Arrangements for the management of urgent retinal detachments in the United Kingdom and Eire in the year 2000: results of a survey.
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PURPOSE: To ascertain the current provision of facilities for the management of vitreo-retinal (V-R) emergencies, and attitudes of V-R surgeons towards the management of V-R emergencies within the United Kingdom and Eire. METHODS: To obtain this information, all 82 consultant members of the Britain and Eire Association of Vitreo-Retinal Surgeons (BEAVRS) were requested to complete a 14-part postal questionnaire in the year 2000. Seventy-eight questionnaires were completed and returned. Data from the questionnaires were collated on a Microsoft Access Database and then statistically analysed using SPSS. The Student's t-test was used to assess relationships between continuous variables, and the Chi-squared and Fisher's Exact tests were used to compare non-parametric data. Analyses of the first 13 parts of the questionnaire are presented in this report. RESULTS: The majority of V-R surgeons (59%) practise in teaching hospitals. There are greater numbers of V-R surgeons per unit in teaching hospitals as compared to District General Hospitals (DGHs). Ophthalmic theatre and ophthalmic theatre staff availability are theoretically high (92.3% and 84.6% respectively) and evenly distributed between teaching hospitals and DGHs, but in reality, access may be difficult. Most V-R surgeons take part in an on-call rota with general ophthalmology colleagues. This formal commitment may be infrequent. Only a small proportion of V-R surgeons (28.3%) officially provide a continuous fixed on-call V-R rota, though in practice, a larger proportion do seem to provide this type of cover informally. Most V-R fellows are located in teaching hospitals (89.5%), and are usually on either a formal or informal on-call rota. Only one unit has a formal continuous on-call rota for fellows allowing no more than 72 hours duty per week. The mean time given in response to the question as to the ideal time within which surgery of an acute macula on supero-temporal retinal detachment should be carried out was 29 hours. Most V-R surgeons would not support, in court, a colleague whose patient lost vision through delay in treating a macula on detachment. CONCLUSIONS: The findings of this survey have important implications for providing a reliable service and for proper cover for doctors in training. (+info)
Characteristics of eye care practices with managed care contracts.
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OBJECTIVES: To describe the variation in practice structure, financial arrangements, and utilization and quality management systems for eye care practices with managed care contracts. STUDY DESIGN: Cross-sectional survey of 88 group and 56 solo eye care practices that contract with 6 health plans affiliated with a national managed care organization. The survey contained modules on practice structure, financial arrangements, utilization management, and quality management. The survey response rate was 85%. RESULTS: Group practices with both ophthalmologists and optometrists were triple the size of ophthalmology-only groups, and 5 times the size of optometry-only groups. Fee-for-service payments were the primary source of group practice revenues, although 60% of groups derived some revenues from capitation payments. Group practices paid their physicians almost exclusively with fee-for-service payments or salary arrangements, with minimal capitation at the individual level. Almost no practices used both capitation and bonuses to compensate providers. Most practices received practice profiles and three fourths were subject to utilization review, which mainly consisted of preauthorization for procedures, tests, or referrals. Nearly all practices used clinical guidelines, protocols, or pathways in managing patients with diabetic retinopathy or glaucoma. Further, nearly all group practices used computerized information systems to assist in delivering care, and most had provider education programs. CONCLUSIONS: Managed care has affected the way eye care providers organize, finance, and deliver healthcare. In general, our findings paint an optimistic picture of eye care practices that contract with managed care organizations. Few practices bear substantial financial risk, and nearly all practices use quality management tools that could help to improve the quality of care. (+info)
Screening for diabetic retinopathy in James Bay, Ontario: a cost-effectiveness analysis.
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BACKGROUND: Retinopathy is a common complication of diabetes mellitus that if detected early by regular retinal examinations can be treated; thus, blindness can be delayed or prevented. Providing high-quality retinal screening is difficult, especially in rural and remote areas. Canada's First Nations population has a higher prevalence of diabetes and is, in general, more geographically isolated than the broader Canadian population. We modelled the cost-effectiveness of retinopathy screening by travelling retina specialists versus retinal photography with a portable digital camera in an isolated First Nations cohort with diabetes. METHODS: The 2 screening programs were modelled to run concurrently for 5 years, with outcomes evaluated over 10 years. To construct economic models for the population of Cree individuals living in the western James Bay area of northern Ontario, we used available data on the prevalence of diabetes in the area and estimates of the incidence of retinopathy derived from the published literature. We compared the screening models and calculated total costs, visual outcome, costs per sight-year saved and costs per quality-adjusted life year (QALY). We also estimated the costs of implementing a screening program for all First Nations individuals in Ontario with diabetes and no access to an ophthalmologist. RESULTS: From the perspective of the health care system the camera program was preferable to the specialist-based program. Over 10 years, 67 v. 56 sight years were saved, compared with no screening, at costs of 3900 Canadian dollars v. 9800 Canadian dollars per sight year and 15,000 Canadian dollars v. 37,000 Canadian dollars per QALY. Generalizing these results to the province of Ontario, the camera system could allow most isolated First Nations people with diabetes to be screened for 5 years for approximately 1.2 million Canadian dollars. INTERPRETATION: A portable retinal camera is a cost-effective means of screening for diabetic retinopathy in isolated communities of at-risk individuals. (+info)
Is ophthalmology evidence based? A clinical audit of the emergency unit of a regional eye hospital.
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AIM: To evaluate the proportion of interventions that are evidence based in the acute care unit of a regional eye hospital. METHODS: A prospective clinical audit was carried out at Hong Kong Eye Hospital in July 2002 to investigate the extent to which ophthalmic practices were evidence based. The major diagnosis and intervention provided were identified through chart review. A corresponding literature search using Medline and the Cochrane Library was performed to assess the degree to which each intervention was based on current, best evidence. Each diagnosis intervention pair was accordingly analysed and graded. The level of best, current evidence supporting each intervention was graded and analysed. RESULTS: A total of 274 consecutive consultation episodes were examined. 22 cases were excluded since no diagnosis or intervention was made during the consultation. 108 (42.9%) patient interventions were found to be based on evidence from systematic reviews, meta-analyses, or randomised controlled trials (RCT). Evidence from prospective or retrospective observational studies supported the interventions in 86 (34.1%) patients. In 58 (23.0%) cases, no evidence or opposing evidence was found regarding the intervention. The proportion of evidence based on RCT or systematic reviews was higher for surgical interventions compared with non-surgical interventions (p=0.007). The proportion of interventions based on RCT or systematic reviews was higher for specialist ophthalmologists than trainee ophthalmologists (p=0.021). CONCLUSION: This study demonstrated that the majority of interventions in the ophthalmic unit were evidence based and comparable to the experience of other specialties. (+info)
Primary care and ophthalmology in the United Kingdom.
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The National Health Service is now primary care led. There are different definitions for primary care and in this review they are analysed and related to ophthalmology to produce a working definition for ophthalmic primary care, summarised as the provision of first contact care for all ophthalmic conditions and follow up, preventive, and rehabilitative care of selected ophthalmic conditions, in a variety of settings, by a diverse workforce. The attributes of primary care are first contact, accessibility, continuity, longitudinality, comprehensiveness, coordination, equity, and accountability. The delivery of ophthalmic primary care should be governed by these and evaluated accordingly. The clinical content of primary care consists of the first presentation of disease, the management of minor illness and trauma, the recurrence of disease, the follow up and support of some chronic conditions, and the delivery of preventive health care. Planning for ophthalmic primary care needs to take service requirements of these categories of disease into account. Primary care research is abundant in ophthalmology but needs to be more structured and targeted. Ophthalmic primary care itself is urgently in need of recognition and formal adoption by the profession. (+info)
Responsiveness of the National Eye Institute Visual Function Questionnaire to changes in visual acuity: findings in patients with subfoveal choroidal neovascularization--SST Report No. 1.
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BACKGROUND: The National Eye Institute Visual Function Questionnaire (NEI-VFQ) measures vision-targeted quality of life, but it is unclear whether it is sensitive to changes within individuals over time. OBJECTIVE: To determine the responsiveness of the NEI-VFQ to "within-individual" changes in visual acuity in patients who had subfoveal choroidal neovascularization in at least one eye secondary to age-related macular degeneration, ocular histoplasmosis syndrome, or idiopathic causes, and who participated in randomized trials of submacular surgery. METHODS: Trained telephone interviewers administered the NEI-VFQ as part of annual follow-up data collection for pilot trials and larger clinical trials of submacular surgery. Best-corrected visual acuity was measured by local vision examiners at 12 months after enrollment and, typically, by central "traveling" vision examiners at 24 months after enrollment. Changes in visual acuity and NEI-VFQ scores from 12 to 24 months were analyzed using linear regression methods. RESULTS: Two-hundred eighteen patients had both interviews and visual acuity measurements at 12 and 24 months after enrollment. Changes in the overall NEI-VFQ score and in 9 of the subscales (near activities, dependency, driving, role difficulties, distance activities, mental health, general vision, peripheral vision, and social functioning) were related to changes in visual acuity of the better-seeing eye based on linear regression analysis (P<.05). In our analysis, a 3-line decrease in the visual acuity of the better-seeing eye was associated with 3.6- to 16.2-point decreases in the overall NEI-VFQ score and 9 subscale scores. CONCLUSIONS: Most of the NEI-VFQ subscales were responsive to changes in the visual acuity of the better-seeing eye over a 12-month interval in this patient population. Thus, the NEI-VFQ can be used to measure change in vision-targeted quality of life over time to augment clinical measurements of visual acuity. (+info)
The incidence of vitreous loss and visual outcome in patients undergoing cataract surgery in a teaching hospital.
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PURPOSE: To determine the incidence of vitreous loss in patients undergoing cataract surgery and the visual outcome in a tertiary teaching hospital. METHODS: Hospital records of 2095 consecutive patients undergoing cataract surgery between July 1999 and June 2000 were reviewed in this non-concurrent cohort study. Incidence and visual outcome of vitreous loss managed using standard vitrectomy techniques were assessed for different cataract surgical techniques (extracapsular, Blumenthal technique and phacoemulsification) as well as at different levels of surgical training. The outcome was compared with matched cases without vitreous loss (controls). RESULTS: Vitreous loss occurred in 160 of 2095 eyes (7.63%; CI -7 to 9.3): 8.3% for ECCE, 8.1% for the Blumenthal technique and 5% with phacoemulsification. Vision > or = 6/18 was achieved in 85% of cases and 95% of controls. For experienced surgeons, 95% of the cases and controls had vision > or = 6/18. 5.8% of cases and 0.7% of controls had vision < 6/60. One patient in each group was blind following cataract surgery; both had operable cataracts in the fellow eye. CONCLUSIONS: The vitreous loss rate in this tertiary teaching hospital is relatively high. This complication, managed with standard surgical techniques, is compatible with good visual outcome. In eyes with vitreous loss, the final visual acuity achieved by experienced surgeons was similar to that in uncomplicated cases. (+info)
Information sources and their use by parents of children with ophthalmic disorders.
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PURPOSE: Parents' input is critical to clinical management in pediatric ophthalmology. The importance of providing parents with appropriate information to enable them to participate effectively is recognized. However, little is known about the range of sources parents use to learn about their child's ophthalmic condition, which sources they find most useful, and how this relates to their understanding. METHODS: Cross-sectional survey of the parents or usual caregivers of children with diverse ophthalmic disorders, diagnosed at least 1 year earlier, who attended pediatric ophthalmology clinics at Great Ormond Street Hospital, London, during 1 week in August 2001. RESULTS: Eighty-nine percent (n = 58) of parents with eligible children participated. Most parents received information from more than one source, with ophthalmologists (79%) and family practitioners (42%) being the two most frequently reported. Family support groups and voluntary organizations (29%) and the Internet (23%) were less commonly cited than anticipated. Parents reported receiving verbal information much more frequently than written information from professionals working with their children. Although 72% (n = 42) of parents could correctly name their child's diagnosis, only 46% (n = 27) were able to describe correctly the nature and impact of the disorder(s). Ophthalmologists were ranked as the most important source overall. CONCLUSIONS: The findings emphasize the key role of ophthalmic professionals in improving parental education directly, as well their responsibilities and opportunities to do so through supporting and shaping information provision through other sources, especially colleagues in primary care and the Internet. (+info)