Six years after introducing a comprehensive, structured and consistent approach to glaucoma detection, Specsavers believes its optometrists have reduced the level of undiagnosed glaucoma among its patients by at least 60%.
This, the company says, appears to be a world first demonstration that the processes implemented have an “impact on undiagnosed glaucoma” and that “doing things in a consistent way” measurably improves outcomes for patients and finds the cases of glaucoma that previously went undiagnosed.
Speaking at Specsavers’ first clinical conference webinar for 2021, Dr Joe Paul from the optometry team at Specsavers’ support office congratulated optometrists for the work being done to detect glaucoma and the “fantastic results” being achieved.
“It’s incredible to think that in the more than 20 years between the Blue Mountains Eye Study and the National Eye Health Survey, there was no real progress in detecting undiagnosed glaucoma. And yet in the six short years since we started implementing a systematic approach, we are now able to point with confidence to your achievements, in detecting more than 60% of the undiagnosed glaucoma among our patient base,” he said.
Indeed, The Blue Mountains Eye Study, undertaken in the early 1990s, found that 50% of glaucoma in their study cohort was undiagnosed. More than 20 years later, the National Eye Health Survey with a larger cohort size found, again, approximately 50% of glaucoma was undiagnosed.
“Despite all of our advances in clinical skills, despite all of our advances in clinical technology, and our understanding of glaucoma, there was no real impact on the diagnosis of glaucoma in the population. It was continuing at the same rate,” Dr Paul said.
Planning the Journey
Specsavers’ journey to significantly reduce undiagnosed glaucoma in Australia began with analysis of the number of its patients having visual field tests, how many were being referred on for glaucoma and the relationship between the two.
“Over several years of measuring, refining, benchmarking and measuring again, we were able to establish baselines… We knew we were referring approximately 0.7% of our patients for glaucoma and that we were doing visual fields on about 4% of our patients,” said Dr Paul.
Armed with this information, Specsavers was able implement changes to clinical technology and clinical processes, then measure the impact on referrals for glaucoma using the same reporting and benchmarking process.
“We believed that because optical coherence tomography (OCT) is more sensitive to structural changes and indeed, because it can improve the lead time in glaucoma diagnosis by up to eight years on visual fields, it stood to reason that performing an OCT on every single patient, would pick up more early structural changes (rather than just confirming a suspicion of optic nerve changes).
“Additionally, we’d be able to give patients appropriate care, whether that was a visual field and monitoring, or a referral to an ophthalmologist sooner than we otherwise could.”
To test their approach, Specsavers installed OCTs in eight stores across Australia and New Zealand.
Across 150,000 patient journeys through those stores, they saw a consistent increase in visual fields and glaucoma referrals of around 0.7%, up to close to 1.5%, which was close to the approximate prevalence of glaucoma in the population.
Findings from this early rollout provided the impetus to install OCTs in every store across Australia and New Zealand, and by late 2019 every patient was having an OCT as part of their standard eye test.
To ensure referrals were both appropriate and accurate, Specsavers integrated Oculo into its practice management system. They also partnered with RANZCO to develop patient care pathways, and standardised guidance on when to manage and when to refer patients.
“We held CPD events… as well as smaller events in stores and in local areas, focused specifically on these pathways to help our optometrists engage with local ophthalmologists and to improve collaborative care practises. The glaucoma referrals increased after these events, alongside better and more consistent use of visual fields,” explained Dr Paul.
“Encouragingly, false positive glaucoma referrals to ophthalmologists decreased to about 17% from over 20%.
“That may sound high but in comparison, up to 50% of glaucoma referrals from optometrists in the United Kingdom are false positives,” he said.
Further statistics add to the evidence of the strategy’s success:
In 2017, its optometrists referred just over 20,000 patients for glaucoma; in 2018, they referred over 33,000; and in 2019, they referred over 42,000 patients.
“We have taken a disease, half of which is undiagnosed, and we have doubled our referrals for it. Importantly, we have not increased our false positive referrals. In fact, with time, these have reduced slightly, now at 15% of our referrals on a far greater number of referrals, which again compares incredibly favourably with the United Kingdom and all similar jurisdictions,” said Dr Paul.
The Bigger Picture
Specsavers sees approximately 40% of all patients across Australia and New Zealand who have annual eye tests. With around 300,000 patients known to be living with glaucoma in Australia (though around 50% remain undiagnosed), we can expect around 120,000 of people with glaucoma to be on the Specsavers’ patient base.
Based on these assumptions, Dr Paul says Specsavers estimates 60,000 of its glaucoma patients were undiagnosed in 2016.
“Over the past five years, we’ve sent more than 150,000 glaucoma referrals, for more than 114,000 unique patients. Since 2018, we have referred more than 46,000 previously undiagnosed patients for their first ophthalmology glaucoma assessment. Taking into account false positive referrals, we have seen more than 40,000 new patients with glaucoma and we estimate that we’ve reduced the level of undiagnosed glaucoma among our patients by at least 60%,” said Dr Paul.
While Specsavers has not yet reached its ultimate goal, it’s on the way and Dr Paul said the team is committed to continuing its work to detect all undiagnosed glaucoma.