Is telephone review feasible and potentially effective in low vision services?

Abstract

Purpose:

Demographic transformations within the UK population combine to contribute to a substantial increase in demand for low vision (LV) services, creating a pressing need to reconsider the appropriate methods for service provision. In this study, we evaluate the feasibility of using telephone triage to assess the need for, and timing of, LV follow-up appointments.

Methods:

A cohort of new patients attending the LV Clinic at Manchester Royal Eye Hospital (MREH) was recruited, independent of vision or visual impairment (VI) registration status. Four weeks after this initial clinic assessment, each patient was telephoned and a structured review was conducted. All patients were subsequently followed up at 3 months in the LV clinic.

Results:

A total of 52 patients were recruited, with the corrected ‘better-eye’ visual acuity (VA) ranging from 0.18 logMAR (6/9.5 + 1) to 1.36 logMAR (6/152 + 2) with a mean of 0.66 logMAR (6/30 + 2). In total, 36 patients completed all aspects of the study. At telephone review, 70 (93%) of the low vision aids (LVAs) loaned were reported to have been used on at least one occasion. Ten patients (22%) were deemed to not require follow-up, 15 (33%) were judged to benefit from an earlier (1 month) review, and 16 (35%) were judged to require 3-month follow-up. Reminding patients at telephone review provided a significant increase in adherence with advice to bring any loaned devices to clinic review (p < 0.01). Face-to-face clinic review outcomes at 3 months permitted some insight into the effectiveness of telephone triage.

Conclusions:

Implementing telephone review is feasible for triaging LV follow-up requirements. A number of patient issues can be dealt with immediately and effectively at telephone review, potentially negating the need for a face-to-face clinic review for some patients while identifying a more pressing need for earlier review in others, factors that might improve cost-effectiveness of service provision if subjected to formal health economic evaluation.

Keywords

Low vision low vision aid low vision pathway low vision rehabilitation telephone triage

Introduction

Considerable demographic change continues to develop in the United Kingdom at present, with population growth, population ageing, and increased life expectancy all combining to contribute to a substantial increase in demand for low vision (LV) services. In 2008, there were estimated to be 1.3 million people aged 85 years and over, a figure projected to increase to 1.8 million by 2018 (Office for National Statistics, 2009). This considerable shift in demographics will in turn result in an increased prevalence of age-related ophthalmic disease, including age-related macular degeneration (AMD), the primary cause of visual impairment (VI) in the United Kingdom.

VI can have a substantial impact on independence and lifestyle, potentially having a negative effect on a person’s social, educational, psychological, and financial welfare, and unsurprisingly, a strong correlation has been found between VI and reduced quality of life (Chia et al., 2004; West et al., 1997). The primary aim of LV services is to provide rehabilitation, to facilitate maximum effective use of remaining vision, thus providing the skills to maintain as independent a lifestyle as possible. At the same time, the increasing demand for LV care has created a pressing need to reconsider the way in which services might be provided. The appropriate timing and requirement for follow-up review appointments is a major issue requiring further consideration in order to ensure effective use of resources while maintaining the quality of care. There has, however, been no published research on optimal follow-up intervals for LV clinic assessments. Without any clear evidence-based recommendations from research, UK LV clinicians have tended to offer follow-up appointments based on a ‘custom and practice’ approach (arguably reflecting a pragmatic balance between what a clinician might like to offer and what the service capacity permits).

This study is a prospective survey at the LV Clinic, Manchester Royal Eye Hospital (MREH), evaluating whether telephone review is feasible and potentially effective in triaging LV follow-up requirements and supporting the patient in low vision aid (LVA) use. The use of telephone review has been successfully demonstrated in other health-care arenas, providing increased efficiency in outpatient services, while maintaining high patient satisfaction (Anderson, 2010; Beaver, Williamson, & Chalmers, 2010) although the authors are unaware of the use of telephone review in ophthalmology, referral triage excepted.

With respect to effectiveness, this term can be defined as the extent to which a specific intervention, when used under ordinary circumstances, achieves what it is intended to. One such method of assessing effectiveness in LV rehabilitation, while open to criticism, is to evaluate usage rates of LVAs (Hall, Sacks, Dornbusch, & Raasch, 1997; Harper, Doorduyn, Reeves, & Slater, 1999; Humphry & Thompson, 1986; Leat, Fryer, & Rumney, 1994; McIllwaine, Bell, & Dutton, 1991; Nilsson, 1990; Shuttleworth, Dunlop, Collins, & James, 1995; Temel, 1989; Van Rens, Chmielowski, & Lemmens, 1991; Watson, De L’Aune, Long, Maino, & Stelmack, 1997a, 1997b). Evaluations from our own service at MREH have found a high usage rate of LVAs, with at least 90% of LVAs being used by patients, approximately two-thirds of which were used on a daily basis (Harper et al., 1999; Hernandez Trillo, 2007; Lennon & Harper, 2008; Reeves, Harper, & Russell, 2004). Obtaining such information during the telephone review will allow the optometrist to judge how well the patient is progressing with their LVA and what, if any, further intervention is required.

The primary purpose of this study was to assess the feasibility of a telephone review to determine whether such an intervention could be used to triage the need for patient follow-up in order to ensure patients gain access to the service at the most appropriate intervals. A secondary purpose was to evaluate usage rates of LVAs with reference to previous findings from MREH.

Current LV service at MREH

The Optometry Department has locally developed guidelines offering recommendations to optometrists working within the LV clinic. These recommendations include guidance on the expected content of assessments and appropriate follow-up intervals. For example, the LVA assessment should include history and symptoms, discussion of visual needs and goal setting, comprehensive visual function assessment, demonstration of and training with appropriate LVAs, provision of relevant advice, and large print literature, with onward referral to other services where required (e.g. patient support, social/rehabilitation services).

Following the initial visit to the LV clinic, or more usually after a first review appointment at 3 months, a ‘see on symptoms’ (SOS) appointment may be offered, whereby the patient is offered the option to telephone the LV clinic directly to request review.

Methods

Prospective study

The present survey (registered audit 1720, Central Manchester University Hospital’s National Health Service [NHS] Foundation Trust) sampled a consecutive cohort of new patients attending the clinic between 16 January 2009 and 26 March 2009, recruited upon satisfying the following inclusion criteria: first assessment, ≥18 years of age, ability to converse in English, willingness and ability to participate in a telephone review appointment, and loaned at least one LVA.

Patients were deemed eligible for recruitment irrespective of their visual function status or their certificate of VI registration status, although all had to have been referred to the LV clinic. The design and purpose of the survey were discussed with any patient meeting the inclusion criteria. If the patient agreed to participate, written consent was obtained, and they were then invited to undertake the subsequent telephone review appointment. All patients agreeing to participate were provided with a large print (font N16) information leaflet for their reference and encouraged to ask any questions they may have regarding the survey. The LV assessment was otherwise conducted in accordance with local guidelines by a registered optometrist or preregistered optometrist working under the supervision of an experienced, registered colleague.

Approximately 4 weeks after this initial clinic assessment, each patient was telephoned and a structured review was conducted by one of two optometrists (C.P. or J.L.), following the format as detailed in a specially designed pro forma. This telephone review ‘appointment’ involved the following: discussing with the patient the usage of each of their loaned LVAs and any problems they may have encountered, issuing a reminder for them to attend the follow-up clinic appointment with their devices, and providing an opportunity to ask any questions relating to the LV service or rehabilitation support (Figure 1).

Figure 1.

Pathway of study.

To enable assessment of the feasibility of such a method, the duration of the telephone review appointment was recorded in addition to the number of attempts that were made to contact the patient. A maximum of three attempts were made to contact each patient by telephone. All patients, regardless of the telephone review outcome, were subsequently followed up at 3 months in the LV clinic, as is current custom and practice, at which stage the remainder of the survey pro forma was completed. This final section of the pro forma contained details of the following: new devices loaned; advice given to patient; other intervention, that is, referral onto other agencies; and demonstration of video magnification/closed-circuit television (CCTV).

Following recruitment of patients for the prospective survey, a secondary companion sample of patients attending the LV clinic was identified at their 3-month follow-up and a note made of their compliance with the routine request to bring loaned LV devices with them to review appointments. The inclusion criteria for this sample included patients who were ≥18 years of age, were attending their first LV 3-month review, and had been loaned at least one LVA. This sample was obtained prospectively from a series of consecutive LV clinics by the optometrists completing a simple pro forma to indicate whether the patient had brought some or all of their LVAs with them. The purpose of this sample was to judge whether the telephone reminder could be considered to have a positive effect on the proportion of patients attending follow-up with their LVAs. We certify that all applicable institutional regulations concerning the ethical use of human volunteers were followed during this study.

Results

Clinical and biographic details

A total of 52 patients were recruited, 31 (60%) were female and 21 (40%) were male. The mean age was 74 years with a range of 28–93 years. AMD was the primary diagnosis in 36 patients (69%), 10 of whom had additional pathology including glaucoma, cataract, and central retinal vein occlusion. Glaucoma alone was diagnosed in five patients and diabetic retinopathy in a further five patients. Of the remaining five patients, two had congenital eye pathology, two had myopic degeneration, and one had uveitis. The best corrected ‘better-eye’ visual acuities (VAs) of these patients ranged from 0.18 logMAR (6/9.5 + 1) to 1.36 logMAR (6/152 + 2), with a mean of 0.66 logMAR (6/30 + 2). Near VAs without magnification were recorded with the patient’s preferred habitual correction (or otherwise unaided) at their preferred working distance, but without the use of any LVAs. The mean near VA was 1.46M (equivalent of ~N12), with a range of 0.5M (N4 equivalent) to 6.3M (N50 equivalent).

Participant progress in survey

From the total of 52 patients recruited, 46 (88%) participated in the ~1-month telephone review and 43 (83%) attended the ~3-month face-to-face clinic review. There were 36 (69%) patients who completed all aspects of the survey, including both the telephone review and the 3-month clinic follow-up; this relationship is summarised in Figure 2.

Figure 2.

Diagram illustrating patient participation in various aspects of the study.

Telephone review summary

Feasibility of telephone call

A maximum of three telephone calls were made in an effort to contact each participant, resulting in 77 calls being made to the total sample of 52 patients, with 46 (88%) patients completing the telephone review. Of the total sample of 52 patients, 34 (65%) answered the first call attempt, 8 (15%) the second and 4 (8%) the third. All patients whom we contacted were able to successfully complete the telephone interview in full. The remaining 6 patients comprised 5 who could not be contacted by the third call and 1 patient who had died prior to any contact attempt. The mean number of days between the initial clinic assessment and telephone review was 31 days (ranges 13–55). The mean call duration was 4.5 min (ranges 2.5–8.25 min).

Reported LVA usage

During telephone review, patients were questioned on the usage of their new LVAs. A total of 70 (93%) of LVAs loaned were reported to have been used on at least one occasion. Of the five devices reported to not be used at all, one was lost and two had been loaned to a patient with progressive dementia and one patient reported that no appropriate surface upon which to use the stand magnifier was available, and one patient gave no specific reason for non-usage. One device initially reported to be used was returned by the patient shortly after their initial LV assessment, with glare being reported to be too problematic.

Issues raised by patients at telephone review appointment

Patients were given the opportunity to ask questions and report concerns during the telephone review. Advice was provided with problems being addressed over the phone, where possible, and patients being informed that requests for additional LVAs or a change in LVA could be dealt with at their subsequent clinic review appointment.

Completion of telephone review permitted the optometrists (C.P. or J.L.) to make a clinical judgement of the appropriate follow-up review period for each patient. A total of 10 patients (22%) were deemed to not require follow-up at all, 15 (33%) were judged to benefit from an earlier (1 month) review than is custom and practice, and 16 (35%) were judged to require the conventional 3-month follow-up (i.e. as in accordance with current practice). The remaining five patients were considered to require a longer follow-up at 6 months (four patients) and 1 year (one patient).

Three-month clinic review outcomes

Forty-three patients out of the possible 52 attended the 3-month clinic review (Figure 2). In accordance with Trust policy, each patient was sent a total of three appointment letters if they failed to attend previous appointments. One patient died subsequent to the initial LV assessment, and the remaining eight patients who did not attend comprised the following: one who was followed up elsewhere by another provider, two patients ‘lost to follow-up’, two patients who failed to attend after three appointments had been offered, with the remaining three patients cancelling their appointments.

Patient adherence with request to attend with devices loaned

Patients were reminded at the end of the telephone review to bring any loaned LVAs to their clinic follow-up. Twenty-nine patients (67%) remembered to bring all of their LVAs and a further four (9%) brought at least one LVA. Our secondary sample of 44 patients attending their 3-month clinic follow-up who had not participated in the survey (i.e. therefore had not received a telephone reminder) were used for comparison purposes. In contrast to the good adherence in the telephone review group, only 16 (36%) patients attended with all of their LVAs and 19 (43%) failed to bring any device at all to the appointment. As might be expected, reminding patients at the telephone review appointment provides a significant increase in adherence with advice to bring devices for clinic review (chi-square = 13.478, degrees of freedom = 2, p < 0.01), thereby facilitating follow-up task performance assessments and cost-efficiency of device changes.

Discussion

Potential benefits of using telephone review appointment

It is evident that a number of patient queries can be dealt with immediately and appropriately over the phone during the telephone review appointment. This can potentially negate the need for a further follow-up clinic appointment, highlighting the effectiveness of the telephone review in addressing patient queries promptly. At the same time, any concerns that cannot be resolved over the phone, and potentially necessitating a more prompt follow-up, can be identified early, thereby leading to more timely review appointments. Equally, however, it is apparent that some patients are using their devices well, raising no concerns, and deferring such patients to a later date (or discharging them from booked review to self-referral) may help to reduce unnecessary visits to the hospital. This flexibility may provide a more efficient and effective service in terms of prioritising follow-up appointments, meeting patients’ needs, improving patient satisfaction, and reducing waiting times.

These results suggest that current ‘across the board’ protocol of 3-month follow-up is appropriate only to a minority of patients, and that it would be beneficial to implement a more individually tailored review policy, guided by telephone triage post LVA provision. Furthermore, reminding patients during the telephone review appointment to attend the clinic review with their LVAs has a positive effect. This opportunity for reminder has the potential to enable the LVA assessment to function more effectively, allowing any damaged or broken LVAs to be replaced and LVA exchanges to be made as necessary.

While it is a limitation that we did not estimate the prevalence of hearing impairment sufficient for exclusion from a telephone review in our sample, many patients with hearing impairment are able to deal with communication rather better over the telephone than when face-to-face with the option of the ‘t-switch’ on their hearing aids. The telephone review also provides an opportunity for reducing the burden of hospital or community clinic visits that can otherwise be problematic for elderly relatives struggling with mobility and transport issues.

Comparison of follow-up interval decisions

This study permits a degree of insight into the value of utilising telephone triage within a LV service. There is an opportunity to analyse the usefulness and effectiveness of the telephone review when comparing the outcome with that of the subsequent face-to-face 3-month clinic review some 2 months later. It must be considered that this comparison does, however, only provide a ‘yardstick’ measure, rather than reflecting a true gold standard of the appropriateness of the clinical decisions made at the telephone review. This is due to the timescale discrepancy of 2 months between the telephone review and face-to-face clinic review, during which time the clinical situation could have altered.

The outcome of telephone review led the optometrists (C.P. or J.L.) to conclude that 15 (32%) of the 46 patients telephoned merited earlier (i.e. sooner than 3 months) follow-up in clinic to reassess the use of their LVAs, either requiring them to be exchanged or requiring an additional LVA to be prescribed. Of these 15 patients, 13 (87%) attended their 3-month clinic review, and 12 (92%) of the 13 patients subsequently did have their LVA exchanged and/or received an additional LVA, as anticipated from telephone review.

At the 3-month clinic review, in addition to the patients discussed above, a further five patients were either loaned an additional LVA or had their current LVA exchanged. These five patients were not identified at the telephone review as requiring this intervention, with three of these patients being deemed appropriate for SOS and two being deemed appropriate for a 6-month clinic review from the outcome of the telephone review. It should be considered, however, that the three patients who were deemed appropriate for SOS may well have self-referred back into the service, but within this study, they were not required to do so because all participants, regardless of the telephone review outcome, had a planned 3-month clinic review.

Thirty-six patients (69%) participated in the telephone review as well as attended the 3-month follow-up clinic enabling the follow-up interval as judged appropriate at telephone review to be compared with that at the 3-month clinic review. At the end of this clinic review, it was concluded that eight patients would have benefited from earlier intervention (i.e. sooner than 3 months), with seven of these eight patients having been previously recognised as such from telephone review, with an earlier appointment being strongly indicated at this point also.

There was complete agreement for the follow-up interval decisions in 18 patients (46%). An explanation for this relatively low rate of agreement could be attributed to the optometrist at the 3-month follow-up clinic recommending that the current local guidance (i.e. a 3-month interval) was appropriate in a majority of 23/36 patients (64%). However, it should be recognised that optometrist recommendations at the 3-month clinic review did not always appear to correspond well with their clinical notes, in that in 9 of these 23 patients, there was either substantial clinical intervention or very little input (i.e. with the patients requiring minimal advice), suggesting that an earlier or later intervention, respectively, would arguably have been more suitable. This discrepancy might be owing to the optometrist being biased towards the current custom and practice of recalling the patient at 3 months.

LVA usage rates of survey patients

Self-reported usage rates of LVAs at telephone review indicated that 92% (69/75) of the LVAs loaned were being used on at least a weekly basis. Forty-five per cent reported using their magnifier for >5 min duration on at least one particular occasion. These results are plotted for comparison with previous studies at MREH in Figure 3. The results from this survey show similar findings to the two previous studies at MREH, displaying a high usage rate of LVAs and indicating a similar patient profile to our earlier surveys, thereby reinforcing the generalisability of the sample included in the survey (i.e. patients appear representative in age, diagnoses, device usage, and so on to our earlier samples).

Figure 3.

Comparison of LVA usage at Manchester Royal Eye Hospital. Use of LVA – the LVA has been used on at least one occasion; daily use of LVA – the LVA is used regularly on a daily basis; and continuous use >5 min – the longest period the LVA has been used in one instance.

Conclusion

This study indicates that completing telephone review ‘appointments’ is feasible for triaging LV follow-up requirements as concluded from the 69% of patients who completed all aspects of the study. Two telephone call attempts per patient can ‘capture’ more than 80% of patients. Telephone time required for triage is approximately 4.5 min per patient, which is considerably shorter than follow-ups in clinic, lasting approximately 20–40 min, albeit it is anticipated that a similar amount of administration time will be necessary to run the telephone review clinic.

As highlighted above, it did, however, prove somewhat more difficult to demonstrate the effectiveness of telephone reviews at triaging follow-up appointments. This is considered to be due to a design flaw, enabling the optometrists completing the 3-month review to preferentially suggest that a follow-up should have been in accordance with the existing protocol, without consideration to the current clinical situation. Upon reflection of this potential source of bias, the intervention suggested at the telephone review was compared to the actual clinical intervention at the 3-month review, rather than comparing with the perceived follow-up interval. This does provide a ‘yardstick’ measure of effectiveness, which arguably does demonstrate some positive outcomes and agreement between the telephone review and clinic follow-up, as highlighted in the section ‘Discussion’.

Anecdotally, from informal feedback received, it appeared that patients were positive regarding the telephone call to discuss how they were progressing. As indicated above, there were a few instances where simple advice could be issued over the phone providing immediate assistance to the patient, which the patients were particularly appreciative of. This indicates how the telephone review can be used as a supportive as well as a triaging measure. It has been noted, however, that it is a limitation of this study that more formal structured feedback was not obtained from the patients.

As part of this survey, optometrists completed the telephone review with the patients; however, it would be feasible for this task to be delegated appropriately to other members of the multidisciplinary team should local circumstances make such an option desirable. Telephone review can follow a structured format and may also be undertaken by LV trained dispensing opticians or perhaps other staff with little current involvement in LV services following appropriate training, including ophthalmic technicians and auxiliary nurses for example.

Provision of high-quality evidence for effectiveness of the telephone review would necessitate a randomised controlled trial (i.e. comparing the conventional LV clinic services against the proposed new, flexible protocol), and such a trial would be costly and arguably unnecessary in view of these data and high ‘face validity’ of the proposed development. It may, however, prove beneficial to complete a full audit of the new pathway, as shown in Figure 4, now that this is embedded into our LV service, and as part of this process, to more formally seek patient views on the new structure.

Figure 4.

Current pathway and proposed new LVA pathway.

Footnotes

Declaration of conflicting interests

The authors declare that they do not have any conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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