satisfied with the service provided by the accredited optometrist.
•
To assess the economic impact of the PEARS and WEHE schemes.
SECONDARY OBJECTIVES
The secondary objectives for the evaluation of the PEARS and WEHE schemes were:
•
To determine which symptoms and signs were referred to the HES by accredited
optometrists.
•
To determine the number and types of eye conditions referred by accredited
optometrists.
•
To determine the socio-economic background of patients attending for a PEARS or
WEHE examination.
METHODOLOGY
Examination findings were recorded by participating optometrists on a standardised
paper or electronic record card designed for the evaluation. The record card was
manually entered onto a password-protected and encrypted custom-designed Access
database. The record card was used to provide comprehensive data on the patient
history, the eye examination findings, the outcome of examination and postcode data.
6432 successive record cards (from 274 optometrists) were utilised during the period
of the evaluation (from 04/04/06 to 21/12/06). 76% of the 6432 cases were for the
PEARS scheme and 24% were for the WEHE. The mean age of patients was 57.2 years
(SD 18.6).
289 randomly selected patients from the 6432 patients underwent a telephone
interview within one week of attending an accredited optometrist. Of these 289 patients,
119 (41%) exhibited persisting symptoms and therefore received a further telephone
interview approximately one month later.
The hospital notes of patients seen by participating optometrists and subsequently
referred to the hospital eye service were used to extract required data. The notes of
392 available consecutive referrals during a four month period between August and
December 2006 were requested from 11 main HES departments in Wales. An
evaluation panel determined if the optometric management and diagnosis of
patients both referred to the hospital eye service and maintained in practice were
appropriate. The panel consisted of the authors and if there was uncertainty the
ophthalmologist was the final arbiter in the decision making process.
SPECIFIC OUTCOMES
Optometric aspects
Referral route to the optometrist
1576 (24.5%) of all referrals to the PEARS and WEHE were from the General
Practitioner (GP). A further 3692 (57.4%) of patients were self-referred.
589 patients (9.2%) were eligible for a WEHE because of a risk of eye disease by
reasons of race or family history. Only in 19 (0.3%) cases were patients eligible for a
WEHE due to ‘race’ alone.
The remaining 556 (8.6%) patients were eligible for a WEHE due to deafness, uniocularity, retinitis pigmentosa, a sibling of a patient with inherited eye disease or referral
from the Diabetic Retinopathy Screening Service of Wales.
Optometric management
Out of the 6432 patients presenting for a PEARS or WEHE examination, 4243 (66%)
were managed by optometrists (i.e. not referred to the HES or GP).
1171 (18%) patients were referred to the HES following examination by an accredited
optometrist.
The remaining 16% (1018) of patients were referred to the GP.
The majority of patients referred by the GP to PEARS and WEHE accredited optometrists
were managed within optometric practice or discharged at the first visit, 9 4 0 ( 6 0 % ) .
Inappropriate management of patients not referred by the optometrist
3 (1%) of 289 patients interviewed by telephone, that had been either discharged by their
optometrist or managed by their optometrist, were deemed to have been inappropriately
managed by the panel.
Number of referrals to HES with suspect glaucoma
129 patients were referred to the HES with suspected glaucoma (2.4% of the PEARS
and WEHE patients over 40 years of age).
Hospital Eye Service (HES) aspects
1171 (18%) of the 6423 patients were referred to the HES. The hospital notes of 392
patients were perused to establish the outcome of these referrals.
Symptoms of patients referred to the HES
Of the 392 patients, the most common presenting symptoms resulting in referral to
the HES were uni-ocular irritated/painful red eye (62 cases, 16%), and flashes and
floaters without visual loss (50 cases, 13%).
Optometric management resulting in referral to the HES
84 (79%) of referrals to the HES were retained in the HES and not discharged at the
first visit. 295 (75%) of the 392 management decisions were deemed to be
appropriate. 49 (51%) of the 97 inappropriate management decisions were due to
posterior vitreous detachment (PVD). Due to local protocols in some areas of
Wales, optometrists are advised by local ophthalmologists to refer all cases of PVD.
Optometric diagnosis resulting in referral to the HES
284 (72%) of the 392 conditions were deemed to be correctly diagnosed.
Corneal disorders (16%) were the most common reason for referral, followed by
optic nerve head disorders (including glaucoma) (16%), vitreous (15%), macular
(12%), other retina (12%) and lens (11%) disorders.
Uncomplicated PVD accounted for 13% of the total number of sampled referrals seen
by ophthalmologists.
Asymptomatic patients referred to the HES
41 patients referred to the HES were asymptomatic. Of these, 33 were retained
within the HES and 8 patients were discharged. Of the 33 patients, 23 (6% of
referrals assessed) had been referred with suspected glaucoma; of these, the
majority (19 cases) were retained within the HES.
Patient aspects
Patient satisfaction with the service
Of the 289 patients interviewed by telephone within one week of their PEARS or WEHE
examination, 94.8% were “very satisfied” and 5.2% “fairly satisfied” with the optometric
service.
The level of satisfaction was independent of deprivation (Welsh Index Multiple
Deprivation, WIMD classification), age, gender, occupational status (NSSEC3
classification), and whether the patient normally paid for an eye examination.
Travel to the optometrist
Of the 289 patients interviewed by telephone, the mean journey time to the optometrist
was 13.0 minutes (SD 11.0). Most patients (66%) travelled by car to reach their
optometrist.
Based upon the postcodes of the 6432 patients, 87.3% had to travel less than 5 miles to
a PEARS/WEHE accredited optometrist. In Mid and West Wales, combined, this
proportion was 78.6%. In areas with the sparsest populations (defined by ONS Census
2001), such as Powys and Ceredigion, the average distance travelled to a
PEARS/WEHE accredited optometrist was 6.1 and 5.8 miles, respectively.
Across all of Wales, 84.9% of patients travelled less than 10 minutes to reach a
PEARS/WEHE accredited optometrist. In Mid and West Wales the proportion was 74.9%.
Patients residing in the most deprived areas (determined by Townsend fifth of
deprivation) did not have to travel any further to a PEARS/WEHE accredited optometrist
than those living in the least deprived areas.
Cost implications
The model for the costing of the PEARS/WEHE scheme was based upon: (a) the
PEARS/WEHE fees to optometrists incurred for the 6432 cases; (b) the
assumption that the 3692 self-referring patients into the PEARS did not consult a GP prior
to self-referral (GP consultation costed at £22.00); (c) the 1576 PEARS patients managed
within optometric practice (thereby saving HES consultations costed at £69.80 per
outpatient consultation, not including procedures); and (d) the costs of inappropriate
optometric management (ranging between £27,853 and £19,823, depending upon the
scenario).
The calculated total expenditure was approximately £244,000 and the resource utilisation
avoided (i.e. the savings on unnecessary HES and GP consultations) was approximately
£191,000. The net cost of the 6423 WEHE/PEARS examinations over the eight month
period of the Evaluation was therefore approximately £77,000, or a cost of approximately
£12 per PEARS/WEHE examination.
CONCLUSIONS
The evaluation showed that PEARS/WEHE accredited optometrists managed the majority
of patients and made acceptable clinical judgements in their management.
Adjustments in training and the setting of protocols for specific eye conditions could
potentially enhance the clinical decision making by optometrists and decrease referrals to
the HES.
PEARS and WEHE examinations provided high levels of patient satisfaction. Patient equity
of access to the service was good within all geographic areas of Wales.
The cost of the PEARS and WEHE examinations is relatively low when the clinical benefits,
coupled with the ease of patient accessibility to these schemes, are considered.