Cooperation between primary and secondary care on a range of major eye disorders has never been closer. Earlier this year NICE published clinical guidelines on three conditions: cataracts, glaucoma and age-related macular degeneration (AMD) and the draft quality standard published reflects the recommendations made in the clinical guidelines.
NICE is opening up the draft quality standard for consultation by commissioners, service providers, health, public health and social care practitioners, and the public with submissions open until October 8. The final standard will be published in February of 2019 replacing the 2011 standard.
Not surprisingly the three conditions covered are exactly the same as those subject to the latest agreements between high street practitioners and hospitals. The previously published clinical guidance and the finalised quality standards will dictate how optometrists communicate, diagnose and refer patients on. The draft quality standard, (www.nice.org.uk/guidance/GID-QS10058/documents/draft-quality-standard) makes six quality statements and then explains the background and rationale behind each.
To aid the consultation NICE asks if the draft quality standard accurately reflects the key areas for quality improvement. Are local systems and structures in place to collect data for the proposed quality measures? If not, how feasible would it be for these to be put in place? Does the person consulting think each of the statements in the draft quality standard would be achievable by local services given the net resources needed to deliver them? NICE goes on to ask those consulting to describe any resource requirements they think necessary along with any potential cost savings or opportunities for disinvestment.
Finally NICE asks for examples from practice of implementing the NICE guidelines that underpin this quality standard. It asks that those examples be uploaded to the NICE website. Examples of using NICE quality standards can also be submitted.
The basis of the draft quality statements stems from recommendations made from the earlier published clinical guidelines many of which cover patient care in the primary sector and as such are of great importance to optometry.
Cataracts in adults
At referral, the clinical guidelines say the patient should be made aware of what cataracts are and how they will affect vision and quality of life. When it comes to the surgery itself patients should be made aware of what is involved, how long it takes, risks and benefits, post-operative support and recovery time. NICE also says longer term outcomes, including the use of spectacles should be discussed as well as the impact on vision and life of not having the surgery at all.
Referral is perhaps the most pertinent part of journey to cataract surgery for optometrists and the draft makes it clear that access to cataract surgery should not be restricted on the basis of visual acuity alone.
It suggests the basis for referral should follow a discussion with the patient and their family, or other appropriate people, about how the cataract affects quality of life, if cataracts are bilateral, the surgery’s risks and benefits, how the patient may be affected if they decline surgery and whether the patient wants surgery.
Less clear is NICE’s position on the type of intraocular lens (IOL) to be fitted in the event of surgery. While the guideline says the type of IOL to be fitted should be discussed with the patient it goes on to suggest that multifocal lenses should not be offered to patients. Other sections on IOL choice have been removed pending further consideration.
Glaucoma
Reassessment is a theme running through the guidelines on chronic open angle glaucoma. The guideline, which was updated in 2017 hints at earlier concerns about false positive referrals. Its first recommendation relates to the series of tests that should be carried out before referral including perimetry, optic nerve assessment with OCT, where available, and intraocular pressure (IOP) measured using Goldmann-type applanation tonometry. The guideline confirms referrals should not be made solely on the basis on non-contact tonometry. Other advice requires that all instrumentation must be regularly calibrated. Practitioners should encourage patients with IOPs of less than 24mmHg to visit their practitioner regularly and practitioners should inform fellow professions involved in the patient’s care of previous records, medication and drug allergies and intolerances.
Age-related macular degeneration
The guidance for AMD is also designed for commissioners and providers of ophthalmic and optometric services and people with age-related macular degeneration, their families and carers. Much is made of the need to describe the condition to sufferers and families.
Asymptomatic dry AMD should not be the subject of referral even for further testing, say the guidelines. The section, on referral and diagnosis, puts the emphasis firmly on action for late AMD (wet active) offering OCT to suspected sufferers and suggesting urgent referrals. These should be within one day but do not need to be emergency referrals. Confirmed cases should be treated within 14 days if suitable.
The AMD guideline spells out information for the public, evidence and history of AMD and provides a series of tools and resources. This goes into bewildering levels of details about the guideline’s formulation covering everything from an equality impact assessment to a list of excluded studies running to over 100 pages.
The consultation clock is running
Perhaps the most pertinent guidance for optometrists is contained in two simple sentences (1.4.11) which says that commissioners and providers should agree a clear local pathway for people with AMD, which should cover referral from primary to secondary care, with direct referral preferred and then discharge from secondary to primary care, covering ongoing management and re-referral when necessary. It is a shame these practical considerations did not make it into NICE’s list of quality statements.
The draft quality standard’s six quality statements
- Adults with cataracts are not refused surgery based on visual acuity alone.
- Adults have case-finding tests in primary care before referral for further investigation and diagnosis of chronic open angle glaucoma (COAG) and related conditions.
- Adults with late age-related macular degeneration (AMD) (wet active) start treatment within 14 days of referral to the macular service.
- Adults with late AMD (wet active) have ongoing monitoring for both eyes.
- Adults with COAG and related conditions have reassessment at specific intervals.
- Adults with AMD or COAG are given a certificate of vision impairment as soon as they are eligible.