Glaucoma specialist email advice service (GSEAS)

Background

Ophthalmology is one of the busiest outpatient service specialties in England; providing over 7.5 million NHS (National Health Service) appointments annually ¹ which is projected to increase amidst the ongoing COVID-19 pandemic. Glaucoma is the leading cause of irreversible blindness worldwide and second most common cause for visual impairment registration in England and Wales.^2,3 Glaucoma refers to optic neuropathies characterised by retinal ganglion cell loss; resulting in peripheral and central visual field defects due to raised intraocular pressure. ³ Glaucoma thus represents a high-volume and high-impact condition.

Assessment of problems

NHS initiative “Getting It Right First Time” (GIRFT) is designed to assess disease burden across ophthalmology services and develop new ways of working to improve care, experience, and choice.^1,4 Its 2019 report of Moorfields Eye Hospital revealed 145,000 delayed patient episodes, of which 5,251 were glaucoma patients lost to follow-up.^1,5 According to the Healthcare Safety Investigations Branch (HSIB) 2020 report, timely monitoring of glaucoma patients is a national patient safety risk ⁶ ; with British Ophthalmological Surveillance Unit (BOSU) research suggesting over 250 patients annually suffer from avoidable sight loss due to delays. ⁶ This has led to GIRFT instituting strict referral criteria in line with 2017 NICE glaucoma guidance, referral filtration schemes, virtual services, and adopting a multidisciplinary approach. ⁷ COVID-19 has led to considerable service loss, ⁸ to which there is great need to generate new avenues using teleophthalmology.

York and Scarborough Teaching Hospital NHS Foundation Trust (YSTHNFT) have an established virtual glaucoma clinic. ¹⁰ Patients with stable glaucoma attend clinics for data capture, with images assessed asynchronously by clinicians and results communicated by letter. ⁹ At YSTHNFT, an adjunct Glaucoma Specialist Email Advice Service (GSEAS) was created in August 2019 alongside the virtual clinic for stakeholders (patients, carers, primary care, pharmacists, and optometrists). Previous correspondences between service users and clinicians were one-sided and fragmented; letters taking several days to arrive and offering impersonal advice. ¹⁰ Service users may also find difficulty contacting an on-call ophthalmologist, or enquiries may be inappropriate or deemed non-urgent. Email advice services allow for query responses within hours to days. To mitigate the risk of visual loss and COVID-19, 80–90% of routine hospital eye service (HES) activity was postponed during the pandemic with additional work provisioned in the community. ¹¹ Thus, there is now a greater need for improved connectivity.

A similar email service has been implemented by the gastroenterology team at Imperial Healthcare NHS trust. ¹⁰ Our study aimed to determine the efficacy of a GSEAS, quantitatively through email correspondences and subjectively by satisfaction questionnaire.

Methods

The GSEAS was publicised by word-of-mouth. Correspondences were extracted from the email inbox from January to December 2020 by five clinicians. Data collected included service user type, source of instigation, nature of enquiry, outcome and actions. Standards from the Imperial Healthcare NHS Trust study were adopted. ¹⁰ Each email correspondence was individually coded using the following outcomes:

Percentage of enquires answered within two working days

Outpatient appointment avoided by enquiry

Streamlining of patients’ care – actions taken other than advice

Service users who accessed the GSEAS within this time frame were invited to a follow-up satisfaction questionnaire. Questions were designed in a Likart scale ¹⁴ 1–10 format based on the family and friends test ¹³ and data was collected by two clinicians. Patients were asked to quantitatively rate their experience of the GSEAS by the following domains:

1. Speed of response

2. Satisfaction from response

3. Did it solve their problem?

4. Did they find this service useful?

5. Would they recommend it to others

6. Free text box for comments and recommendations

Results

The GSEAS generated 126 enquiries from 62 different service users, averaging ten per month. 65 enquiries were from patients (51.6%), followed by 13 from nurses (10.3%). Primary care admin teams (8.7%) and other colleagues within HES (8.7%) generated 11 enquiries each, community optometrists nine enquiries (7.1%), general practitioners seven enquiries (5.5%) and pharmacists four enquiries (3.2%). One regional eye unit used GSEAS once (0.8%). Of 126 enquiries, 116 (92.0%) required a response. Of the 116 queries, 109 (93.9%) were responded to within two working days and one was responded to on 3^rd working day (0.9%). The remaining six (5.2%) whilst not formally responded to, had evidence in their medical records of actioned enquiries.

Of 126 email enquiries, 95 (75.4%) were “true” queries which had been solved. Three requests (2.3%) were unclear without additional information and 28 (22.2%) were “not true” queries such as confirmation of appointments or emails thanking the HES. Of 98 “true” queries, 16 (16.3%) required action other than written advice. Enquiry themes included managing red eye, administering medications, referrals to the on-call ophthalmologist and chasing appointments. Practical solutions to enquiries included appointment expedition, referrals and posting prescriptions. Appointment expedition was the most common action with 11 of 16 (68.8%) and referrals to vitreoretinal and wet AMD services were second most common, 3 of 16 (18.7%). In 75% of GSEAS enquiries, a possible outpatient appointment was avoided. In one circumstance, an action included use of video consultation, avoiding a face-to-face appointment.

Of 62 service users, 25 (40.3%) had completed the satisfaction questionnaire. ¹³ All respondents (100%) would recommend the GSEAS and agreed it had solved their query. Response times had a mean score of 9.4 (upper value 10, lower value 8), response satisfaction 9.88 (upper value 10, lower value 9) and response usefulness 9.72 (upper value 10, lower value 8). One user commented on its user-friendliness; “Emailing my consultant was easier than ringing the department. It was also useful to have the reply in writing.” A second user commented on time saved; “It saved travel and wait time to or at hospital…” A third user commented on repeated use of GSEAS; “I have used [GSEAS] when there has been a clear deterioration in my eye, for reassurance as to whether a symptom was normal and to confirm appointment dates. It has felt especially supportive during the pandemic period.” Finally, one user commented on how GSEAS improved patient involvement; “Being thoroughly communicated to gives a sense of involvement and reduces feelings of passiveness”.

Discussion

We have demonstrated GSEAS improves communication to service users with high satisfaction. However, its usefulness is not limited to a state funded health service. In fact, authors DB, JL and PA have implemented similar approaches in their respective private practices with expanded utility for accepting referrals and communication with primary care and insurance companies.

Sixty-two different service users generated 126 enquiries, highlighting continued engagement. Albeit promising, this was a relatively small number of users given the larger case load of glaucoma patients in addition to other service users. Although this is a study limitation, over time the GSEAS may mature. Increasing engagement other than by word-of-mouth such as social media platforms and embedding the service email in patient and primary care correspondence has been utilised. Another limitation is some patients may lack internet or email access, or a patient's glaucoma is too disabling to render an email service usable, contributing to selection bias. A formal telephone line complementing GSEAS has subsequently been set up to improve accessibility for advanced glaucoma patients or those without internet. Developing a GSEAS two-way platform can help further minimise outpatient appointments, as at present it is a one-sided communication platform. Furthermore, no formal stratification tool for patients were in place for GSEAS. Patient stratification into low, medium and high-risk groups help determine which queries require an urgent response. Over time, this enables the GSEAS service to be safely targeted to the most appropriate user group, increasing capacity to monitor high-risk patients face-to-face. Moreover, it is unclear where enquiries originate from within the YSTHFT region. Recording location demographics such as postcode will help target service users, facilitating better engagement. With respect to feedback, the glaucoma team invited each user to complete a survey often sometime after initial query. Designing an automated service within a shorter timeframe post-query allows for service users to better recollect experiences of the GSEAS, minimising recall bias.

Current enquiries were responded to by five clinicians within the glaucoma HES. In-house training should be employed for allied healthcare professionals and non-clinical staff to expand the GSEAS, which may be time-consuming and costly, particularly for non-clinical staff with high turnover. One benefit is clinical queries can be triaged for an appropriate clinician response, such as management of red eye, whereas prescription or appointment queries may be appropriately triaged to clerical staff, saving time and resources. This is one small example of non-ophthalmologist involvement within the HES in line with the “Way Forward Report” recommendations. ¹² Expansion of GSEAS to other sub-specialties may be useful for identifying common issues across ophthalmology. In the future a pan-specialty advice service could be considered particularly in specialties with high volume outpatient work such as dermatology. ¹⁵ Support from senior management and clinical leads within hospital is essential to facilitate new service development.

Traditional methods of dealing with current backlogs include running additional clinics and recruitment of further ophthalmologists. These are however labour intensive and costly. An online advice service is therefore an effective, affordable resource in the assessment of new referrals or following up some glaucoma patients. A cost-benefit analysis is however required to validate study findings.

At YSTHNFT, we demonstrated GSEAS can bridge communication between service users and the HES. GSEAS has been a novel and cost-effective method of meeting demand with utility to both public and private healthcare services. This study has good potential to contribute to a model of decentralised ophthalmic care and we hope other ophthalmology services globally adopt similar approaches for service improvement.