RNIB – supporting people with sight loss
Research briefing
Expanding community eye care for
glaucoma: a pilot Ophthalmic Diagnostic
and Treatment Centre
Author: Helen Lee; Publisher: RNIB; Year of Publication: 2015
Key findings from the evaluation
With the successful implementation of an optometry-led
Ophthalmic Diagnostic and Treatment Centre (ODTC) for
glaucoma:
 Waiting times between appointments were reduced.
 The hospital rescheduled fewer appointments in general
ophthalmology outpatient clinics. Although one in four
appointments at the ODTC were rescheduled adding, on
average, 29 days between appointments.
 Patient satisfaction with the ODTC was almost universal.
The lack of readily available routine data with which to identify
glaucoma patients and their appointment activity presented
challenges to the evaluation of the pilot.
The actual cost of the ODTC pilot was £291.56 per patient seen;
this includes significant staff training costs. Without training costs,
and assuming the ODTC was to operate at full capacity with no
DNAs (did not attend) the cost would be £122.48 per patient.
Background
Glaucoma is the second most common cause of certified sight loss
in the UK. 3,291 people in England and 192 people in Wales aged
over 40 were certified as visually impaired due to glaucoma,
between 1st April 2012 and 31st March 2013 (1). With early
detection and treatment of ocular hypertension and glaucoma
visual field loss can often be prevented or minimized. There is an
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association between people experiencing high rates of
socioeconomic deprivation and presenting in health care settings
with advanced glaucoma (2, 3, 4, 5).
There is increasing demand on ophthalmology departments but
without increasing resource this has led to a serious problem of
lack of capacity. This has resulted in follow-up appointments being
delayed and many incidences of patients not receiving appropriate
treatment in a timely fashion (6). Recent research conducted for
RNIB Cymru found Consultant Ophthalmologists in six Welsh
Health Boards stating that patients are losing their sight due to
excessive waiting times (7).
In 2011 RNIB began work with Cwm Taf Health Board in South
Wales to explore barriers to accessing eye care services and
identify potential interventions to prevent avoidable sight loss.
Public Health Wales conducted an eye health equity profile (8) and
Shared Intelligence undertook qualitative research with service
users and service providers (9). Informed by these pieces of work
it was agreed that RNIB and Cwm Taf Health Board would work in
partnership to pilot a new service for people with ocular
hypertension and ‘stable’ glaucoma. The service is called an
Ophthalmic Diagnostic and Treatment Centre (ODTC).
The development and implementation of ODTCs to help manage
capacity issues within ophthalmology departments and improve the
patient pathway is central to the Welsh Government’s, five year
Eye Health Care Delivery Plan (2013). This pilot project was
designed to gather learning prior to the roll out of ODTCs; to
consider patient flow, assess impact on quality of service, patient
satisfaction, waiting times and attendance at both the ODCT and
consultant led ophthalmology clinics.
Methods
The Ophthalmic Diagnostic and Treatment Centre (ODTC) was
designed to provide a service for people aged over 40 living in a
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particular area of high socioeconomic deprivation within the
Rhondda Valley. The ODTC aimed to:
 Reduce waiting times for the management of people with stable
glaucoma and ocular hypertension.
 Improve patient satisfaction offering a more flexible service
closer to home.
 Improve service uptake and reduce non-attendance at
secondary care glaucoma clinics.
The service was located in a local community hospital and was
originally designed to be led by a specialist nurse managing a
team of technicians, seeing patients with ‘stable’ glaucoma and
ocular hypertension. Patients with ‘stable’ glaucoma refers to those
who, for a period of two years have: experienced no new
symptoms which could be attributable to progressive visual
deterioration (such as a drop in acuity or subjective change of a
paracentral visual field defect); intraocular pressure remaining
below a level satisfactory for the individual patient; no change in
the optic disc appearance; and no significant change in visual field.
Over the period of implementation the service evolved to be
optometry-led, seeing patients with suspect, stable and ‘simple’
glaucoma and ocular hypertension. More information about the
changes in staffing are provided in the process evaluation section
of this briefing. ‘Simple’ glaucoma refers to patients who do not
require consultant care (unlike complex cases) but may not have
been ‘stable’ for two years.
The service was nurse-led from July 2012 to June 2013; in July
2013 it became optometrist led. Evaluation data was collected until
mid November 2014. Cwm Taf Health Board has continued to
fund the ODTC beyond the lifetime of the pilot project.
London School of Hygiene and Tropical Medicine (LSHTM)
conducted independent process, outcome and economic
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evaluation of the pilot. There were five components of the
evaluation:
1. Analysis of routine hospital data
2. Patient satisfaction surveys conducted before and after the
introduction of the new services
3. Follow-up interviews with patients attending the ODTC
4. Process interviews with key people involved in the
development, implementation and delivery of the ODTC
5. A cost consequence analysis.
The evaluation included a comparison group of patients with
‘stable’ or ‘simple’ glaucoma living in the Cynon Valley and using
ophthalmology services in various local hospitals.
The evaluation was granted NHS ethical approval from Bromley
Research Ethics Committee (11/LO/1264) and local Research &
Development (R&D) office approval from Cwm Taf Health Board
(CT/214/80513/11/12).
Findings from analysis of routine data
For baseline data appointment activity of 1,429 patients was
analysed for a minimum of one year prior to the opening of the
ODTC. One third of patients (435/1,429) were from the intervention
area.
For the follow up period, once the ODTC was operating as an
optometry-led, appointment data for 1,412 patients was analysed.
As at baseline nearly a third of patients were from the intervention
site (421/1,421).
At baseline:
 The mean interval between appointments (excluding new
referrals) was 160 days.
 The average waiting time between appointments was
significantly longer for people from the intervention area. People
in the intervention area waited on average 208 days compared
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to those from the comparison site who waited on average 137
days.
 Over one in five follow-up appointments were rescheduled by
the hospital (23%) adding on average 48 days to the interval
between appointments.
 Newly referred patients did not experience rescheduling of
appointments to the same extent as continuing patients, which
may be related to performance targets.
 Only 5% of patients did not attend (DNA) their ophthalmology
outpatient appointment.
At follow up:
 The mean number of days between appointments for patients
from the intervention area reduced 208 days to 126 days for
those seen at the non-ODTC clinics and 111 days for those
seen at the ODTC.
 There was no longer a significant difference in waiting times
between appointments for patients from the intervention and
comparison areas.
 Rescheduling of appointments at non-ODTC clinics was
reduced to 10% (compared to 23% at baseline) adding an
average of 53 days to the interval between appointments.
 However, 25% of appointments were rescheduled for patients
attending the ODTC. On average extending the interval
between appointments by 29 days.
 Only 4.6% of patients did not attend (DNA) at the ODTC clinic
and 3.6% of non-ODTC clinics.
At the same time as the ODTC was established the general
ophthalmology outpatient clinics were reorganised.
The table below summarises this information.
Measure
At baseline
At follow up
Non-ODTC ODTC
clinics
The mean interval
160 days
126 days
111 days
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between
appointments
Appointments
23%
cancelled by the
hospital
Extra days added
48 days
due to hospital
rescheduling
Patient did not attend 5%
(DNA)
10%
25%
53 days
29 days
4%
5%
The lack of readily available routine data with which to identify
glaucoma patients and their appointment activity presented
challenges to the evaluation of the pilot. It is also likely to inhibit
effective service planning. At the outset of the project it was
assumed non attendance by patients (DNAs) was a significant
problem that the ODTC would help to address. Once the
independent evaluators LSHTM had analysed hospital data it
became apparent that DNAs were at such a low level there was
little room for improvement; however hospital initiated cancellation
were a significant problem.
Findings from the patient satisfaction survey
At baseline:
 86 usable questionnaires were completed by glaucoma patients
attending general ophthalmology clinics; 24 were from the
intervention area and 59 from the comparison site.
 66% of patients thought it important to see a doctor.
 48% of patients were shown how to administer their eye drops.
At follow up:
 112 useable questionnaires were completed, 53 from ODTC
and 59 from the general ophthalmology clinic.
 Patients at the ODTC travelled less distance, were less likely to
use a car and incurred less travel costs.
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 Only 26% felt it important to see a doctor compared to 66% at
baseline.
 In response to an open question, patients most commonly
reported that they didn’t mind who they saw as long as
“they know what they are doing”; “are qualified”;
“properly trained”; and “know their job”.
 ODTC patients were younger than those seen elsewhere and a
lower proportion reported co-morbidities.
 Fewer ODTC patients reported being ‘bothered’ by their
treatment.
 50% of ODTC patients reported being shown how to use their
drops and 71% of patients in general ophthalmology clinics
compared to 48% of patients at baseline.
The table below summarises this information.
Measure
At baseline
At follow up
NonODTC
clinics
Usable questionnaires 86
59
Felt it important to see 66%
43%
a doctor
Shown how to
48%
71%
administer eye drops
ODTC
53
26%
50%
Process evaluation
Staffing and tests
Telephone interviews were conducted with six staff members
involved in developing and implementing the ODTC.
It was originally intended that that ODTC in the Rhondda Valley
would be led by a specialist nurse, supported by two Band 3
ophthalmic technicians. The nurse would provide:
 Patients with advice about treatment adherence.
 Visual fields interpretation.
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 Optic disc assessment.
 Stereo-disc photography.
The ophthalmic technicians would conduct:
 Visual acuity (Snellen).
 Visual fields (field of vision).
 Pachymetry (thickness of the cornea).
 Goldmann applanation tonometry (inner eye pressure).
 Pharmacological dilatation of the pupils (shape and appearance
of the optic nerve).
However, a number of challenges emerged with this arrangement.
Most importantly perhaps it was realised that the lead person
needed more diagnostic expertise if the ODTC was to save time
and provide efficiencies.
The rural location of the Rhondda Valley ODTC was found to be
one of the major reasons why a nurse-led model did not prove
suitable. The ODTC was not located close to a specialist
ophthalmology- led clinic, so if any concerns emerged, it was not
possible for staff to easily ask the consultant to assess and advise,
or simply redirect the patient from the ODTC back into the general
clinic, without additional appointments. During the pilot phase the
ODTC was not linked to ophthalmology practitioners electronically.
In the absence of specialist training pathways for nurses in this
field, the development of the necessary expertise relied on learning
through experience ‘on the job’. The lack of sufficiently specialist
skills, combined with the lack of electronic/digital facilities to share
data, necessitated referring patients from the ODTC back into the
hospital system for a second opinion. While this was essential for
the safety and well-being of patients, it undermined one of the
original aims: namely to reduce the necessity for patients to attend
the hospital out-patient clinics.
Therefore a decision was made to appoint two part-time
optometrists in place of the specialist nurse to lead a team of
ophthalmic technicians. In preparation for leading the ODTC the
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optometrists worked alongside the consultant ophthalmologist for
several months. The optometrists competency for seeing patients
within the ODTC was established by competency based
supervised practice, working alongside the consultant
ophthalmologist in his general clinic prior to starting in ODTC.
Once deemed competent, the consultant would review the notes of
the patients seen on a weekly basis. There is no national EPR
available, therefore the consultant would review the notes, visual
fields and 3D images the following day prior to starting his own
clinic. Any discrepancies between findings and decision making
were highlighted to the optometrist. In addition to this, patients
who showed deterioration of their visual field, disc appearance or
control of inter-ocular pressure at the ODTC were booked back
into the consultant led clinic. Therefore review of ODTC findings
also happened as part of the process of clinicians reviewing
patient’s notes prior to seeing a patient. Consultant support was
available for the ODTC provided by non glaucoma consultant led
clinics running alongside the ODTC and specialist Glaucoma
advice was available by telephone from the District General
Hospital. With two optometrists working in the clinic, interoptometry peer support and review was available between staff.
Within the ODTC the optometrists provided advice to patients
about treatment adherence, examined patients, reviewed their
conditions, analysed the results of the tests conducted by
technicians and prescribed, advised, or referred accordingly. If
optometrists noted some concerns, such as the deterioration of a
patient’s condition, but felt these were not major enough to warrant
a referral to the hospital, they could make another appointment
sooner than they would routinely and so keep the patient under
closer review. If, for example, a cataract was detected, the
optometrists could refer the patient directly for an operation without
the patient having to be seen in the ophthalmologist’s clinic first for
a referral to surgery. They also undertook gonioscopy tests (to
assess the angle in the eye where the iris meets the cornea).
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There was not consensus about whether a remotely based ODTC
needs to be led by an optometrist or a specialist nurse but rather a
strong feeling the lead health professional requires specialist
training to ensure they have the necessary insight, experience and
diagnostic skills.
The ODTC enabled patients to have additional tests during a
single visit. Previously patients would have attended a separate
clinic for a visual field test.
Criteria for seeing patients: stable or simple glaucoma
The original intention was that the ODTC would see patients with
stable glaucoma. However it became apparent that in practice this
was not a reliable basis for selection, as any such diagnosis or
conclusion can quickly become out of date. So when the service
became optometry-led the criteria for selecting patients was
revised, from ‘stable’ to ’simple’, meaning that most patients with
glaucoma and OHT in the geographical catchment area aged who
were aged over 40 effectively became eligible.
Patient perspective
In-depth interviews were conducted with twelve patients attending
the ODTC.
Most were unaware of the type of professional they saw, for
example, ‘Mr A’s deputy’, ‘specialist nurse’, ‘a nice young man’.
Patients’ main concern was that the health professional was
someone who ‘knows what they’re doing’.
Patients who had previously attended the Royal Glamorgan
Hospital were asked if they had experienced hospital initiated
cancellation of appointments. Several had, and they described it as
happening frequently and often the rescheduled appointment was
also cancelled. Feelings about this were mixed. Some people did
not see it as a problem if the appointment is quickly rescheduled.
However one patient described being concerned about the high
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pressure in her eyes as she was due to be seen in six months but
ended up waiting twelve months before being seen.
Patients were asked about their experience of time spent with staff
and information provided at the ODTC as compared to the general
ophthalmology clinic. However they were not able to comment on
any differences. It is probable that patients will have to attend
fewer appointments at the ODTC compared to attending
ophthalmology outpatient clinics because visual field tests are
conducted during the one appointment alongside other tests and
examinations.
Economic evaluation
 The actual cost of the ODTC pilot was £291.56 per patient; this
includes significant staff training costs.
 The cost of running an ongoing ODTC service without including
initial staff training costs, assuming 85% capacity and 5% DNAs
would be £186.91.
 If the ODTC was operating at full capacity without training costs
and assuming no DNAs the cost would be £122.48 per patient.
Conclusion
The pilot ODTC in the Rhondda Valley has resulted in reduced
waiting times between appointments for patients. Patient
satisfaction was near universal, and patients from the Rhondda
seen at the ODTC travelled less distance, were less likely to travel
by car and incurred less cost than patients from the intervention
area seen at other clinics. Patients attending the ODTC generally
had to attend fewer appointments compared to those attending
consultant led ophthalmology outpatient clinics. This is because at
the ODTC visual field tests were conducted during the one
appointment alongside other tests and examinations.
The increased capacity that the ODTC provides appears to have
had a positive effect on general ophthalmology clinics in that a
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lower proportion of patients experience hospital initiated
rescheduling of appointments. However rescheduling of
appointments at the ODTC was significant.
Recommendations
1. Disseminate learning from this pilot project across Wales and
the rest of the UK to inform the development of eye care
service delivery, to help increase capacity within glaucoma
clinics and therefore ensure patients’ receive timely
treatment.
2. Our pilot indicated that Ophthalmic Diagnostic and Treatment
Centres (ODTC) can be led by a range of eye health
professionals including ophthalmic nurses or optometrists. It
is however essential these professionals receive specialist
training to ensure they have appropriate expertise and
diagnostic skills.
3. Hospital data about attendance at glaucoma ophthalmology
outpatient clinics improved over the lifetime of the project. It
is essential that detailed, accurate and update information is
available on attendance and outcomes from outpatient
ophthalmology clinics to monitor and evaluate the impact of
services and enable effective service planning.
4. Adherence to treatment for glaucoma and ocular
hypertension can be problematic for patients, changes in
lifestyle, co-morbidities etc effect people’s ability to comply
with treatment regimes. It is therefore recommended that
treatment adherence is routinely discussed with patients in
all glaucoma clinics.
5. It became apparent through this pilot study that hospital
initiated rescheduling of appointments was a significant issue
in both consultant led ophthalmology clinics and the ODTC.
This is problematic for patient care and increases the risk of
patients being ‘lost’ in the system. It is recommended that
examples of good practice are identified where
ophthalmology services have reduced rescheduling of
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appointments and these are shared throughout the UK to
improve patient care.
References
(1) Leamon, S., Davies, M., (2014) Number of adults and
children certified with sight impairment and severe sight
impairment in England and Wales: April 2012 to March 2013.
RNIB
(2) R., Wood, F., (2010) A glaucoma equity profile: correlating
disease distribution with service provision and uptake in a
population in Northern England, UK. Eye 24:1478-85
(3) Fraser, S., Bunce, C., Wormald, R., Brunner, E. (2001)
Deprivation and late presentation of glaucoma: case-control
study. Br Med J 322:639-43
(4) Ng, W.S., Agarwal, P.K., Sidiki, S., McKay, L., Townend, J.,
Azuara-Blanco, A., (2010) The effect of socio-economic
deprivation on severity of glaucoma at presentation. Br J
Ophthalmol 94:85-7
(5) Sukumar, S., Spencer, F., Fenerty, C., Harper, R., Henson,
D., (2009) The influence of socioeconomic and clinical
factors upon the presenting visual field status of patients with
glaucoma. Eye 23:1038-44
(6) National Patient Safety Agency (2009) Rapid Response
Report. Preventing delay to follow up for patients with
glaucoma. NHS National Patient Safety Agency.
(7) Boyce, T., (2014) Real patients coming to real harm.
Ophthalmology services in Wales. RNIB Cymru
(8) Reilly, R., Humphreys, C., (2011) Cwm Taf Eye Health
Equity Profile. Public Health Wales NHS Trust
http://www.wales.nhs.uk/sitesplus/922/page/49905
(accessed 15/7/15)
(9) Richardson, I., (2012) The barriers and enablers that affect
access to primary and secondary eye care services – Cwm
Taf site report. RNIB
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End of document
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