The equity profile of an enhanced optometry scheme

Dear Editor-in-Chief, Equity profiling is an important tool which enables effective commissioning of healthcare that is mapped directly to the needs of the population at a local level. Equity profiling in the ophthalmic literature has focused on socially deprived urban populations. Whilst this is undoubtedly a key demographic, it is by no means representative of the entire population. This brief report provides results of an equity profile carried out for a semi-rural, relatively affluent population to establish the differences, if any, with respect to the provision and distribution of eye health care. Moreover, this report is the first equity profile of an enhanced optometry scheme. Demographic data, diagnosis, mean deviation of the presenting visual field, the distance travelled to each appointment as well as the Index of Multiple Deprivation was collected for a total of 2794 patients that were seen in the CHANGES glaucoma referral refinement scheme between August 2006 until June 2011. This scheme serves the catchment area for Hinchingbrooke hospital in Huntingdon, Cambridgeshire, UK. Glaucoma referrals are triaged by the hospital as either high or low risk based on fixed referral criteria. 2078 (74.4%) patients were deemed a high risk referral and sent directly to the hospital eye service (HES) of which 236 (11.4%) were diagnosed with glaucoma. 716 (25.6%) patients were deemed a low risk referral and were seen by a community-based optometrist with specialist interest in glaucoma and only referred to the HES if glaucoma was suspected. In this group only 31 (4.3%) patients were diagnosed with glaucoma. The road distance travelled was calculated using the Geographical Information System package ArcGIS v10. Categorical variables have been analysed using Fisher’s Exact Test, and the means of continuous variables have been compared using permutations tests which do not require the usual distributional assumptions. High risk patients travelled a mean distance of 8.2 km to the referring optometrist and 13.6 km to the HES. Low risk patients travelled a mean distance of 9.0, 8.4 and 12.5 km to the referring optometrist, community-based optometrist with specialist interest in glaucoma and HES respectively. Patients who presented with advanced visual field loss as a result of glaucoma (defined as a mean deviation of >12 in the worse eye) lived an average of 2.6 km closer to the referring optometrist than those with mild disease. Of the low risk referrals that live closer to the HES than the referring optometrist only 2% were from the most deprived quartile; this was 13% for high risk referrals. In this study there was no association between final diagnosis and distance to an eye health professional, in particular the optometrist. The severity of glaucoma at presentation was independent of deprivation and distance to the optometrist or hospital, with patients who were diagnosed with glaucoma and had a severe visual field loss actually living closer to the optometrist than those with mild or moderate visual field loss with no significant differences in deprivation scores. This is in contrast to Fraser et al. who found deprivation to be linked with late presentation of glaucoma to the hospital. Day et al. found the location of community optometrist practices were poorly correlated with service demands with fewer optometrists in areas of higher social deprivation, a finding again not reflected in this study. The populations from those studies were urban and predominately deprived, whereas this population is semi-rural and relatively affluent. The variation in optometric distribution between urban and rural, as well as deprived and affluent populations highlight the need for commissioning of eye health care to be planned and delivered at a local level. Equity profiling is a relatively quick and inexpensive way for health professionals and commissioners to understand the need, met or unmet, for their population.This study demonstrates that the CHANGES scheme does provide a local and easily accessible enhanced optometry service for its population. This may contrast with the provision of ‘high street’ optometrists nationally, which are private providers and therefore priority is more towards economically viability rather than service needs of its population. This variation needs to be considered when planning an enhanced optometry scheme.