Pre- and Post-Operative Cataract Services Ensuring Patient Centred Care

Pre- and post-operative cataract services – ensuring patient centred care

RNIB is hosting a roundtable discussion, on 24 May 2017 in Bristol, at which invited experts will consider how patients can be at the heart of considerations when developing pre- and post-op cataract services.

This brief is produced by RNIB resulting from a rapid review of published literature (Appendix 1 describes the methodology used) looking at evidence relating to the patient’s experience of innovative models of pre- and post-operative care. It identifies a set of questions to focus discussion during the roundtable.The event is sponsored by Specsavers.

Information from this and four other roundtable discussions will be submitted to the All Party Parliamentary Group on Eye Health and Visual Impairment’s Inquiry into capacity issues in ophthalmology, and collated into a formal report as the final stage.

Context

Cataracts lead to deterioration of vision which can restrictindependent living [1,2],and canresultindiminished quality of life [3] and an increased risk of falls [4].Higher rates of cataracts have been linked with ethnicity (because of the link between cataracts and diabeteswhich is more prevalent in Asian and African/African Caribbean populations[5]) and deprivation status(because of an association between cataracts and lifestyle factors such as smoking and diet [6]).

Cataract surgery is the only effective method to restore clear sight[7] and is the most frequently conducted elective procedurein the NHS [8,9]. The majority of operations are performed on patients aged 60 years or over [7]. Numbers of cataract surgeries performed in England annually is growing, with almost 400,000 operations carried out in 2014/15 [10], compared to340,809 in 2012/13[11].

Even with the high rate of surgeries performed, formany patients, significant barriers to access remain in the form of regional variation in waiting times, restrictive referral criteria andrationing of second-eye surgery [7, 12].

Demand for cataract surgery is predicted to continue to rise substantially, due to the growing elderly population and development of new technologies, and resources are not expected to grow at the same rate [13, 14].The Royal College of Ophthalmologists (RCOphth)recently published TheWay Forward[14] highlighting that services delivering‘traditional’cataract pathways(i.e. an ophthalmologist seeing to the patient throughout the whole pathway) will not be able to cope with increasing demand much longer. Services mustadapt to improve efficiency and sustainability ‘in the face of such growing disparitybetween demand and resource’ [14].

There is increased emphasis on moving eye care into the community to relieve the pressure on hospital services [14-19]. Community shared care is also known as ‘enhanced care’ pathways asthey operate outside General Ophthalmic Services (GOS) and must be locally commissioned.

To help remove the postcode lottery of availability the Local Optical Committee Support Unit(LOCSU)has called for widespread adoption of their cataract pathway where high street optometrists lead the pre- and post-opassessment [18]. This pathway aims to reduce unnecessary patient referrals to the hospital eye service and increase capacity within the department, reduce patient anxiety and provide a more cost effective service. The requirement for a visit to the GP would be eliminated and adomiciliary service is also offered.

What challenges do cataract patients experience during the cataract pathway?

• Access: In 2013, RNIB reported analysis of five years of Hospital Episode Statistics (HES) data, identifyingrationing of cataract services on the basis on arbitrary visual acuity thresholds, and in a few areas on the basis of cost. Widespread regional variation in time taken to access the service was also identified- for example, in the London borough of Enfield, average waiting times were 15.5 months, compared to just two weeks between outpatient appointment and surgery in Luton [20].

• Delays/cancellations: Research indicates that patients with cataract and other conditions where there is permanent sight loss are losing their sight unnecessarily because of capacity problems in eye clinics [21, 22].The NHS recently announced that they are lifting the requirement on hospitals to treat cataracts within 18 week, and as a result, longer waiting times for patients are expected.

• A recent RNIB study exploring experiences of cataract patients found that a number of participants reported a lack of reassurance and emotional supportthroughout their cataract journey [2].

• Following referral, inadequate information provision at the pre-assessment can leave patients feeling ill-equipped to be fully involved in decision making[2]. Patients suggest that fears about the anaesthetic injection and the operation itself could be reduced by providing more comprehensive information about the procedure, and what to expect from cataract surgery [23].Written information should be provided to reinforce verbal information [24].One US based study found that informed consent information sheets at lower reading grade levels and videotape presentation optimized patient understanding of the risks, benefits, and treatment alternatives to cataract surgery [25].

• Cataract pathways can be complex. ‘Traditional’pathwaysrequire multiple hospital visits, which are difficult for many patients to attend. As such, current guidelines for service development aim to reduce the number of hospital appointments required [7, 26].Post-operatively, patients reported being confused by unclear, incomplete and contradictory patient information, and blamed this confusion on the discontinuity of doctors at subsequent visits [23]. Patients also reported being worried about short-term compliance with the post-op regimen and felt that unambiguous guidance about post-op restrictions would generate reassurance [23].

• Patients have told RNIB that long waits between first and second eye surgerycan leads to problems with having to pay for new glasses after surgery on the first eye and another pair following second surgery [2].

What ways of delivering pre- and post-operativecataract care are in place?

Latest guidance recommendations:

During the pre-op assessment, the presence of a cataractshould be confirmed and the patient should indicate willingness for surgery (following an explanation of the risks and benefits) [27]. Patients should also be provided with information about their surgery (what to expect, and the pros, cons and risks involved), be counselled on their expected treatment, and be allowed time to consider the need for an operation [7].The ophthalmologist performing the pre-op assessmentshould be appropriately trained if they are not the operating surgeon [7].

A post-op assessment is necessary for all patients not seen during a first day review and can be carried out by an ophthalmologist or non-clinical health care professional (HCP) working within the unit, or by an accredited optometrist working outside of the unit [7]. The post-opassessment should include a clinical examination to check for ortreat any post-op complications, assess visual outcome and refractive status andascertain patient satisfaction[27].

Delivery pathways:

The ‘Way Forward’ (2016) report aimed to capturesome of the innovative cataract service re-designs currently being implemented in the UK. Just four of the 39 eye departments surveyed were still offering a ‘traditional’ service, with the rest delivering a ‘new’ alternativepathway. Some of these new pathwaysincludedcommunity optometrist-led care[14].

In regards to the pre-op assessment, one model featured uses a standardised questionnaire referral from the community optometrist, and anotherpays an enhanced fee from their tariff to permit accredited community optometrists to provide pre- and post-op services.These two models were deemed by report authors to be more ‘efficient’ for patients as the use of community optometrists resulted in a reduction in the number of hospital visits required [14].

Regarding post-op assessment, just over a quarter of eye departments surveyed in the Way Forward (2016) reported discharging patients straight from theatre after uncomplicated surgery to community optometry; half of these use the standard GOS, but half have this service attract an enhanced tariff. Two departments reported a hybrid arrangement; seeing a nurse after first eye surgery and discharge from theatre for the second eye to a high street optometrist [14].

Do patients get the same quality of care from different pre- and post-op service pathways?

There is little evidence in the way ofevaluations and particularly patientexperience/outcomescomparing differentcataract shared carepathwayswithin the UK, resulting in a lack of evidence to inform local decision making about existing and future services [28].

Individual eye departments may be capturing outcomesdata/learning for their service, for example, we know that in Wolverhampton, three new integrated pathways have been created to improve the quality of ophthalmology referrals, reduce attendance at Accident and Emergency, and provide care closer to home. Patients undergo pre-op assessment with a high street optometrist.

Voyatzis and colleague’s 2014 community shared care pathway evaluation appears to be the only UK based source of evidence[29]. Key evidence prior to this are largely US based, are quite out of date (15 years plus old), focus on early referral refinement schemes or focus on schemes for other eye conditions such as Glaucoma or AMD.

Advantages of the community optometrist led post-op discharge modelevaluated by Voyatzis et al. (2014) included care provided closer to home and a reduction in unnecessary hospital visits for patients undergoing uncomplicated surgery.Patient satisfaction was not monitored. Authors proposed that there may be added confusion for patients because of the variation in when post-op assessmentis delivered (between day one and week five) and who it is delivered by (it may be one of multiple professionals) [29].

Evaluation of the Scottish community optometry service and Eye care Integration Project (which introduced electronic connection of community optometrists to hospitals) reported that the model was a significant step change towards meeting demand for a multi-disciplinary approach, bringing ophthalmic care closer to home and into the community [30].

Generally, in comparison with ‘traditional’ models of care, community shared care pathways are considered to facilitate timely assessment of patient needs, reduce inappropriate referrals into secondary care, possible result in an increase in the skills of the optometric workforce, and ensure the patient pathway is as short as possible with appropriate choice of service access [31]. Not being able to see the operating ophthalmologist until the day of the surgery may slow down the procedureas patients ask questions of the ophthalmologist directly [14:].

Discharging patients immediately post–operatively (with full back-up) was viewed by many eye departments as an adequately safe way to release capacity for higher risk patients [14].

Internationally, the available evidence on cataract shared care evaluations appears to be, relatively, out of date and won’t reflect UK policy. One Belgiumbased study appears to indicate that althoughpatients with cataract highly rated share care pathways without any post-op contact with ophthalmologists, they still preferred to see an ophthalmologistpost-op [32].

What are the ways to ensure that patients get the best pre- and post-op services?

The following elements should be considered in order to develop and maintain a successful a pre- and post-op service:

• Adherence to RCOphth commissioning guidelines:New eye-care pathways should adhere to a common framework while taking local need into account [16, 27]. The commissioning process needs to ensure that pre- and post-op services are delivered safely, by an appropriately trained workforce, follows evidence based guidelines and is audited for outcomes and value for money [27].

• Address access inequalitiesto reduce the post code lottery of service provision.

• Ophthalmologist-led service, ensuring appropriate training and monitoring where pre- and post-op care isdelegated to others [7].

• Trainee ophthalmologistsshould retain exposure to a reasonable sample of pre- and post-op cases, allowing themto develop sufficient experience in evaluating the appropriateness of a decision to offer surgery, and to understand the acceptable variations and common complications in the post-op period [14].

• Good record-sharing protocols and IT systemsbetween community optometrists and hospital eye services to reduce delays and avoid patients getting lost in the system [17, 27].

• Monitoring outcomes and patient satisfaction would inform commissioning and delivery plans[17, 27, 33]. A National Institute for Health Research (NIHR) applied cataract research programme is currently being funded to develop a short-form cataract Patient Reported Outcome Measure (PROM). The Clinical Council for Eye Health Commissioninghas also endorsed the portfolio of indicators developed by the VISION 2020 UK Ophthalmic Public Health Committee which has a follow up indicator.

• Sustainability planning: High staff turnover can be frustrating within ‘traditional’ models as training non-clinical staff to pre- and post-op roles can be resource intensive, undermining sustainability [14, 31, 34].

Gaps in the evidence

• UK based evaluation ofdifferent pathways including patient experience.

• UK based studies testing new pathways of care to scale.

• UK based cost analysis studies of different pathways.

• UK based studies investigating types of information provision and what works best.

• Up-to-date studies on consent taking by non-clinical staff.

• A large scale, randomised study is in progress to assess whether patients prefer, nurse-led, telephone follow-up in place of the routine post-op assessment. Early findings suggest high level of patient satisfaction, with no additional visits required [35].

• Forthcoming resource: The National Institute for Health and Care Excellence (NICE) are currently consulting on the development of a cataract pathway. RNIB will be consulting with cataract patients to inform their organisational response to the consultation draft.

What do we still need to know about commissioned models of pre- and post-operative services to ensure patients get the best outcomes?

1. How can we ensure that quality and patient safety is not sacrificed to improve efficiency?

2. What evidence and information do commissioners need to improve delivery of cataract care?

3. How can eye care professionals work together to support the commissioning of effective cataract pathways?

Authors

Puja Joshi, Catherine Dennison and Helen Lee. RNIB.

Appendix 1 Methodology

PJ carried out the searches to identify relevant material published in, and since, 2000, using the search engines PubMed and Science Direct. The following key words were used: Cataract*, Commission* Service*, Shared Care, Enhanced, Community, Patient*, Diagnos*, Ophthalmology, Optom*, Referral*, Consultation*, Outcome, Evaluation, and Local. Over 50 peer reviewed papers, reports, guidance documents and articles were identified. Reference lists were hand-searched.

PJ carried out the rapid reviewing and wrote this paper. CD and HL made comments.

Appendix 2 References

[1] Frampton G, Harris P, Cooper K. (2014). The clinical effectiveness and cost-effectiveness of second-eye cataract surgery: a systematic review and economic evaluation. Health Technology Assessment; 18:68.

[2] Fraser ML, Meuleners LB, Lee AH, Ng JQ, Morlet N. (2013). Which visual measures affect change in driving difficulty after first eye cataract surgery? Accid Anal Prev; 58:10–14.

[3] Knudtson MD, Klein BE, Klein R, Cruickshanks KJ, Lee KE.(2005). Age-related eye disease, quality of life, and functional activity.Arch Ophthalmol; 123:807–14

[4] Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T.(2005). Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial.Br J Ophthalmol; 89:53–9.

[5] Access Economics. (2009). Future Sight Loss UK (1): Economic Impact of Partial Sight and Blindness in the UK adult population. RNIB.

[6] Van de Venter E. (2009). Cataract Health Equity Profile for Primary Care Trusts in Avon.

[7] Royal College of Ophthalmologists (RCOphth). (2010). Cataract surgery guidelines. RCOphth.

[8] Day AC, Donachie PHJ, Sparrow JM, Johnston RL.(2015). The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications.Eye (Lond);29: 552–560.

[9] Prokofyeva E, Wegener A, Zrenner E.(2013). Cataract prevalence and prevention in Europe: a literature review.Acta Ophthalmol; 91:395–405.

[10] Health and Social Care Information Centre (HSCIC). (2015). Hospital Episode Statistics, Admitted Patient Care – England, 2014-15. HSCIC.

[11]Health and Social Care Information Centre (HSCIC). (2012). Hospital Episode Statistics, Admitted Patient Care - England, 2011-12. HSCIC.

[12] RNIB. (2016). Improving cataract care in England. Patient and health professional perspectives of the cataract patient pathway. RNIB.

[13] Minassian DC, Reidy A. (2009). Future Sight Loss UK (2): An epidemiologic and economic model for sight loss in the decade 2010-2020. RNIB.

[14] Royal College of Ophthalmologists (RCOphth). 2016. The Way Forward: Options to help meet demand for the current and future care of patients with eye disease - cataract. RCOphth.

[15] NHS. 2016. NHS Business Plan 2015/16. NHS.

[16] NHS. 2014. NHS Five Year Forward Plan. NHS

[17] College of Optometrists (CoO). 2016. The optical professions: what does the future hold? CoO.

[18] Local Optical Committee Support Unit (LOCSU). (2013). Pre and Post-operative Cataract Pathway. 2008 (revised November 2013). LOCSU.

[19] Clinical Council for Eye Health Commissioning (CCEHC). (2015). The Clinical Council for Eye Health Commissioning: Primary Eye Care Framework for first contact. CCEHC.

[20] RNIB. (2013). Surgery deferred. Sight Denied. Variation in Cataract Surgery Provision Across England. RNIB.

[21] Boyce T. (2014). Real patients coming to real harm Ophthalmology services in Wales. RNIB.

[22] National Reporting and Learning System (NRLS) reported by Professor Carrie MacEwen, President of RCOphth. (2016). Retrieved from rcophth.ac.uk/2016/03/increasing-demand-on-hospital-eye-services-risks-patients-losing-vision

[23] Nijkamp MD, Ruiter RA, Roeling M, et al. (2002). Factors related to fear in patients undergoing cataract surgery: a qualitative study focusing on factors associated with fear and reassurance among patients who need to undergo cataract surgery.Patient Educ Couns; 47(3):265–272.

[24] Elder MJ, Suter A. (2004). What patients want to know before they have cataract surgery. British J Ophthalmology; 88:331–332.

[25] Skukla AN, Daly MK, Legutko P. (2012). Informed consent for cataract surgery: patient understanding of verbal, written, and videotaped information. J Cataract Refract Surg; 38(1):80-4.

[26] NHS England. (2015). Eye Health Network for London: Achieving better outcomes. NHS England.