When Specsavers optometrists electronically refer patients for specialist glaucoma assessment, the referral contains a mandatory classification into one of three categories: ‘new assessment’ for patients who are newly diagnosed by the optometrist and have never been seen by an ophthalmologist; ‘glaucoma review’ for patients with existing confirmed glaucoma; and ‘suspect review’ for those who have seen an ophthalmologist before due to high risk factors, but haven’t been diagnosed with the condition.

Implemented by Specsavers in 2018 to align with the RANZCO Referral Pathway for Glaucoma Management, the classification works by encouraging optometrists to be clear with their rationale for referrals, specify urgency judiciously and promote clear patient communication relating to the referral. This data is also providing valuable insight into clinical assessments that occur for patients before the point of diagnosis – a critical period in terms of clinical decision making and optometric management plans.

Since 2018. glaucoma referral data shows approximately 50% of patients are referred as a ‘new assessment’, 30% ‘glaucoma review’ and 20% ‘suspect review’. In 2020, 8,355 referrals were made for patients classified ‘suspect review’ across Australia. This is a group of patients who have enough clinical risk factors (or progression of risk factors) to lead an optometrist to recommend an ophthalmologist assessment for glaucoma.

Here, we outline observations specific to ‘suspect review’ patients, including feedback from ophthalmology, optometric attendance and recall response rates.

False positives

Since 2019, Specsavers has been working with e-referral platform Oculo and many ophthalmologists in Australia to obtain feedback on glaucoma referrals and identify the rate of false positives following specialist assessment.

The feedback can be linked to the referral classifications mentioned above and adds further context to referrals for ‘suspect review’ glaucoma patients.

Reviewed from 2019-2020, a subset of 784 referrals from ophthalmologists gave patients one of three diagnoses: ‘glaucoma’; ‘glaucoma suspect’ for patients in whom glaucoma was probable but progression had not been confirmed; or ‘no glaucoma’ which indicated the referral was false positive.

Of the referrals classified by optometrists as ‘suspect review’, 87% were confirmed to have definite or probable glaucoma with the remaining 13% deemed false positive. This is a strong indication of alignment between optometry and ophthalmology when it comes to the index of suspicion for glaucoma but also highlights that a formal diagnosis is not the predestined outcome for all suspects. In fact, 42% of ‘suspect review’ referrals remained ‘glaucoma suspects’ after ophthalmological review.

While collaborative care is often discussed in the context of diagnosed patients, this feedback data exemplifies the joint role of optometry and ophthalmology in monitoring suspects and that the lead up to a glaucoma diagnosis is not always clear cut, with every scheduled review playing an important role in determining and adjusting the management plan for the individual.

Optometric monitoring of glaucoma suspects

Analysis of retrospective data from 2018 until the end of 2020 shows 81% of patients referred with a ‘suspect review’ classification in 2020 had visited an optometrist at least once in the two-year period leading up to their referral.

Nearly half (46%) of these patients had attended consecutive annual appointments in the preceding two years. This reveals that the vast majority of glaucoma suspects were being closely monitored by an optometrist prior to their point of referral, closely aligning with the recommendations in the RANZCO Referral Pathway for Glaucoma Management.

In addition, 43% of the glaucoma referrals classified ‘suspect review’ in 2020 were issued as part of continued collaborative care. This means they were repeat referrals for patients already referred as ‘suspect reviews’ in the preceding two years.

Seventy-four per cent of referred ‘suspect review’ patients in 2020 were recommended to return for ongoing care in a timeframe between six to 12 months from their eye test date. This figure indicates the degree of caution that optometrists exercise for a sight-threatening disease that has potential to progress at varying rates, with little to no symptoms.

Recall communications

Ensuring clear recall communication is crucial so patients are informed of their need to return for assessment and the reasons for their recommended appointment. This is particularly important for patients where a diagnosis is not yet confirmed as they might not understand the potential risks of missing an optometrist visit. Other considerations such as timing and frequency of reminders, format, communication channel and language, are all reported to have an influence on patient engagement and return rates.

Specsavers’ recall communication system gives optometrists the opportunity to sign patients up to a specific glaucoma recall at their appointment. This sees patients receiving a series of relevant glaucoma-related reminder notices, the first arriving in time for the optometrist’s recommended follow up date. This function is used for any patient who requires an ocular health follow up due to risk of or confirmed glaucoma.

A combination of email, SMS and letters are used based on patient preference, available contact details and appropriateness. The personalised messaging clearly identifies the reason for the recall and, as the notices continue, whether the patient’s assessment is due or overdue. This personalised, condition-specific messaging continues to be a point of focus, with ongoing testing showing more effective engagement when the messaging is specific to a patient’s needs, as compared to standardised communications.

On 30 March 2020, Specsavers began operating under an urgent and essential care model, following government guidelines brought about by the national spread of COVID-19. As part of this, all recall communications paused, including glaucoma recall. While practices were available to assist patients with glaucoma who proactively requested an assessment, routine reviews were not undertaken. This, of course, had ramifications for those being monitored for risk of glaucoma.

After receiving advice from health department guidelines in May, and reopening in a modified COVID-safe practice environment, a gradual re-establishment of the recall system began. Modifications were required to prioritise patients with heightened risk of eye disease, including those who had been designated a glaucoma or diabetes recall by their optometrist.

The return attendance rates across 2020 for patients who received a glaucoma recall can be seen in the graph below. There was a relatively quick recovery to pre-COVID recall response rates for younger patients. Interestingly, the data shows those over the age of 65 responded at a slower pace initially but ended up returning in significantly higher numbers as 2020 progressed.

A year-on-year response rate comparison against the same dataset in 2019 showed that while responses for those aged under 39 remained steady, increases in return rates for those between 40-64 and over 65 increased. Most notably, return attendance rates increased by 5% for those over the age of 65.

While there could be many explanations for this change in behaviour, one might attribute this to a combination of increased health awareness post-pandemic lockdowns, pent-up demand, and an increasing sense of trust and security as COVID-safe environments became normalised, particularly for this vulnerable population.

Communication regarding COVID-safe optometry protocols have become a crucial part of patient communication for practices and something that can help to provide comfort to patients and enhance compliance.

The recovery, and in some cases improved appointment attendance rates for glaucoma patients, has demonstrated the importance of timely reminders and a considered approach to recalling those at risk of progressive eye conditions.

This analysis reveals trends which provide some visibility of the less linear aspects of glaucoma detection and management. As the data shows, many glaucoma suspects enter into collaborative care after a period of close monitoring by an optometrist. However, their outcome is not predetermined. A significant proportion remain as glaucoma suspects for prolonged periods of time and rely on a robust system of communication and collaborative care for timely intervention.

Despite significant improvements in response rates in the past few years as evidenced by continued measurement of recall response rates, there is still a way to go to ensuring all patients obtain the care they require.

An example of a communications solution that offers inspiration for this challenge is the KeepSight reminder system in place for people living with diabetes, run by Diabetes Australia in partnership with Vision 2020 Australia, Centre for Eye Research Australia (CERA) and Oculo. It has been co-funded by the Australian Government, Specsavers, Bayer, Novartis and Mylan. KeepSight works as a secondary recall reminder system to Specsavers’ optometrist recall communications, giving third-party endorsement to patients, resulting in higher adherence rates to follow up appointments recommended by optometrists. The early trends concerning patient adherence to recommended appointments for those on the KeepSight database will be described in more detail in future on HealthHub.