Follow-up visual field testing

The following case was published on the Health and Disability Commissioner's website today.
 
Follow-up visual field testing

17HDC00550

Health and Disability Commissioner Anthony Hill today released a report finding a District Health Board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to prioritise a man’s visual field testing in light of his established glaucoma.
The man had been a patient of a DHB ophthalmology service since 2006 for the treatment of his complex glaucoma. In 2012, testing of the man’s visual field showed that he had a visual field index (VFI) of 80% vision bilaterally. In November 2014 the man had visual field testing following which he was referred for ongoing ophthalmology review. In October 2015, the man was seen by a locum consultant ophthalmologist who deferred the man’s next visual field test scheduled for November 2015 to April 2016 (i.e. five months later). The DHB reported that this deferral was made without a documented reason and that there was no way to identify that the visual field testing regimen had been missed or extended. The locum explained that he thought it would be best to do the visual field testing after the man’s cataract surgery, as a cataract can interfere with the outcome of a visual field test, and a more accurate representation could be obtained after the surgery. The man underwent left cataract surgery privately in November 2015.
As the man’s visual field testing appointment in April 2016 approached, his wife contacted the ophthalmology service on several occasions regarding a specific appointment date. The planned April 2016 appointment did not go ahead for the man until the end of July 2016. At that stage, it had been approximately 18 months since the man’s previous visual field test in November 2014. The July 2016 visual field testing showed advanced glaucomatous changes requiring urgent review. In early August a consultant ophthalmologist reviewed the man and advised that because of his glaucoma and visual field defects, the man was not fit to drive. Following further ophthalmology/surgical reviews the man’s left eye was deemed to be extremely high risk and further surgery was performed.
The DHB stated that the reason for the delay in the visual field appointment was related to demand on the DHB service. In relation to processes in place at that time to clinically prioritise patients for specialist follow-up and visual field testing, the DHB told HDC administration staff booked the short-term follow-ups and urgent patients into the regular appointment slots within the time frame identified by the ophthalmologist and that the remaining slots were assigned to the patients who had been waiting the longest. At the time an acuity tool was not utilised.

Findings

Mr Hill was mindful of a combination of factors that have driven rapidly increasing demand for ophthalmology services in New Zealand, including outpatient clinic time, over the last ten years. A key factor has been the introduction of very effective new therapies and treatment, which have resulted in consumers needing to see specialists for regular ongoing follow-up and/or treatment, fuelling increased demand for ophthalmology services. Mr Hill considers that the Ministry of Health has a role, with DHBs, to recognise the effect of the introduction of such new technologies and associated pressures on the system, and plan accordingly.
Mr Hill commented that provider accountability is not removed by the existence of such systemic pressures, and that a key improvement that all DHBs and the Ministry of Health must make, now and in the future, is to assess, plan, adapt, and respond effectively to the foreseeable effects that new technologies will have on systems and demand.
Mr Hill stated that it was wholly inappropriate for the DHB booking staff to be tasked with the important responsibility of prioritising ophthalmology follow-up appointments without sufficient information on which to base prioritisation decisions, and clear direction about what might constitute a higher risk patient requiring clinical escalation. Mr Hill found that in this respect the DHB failed its staff as well as consumers, including the man.
Mr Hill stated that whilst the deferral of the man’s visual field testing from November 2015 to April 2016 was clinically defensible due to surgery, the man still required effective prioritisation of his testing to ensure timely and ongoing monitoring of his glaucoma. Mr Hill found that the further three month delay from April to July 2016 to the man’s visual testing was not appropriate and considered the key failure in this case was the failure to prioritise the man’s visual field testing in light of his established glaucoma.

Recommendations

Following on from a HDC case completed earlier this year, in which Mr Hill made a series of detailed recommendations in respect of the DHB regarding it ophthalmology service which were also applicable to this case. Mr Hill recommended that the DHB continue auditing the remedial actions taken to shift patients to clinically appropriate times. It was also recommended that the DHB apologise to the man.