Virtual glaucoma clinics: the future of patient management?

Virtual glaucoma clinics were create to allow for rapid and reliable patient assessment. Within these clinics, data is collected by nursing and non-medical staff and is then reviewed virtually by a senior ophthalmologist. However, despite it’s benefits to the healthcare system as a whole, it is vital to confirm that patients are satisfied with this aspect of service delivery and that patient education remains adequate.

Assessing patient satisfaction

A recent study, published in Clinical Ophthalmology, compared patient treatment experience and understanding of glaucoma for the virtual clinic versus the standard clinic. The data collected included standardised history and slit lamp examination, intraocular pressure (IOP), optic disc imaging (Heidelberg Retina Tomograph [Heidelberg Engineering, Heidelberg, Germany], and/or Kowa Non-mydriatic 3D [Kowa Medical, Hamamatsu, Japan]) and Humphrey 24-2 visual fields (Carl Zeiss Meditec AG, Jena, Germany).

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Non-medical staff clinical competencies for slit lamp eye examination, measurement of IOP, interpretation of visual fields, and clinical decision making is based on the same scheme of assessment as for medical ophthalmic trainees using the portfolio system of the Royal College of Ophthalmologists.

In September 2013, all 135 patients reviewed via the virtual clinic from April to August 2013 were sent general and patient satisfaction questionnaires (modified ‘QUality Of care Through the patient’s Eyes’ QUOTE questionnaire, Nijkamp et al) via post. For the control group 100 patients attending standard glaucoma clinics in October 2013 were handed questionnaires at their scheduled clinic appointment.

Data were obtained for demographics, understanding of glaucoma, the patient’s own condition and its management, together with their experience satisfaction (modified QUOTE questionnaire), and quality of information received. Patient responses were analysed in conjunction with clinical record data.

Next: Study results

The demographics of the standard and virtual clinic patients were generally comparable. The questionnaire results were analysed by looking at the analysis of variance (ANOVA). Over a series of questions, patients scored their satisfaction from 1 (very dissatisfied) to 5 (very satisfied).

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Patients were questioned on their diagnosis and treatment and their answers were compared with the doctors’ recorded clinical notes to assess individuals’ understanding of their own condition. A total of 85% of clinic patients and 63% of virtual clinic patients responded to the PSQ and reported an overall mean satisfaction score of over 4.3/5 in all areas. Investigators found that virtual clinic patients’ understanding of glaucoma was very good, with 95% correctly identifying their condition as glaucoma, 83% as ocular hypertension and 78% as suspects. Of note, there was a complete lack of evidence to support inferior knowledge or understanding compared to patients attending a standard clinic.

In the virtual clinic, patients were also handed an information leaflet on glaucoma written by the lead glaucoma consultant (MA) and approved for patient-suitable language. Over 95% of patients found this leaflet useful. Forty percent of patients went on to seek additional information, but less than 20% used the internet for this purpose.

The study identified nine patients who had been started on treatment via the virtual clinic. This new treatment is issued via a treatment recommendation form sent to the patient to take to their general practitioner to alter their prescribing record. They are informed about this process at their initial appointment when their data are collected, receive a telephone call by the glaucoma nurse practitioner to discuss it, and are brought back to clinic for early review. Three patients were identified as requiring trabeculectomy surgery and attended the clinic to confirm and discuss this.

One percent of virtual clinic patients and 17% of standard clinic patients said they would object to receiving a prescription for a new eye drop through the post. Patients are telephoned by the nurse practitioner to initiate a new treatment in addition to the written report and prescription as a result.

Interestingly, there were no statistically significant differences for any parameters on account of age.

Next: A high level of patient understanding

The key finding in this study was the high level of service satisfaction expressed by patients. This satisfaction was high regardless of whether patients were reviewed via the virtual or standard clinic. No evidence supported a hypothesis that patients reviewed virtually rather than in person by a doctor feel they receive an inferior service.

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A high level of diagnosis and condition/treatment understanding was observed across both groups. The majority of patients knew that glaucoma affects the optic nerve, is often caused by high IOP and with treatment vision usually remains good. Although the intricacies of normal tension glaucoma, ocular-hypertension and glaucoma suspects were found to be less well understood, this was concluded by the investigators to be unlikely to impact management concordance.

Patients with advanced glaucoma

The study groups perhaps did not include sufficient numbers of patients with advanced glaucoma to be able to draw specific conclusions on more complex therapeutic decision-making and communication requirements for these patients. However, the additional clinic capacity gained by employing virtual clinic services for less demanding individuals would of course free up more time for those with more complex needs.

Next: Taking the virtual experience to the next level

Virtual clinic models help optimise the use of resources on increasingly busy hospital eye services. As a result, doctors’ time can be prioritized and given to the most complex patients and those at greatest risk of progression. The results of this survey shows that patients seen via virtual clinics do indeed receive adequate information and education about their condition. This information is delivered in the hope that it will help maintain appreciation of the value of follow-up appointment attendance and treatment adherence. It is of course important to regularly confirm the clinical and communication competencies of all staff involved in the virtual experience to maintain a high quality service.

Taken as a whole, these study results suggest that this model of care is acceptable for both new and follow-up patients. However, further cost-benefit analyses and studies investigating optimisation of the care pathway would be highly useful in determining the overall best model of care.