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It is reassuring to learn that the Bristol shared care glaucoma study, reported in the May issue of theBJO,1 confirms that the clinical outcome for patients followed up by community optometrists is similar to that for those who remained in the conventional hospital eye clinic. That should not surprise us because we know from many years of experience sharing patient care with optometrists, orthoptists, and nurse specialists, that our colleagues in these professions can be relied on to work with precision and integrity. The General Medical Council distinguishes delegation from referral.2 Shared care schemes3 are examples of delegation where the medical practitioner, in this case the ophthalmologist, remains responsible for the overall management of the patient and has a duty to ensure that the optometrist is suitably trained and qualified for the task. The separate process of referral to an optometrist will also be appropriate for some patients in whom a possible but low risk of glaucoma has been identified. They are referred to the community optometrist for the usual regular eye examination with the request that they be sent back to the ophthalmologist if the findings indicate an increasing risk. Here, it is the optometrist who assumes professional responsibility. Therefore when setting up shared care schemes it is necessary to avoid overloading the system with patients who should be referred (discharged) to the optometrist. Even when patients are properly included in shared care schemes they should be reviewed periodically and discharged to the care of an optometrist if, after a period of supervision, the risk of glaucoma is judged to be reduced.
The Bristol study uses a commendably simple test of field of vision which is rapid and reliable, without the spurious hyperaccuracy of more complex testing stratagems. This is one example of the strict discipline of the study and it minimises inaccuracies which might be caused by the use of different field testing equipment or programmes. In other ways the problems of communication and standardisation have been closely controlled, but this may not always be possible and could affect reliability when shared care is developed elsewhere. It is surprising to note that 55% of the community patients were sent back to hospital at least once in the relatively short (for glaucoma) follow up period of 2 years. This seems a high figure for such a carefully specified scheme and it may limit the efficiency and viability of the system.
The great source of disappointment in the experience of the Bristol group is that the cost analysis shows the community based scheme to be so much more expensive than the hospital clinic that it is likely to overwhelm the balancing advantage of improved geographic access. If lack of hospital capacity is a problem then expanding that capacity would be more cost effective and, in any case, the stable glaucoma patients are likely to require follow up visits at infrequent intervals of between 6 months and 1 year. It is therefore likely that the cost will be the critical factor in deciding whether shared care for glaucoma in the community will be worthwhile. Calculating the true cost will be complex and must assess five elements: the cost of each examination in terms of staff, equipment, and administrative overheads; the cost of timely communication between the professionals who share the care; the cost of additional examinations which take place because there has been uncertainty about the significance of a result—uncertainty may be more likely to occur if a practitioner sees few patients and consequently has less extensive experience; the opportunity costs of losing the ability to deploy professional skills elsewhere; and the cost of unnecessary examination of patients whose risk of sight threatening disease is so low that they should be discharged. If sufficient care is taken to supervise the shared care schemes in the community, there is no doubt they can be safe and effective but it is likely that they will not represent the most efficient use of resources, except in areas where travel to the hospital clinic is especially difficult.