Impact of the Manchester Glaucoma Enhanced Referral Scheme on NHS costs

Objectives: Glaucoma filtering schemes such as the Manchester Glaucoma Enhanced Referral Scheme (GERS) aim to reduce the number of false positive cases referred to Hospital Eye Services. Such schemes can also have wider system benefits, as they may reduce waiting times for other patients. However, previous studies of the cost consequences and wider system benefits of glaucoma filtering schemes are inconclusive. We investigate the cost consequences of the Manchester GERS. Design: Observational study. Methods: A cost analysis from the perspective of the National Health Service (NHS) was conducted using audit data from the Manchester GERS. Results: 2405 patients passed through the Manchester GERS from April 2013 to November 2016. 53.3% were not referred on to Manchester Royal Eye Hospital (MREH). Assuming an average of 2.3 outpatient visits to MREH were avoided for each filtered patient, the scheme saved the NHS approximately £2.76 per patient passing through the scheme. Conclusion: Our results indicate that glaucoma filtering schemes have the potential to reduce false positive referrals and costs to the NHS

Care pathways for glaucoma detection and monitoring in the UK

Glaucoma presents considerable challenges in providing clinically and cost-effective care pathways. While UK population screening is not seen as justifiable, arrangements for case finding have historically been considered relatively ineffective. Detection challenges include an undetected disease burden, whether from populations failing to access services or difficulties in delivering effective case-finding strategies, and a high false positive rate from referrals via traditional case finding pathways. The enhanced General Ophthalmic Service (GOS) in Scotland and locally commissioned glaucoma referral filtering services (GRFS) elsewhere have undoubtedly reduced false positive referrals, and there is emerging evidence of effectiveness of these pathways. At the same time, it is recognised that implementing GRFS does not intrinsically reduce the burden of undetected glaucoma and late presentation, and obvious challenges remain. In terms of diagnosis and monitoring, considerable growth in capacity remains essential, and non-medical health care professional (HCP) co-management and virtual clinics continue to be important solutions in offering requisite capacity. National guidelines, commissioning recommendations, and the Common Clinical Competency Framework have clarified requirements for such services, including recommendations on training and accreditation of HCPs. At the same time, the nature of consultant-delivered care and expectations on the glaucoma specialist's role has evolved alongside these developments. Despite progress in recent decades, given projected capacity requirements, further care pathways innovations appear mandated. While the timeline for implementing potential artificial intelligence innovations in streamlining care pathways is far from established, the glaucoma burden presents an expectation that such developments will need to be at the vanguard of future developments

Clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme

BACKGROUND: Glaucoma referral filtering schemes have operated in the UK for many years. However, there is a paucity of data on the false-negative (FN) rate. This study evaluated the clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme (GERS), estimating both the false-positive (FP) and FN rates. METHOD: Outcome data were collected for patients newly referred through GERS and assessed in 'usual-care' clinics to determine the FP rate (referred patients subsequently discharged at their first visit). For the FN rate, glaucoma suspects deemed not requiring referral following GERS assessment were invited to attend for a 'reference standard' examination including all elements of assessment recommended by National Institute for Health and Care Excellence (NICE) by a glaucoma specialist optometrist. A separate 33 cases comprising randomly selected referred and non-referred cases were reviewed independently by two glaucoma specialist consultant ophthalmologists to validate the reference standard assessment. RESULTS: 1404 patients were evaluated in GERS during the study period; 651 (46.3%) were referred to the Hospital Eye Service (HES) and 753 (53.6%) were discharged. The FP rate in 307 assessable patients referred to the HES was 15.5%. This study reviewed 131 (17.4%) of those patients not referred to the HES through the GERS scheme; 117 (89.3%) were confirmed as not requiring hospital follow-up; 14 (10.7%) required follow-up, including 5 (3.8%) offered treatment. Only one patient (0.8%) in this sample met the GERS referral criteria and was not referred (true FN). There were no cases of missed glaucoma or non-glaucomatous pathology identified within our sample. CONCLUSION: The Manchester GERS is an effective glaucoma filtering scheme with a low FP and FN rate

Adherence to ocular hypotensive therapy: patient health education needs and views on group education

Heather Waterman,1 Lisa Brunton,1 Cecilia Fenerty,2 Jane Mottershead,2 Cliff Richardson,1 Fiona Spencer21School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK; 2Manchester Royal Eye Hospital, Manchester, UKBackground: In this study the authors sought both to understand the health education needs of patients with glaucoma, with particular regard to adherence to glaucoma treatment, and to examine these patients' views of group education.Methods: Using a health promotion approach to health education, 27 qualitative interviews with new and established patients receiving glaucoma treatment were conducted. Health promotion is defined as a way of strengthening people's capacities to control and optimize their own health. The interviews were transcribed and were then analyzed thematically.Results: Nine categories of health education needs were identified from the transcripts: (1) to understand glaucoma; (2) to understand their diagnosis or understand the difficulties in giving a diagnosis; (3) to understand the implications of eye drops, their side effects, and how to renew the eye drops; (4) to feel confident to put in eye drops; (5) to put the condition into perspective – to know how to manage their risk; (6) to be able to ask questions of clinicians; (7) to be able to navigate the health care system; (8) to understand and be able to manage own adherence behavior; and (9) to know where to access other sources of information. The majority of patients had something positive to say about group education, and about half of the patients said they would attend group education if they were offered the opportunity.Conclusion: A health promotion approach identified a wide range of patient-centered health education needs regarding adherence to glaucoma treatment. Group education will be attractive to some patients. Clinicians could use the health education needs identified in this study to guide the development of either individual or group-based educational intervention to improve adherence to glaucoma treatment. However, clinicians need to be aware that when developing a group intervention, attention will need to be given to making the education relevant to the circumstances of each patient.Keywords: glaucoma, patient compliance, treatment compliance, therapy adherence, action researc

A study to assess the feasibility of undertaking a randomized controlled trial of adherence with eye drops in glaucoma patients

Cliff Richardson,1 Lisa Brunton,1 Nicola Olleveant,1 David B Henson,1 Mark Pilling,1 Jane Mottershead,2 Cecilia H Fenerty,2 Anne Fiona Spencer,2 Heather Waterman1 1School of Nursing, Midwifery and Social Work, University of Manchester, 2Royal Manchester Eye Hospital, Central Manchester Foundation Trust, Manchester, United Kingdom Background: Adherence with therapy could influence the progression of glaucoma and ultimately affect the onset of visual impairment in some individuals. This feasibility study evaluated the measures to be used for a future randomized controlled trial assessing the effects of group-based education on adherence with eye drops. Methods: People diagnosed with glaucoma within the previous 12 months attending a regional ophthalmology clinic in the North West of England were recruited. A two-session education program delivered one week apart had been devised as part of a previous project. A combined adult learning and health needs approach to education was taken. Outcomes measured were knowledge of glaucoma, self-report of adherence, illness perception, beliefs about medicines, patient enablement, and general health (Short Form-12). Adherence was also measured objectively using a Medical Events Monitoring System device. Results: Twenty-six participants consented to undertake the educational program and 19 produced analyzable data. Knowledge of glaucoma, illness perception, beliefs about medicine, and patient enablement all showed statistically significant improvements after education. Mean adherence with eye drops was maintained above 85% before and for 3 months after attendance at the educational program. Self-report exaggerated adherence by at least 10% when compared with the objective Medical Events Monitoring System data, and in fact the kappa agreement was zero. Conclusion: All questionnaires other than the Short Form-12 were considered to be valuable measures and use of a Medical Events Monitoring System device was considered to be an objective surrogate measure for adherence with eye drops. A multicenter, randomized, controlled equivalence trial of group versus individualized education using adherence as the primary outcome is the next step. Keywords: group-based education, glaucoma, adherence, patient complianc