The Bristol shared care glaucoma study: outcome at follow up at 2 years

Abstract

Aim-To examine the outcome of care for patients with glaucoma followed up by the hospital eye service compared with those followed up by community optometrists. Methods-A randomised study with patients allocated to follow up by the hospital eye service or community optometrists was carried out in the former county of Avon in south west England. 403 patients with established or suspected primary open angle glaucoma attending Bristol Eye Hospital and meeting defined inclusion and exclusion criteria were studied. The mean number of missed points on visual field testing in the better eye (using a "better/worse" eye analysis) in each group were measured. The visual field was measured using the Henson semiautomated central field analyser (CFA 3000). Measurements were made by the research team on all patients at baseline before randomisation and again 2 years after randomisation. The mean number of missed points on visual field testing in the worse eye, mean intraocular pressure (mm Hg), and cup disc ratio using a "better/worse" eye analysis in each group at 2 years were also measured. Measurements were made by the research team on all patients at baseline before randomisation and again 2 years after randomisation. An analysis of covariance comparing method of follow up taking into account baseline measurements of outcome variables was carried out. Additional control was considered for age, sex, diagnostic group (glaucoma suspect/established primary open angle glaucoma), and treatment (any/none). Results-From examination of patient notes, 2780 patients with established or suspected glaucoma were identified. Of these, 752 (27.1%) fulfilled the entry criteria. For hospital and community follow up group respectively, mean number of missed points on visual field testing at 2 year follow up for better eye was 7.9 points and 6.8 points; for the worse eye 20. Conclusions-It is feasible to set and run shared care schemes for a proportion of patients with suspected and established glaucoma using community optometrists. After 2 years (a relatively short time in the life of a patient with glaucoma), there were no marked or statistically significant diVerences in outcome between patients followed up in the hospital eye service or by community optometrists. Decisions to implement such schemes need to be based on careful consideration of the costs of such schemes and local circumstances, including geographical access and the current organisation of glaucoma care within the hospital eye service.

The influence of the new general ophthalmic services (GOS) contract in optometrist referrals for glaucoma in Scotland

“…10 In Bristol, specially trained and accredited glaucoma optometrists were shown to perform as well as the routine HES glaucoma review in the management of stable primary open-angle glaucoma and OHT, with no statistically significant difference in outcome. 11,12 However, the authors found that the optometrists were rather cautious in their approach, with a relatively high proportion of patients being referred back to the HES. 12 The authors concluded that glaucoma screening through community optometrists would not generate savings, and that shared care schemes were not more costeffective than HES care.…”

“…11,12 However, the authors found that the optometrists were rather cautious in their approach, with a relatively high proportion of patients being referred back to the HES. 12 The authors concluded that glaucoma screening through community optometrists would not generate savings, and that shared care schemes were not more costeffective than HES care. 12 This was in contrast with another report, which found that the accredited glaucoma optometrists reduced the number of glaucomasuspect referrals to the HES by 40%, and was able to save the NHS approximately d17 per patient.…”

“…12 The authors concluded that glaucoma screening through community optometrists would not generate savings, and that shared care schemes were not more costeffective than HES care. 12 This was in contrast with another report, which found that the accredited glaucoma optometrists reduced the number of glaucomasuspect referrals to the HES by 40%, and was able to save the NHS approximately d17 per patient. 13 Although the requirements of the new GOS contract was not intended for community optometrists to become specifically trained in glaucoma screening, the increasing prevalence of glaucoma means that the optometrists will be faced with more and more glaucoma-suspect patients.…”

Agreement between specially trained and accredited optometrists and glaucoma specialist consultant ophthalmologists in their management of glaucoma patients

“…13 In 2006, a national survey identified 66 secondary care-led glaucoma shared care schemes in operation in England, 36 of which employed optometrists in some capacity (14 in the community and 22 'in-house'). 14 To our knowledge, there have been two previous studies that have compared the management decisions made by optometrists working within the hospital glaucoma service with those of consultant ophthalmologists 4,11 and three involving specially trained community optometrists assessing new referrals, 8 diagnosed glaucoma/glaucoma suspect patients 9 , or a combination of both. 10 Although all of these optometrists had undergone additional training, as far as we are aware, none had completed the College of Optometrists Diploma in Glaucoma and the hospital-based optometrists were working alongside the consultant ophthalmologist who was responsible for the patients.…”

“…4,[9][10][11] It has been shown that specially trained community optometrists are able to make satisfactory decisions regarding the diagnosis and initiation of treatment for glaucoma 8 and can help to reduce the number of false positive referrals into the Hospital Eye Service (HES) by up to 53%. [5][6][7] However, there remains a large number of individuals considered to be at risk of developing glaucoma who are still being monitored within the HES and, once a diagnosis of glaucoma is confirmed, follow-up becomes lifelong.…”