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HomemieyecareThe Circle of Care for Glaucoma Patients

The Circle of Care for Glaucoma Patients

Faced with an increasing prevalence of glaucoma in Australia, the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) is exploring new models for collaborative care that will ease the burden on eye health practitioners while achieving optimum outcomes for patients.

Glaucoma is one of the leading causes of vision impairment and blindness in the world.1 It’s chronicity and potential to progress warrants lifelong surveillance and management, and thus burdens our health systems. The Australian Bureau of Statistics has projected our current 2022 population of 26 million to increase to between 34.3 to 45.9 million people by 2071, with the median age projected to increase from 38.5 years to between 43.8 and 47.6 years.2 The prevalence of glaucoma in Australia ranges from 2.2%3 to 3.0%4 of persons older than 50 years, and increases exponentially as a person gets older.4 As a result of these demographic changes, the number of patients with glaucoma in Australia is predicted to increase to 379,000 by 2025.5

Collaborative or shared care is an integrated approach to healthcare, where two or more providers are involved with, and communicate about, a patient’s diagnosis and treatment. This can include ophthalmologists working together with optometrists in the traditional manner, but also with other health care providers such as orthoptists, nurse practitioners, ophthalmic technicians, general practitioners, and non-ophthalmic physicians. Collaborative care can take various forms; for example, eye care professionals may work together at one site, or at different locations, at the same time or asynchronously, using the same or different medical record systems or ophthalmic equipment.

The goals are to enable safe and timely diagnosis, monitoring, and management for glaucoma patients, and efficient cost-effective care. Shared care should enable rapid and sustainable improvements in outcomes for glaucoma patients, where the patient undergoes consultation with the right practitioner, in the right place and at the right time, as highlighted by the Australian Commission on Safety and Quality in Health Care.6

ROLE OF SHARED CARE OF GLAUCOMA IN AUSTRALIA

Glaucoma lends itself to collaborative care as it is a chronic disease requiring ongoing monitoring, has a high prevalence in the community, and has early or pre-clinical stages of disease, or suspect forms. These patients are generally at low risk of progression but require ongoing monitoring. However, one of the main drivers towards shared care is the high demand on services for chronic eye disease due to the growing and ageing population. Delayed access to care can lead to adverse vision outcomes.7 Shared care seeks sustainable and acceptable solutions to increase service delivery capacity, thus increasing access to care and improving patient outcomes. These outcomes can be provided directly, through care of the glaucoma patient, or indirectly via freeing appointment slots for new referrals.6 Demand on highly specialised services is potentially reduced by redirecting some aspects of care to other appropriately trained practitioners.8 The benefits of shared care have been demonstrated in previously published research.7

RANZCO’s Clinical Practice Guidelines for Collaborative Care of Glaucoma Patients outlines the important elements for an ideal collaborative care program in Australia, and remains a reference resource for several optometry-led collaborative care programs.9,10 The United Kingdom’s National Institute of Clinical Excellence (NICE) guidelines and Canadian models of collaborative care,11,12 published over a decade ago, propose that any model of collaborative care should deliver a more efficient service than the status quo and typically utilise existent services. Importantly, in all models, the ophthalmologist performs at least the initial assessment and formulates the management plan for the co-collaborator.

Redistribution of health care resources to reduce duplication of testing, unnecessary provider visits, and inappropriate or unnecessary treatments is a priority. Provided it is clinically appropriate, patients should always have a choice of their preferred model of care, and therefore any collaborative care arrangements should ideally be on an opt-in basis and be consensual. Care must be patient focussed, individualised, and evidence-based, with no compromise in the overall standard of care or outcomes.9,10

WHERE ARE WE NOW?

Over the past decade at least a dozen glaucoma-related shared care models have evolved and been described in Australia. Some have been established for many years, others are just beginning or in concept. Unsurprisingly, a wide variation of models exists, differentiated by the source of the patient (public or private), which practitioner is collaborating with the ophthalmologist (optometrist, orthoptist, or nurse practitioner), and the location for the collaborative care clinic. Clinic locations vary from public hospital eye clinics in metropolitan or regional areas, to private ophthalmology clinics, local medical clinics, and optometric clinics. Clinics can either be university-based, ‘high street’ level or more specialised ‘intermediate tier’ clinics. The level of supervision also varies from direct oversight (as for some hospital-based virtual arrangements), or virtual telehealth (as for rural and remote areas).

Arrangements of shared care may be ad hoc or formal, with variations in accessibility to health care providers and services; examples here include relationships between public hospital clinics and ophthalmic or optometric practices in metropolitan versus regional areas. The nature of individualised programs can also be determined by variations in workforce expertise, skill and responsibilities, and resources and renumeration. This limitation of services and resources creates many different types of collaborative care programs, each one individualised to suit the site. Ideally though, over time, there should be enough similarity of service for some centres to adopt another’s program.

RANZCO’s Vision 2030 and Beyond strategic framework will work towards eliminating avoidable blindness in Australia,13 with key themes to include service delivery and preventative healthcare. As one of its many arms, the Collaborative Care for Age-Related Macular Degeneration (AMD) and Glaucoma working group will evaluate these shared care models currently in use within Australia and provide guidelines for safe and appropriate collaborative care for eye health care providers, in consultation with key stakeholders. The RANZCO 2022–2023 pre-budget submission to the Department of Health has several relevant key recommendations.14 These include supporting ongoing collaboration between eye care stakeholders through endorsing screening and referral pathways for major eye diseases, identifying opportunities to scale-up state-based initiatives /programs that have been proven effective, prioritising prevention, and providing early intervention strategies.

OVERCOMING BARRIERS

The elements for delivery and sustainability of a collaborative care arrangement are multiple and complex. Ford et al. has identified themes supporting implementation and scalability of shared care models using a ‘realist’ evaluation framework of context-mechanisms-outcome configuration for each theme.7 Some of these themes are summarised briefly below.

Government Incentives

Financial incentives recognise the additional clinical and administrative workload, including supervision and training, enhancement of infrastructure, and effort. These are offset by cost-savings and efficiencies from shared care. This motivates providers to participate and sustain various shared care schemes. In Australia, this funding should be provided by Primary Health Networks, Local Hospital Networks, Commonwealth Department of Health grants, and/or modifications to the Medicare Benefits Schedule items.

The Collaborative Care in AMD and Glaucoma working group will help define a starting point for the Vision 2030 and Beyond steering group to commence negotiations with the government to advocate for various collaborative care models that may currently be unfairly reimbursed or not in current common practice. Appropriate funding models are essential to allow engagement and retention of the various health partners.

Data Management and Communication

Integrated information systems, such as for the large amount of investigative data, medical records, and transfer of information and reports to the providers, requires investment to enable efficiency, continuity of care, and scalability. Systems need to be fast, user friendly, secure, and reliable. This will allow transfer of data to a broad network of providers.

Governance

Under the umbrella of governance and quality assurance are contractual and regulatory issues, program administration, policy and guidelines, accreditation and education, and ongoing safety and audit.6 This may be determined locally or by national guidelines. Clearly defined clinical protocols for standardised clinical care ensure a safe and streamlined service. Scopes of practice for clinical providers within their area of expertise are required.

Interprofessional Trust and Evidence

Resistance to change is recognised as one of the major hurdles for embracing shared care models. Ways to build trust include familiarity with the co-collaborator, formal training sessions, and communication of positive patient outcomes. Evidence of safety, efficiency, and cost-effectiveness promotes acceptance and hence adoption and sustainability of programs.

Outcomes

Longer-term health outcome measures, including vision loss, progression and access to care, and economic outcomes, are required to validate longevity of outcomes and the productivity of current models.

TOWARDS A COMMON GOAL

The collaborative care space has evolved considerably over the past 10 years and is set to grow further. Paramount in the process is the establishment and maintenance of trust, communication, and collegiate relationships between partners. A tailored approach is required for each location and patient. We hope that by sharing insights we can work and contribute together more effectively towards a common goal of streamlined and effective patient care.

Dr Anne Lee is the current co-chair of RANZCO’s Vision 2030 Collaborative Care in AMD and Glaucoma initiative, and is the Head of Ophthalmology at Liverpool Hospital, NSW. Her clinical glaucoma commitments also include Sydney Eye Hospital and Royal Darwin Hospital, where she is involved with registrar teaching and training at these institutions.

References

  1. Flaxman, S.R., Wong, T.Y., Taylor, H.R., Vision loss expert group of the global burden of disease study. Global causes of blindness and distance vision impairment 1990–2020: a systematic review and meta-analysis. Lancet Glob Health. 2017 Dec;5(12):e1221-e1234. DOI: 10.1016/S2214-109X(17)30393-5.
  2. Australian Bureau of Statistics, Population Projections, Australia. Release date 23 Nov 2023.
  3. Keel, S., Crowston, J., Taylor, H. R., Dirani, M. (2019). Prevalence of glaucoma in the Australian National Eye Health Survey. British Journal of Ophthalmology, 103(2), 191–195. DOI:10.1136/bjophthalmol-2017-311786.
  4. Mitchell, P. et al., Prevalence of open-angle glaucoma in Australia: The Blue Mountains Eye Study. 1996 Oct;103(10):1661–9. DOI: 10.1016/s0161-6420(96)30449-1.
  5. Paul, J., Tran, T., The ophthalmology local education and engagement program. RANZCO Eye2Eye Quarter 4. 2019.
  6. Australian Commission on Safety and Quality in Health Care, About Us (webpage). Available at gov.au/about-us [accessed 25 Jan 2024].
  7. Ford, B., Angell, B., Liu, H. et al., Implementation and scalability of shared care models for chronic eye disease: a realist assessment informed by health system stakeholders in Finland, the United Kingdom, and Australia. Eye 37, 2934–2945 (2023). DOI: 10.1038/s41433-023-02444-9.
  8. Ford, B.K., White, A.J.R., Keay, L.J. et al., Improving patient access and reducing costs for glaucoma with integrated hospital and community care: a case study from Australia. Int J Integr Care. 2019 Nov 6;19(4):5. DOI: 10.5334/ijic.4642.
  9. White, A., Goldberg, I., Australian and New Zealand Glaucoma Interest Group and the Royal Australian and New Zealand College of Ophthalmologists. Guidelines for the collaborative care of glaucoma patients and suspects by ophthalmologists and optometrists in Australia. Clin Exp Ophthalmol. 2014 Mar;42(2):107–17. DOI: 10.1111/ceo.12270.
  10. Glaucoma: diagnosis and management. National Institute for Health and Care Excellence (NICE) guideline NG81. Published 1 Nov 2017, last updated: 26 Jan 2022. Available at: nice.org.uk/guidance/ng81 [accessed 25 Jan 2024].
  11. Canadian Glaucoma Society Committee on Interprofessional Collaboration in Glaucoma Care. Model of interprofessional collaboration in the care of glaucoma patients and glaucoma suspects. Can J Ophthalmol. 2011 Nov–Dec;46(6 Suppl):S1-21. English, French. DOI: 10.1016/j.jcjo.2011.09.001.
  12. RANZCO, Vision 2030 and beyond: RANZCO’s vision for Australia’s eye healthcare to 2030 and beyond (v2, April 2023) available at: https://ranzco.edu/home/community-engagement/vision2030-beyond/ [accessed 25 Jan 2024].
  13. RANZCO, Pre-budget submission 2022–2023 available at: ranzco.edu/wp-content/uploads/2022/02/RANZCO-Pre-budget-Submission-2022-23-Final_270122.pdf [accessed 25 Jan 2024].

Optimising Outcomes

  • Collaborative care in glaucoma can be extended beyond the traditional ophthalmologist/optometrist models and can include utilising existing orthoptic, general practitioners or nurse practitioner workforces, especially in public hospital settings or remote or regional areas.
  • Goals for any collaborative care plan are patient safety and timely care with increased access to care, and efficient and cost-effective practice. Each patient needs to be evaluated for suitability regarding their potential inclusion in a shared care program.
  • Successful implementation requires leadership by clinicians, targeted and adequate resources, building of interdisciplinary trust, monitoring and standardised care protocols.
  • Integrated data information systems and local governance will help to promote longevity and scalability of programs.6