Ординатура / Офтальмология / Английские материалы / Glaucoma Identification and Co-management_Edgar, Rudnicka_2007

they alone are able to perform, such as surgical procedures and the management of outpatients with more complex problems.

■Many optometrists would like to become involved in secondary healthcare. As routine examiners of the visual field, intraocular pressure (IOP) and optic discs, optometrists are familiar with the procedures fundamental to glaucoma follow-up. Therefore, many optometrists wish to see their role expand beyond pure ‘casefinding’ into areas such as the monitoring of POAG.9,10

■Other professionals, such as orthoptists and nursing staff, the traditional outpatient support staff, would also like to increase their clinical roles.

■The College of Optometrists launched a series of postgraduate diplomas for College registered optometrists in 1999. These qualifications provide accreditation of those with specialist background knowledge and skills appropriate for co-management. The original syllabus included a single certificate in glaucoma contributing towards the diploma in ocular conditions. A second glaucoma certificate was added in 2004, with emphasis on glaucoma monitoring. Optometrists with both certificates receive a diploma in glaucoma.

13.2.3 CARE ENVIRONMENT

■Modern NHS design makes co-management/ shared care logistics relatively easy. The pur- chaser–provider climate developed within the NHS in the 1990s popularised the concept of ‘units’ of care. For example, it is commonplace for a primary care trust to buy a number of glaucoma outpatient visits at a specified NHS trust hospital on behalf of the GPs they represent. Such a system is easily applied to the purchase of services by care providers other than NHS trusts, such as glaucoma follow-up visits carried out by optometrists. If optometrists are recognised as providers of this care by the relevant professional bodies and an appropriate fee for each ‘unit’ can be agreed, there appears to be no logistical reason to prevent optometric involvement. Some optometrists already have

‘provider-codes’ allowing them to contract their services for specified tasks.

■NHS restructuring may prioritise comanagement. As strategic health authorities and primary care trusts evolve they are becoming more interested in the primary care professions and are developing primary care services, including optometric involvement in comanagement schemes. As a result, the policy of always purchasing services, e.g. glaucoma follow-up appointments, from hospitals may be relaxed, encouraging the purchase of care from local providers such as accredited optometrists.

■NHS sight test availability may be extended to further high-risk groups. Depending upon current government policy, the availability of ‘free’ sight tests to those at high risk, for example black people, will inevitably affect the number of referrals for suspected POAG, because more people will have an eye examination if they do not have to pay for it. The number of referrals for suspected glaucoma dropped dramatically (by around 16%) when the universal NHS sight test was removed in 1989, and it is likely that numbers rose with subsequent partial reintroduction (for those over 60 years) in 1999.

■NHS financial constraints make increases in the number of ophthalmologists working in the HES unlikely. The increased burden on the HES caused by POAG could be reduced by increasing the number of ophthalmologists. However, this is likely to be prohibitively expensive, and ophthalmology training levels may not be able to meet demand for staff.

13.3CO-MANAGEMENT: SOLUTION TO THE PROBLEM?

A successful co-management scheme should benefit each patient by maintaining or improving the accessibility and/or quality of care,11 and several possible models for the scheme could be adopted.

One model is to use non-ophthalmologists within the HES. Optometrists’ knowledge and skill in detection of glaucoma places them in a strong position to fulfil this role. This approach has the

benefit of allowing direct multidisciplinary contact and so may be a viable option. Although this model may work well in some hospitals, others simply do not have the physical space to accommodate extra clinicians, nor are there sufficient optometrists working within the NHS. This suggests a second model, using optometrists in a community-based environment, either alongside GPs or in their own practices. The latter option seems to be preferable since it utilises existing instrumentation and provides services close to where patients live.

13.3.1 TYPES OF CO-MANAGEMENT/ SHARED CARE SCHEME

There are several models of glaucoma co-manage- ment, in which the role and responsibilities of the optometrist can differ significantly.12,13 One constant factor in all the current models is that, as stated by the Royal College of Ophthalmologists, the ultimate responsibility for the patient rests with the ophthalmologist.11 Three main types of scheme can be identified as shown below.

Parallel care

■All tests are performed by the optometrist.

■Results are passed to the ophthalmologist for treatment decisions.

■All responsibility lies with the ophthalmologist, but they do not need to be in attendance when the tests are performed.

■Works well in community-based or hospitalbased practice.

Co-managed or managed care

■The optometrist must decide whether the patient’s condition is stable or progressive.

■The optometrist’s decision is based on a protocol.

■The optometrist’s responsibility has been described as ‘direct’ but not ‘ultimate’.

■Ideally suited to community optometric practice.

True shared care

■Typically the optometrist works in the HES outpatient clinics with the ophthalmologist.

■The optometrist takes the decision-making role for the management of the patient.

■The ophthalmologist should be freely available for consultation with the optometrist.

■The optometrist must be familiar with ophthalmologists’ practice and typically works to a protocol.

■The optometrist’s role closely resembles that of an ophthalmological clinical assistant.

If there is proof that optometrists can be successful in monitoring disease, this may prompt future expansion of the optometric role within comanagement schemes. Since the boundaries of the issues of responsibility remain the subject of some debate, it would seem sensible for optometrists to ensure that they have appropriate indemnity before joining a co-management scheme. Information on, and clarification of the issues concerning indemnity are available from the Association of Optometrists’ website (http://www.assocoptometrists.org).

13.4 THE TRIPARTITE DOCUMENT:

A FRAMEWORK FOR SHARED CARE

Guidelines for the initiation of comanagement/shared care schemes resulted from constructive negotiations between the Royal College of Ophthalmologists, The Royal College of General Practitioners and the College of Optometrists. In January 1996, these three parties published a set of general guidelines for the clinician about to enter shared care.11 They provide an outline of the requirements of schemes and how they should be designed. A summary of the important points within these Tripartite documents follows. The reader is also referred to the documents themselves.

13.4.1 GENERAL FRAMEWORK

Participation in co-management/ shared care schemes

Participation should be by named individuals, not practices.

Funding

Funding for schemes comes from the commissioners of the service, who are usually the primary care trust or its equivalent. Local contracts could be established with individual optometrists to provide designated services.

Local organisation

Schemes arising from the enthusiasm of local professionals should, upon reaching formal discussions, develop a local framework, for example a committee representing participating professions, and a point of contact. All potential participants should be consulted and the final scheme should be acceptable to all. Consultation and representation on management committees should extend beyond the eye care professions and involve administrative funding bodies and patient interest groups. Local optometric committees (LOCs) are the usual forum for local discussion among optometrists, and LOCs can play a key role in the design and management of co-management schemes.

Protocols

A description of the local co-management/shared care service, including aims and objectives, should be produced. Procedures, rules and instructions should be agreed upon, clearly stated and adhered to at all times. A formal protocol of precise clinical requirements and specified clinical responsibility at each point within the scheme should be clearly stated.

Training

Further and continuing education will be required to ensure all participants are up-to-date with modern concepts regarding the disease process, its management, and relevant clinical techniques. Arrangements for the training of participants should be incorporated into the protocol.

Review and audit

Mechanisms should exist to review objectively the efficiency and effectiveness of the scheme, and these can be used to identify educational needs.

13.4.2 FRAMEWORK FOR PATIENTS WITH STABLE GLAUCOMA AND OCULAR HYPERTENSION

1.Suitable patients. A patient’s condition should be stable with unchanged treatment for 2 years.

2.Equipment standardisation. High quality, standardised equipment is imperative. All participants should agree upon standards so results are reproducible between the HES and the optometric co-management practitioner (see Table 13.1).

3.Training. Participating optometrists should be trained to an agreed standard. Some of this may be provided within local HES clinics under supervision by the consultant ophthalmologist who may then assess the standards reached by all participants.

Table 13.1 Details of equipment

standardisation*

* After Tripartite Document.11

4.Communication. Full reports should be sent from the ophthalmologist to the GP and comanagement optometrist upon the entry of a patient into a co-management scheme. Both the GP and ophthalmologist should be informed of the results at each patient visit. This information should include details of new symptoms, compliance with treatment and clinical results.

5.Follow-up. Co-management assessments may take place at 6, 9 or 12 months, tailored to each patient, and the facility for ophthalmological review every 2 years should be considered.

6.Re-referral. Any signs of glaucomatous progression should produce re-referral to the ophthalmologist. Such signs include symptoms attributable to significant visual loss, IOP greater than the patient’s agreed target pressure, deterioration of the visual field or change in the appearance of the optic disc.

13.5VALIDATION

13.5.1 BRISTOL SHARED CARE GLAUCOMA STUDY

Because shared care represents a departure from routine clinical practice, it is important to ensure that it is validated, and explicitly provides a quality of care that is at least of equal standard to current practice patterns. In the context of glaucoma comanagement, robust evidence for this and other aspects of co-management is available from a randomised controlled trial, the Bristol Shared Care Glaucoma Study.13–19 This prospective investigation assessed community-based optometric managed care. The study revealed that around 23% of individuals passing through HES glaucoma clinics (around 6% of the total outpatient load) were eligible for optometric co-management according to defined recruitment criteria (Table 13.2). At each 6-monthly co-management followup appointment, around 20% of patients within the scheme were re-referred, following comparison of test results with baseline data (see Table 13.3 for criteria), for suspected glaucomatous instability. Four key aspects critical to the success of co-man- agement were investigated.

Table 13.2 Bristol Shared Care Glaucoma

Study recruitment criteria*

* After Spencer et al.14

Measurement reliability

For applanation tonometry, binocular indirect ophthalmoscopic optic disc assessment, and Henson 132-point threshold-related suprathreshold visual field analysis, measurements made by glaucoma-trained optometrists were found to be as reliable and valid as those made within the traditional HES outpatient environment.16,17

Equality of outcomes

Over a 2-year longitudinal follow-up period, there were no marked or statistically significant differences in clinical outcomes (measures of the visual field, cup-to-disc ratio or IOP) between patients followed up in the hospital eye service or by community optometrists.18

Patient satisfaction

Information was collected on the time patients spent at appointments, their travelling costs and their perception of service quality. This revealed that patients were significantly more satisfied with

Increase in number of points missed at any suprathreshold increment by ≥ 4 (mean increase of two tests)†

a number of aspects of care provided by community optometrists compared with the HES. This was particularly evident for waiting times, where periods of at least 30 minutes were exceeded in 50% of HES attendances compared with only 1% for optometric practice.16

been achieved. Validation for individual schemes may be gained using the audit process. Audit of scheme structures (e.g. equipment, training) and processes (e.g. all patients seen, follow-up intervals) may be beneficial early in the course of the scheme, with regular clinical audit to monitor decision-making thereafter.

Cost analysis

Objective determination of the costs of hospital and optometric practice is complex: a simple comparison is inappropriate. A full discussion of this issue is beyond the scope of this chapter and for a detailed discussion the reader is referred to Coast et al.15 This paper is the only available detailed cost analysis of a co-managed scheme for glaucoma. Briefly, a variety of different approaches to cost analysis reveal that with an optometrist performing all investigations, community optometric co-man- agement is unlikely to be the least expensive option. For equal (6-month) follow-up intervals, annual cost per patient (1994 prices) for optometric monitoring varied from £68.98 to £108.98 compared with £24.16 to £99.92 for the HES.13,15 It should be stressed that these are actual costs and do not represent a recommendation for a service fee. Delegation to non-optometrically qualified staff of certain tasks may considerably reduce these figures for optometric monitoring, enhancing optometric competitiveness.

Although the Bristol Study therefore provides evidence that supports the feasibility of glaucoma co-management, the success of local schemes depends upon their validation, which should also demonstrate that a satisfactory care standard has

13.6 SOME EXAMPLES OF CO-

MANAGEMENT/SHARED CARE SCHEMES

The following examples of schemes describe different approaches to co-management/shared care, each of which is tailored to the requirements of the area in which it operates.

13.6.1 GLASGOW REVIEW CLINIC

This model of parallel care is based within the HES, uses existing optometric staff and facilities, and stratifies patients by risk. In the Glasgow Review Clinic, patients referred for ophthalmological assessment and found to be at low risk of developing glaucoma were discharged, whereas those requiring close supervision but not warranting ophthalmologist attention were placed within the shared care review clinic, being seen at 6–12 month intervals. This group of patients included both patients with POAG and those suspected of having glaucoma. A standard test protocol was used, including questions about compliance with treatment. Re-referral to the ophthalmology clinic was available if indicated, otherwise patient notes were reviewed annually by their consultant.

The results of an audit at 3 years showed that 50% of patients in the review clinic had POAG, 30% were suspected of having glaucoma with the remainder having angle closure or other types of glaucoma. Over 50% of attendees were on treatment. Over a 2-year period, the re-referral rate was 41%, although around half of these were classified as being over-cautious and were not confirmed as cases of instability.

The benefits of this scheme include the minimisation of the logistical problems of personnel, training, equipment and assessment standardisation. Interdisciplinary communication and patient follow-up are readily organised, even in the event of non-attendance. A major disadvantage is the administrative burden borne by the ophthalmologist in the annual assessment of case notes.

13.6.2 BRISTOL EYE HOSPITAL SHARED CARE DEPARTMENT

This model represents an example of true shared care. This clinical service development demonstrated a commitment to shared care as an accepted method of glaucoma care provision by establishment of an independent hospital department in 2000. Optometrists in the Shared Care Department are trained by formalised apprenticeship, using an ‘in-house’ training period spent gaining hands-on experience with glaucoma subspecialist consultants. Completion of training is assessed by comparison of a number of clinical measures and decisions. Trained ‘shared care practitioners’ work alongside consultant ophthalmologists in both new and follow-up outpatient glaucoma patient clinics. Practitioners have a high degree of autonomy, making all test-appropriate clinical measurements and taking clinical decisions regarding glaucoma status for follow-up patients, and discussing any uncertainties and treatment intervention requirements with the consultants. For new patients, practitioners make all baseline test measurements and make a provisional diagnosis and treatment suggestion, overseen on a case-by-case basis by the consultant.

At the present time, in excess of two-thirds of glaucoma follow-up in Bristol is performed by optometrists. Because of the need to seek approval

for all treatment changes, limited prescribing status has been obtained for specified anti-glaucoma medications using a Patient Group Direction NHS procedure.

13.6.3 COMMUNITY BASED COMANAGEMENT SCHEMES

Schemes have been established in many areas, including Bradford, Burton, Humberside, Hull, South Staffordshire and West Kent. All follow the frameworks given in section 13.4, though each scheme has its local variations. Details of all these schemes are available on the Association of Optometrists (AOP) website. On its website the AOP has provided an excellent resource on comanaged care for the optometric profession, with sections on ‘Getting involved in co-management’, ‘Contracts, indemnity and fees’, schemes for the management of glaucoma, cataract, diabetes, etc. A copy of the joint AOP, College of Optometrists and Federation of Ophthalmic and Dispensing Opticians (FODO) document ‘Guidance on Transparency in Co-Management’ is available on this site, and tackles important clinical governance issues, notably ensuring that there is fairness and transparency in how schemes are established and how participating optometrists are selected.20

13.7 SUMMARY

Co-management is an exciting response to a variety of factors generating optometric involvement in aspects of secondary care of chronic eye disease. It is likely that participation in a scheme will play an increasing part in the workload of optometrists who elect to become involved. The new and interesting nature of the responsibilities co-management entails will increase and diversify optometrists’ clinical abilities and role. Considerable information about initiating and designing a scheme is available in the form of the tripartite guidelines and from existing examples of comanagement/shared care schemes. These should provide the potential participant with a framework for a scheme which may be tailored to meet the

demands unique to their area. Development of optometric anti-glaucoma medication prescribing either within NHS Trusts or more widely may further extend the scope of co-management/ shared care schemes.

Acknowledgements

The author extends thanks to Mr JF GiltrowTyler, MCOptom, and Mr JM Sparrow, FRCOphth, for their valuable input to this manuscript.

1.NHS Executive. Integrating Primary and Secondary Healthcare. London: National Health Service; 1991.

2.Sparrow JM (chairman), Spry PGD, Murdoch I. Shared Care Debate. Royal College of Ophthalmologists Annual Congress, Birmingham, England, 2003.

3.Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol 2002; 120:714–20; discussion 829–830.

4.Gordon MO, Kass MA. The Ocular Hypertension Treatment Study: design and baseline description of the participants. Arch Ophthalmol 1999; 117:573–583.

5.AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS): 1. Study design and methods and baseline characteristics of study patients. Control Clin Trials 1994; 15:299–325.

6.AGIS Investigators. The advanced glaucoma intervention study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration. Am J Ophthalmol 2000; 130:429–440.

7.Musch DC, Lichter PR, Guire KE, et al. The Collaborative Initial Glaucoma Treatment Study: study design, methods, and baseline characteristics of enrolled patients. Ophthalmology 1999; 106:653–662.

8.Hicks NR, Baker IA. General practitioner views of options of health services available to their patients. Br Med J 1985; 302:991–993.

9.Various authors. Shared care in glaucoma and ocular hypertension. Highlights of a national conference held at Coombe Abbey, Binley, June 1996. Kingston-upon-Thames: Medicom (UK) Publ Ltd; 1996.

10.Giltrow-Tyler F. Sharing the responsibility. Optician 1993; 206:15–17.

11.Royal College of Ophthalmologists, Royal College of General Practitioners, College of Optometrists. Shared care for patients with stable glaucoma and ocular hypertension. General framework for shared care schemes. London: Royal College of Ophthalmologists; 1996.

12.Giltrow-Tyler F. Shared care. Optometry Today 1996: 26–30.

13.Spencer IC, Coast J, Spry PG, et al. The cost of monitoring glaucoma patients by community optometrists. Ophthalmic Physiol Opt 1995; 15:383–386.

14.Spencer IC, Spry PG, Gray SF, et al. The Bristol Shared Care Glaucoma Study: study design. Ophthalmic Physiol Opt 1995; 15:391–394.

15.Coast J, Spencer IC, Smith L, et al. Comparing the costs of monitoring glaucoma patients: hospital ophthalmologists versus community optometrists. J Health Serv Res Policy 1997; 2:9–25.

16.Gray SF, Spencer IC, Spry PG, et al. The Bristol Shared Care Glaucoma Study – validity of measurements and patient satisfaction. J Public Health Med 1997; 19:431–436.

17.Spry PGD, Spencer IC, Sparrow JM, et al. The Bristol Shared Care Glaucoma Study: reliability of community optometric and hospital eye service test measures. Br J Ophthalmol 1999; 83:707–712.

18.Gray SF, Spry PG, Brookes ST, et al. The Bristol shared care glaucoma study: outcome at follow up at 2 years. Br J Ophthalmol 2000; 84:456–463.

19.Spry PGD, Sparrow JM. Can optometrists monitor glaucoma? A review of the Bristol shared care glaucoma study. Optometry Pract 2001;

2:47–56.

20.Association of Optometrists, College of Optometrists, and Federation of Ophthalmic and Dispensing Opticians. Guidance on Transparency in Co-Management. 2004. Available at: www. assoc-optometrists.org

acetazolamide 149, 156 costs 158

history 154

and ocular blood flow 163 acetylcholine 138, 139

acute angle closure glaucoma 39 adrenaline

adverse effects 156

in aqueous drainage 24

and aqueous humour dynamics 146 dosage/time of action 147 receptor activity 146

adrenergic antagonists (sympatholytics) 149

adrenergic receptors 140 adrenoceptor (adrenergic) agonists

(sympathomimetic agonists) 146–8

action 146 adverse effects 147

dosage/time of action 147 drug interactions 147 glaucoma management 146 history 154

IOP reduction 141 receptor activity 146

Advanced Glaucoma Intervention Study (AGIS) 10, 107, 112

adverse effects 156–7

see also specific drugs/classes of drug age

and IOP fluctuations 110 in POAG

prevalence 4, 5 as risk factor 7

alcohol consumption in IOP 110

as POAG risk factor 8 α-agonists 154

action 147 pharmacological 148

adverse effects 147

and aqueous secretion 21 drug interactions 148 glaucoma management 148 IOP reduction 141

Alphagan 158, 159 α-receptors 139, 140

ocular 141 Alzheimer’s disease 10

American Optical tonometer 114 anatomical recording system 52 anatomy

anterior chamber 18

aqueous humour drainage 22–4 canal of Schlemm 22–4

ciliary body 19–20 gonioscopic

ciliary body 47 iris root 47

Schwalbe’s line 46–7 scleral spur 47 trabecular meshwork 47

angle classification systems 50–2 angle closure glaucoma 2

anatomical predisposition 18 causes 177

gonioscopy indications 38–9 management 153

treatment options 177 angle closure PAS 48 angle neovascularisation 48 angle recession 48

anterior chamber anatomy 18

angle evaluation see gonioscopy applanation tonometry 113–16

Goldmann 113–14, 115 non-contact tonometry 114–15 regression towards mean effect

115–16 apraclonidine 148, 172

aqueous collector channels 21 aqueous humour 17–26

composition 18 drainage 21–5

conventional pathway 18, 21–5

anatomy 22–3

canal of Schlemm 23–4 schematic representation 24

in glaucoma 24–5

regulation 24

uveoscleral pathway 18, 24 dynamics 18

outflow 140, 143 production 18–21

mechanism 20–1 rates 17–18

determination 17 regulation 21, 143

protein in 18 aqueous veins 21, 23–4 arcuate defects

with chorioretinal lesions 58 in early glaucoma 79

on Henson Pro 5000 60, 61 in open angle glaucoma 57

argon laser trabeculoplasty 172 argon lasers 177

arterial circle of Zinn and Haller 30 arterial pulse 108–9

arterial supply to ONH 30 artificial neural networks (ANNs)

102–3

astrocyte dysfunction 32 autoimmune reactions 6 autonomic nervous system 137

neurohumoral transmitters 138–9 neurotransmission 137

schematic of 139 receptors 139–41

ocular 141

autoregulation of blood supply 30 axon transport in glaucoma 32 Azopt 149, 156, 158

Baltimore Eye Study 4, 5, 6, 7 Barbados Eye Study 4, 5, 7 bayonetting 126

β-adrenergic system 21

β-blockers (β-adrenoceptor antagonists) 141–4

action 141–3 pharmacological 143

adverse effects 142, 143–4, 156 and aqueous secretion 21 differences in activities 142–3