Glaucoma

1. v Glaucoma Implementing NICE guidance Slide set updated May 2011 NICE clinical guideline 85

2. What this presentation covers • Background • Scope • Key priorities for implementation • Costs and savings • Discussion • Find out more • NICE Quality standard

3. Background • Chronic open angle glaucoma (COAG) is a common and potentially blinding condition, and is usually asymptomatic until advanced • Ocular hypertension (OHT) is a major risk factor for developing COAG • Approximately 10% of UK blindness registrations are attributed to glaucoma • By implementing this guideline more people will be prevented from going blind

4. Scope • The diagnosis and management of people with COAG and OHT in community, primary care, secondary care outpatient and day treatment services and tertiary care specialist services for people in the following groups: • adults (18 and older) with a diagnosis of COAG or OHT • people with chronic open angle glaucoma or ocular hypertension associated with pseudoexfoliation or pigment dispersion • people who have a higher prevalence of glaucoma and may have worse clinical outcomes

5. Key priorities for implementation

6. Diagnosis • At diagnosis offer all people who have COAG, who are suspected of having COAG or who have OHT all of the following tests: • intraocular pressure (IOP) measurement using Goldmann applanation tonometry (slit lamp mounted) • central corneal thickness (CCT) measurement • peripheral anterior chamber configuration and depth assessments using gonioscopy • visual field measurement using standard automated perimetry (central thresholding test) • optic nerve assessment, with dilatation, using stereoscopicslit lamp biomicroscopy with fundus examination

7. Diagnosis • Ensure that all of the following are made available at each clinical episode to all healthcare professionals involved in aperson’s care: • records of all previous tests and images relevant to COAG and OHT assessment • records of past medical history which could affect drug choice • current systemic and topical medication • glaucoma medication record • drug allergies and intolerances

8. Monitoring Monitor at regular intervals people with OHT or suspected COAG recommended to receive medication (see ‘Treatment for people with OHT or suspected COAG’), according to their risk of conversion to COAG (see next slide)

9. Monitoring intervals for peoplewith OHT/suspected COAG recommended to receive medication

10. Monitoring Monitor at regular intervals people with COAG according to their risk of progression to sight loss (see next slide)

11. Monitoring intervals for people with COAG

12. Treatment for people with OHT or suspected COAG Offer people with OHT or suspected COAG with high IOP treatment based on estimated risk of conversion to COAG using IOP, CCT and age (see next slide)

13. Treatment for people with OHT or suspected COAG BB: betablocker PGA: prostaglandin analogue

14. Treatment for peoplewith COAG • Offer people newly diagnosed with early or moderate COAG, and at risk of significant visual loss in their lifetime, treatment with a prostaglandin analogue • Offer surgery with pharmacological augmentation (mitomycin C [MMC] or 5-fluorouracil [5-FU]) as indicated to people with COAG who are at risk of progressing to sight loss despite treatment. Offer them information on the risks and benefits associated with surgery

15. Organisation of care • Refer people with suspected optic nerve damage or repeatable visual field defect, or both, to a consultant ophthalmologist for consideration of a definitive diagnosis and formulation of a management plan • People with a diagnosis of OHT, suspected COAG or COAG should be monitored and treated by a trained healthcare professional who has all of the following: • a specialist qualification (when not working under the supervision of a consultant ophthalmologist) • relevant experience • ability to detect a change in clinical status

16. Provision of information Offer people the opportunity to discuss their diagnosis, prognosis and treatment, and provide them with relevant information in an accessible format at initial and subsequent visits

17. Costs and savings per 100,000 population

18. Costs and potentialresource shift • Recommendations in the following areas may result in additional costs depending on local circumstances: • more regular monitoring and treatment of people with OHT or suspected COAG • surgery for people who have COAG progression despite treatment as a result of improved sequential data • potential resource shift from hospital eye services to community (where appropriate) as a result of increased monitoring of people with OHT and suspected COAG

19. Discussion • How effective are local diagnostic services? • What changes might we need to make to achieve the monitoring intervals for each patient group? • What are the options that local commissioners might consider for delivering this guideline? • How are patient information needs currently met?

20. Find out more • Visit www.nice.org.uk/CG85 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • NICE Pathway • costing report and template • audit support • commissioning guide • online educational tool • Glaucoma Quality Standard can be found atwww.nice.org.uk/guidance/qualitystandards/glaucoma/Home.jsp

21. NICE Quality Standard Glaucoma www.nice.org.uk/guidance/qualitystandards/glaucoma/Home.jsp

22. Quality standards • A quality standard is a set of specific, concise statements that: • act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment and prevention • are derived from the best available evidence such as NICE guidance or other NHS evidence accredited sources and produced collaboratively with the NHS and social care, along with their partners and service users.

23. Glaucoma quality standard • The glaucoma quality standard consists of 12 statements that describe the care for people with chronic open angle glaucoma (COAG), suspected COAG or ocular hypertension (OHT). • Desired outcomes are to: • enhance the quality of life for people with COAG • ensure people have a positive experience of care • treat and care for people in a safe environment • contribute to a reduction in Certificate of Visual Impairment registration rates for glaucoma.

24. Quality statement 1- Referral • People are referred to a consultant ophthalmologist for further assessment and definitive diagnosis if the optometrist or other healthcare professional suspects COAG. There are local agreements in place for referral refinement. Quality measure Process: a) Proportion of people in whom an optometrist or other healthcare professional suspects COAG who undergo further assessment with referral refinement. b) Proportion of people who undergo referral refinement who are subsequently referred on to a consultant ophthalmologist for definitive diagnosis because COAG is suspected.

25. Quality statement 2 - Referral • People with elevated IOP alone are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG. There are agreements in place for repeat measures. Quality measure Process: a) Proportion of people with elevation of IOP alone, who are referred for repeat measures to an appropriately qualified healthcare professional. b) Proportion of people with confirmed elevation of IOP alone, who are referred to an appropriately qualified healthcare professional for further assessment on the basis of perceived risk of progression to COAG.

26. Quality statement 3 - Diagnosis • People referred for definitive diagnosis in the context of possible COAG or with OHT receive all relevant tests in accordance with NICE guidance. Quality measure Process: Proportion of people referred for definitive diagnosis in the context of possible COAG or with OHT who attend and receive all relevant tests in accordance with NICE guidance.

27. Quality statement 4 – Diagnosis and management plan • People with COAG, suspected COAG or with OHT are diagnosed and have a management plan formulated by a suitably trained healthcare professional with competencies and experience in accordance with NICE guidance. Quality measure Process: a) Proportion of people with COAG, suspected COAG or with OHT who are diagnosed by a suitably trained healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance. b) Proportion of people with COAG, suspected COAG or with OHT who have a management plan formulated by a healthcare professional with competencies and experience in the relevant condition in accordance with NICE guidance.

28. Quality statement 5 - Monitoring • People diagnosed with COAG, suspected COAG or with OHT are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance. Quality measure Process: Proportion of people with COAG, suspected COAG or with OHT who are monitored at intervals according to their risk of progressive loss of vision in accordance with NICE guidance.

29. Quality statement 6 - Management • People with suspected COAG or with OHT are managed based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance. Quality measure Process: a) Proportion of people diagnosed with suspected COAG or with OHT who are assessed for treatment eligibility based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age. b) Proportion of people diagnosed with suspected COAG or with OHT who are eligible for treatment based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, who are managed in accordance with NICE guidance.

30. Quality statement 6 – Management cont. • People with suspected COAG or with OHT are managed based on estimated risk of conversion to COAG and progression to visual impairment using IOP, CCT and age, in accordance with NICE guidance. Quality measure Process: c) Proportion of people diagnosed with suspected COAG or with OHT at low risk of progressing to visual impairment who receive no treatment in accordance with NICE guidance.

31. Quality statement 7 – Stopping treatment • People with COAG, suspected COAG or with OHT have a regular review of management options with their healthcare professional, taking into account comorbidity and other changed circumstances, including a discussion of the benefits and risks of stopping treatment for those at low risk of progressing to visual impairment. Quality measure Process: a) Proportion of people with COAG, suspected COAG or with OHT who have a regular review of management options with their healthcare professional taking into account comorbidity and other changed circumstances. b) Proportion of people with COAG, suspected COAG or with OHT at low risk of progressing to visual impairment who have a discussion of the benefits and risks of stopping treatment.

32. Quality statement 8 – Service capacity • People diagnosed with COAG, suspected COAG or with OHT have access to timely follow-up appointments and specialist investigations at intervals in accordance with NICE guidance. Sufficient capacity is put in place to provide this service, and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed. Quality measure Process: a) Proportion of people with COAG, suspected COAG or with OHT who have access to timely follow-up appointments and specialist investigations at appropriate intervals in accordance with NICE guidance. b) Proportion of people with COAG, suspected COAG or with OHT, whose appointment has been cancelled, delayed or missed who have their clinical priority assessed.

33. Quality statement 8 – Service capacity cont. • People diagnosed with COAG, suspected COAG or with OHT have access to timely follow-up appointments and specialist investigations at intervals in accordance with NICE guidance. Sufficient capacity is put in place to provide this service, and systems are developed to identify people needing clinical priority if appointments are cancelled, delayed or missed. Quality measure Process: c) Proportion of people with COAG, suspected COAG or with OHT whose cancelled, delayed or missed appointment is rescheduled within an appropriate time interval.

34. Quality statement 9 - Documentation • Healthcare professionals involved in the care of a person with COAG, suspected COAG or with OHT have appropriate documentation and records available at each clinical encounter in accordance with NICE guidance. Quality measure Process: Proportion of people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) whose documentation and records are available to healthcare professionals at each clinical encounter.

35. Quality statement 10 - Surgery • People with COAG who are progressing to loss of vision despite treatment or who present with advanced visual loss are offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated and information on the risks and benefits associated with surgery. Quality measure Process: a) Proportion of people with COAG who are progressing to loss of vision despite treatment or who present with advanced visual loss who are offered surgery with pharmacological augmentation (for example, MMC or 5FU) as indicated. b) Proportion of people with COAG offered surgery because they are progressing to loss of vision despite treatment or who present with advanced visual loss, who receive information on the risks and benefits associated with surgery.

36. Quality statement 11 - Information • People with COAG, suspected COAG or with OHT are given the opportunity to discuss their diagnosis, prognosis and management, and are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance. Quality measure Process: Proportion of people with COAG, suspected COAG or with OHT who are given the opportunity to discuss their diagnosis, prognosis and management and who are provided with relevant and accessible information and advice at initial and subsequent visits in accordance with NICE guidance.

37. Quality statement 12 - Discharge • People with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable are discharged from formal monitoring with a patient-held management plan. Quality measure Process: Proportion of people with suspected COAG or with OHT who are not recommended for treatment and whose condition is considered stable who are discharged from formal monitoring with a patient-held management plan.

38. What do you think? • Has this implementation tool met your requirements, and will it help you to put the NICE guidance into practice? • We value your opinion and are looking for ways to improve our tools. Please complete a short evaluation form by clicking here • If you are experiencing problems accessing or using this tool, please email implementation@nice.org.uk To open the links in this slide right click over the link and choose ‘open hyperlink’