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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.