Feature, Report

An invaluable tool in a holistic eyecare model

In the same way OCT should not be used in isolation to assess glaucoma, Specsavers’ nationwide OCT rollout also should not be considered on its own.Instead, it should be viewed as just one component amongst a series of significant investments in equipment, technology, training, IT, data and collaboration strategies designed to detect eye disease at prevalence rates on a whole-of-population basis.

Specsavers is charting new territory with the routine use of OCT in a progressive initiative that the sector is watching with interest. We want to take this important opportunity to explain our philosophy, approach and subsequent success.

The OCT rollout commenced following the completion of a 2017 multisite pilot, in which the resulting data showed use of the technology on every patient, as part of a comprehensive eye examination, led to better patient outcomes for detection of the major causes of avoidable blindness.

Once we had this information it was clear we had a duty to make OCT available to everyone and help move the needle on some poor national eye health statistics. Today, our OCT rollout is the only scaled evidence-based solution to impact – as an important example – the detection of undiagnosed glaucoma within an optometric patient base.

Specsavers has since invested more than $30 million to provide routine access to OCT. As of 1 August, 325 of Specsavers’ 380 Australian and New Zealand stores are live with a Topcon 3D OCT-1 Maestro, which also provides digital fundus photography. Completion of the national rollout is on track for the end of the year.

Numbers talk

The numbers speak for themselves. During the past 12 months more than 3.5 million eye examinations have been performed, with more than 190,000 referrals for avoidable and treatable causes of blindness – a rate of around 6%.

Importantly, 38,870 of those have been referred to ophthalmology for glaucoma, which is 16,659 – or 57% – more than the preceding year. It is important to consider why an increase on this scale is critical as we attempt, as a profession, to identify all those in the population with glaucoma.

While consistent use of OCT on every patient forms the basis of these enhanced figures, it would be a mistake to attribute this to OCT alone. It also involves ophthalmology-led training on systematic application of the RANZCO referral guidelines, optometric assessment, relevant diagnostic tests and monthly benchmark reporting direct to each optometrist.

The central topic of debate is: ‘Does the addition of OCT to the standard eye examination improve detection of glaucoma?’. To date, the best available international evidence is the publication of Specsavers data relating to 6 million patient outcomes in the inaugural 2018 State of the Nation Eye Health Report.

As the most in-depth examination of Australian and New Zealand eye health, it demonstrates consistent application of OCT within an optometric consultation results in improved glaucoma detection rates to a level that aligns with internationally published prevalence rates for the condition, including the Blue Mountains study.

In essence, Specsavers is spearheading a world-first solution to find the 50% of undiagnosed glaucoma in the community. Further aligning with this well-established metric, our statistics show 51% of those now referred to ophthalmology are new glaucoma suspects being referred for the first time.

Additionally, new Specsavers-commissioned research has shown that the benefit to cost ratio, on a prevalence-weighted average, from OCT screening is 4.65:1. With some caveats, it would only require an OCT machine ($50,000) to successfully identify one or two cases of glaucoma, AMD or diabetic retinopathy to pay for itself from a societal point of view in terms of prevented vision impairment.

Dispelling the mythSpecsavers’ optometrists practice a complete a gamut of assessments before considering the diagnosis and communicating the overall conclusion to the patient. Dr Angelica Ly, from the Centre for Eye Health, is correct when she identifies OCT should not be used in isolation to assess patients for glaucoma and other ocular diseases.

For example, it is well known that glaucoma is a complicated condition requiring the use of multiple pieces of technology and professional judgement to accurately assess an individual’s risk.As such, each time a patient visits a Specsavers practice they go through a pre-examination process where a clinical assistant completes a 3D-widefield OCT scan that captures the disc and macula areas as well as a digital retinal photograph, followed by non-contact tonometry and then autorefraction, autokeratometry and, with many stores, pachymetry.

Specsavers follows the medical model of delegated responsibly to efficiently obtain high quality images. All practices have trained personnel operating OCT. During the rollout, training is provided by expert technicians of the local distributers, according to protocols developed by the Specsavers optometry team in conjunction with the instrument manufacturer.

Based on these scan results and the patient’s history, the optometrist considers the need for a threshold visual field. Making referrals on a volume basis means working to an agreed set of guidelines; so Specsavers was an eager collaborator and adopter of RANZCO’s referral guidelines when they were formally introduced in 2017. These guidelines ensure consistency and that our referrals are made on an agreed basis, not on a whim.

Adhering to the guidelines, a functional assessment for glaucoma is performed based on family history, intraocular pressure, structural abnormality of the disc or nerve fibre layer.

Collecting this clinical information prior to the consultation allows the optometrist to conduct a well-informed examination. This begins with the optometrist engaging with the patient to gather their history and understand their needs followed by visual assessment, refraction, anterior and posterior eye assessment, communication of findings, recommendations and collaborative development of a managent plan.

Setting the benchmark

If the combination of the pre-examination results, visual field and findings during the examination suggest a significant risk of glaucoma in line with the guidelines then, in discussion with the patient, a referral is made to an ophthalmologist and possibly Glaucoma Australia.

This is facilitated by the Oculo eReferral platform that is integrated with our record managent system. With the press of a button the relevant clinical information is sent to the ophthalmologist. Both the patient and optometrist receive a notification when the referral is accepted by the specialist and an appointment is made. The feedback loop within the system also allows the ophthalmologist to return reports back to the optometrist and confirm or correct the initial diagnosis.

This is important. Any strategy is only as good the individuals responsible for delivering it. Our optometrists need to be informed on how they are tracking personally on detection and referral rates in comparison to the market benchmarks and their colleagues.

Additionally, optometrists are provided with weekly ‘Professional Benchmark Reports’ that set out an easy-to-read summary of how they are personally tracking.

To further support optometrists professionally, the annual Specsavers Clinical Conference hosts leading ophthalmologists from Australasia to present clinical information on appropriate detection and referral of the major causes of avoidable blindness.

This is supplented with online learning resources targeted at improving detection rates. Last year Specsavers also introduced the Ophthalmologist Local Education and Engagement Program (OLEEP), which sees local in-practice ophthalmology-led training sessions on use of RANZCO referral guidelines and related clinical skills development.

This is unique professional development collaboration between Specsavers and RANZCO tracks the improvent in patient outcomes following the series of education sessions. Each session involves reflection on both individual and group changes in referral patterns and patient outcomes using Specsavers’ professional benchmark summaries. The pilot of this program has already demonstrated improved detection rates for glaucoma.

Finally, it is not enough simply to say we are improving health outcomes – we know that we must be able to demonstrate measurably what those outcomes are and how we are producing them.

It is also incumbent on us – as a business, as a major provider under Medicare and as a significant contributor to eye health outcomes in Australia – to report on our progress against all of the major conditions and disease types, while proving the value of optometry in the publicly funded health system.

The base document for this has been the Specsavers State of the Nation Eye Health Report. With a clear and growing dataset, we can measure, further refine and strategise activity to target the next phase of improved health outcomes – a virtuous circle in eye health.

About the Author

Peter Larson, Group Eye Health Stratery Director

Peter is Specsavers’ global group eye health strategy director. In this newly created role, he will implent the integrated eyecare model, pioneered in Australia and New Zealand, across all of Specsavers’ international markets.