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Clinical science
Expansion of patient eligibility for virtual glaucoma clinics: a long-term strategy to increase the capacity of high-quality glaucoma care
  1. Eleni Nikita1,
  2. Gus Gazzard1,2,3,
  3. Dawn A Sim3,4,
  4. Sandro Fasolo5,
  5. Karsten Kortum4,
  6. Hari Jayaram1,2,3
  1. 1 Glaucoma Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
  2. 2 Institute of Ophthalmology, University College London, London, UK
  3. 3 NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
  4. 4 Medical Retina Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
  5. 5 Performance & Information, Moorfields Eye Hospital NHS Foundation Trust, London, UK
  1. Correspondence to Dr Eleni Nikita, Moorfields Eye Hospital NHS Foundation Trust, London EC1V 2PD, UK; eleni.nikita{at}nhs.net

Abstract

Aims The virtual glaucoma clinic (VGC) is a well-established diagnostic pathway for delivery of glaucoma care. Current UK national guidance recommends VGCs for patients with ocular hypertension, glaucoma suspects or early glaucoma. This study evaluates whether expanded eligibility criteria, including other glaucoma phenotypes and disease stages, can deliver safe and effective care with a positive patient experience.

Methods Records of over 8000 patients were reviewed in order to determine suitability for VGC attendance using expanded eligibility criteria. Patients with three prior consecutive visits within the glaucoma service were included. Follow-up interval, clinic type, visual acuity (VA), intraocular pressure (IOP) and visual field performance were recorded. Patient satisfaction was recorded for a sample of 118 patients.

Results 2017 patients over 31 months were included. Two-thirds of eyes had ocular comorbidities, a fifth of eyes had undergone prior cataract surgery and 10% of eyes had undergone a prior laser treatment for glaucoma. After three visits, 32% of patients remained in the VGC, 42% were seen in face-to-face clinics and 25% were discharged. There were no clinically significant changes in VA, IOP and visual field performance during follow-up. 72% of patients expressed a preference to continue their care within VGCs.

Conclusions This study demonstrates that VGCs with expanded patient eligibility criteria can deliver high-quality glaucoma care that is safe, effective and with high levels of patient satisfaction. This approach provides a long-term solution to adapt delivery of glaucoma care to our expanding and ageing population.

  • glaucoma
  • telemedicine

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All participant data used were deidentified.

http://dx.doi.org/10.1136/bjophthalmol-2020-318556

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    Introduction

    Glaucoma is the leading cause of preventable sight loss in the UK and is responsible for almost a third of new vision impairment certifications.1 The delivery of high-quality glaucoma care across the UK was a challenge even prior to the COVID-19 pandemic, primarily as a consequence of increasing life expectancy. In 2016, the president of the Royal College of Ophthalmologists (RCOphth) summarised the landscape as ‘a perfect storm of increased demand, caused by more eye disease in an ageing population requiring long-term care’.2

    In response, the RCOphth commissioned the ‘Way Forward’ project, to increase awareness of the growing challenges associated with the delivery of glaucoma care and develop solutions to the demand: capacity mismatch within outpatient care settings.3 This project predicted a 44% increase in the number of people with glaucoma in the UK from 2015 to 2035. The projected rise was already tangible, with hospital-initiated appointment rescheduling becoming a frequent occurrence, leading to significant lengthening of patient monitoring intervals.4 The RCOphth also issued national guidance in 2016 regarding the conduct and patient eligibility criteria for ‘virtual glaucoma clinics’ (VGCs) to help increase capacity.5 This guidance was based on prior evidence demonstrating the safety,6 efficiency7 8 and acceptability to patients9 10 of this model of care.

    However, delayed follow-up and a lack of capacity within hospital eye services continued to be responsible for cases of permanent and severe vision loss.11 12 In early 2020, a formal investigation by the Healthcare Safety Investigation Branch starkly highlighted the problems with a lack of timely monitoring for patients with glaucoma and made recommendations including the need for appropriate specialist-led clinical decision making and further clinical pathway redesign.13

    The urgency in this daunting clinical challenge has only been magnified by the recent COVID-19 pandemic, which will undoubtedly influence how we deliver glaucoma care to our patients in the medium to long term.14 Approximately 120 000 patients attended outpatient consultations within the glaucoma service across the Moorfields network over the past year, and almost 40 000 glaucoma outpatient appointments were deferred between April and July 2020. In accordance with the RCOphth guidance,5 we have used technician-led VGCs for those patients at lowest risk15 for several years. However, prior to the pandemic, 86% of all glaucoma attendances across the Moorfields network continued to involve a face-to-face (F2F) appointment within the hospital setting. To address this sudden and increased demand for capacity within glaucoma services, an expansion of the patient eligibility criteria for VGCs to include most glaucoma phenotypes and more advanced stages of disease, along with the appropriate specialist oversight, is essential in order to deliver safe and timely care to patients.

    This pilot study aimed to evaluate whether expanded criteria for VGCs, reviewed by fellowship-trained glaucoma specialists, can facilitate the expansion of glaucoma care that is safe, effective and with a positive patient experience.

    Materials and methods

    This study was registered and approved by the Clinical Audit and Assessment Committee at Moorfields Eye Hospital (ref: CA18/GL/13–108).

    Clinical records of 8000 patients in the Moorfields South Division were retrospectively reviewed by a consultant ophthalmologist (EN) to determine suitability for VGC, according to newer expanded inclusion and exclusion criteria (online supplemental table 1). Patients deemed suitable for VGCs were sent an appointment letter by post including a detailed information sheet about the clinic, approved by Moorfields’ communications department.

    Patient attendances were handled by ophthalmic technicians who received bespoke training and accreditation through our institution to independently manage VGCs. Technician training was based on the RCOphth guidance for non-medical eye healthcare professionals delivering patient care in a multidisciplinary team setting.16 Patients were asked a standardised set of questions relating to their medical and ophthalmic history (online supplemental table 2), followed by measurement of visual acuity (VA) and intraocular pressure (IOP) using the Ocular Response Analyser (Reichert Ophthalmic Instruments, Buffalo, New York, USA). These data were entered into an electronic medical record (EMR) (Medisoft, Leeds, UK). Further testing involved standard automated perimetry using the SITA Standard 24-2 algorithm (Humphrey Visual Field Analyser, Carl Zeiss Meditec AG, Jena, Germany), optical coherence tomography (OCT) imaging of the peripapillary retinal nerve fibre layer (3D Topcon 2000, Oakland, USA) and capture of a non-mydriatic colour optic disc photograph (Kowa Medical, Hamamatsu, Japan). Anterior segment OCT (3D Topcon 2000, Oakland, USA) was performed for all new patients but only on prior request from clinicians for follow-up attendances. All diagnostic tests fed their outcomes directly into the EMR.

    All clinical attendances in the VGC were reviewed by a fellowship-trained EN. Clinical data from patients attending the VGC were collected in a linked-anonymised manner across three consecutive VGC appointments over a 4-year period between January 2016 and January 2020.

    Outcomes from VGC attendances were collated using Microsoft SQL Server Reports Software, combining data from our EMR system (Medisoft, Leeds, UK) and patient administration system (Silverlink Software, UK). Individual patient encounters were reviewed manually within the EMR in order to confirm the diagnosis and outcome. Outcomes were categorised into three groups: (1) discharge from the glaucoma service, (2) ongoing follow-up in a VGC and (3) referral to an F2F consultant-led glaucoma clinic. The clinical reasons for future F2F review rather than ongoing care in the VGC were explored using a random sample of 248 patients. In the event that new comorbidities, other than glaucoma, were discovered, an internal referral letter was sent by the clinician to the relevant service. Further analysis of the number and type of such referrals was not performed as a part of this study.

    Quantitative data generated per patient at each glaucoma visit, along with ocular diagnoses and details of previous surgeries, were extracted into Microsoft Excel. Statistical analyses were performed using GraphPad Prism (San Diego, California, USA).

    Evaluation of patient satisfaction

    In order to evaluate patient acceptance and satisfaction, all patients who attended VGCs between April and June 2018 were sent an initial invitation and two follow-up email reminders inviting them to participate in an anonymous online survey hosted by Survey Monkey based on on a standard Moorfields’ patient feedback form. To further understand patient perceptions of the VGC, patients were also asked their opinion on the environment of our virtual hub, their understanding of not seeing a doctor in person on the day of review, their rating of the content of the outcome letter sent to them by post, their suggestions for improvement and their preference for their upcoming review (VGC vs F2F). We also allowed for free-text comments to be added to responses.

    Results

    Two thousand and seventeen patients fulfilled the expanded criteria specified in online supplemental table 1 for attendance at VGCs, and the characteristics of this population are summarised in table 1. There is marked ethnic diversity among the patient population study, which is reflective of the nature of the catchment area served by Moorfields. Most eyes were either glaucoma suspects (40%) or had a diagnosis of primary open-angle glaucoma (35%). A fifth of eyes had undergone prior cataract surgery, and 2% had undergone prior trabeculectomy. Ten percent of eyes had undergone a prior laser treatment for glaucoma, with 6% of eyes having undergone prior laser peripheral iridotomy.

    View this table:
    Table 1

    Summary of patient characteristics

    Ocular comorbidities are described in detail in table 2. The majority of eyes (64%) had coexisting ocular comorbidities, among which cataract (37%) and diabetic eye disease (10%) were the most common.

    View this table:
    Table 2

    Summary of ocular comorbidities

    Clinic outcomes of VGC attendances

    The clinical outcomes of patients invited to attend the expanded criteria VGCs are summarised in the flowchart in figure 1.

    Figure 1
    Figure 1

    Flowchart illustrating follow-up outcomes of patients during the study. F2F, face to face; VGC, virtual glaucoma clinic.

    Outcome of first visit

    Five hundred fifty-nine (27.5%) patients were new appointments, and 1468 (72.5%) were follow-ups. Six hundred fifty of 2017 patients were rebooked into a VGC (32%), 987 were booked into F2F clinics (49%), 273 were discharged (14%) and 107 did not attend clinics (DNA) (5%). Among the discharged patients, 34 (12.5%) were new referrals. All DNAs were rebooked for a further VGC appointment. In total, 37% of patients were booked into a subsequent VGC appointment.

    Outcome of second visit

    The median interval between first and second visits was 6.6 months. Five hundred sixty-one of 1744 remaining patients were rebooked into a VGC (32%), 934 were booked into F2F clinics (54%), 121 were discharged (7%) and 128 were DNAs (7%). All DNAs were rebooked into VGC again. In total, 39% of patients were booked into a subsequent VGC appointment.

    Outcome of third visit

    The median interval between second and third visits was 5.8 months. Five hundred eighty-seven of the remaining 1623 patients were rebooked into a VGC (36%), 844 were booked into F2F clinics (52%), 109 were discharged (7%) and 83 were DNAs (5%). Sixteen patients among DNAs were deceased. All remaining DNAs were rebooked into a VGC again. In total, 41% of patients were booked into a subsequent VGC appointment.

    Summary after three visits

    Among the original cohort of 2017 patients who were initially reviewed in the VGC, 654 patients remained in the VGC (32%), 844 went to F2F clinics (42%), 503 were discharged (25%) and 16 died (<1%). A need for drainage angle assessment, ineligibility for VGC attendance and unreliable diagnostic tests were the leading reasons for subsequent rebooking into an F2F clinic and are summarised in table 3.

    View this table:
    Table 3

    Causes for F2F booking following initial VGC review

    Among the original cohort of 559 new patients, 128 were discharged by the third visit (23%). All of them had at least one F2F review before being discharged.

    Ophthalmic outcomes of VGC attendances

    Visual acuity

    The mean (±SD) VA of all eyes at the first VGC attendance was 84±11 letters compared with 83±12 letters at the third attendance. The mean difference between the first and third VGC attendances of −0.9 letters (95% CI −1.4 to –0.4) reached statistical significance (paired t test, p=0.0003) but is not considered to be clinically significant.

    Intraocular pressure

    The mean (±SD) IOP of all eyes at the first VGC attendance was 16.7±4.4 mm Hg compared with 16.4±4.6 mm Hg at the third attendance. The mean difference between the first and third VGC attendances of −0.3 mm Hg (95% CI −0.5 to 0.0) was not statistically significant (paired t test, p=0.05).

    Visual field performance

    The mean (±SD) Humphrey Visual Field mean deviation of all eyes at the first VGC attendance was −3.2±4.3 dB compared with −3.4±4.2 dB at the third attendance. The mean difference between the first and third VGC attendances of −0.2 dB (95% CI −0.3 to 0.0) reached statistical significance (paired t test, p=0.03) but is not considered to be clinically significant.

    Patient-centred outcomes of VGC attendances

    The online survey was completed by 118 of the 193 invited patients (response rate of 61%), and the results are summarised in table 4. The majority of patients found all aspects of the service to be either ‘excellent’ or ‘satisfactory’. Over 70% of patients clearly understood that a doctor would not be present during their VGC attendance and, if given the choice, would chose to have another VGC appointment rather than a traditional F2F appointment.

    View this table:
    Table 4

    Summary of results of patient satisfaction survey

    Two hundred fifty-eight free-text comments were documented. Positive feedback included the reduced time spent at the appointment, the friendliness of the staff, the cleanliness of the environment and the general efficiency of the process. The main themes for suggested improvement are related to the absence of an interaction with a doctor on the day and adoption of a system that would allow the immediate resolution of queries and for clinical letters to be more patient friendly.

    Discussion

    Increasing demand for clinic capacity has a significant impact on service delivery throughout all healthcare systems. Prior to this pilot study in the Moorfields South Division, 11% of glaucoma appointments were being rescheduled, and F2F clinics were overbooked by 20%. This had a negative impact on staff morale and turnover, increased rates of patient non-attendance and the risk of clinical incidents associated with delayed care.13 Historically, staff shortages have been managed using temporary staff incurring unsustainable financial costs. A major advantage of VGCs is the ability for senior clinicians to make more rapid clinical decisions using a standardised dataset when compared with traditional F2F consultations, enabling a more efficient use of specialist time.

    Current national guidance regarding patient eligibility for VGCs only includes a small cross section of patients seen regularly in glaucoma clinics, namely, those with ocular hypertension, suspected glaucoma, mild–moderate primary open-angle glaucoma in the worse eye or mild–moderate primary angle-closure glaucoma in the worse eye in those who have undergone previous bilateral cataract surgery.5 A national survey showed that although most clinicians work in line with these recommendations, almost a third of respondents included patients outside of the specified criteria.17 The formal expansion of eligibility criteria for VGCs appeared to be the most rational approach to resolve the operational and clinical challenges to reduce the mismatch between existing outpatient capacity and demand. The UK National Health Service organises itself around a single definition of quality: care that is safe and effective and that provides as positive an experience for patients as possible.18 This study therefore aimed to evaluate whether these changes could be implemented while continuing to deliver high-quality glaucoma care.

    We expanded existing criteria based on the RCOphth guidance5 to include patients with most glaucoma phenotypes and severities, provided that patients with advanced glaucoma had been stable for over a year. This resulted in a massive capacity expansion, with a threefold increase in the eligible patient population, as 1546 patients from our cohort had either secondary glaucoma or other comorbidities and hence would have been excluded from VGCs had current RCOphth guidance been followed. Despite diagnostic diversity and high incidence of ocular comorbidities, only 42% of patients were redirected to an F2F clinic following three consecutive visits, primarily to perform gonioscopy to evaluate drainage angle anatomy in 28%. Historically, gonioscopy has been considered the ‘gold standard’ technique for drainage angle evaluation leading to reluctance for this to be replaced by imaging. However, this is likely to change as contemporary literature suggests anterior segment OCT imaging allows more accurate, objective and reproducible assessments of anatomy.19–21 Moreover, recent changes to RCOphth guidance on the management of angle-closure suspects abandon prophylactic iridotomy for most patients classified as Primary Angle Closure Suspects, which will further dramatically reduce the need for F2F gonioscopy.

    Our study also demonstrated that a further 10% of patients, who were directed into F2F clinics, could have remained in VGCs had graders followed the modified guidance on VGC eligibility criteria. The revised guidance may be perceived as only a small change stratification into glaucoma care pathways. In reality, however, it mandated a significant change in approach, and evidence suggests that the adoption journey for organisational changes of this nature is complex and requires time, persistence and constant engagement.22

    The discharge rates in VGCs resemble those seen in F2F clinics (10% on average and 25% cumulatively over the 3-year period), which appear to be low, considering that 40% of eyes were glaucoma suspects. However, a third of our patient cohort was reviewed in the VGC setting for the first time, which can account for lower than expected discharge rates. Additionally, as NICE (National Institute for Health and Care Excellence) guidance recommends 2–3-year follow-up of glaucoma suspects prior to discharge to community monitoring, the observed discharge rate is compatible with national guidance.23

    Most importantly, this study demonstrated that safe and effective glaucoma monitoring can be delivered using the expanded VGC eligibility criteria. Over the course of the study, no evidence of clinical deterioration was observed through comparison of VA, IOP and severity of visual field loss—the primary objective indicators of glaucoma stability. Our results also confirm the findings of a previous study, which reported that clinical findings and data relating to newly referred patients can be safely evaluated in a virtual clinic with satisfactory accuracy.24

    Patient satisfaction, the third pillar of high-quality care,18 was extremely high for all components of care in this virtual setting. The majority of patients expressed a wish to continue their glaucoma monitoring within this new model of care—with over 100 comments praising the efficiency of the clinic from a patient’s perspective. An internal audit found that the average patient journey within the VGC was 37 min, compared with the trust-wide average of 92 min for F2F glaucoma clinic appointments. While high patient satisfaction levels of VGCs and reduced patient journey times do not guarantee safety, they provide evidence of an efficient service, which should be a prerequisite for any service redesign strategy aiming to cope with increasing demand.

    A small proportion of patients expressed some concerns regarding the lack of an immediate response to their queries and absence of a doctor on the day. A legacy of the COVID-19 pandemic has been the increased utilisation of patient helplines, remote telephone consultations and video consultations. These adjuncts will be incorporated into standard operating procedure for VGCs and will enable a more responsive service to patients’ concerns, which will be supported by a written summary of the discussion to be posted out after the consultation. Our patient satisfaction survey was developed internally, without formal external validation to assess how well it measures main elements of glaucoma care and patient experience. To the best of our knowledge, there are no validated instruments currently available for this purpose, apart from questionnaires designed for patients with cataract.25 We also aimed to minimise sampling bias in the patient satisfaction survey by inviting patients within a fixed 3-month timeframe. It is likely that the level of engagement differed according to age, occupation and other factors including access to a computer. However, we felt that an online, anonymous survey would yield less selection and response bias than an F2F survey.

    Incentivising clinicians to meet patient satisfaction benchmarks has become more prevalent and can be a source of controversy.26–29 However, it is clear that results from patient satisfaction surveys can facilitate positive changes and quality improvements in healthcare delivery that are responsive to patients’ needs. The need for such surveys is crucial for the future development and improvement of VGCs, as this method of care will likely become the core modality for a significant proportion of patients with glaucoma under secondary care within the UK.

    There is a paucity of literature relating to patient satisfaction with teleophthalmology clinics.9 10 30–33 Extensive research in this domain has been performed within specialties such as dermatology and oncology, reporting an overall high satisfaction level and acceptance, because of increased accessibility, reduced patient journey times and reduced travel costs.27 34 35 A prior study at Moorfields to explore patients’ perspectives on VGCs reported that most are accepting this model of service, as long as they are informed on status of their condition and are reassured by the staff that they meet.10 A study from Swansea reported high levels of patient satisfaction with glaucoma virtual clinics, but the emphasis of the questionnaire used was heavily weighted towards patient education.9 However, both of these studies lacked any anonymity of feedback, which is a potential source of bias, an issue that did not influence the online patient satisfaction survey used in this study.

    Over 40 000 glaucoma outpatient appointments were cancelled across the Moorfields network due to the COVID-19 pandemic. The most efficient method to handle this backlog while incorporating social distancing measures is to maximise the utilisation of VGCs for a significant proportion of these patients. VGCs are well established in the UK and supported by RCOphth guidance5 but with limited eligibility criteria. This study provides firm evidence that VGCs with expanded patient eligibility criteria are able to deliver high-quality glaucoma care that is safe, effective and with high levels of patient satisfaction. A similar methodology may be applied to other high-volume outpatient ophthalmic specialties including monitoring of diabetic retinopathy and age-related macular degeneration in order to optimise resource utilisation. This approach provides not only a strategy for the recovery from the COVID-19 pandemic but a long-term solution for the safe, effective and efficient delivery of glaucoma care to our expanding and ageing population.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information. All participant data used were deidentified.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    GG is employed by University College London (UCL) and supported by grants from the National Institute for Health Research (HTA 09/104/40), Moorfields Eye Charity, British Council to Prevent Blindness, Fight For Sight and the International Glaucoma Association. HJ is supported by the Moorfields Eye Charity. GG, DAS & HJ are grateful for the support of the National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and the UCL Institute of Ophthalmology. The views expressed in this paper are those of the authors and not necessarily those of any funding body or the UK Department of Health.

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    Footnotes

    • Twitter @gusgazzard, @dawnasim

    • Contributors EN, SF and KK carried out the data collection and analysis; EN, HJ and GG contributed to the first draft; and all authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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    • Highlights from this issue
      At a glance
      Frank Larkin
      British Journal of Ophthalmology 2022; 107 i-ii Published Online First: 15 Dec 2022. doi: 10.1136/bjo-2022-323002