Real-world clinical and cost-effectiveness of community clozapine initiation: mirror cohort study.

BACKGROUND: Clozapine is the only drug licensed for treatment-resistant schizophrenia (TRS) but the real-world clinical and cost-effectiveness of community initiation of clozapine is unclear. AIMS: The aim was to assess the feasibility and cost-effectiveness of community initiation of clozapine. METHOD: This was a naturalistic study of community patients recommended for clozapine treatment. RESULTS: Of 158 patients recommended for clozapine treatment, 88 (56%) patients agreed to clozapine initiation and, of these, 58 (66%) were successfully established on clozapine. The success rate for community initiation was 65.4%; which was not significantly different from that for in-patient initiation (58.82%, χ2(1,88) = 0.47, P = 0.49). Following clozapine initiation, there was a significant reduction in median out-patient visits over 1 year (from 24.00 (interquartile range (IQR) = 14.00-41.00) to 13.00 visits (IQR = 5.00-24.00), P < 0.001), and 2 years (from 47.50 visits (IQR = 24.75-71.00) to 22.00 (IQR = 11.00-42.00), P < 0.001), and a 74.71% decrease in psychiatric hospital bed days (z = -2.50, P = 0.01). Service-use costs decreased (1 year: -£963/patient (P < 0.001); 2 years: -£1598.10/patient (P < 0.001). Subanalyses for community-only initiation also showed significant cost reductions (1 year: -£827.40/patient (P < 0.001); 2 year: -£1668.50/patient (P < 0.001) relative to costs prior to starting clozapine. Relative to before initiation, symptom severity was improved in patients taking clozapine at discharge (median Positive and Negative Syndrome Scale total score: initial visit: 80 (IQR = 71.00-104.00); discharge visit 50.5 (IQR = 44.75-75.00), P < 0.001) and at 2 year follow-up (Health of Nation Outcome Scales total score median initial visit: 13.00 (IQR = 9.00-15.00); 2 year follow-up: 8.00 (IQR = 3.00-13.00), P = 0.023). CONCLUSIONS: These findings indicate that community initiation of clozapine is feasible and is associated with significant reductions in costs, service use and symptom severity.

Referral thresholds for an integrated learning disability eye care pathway: a consensus approach.

INTRODUCTION: Local Optometric Support Unit (LOCSU) have published their refreshed clinical pathway for eye care for people with a learning disability. The document sets out the adjustments to practice that a community optometrist might make in order to provide optimal care for a person with learning disability attending a primary eye care assessment. The pathway specifically points to the need to retain patients in primary care where appropriate and 'reduce the number of people with learning disability who are inappropriately referred into the Hospital Eye Service (HES).' Pivotal to this refreshed pathway is the integration with secondary care, with local arrangements to facilitate referral and hospital management where appropriate. There are few ophthalmologists nationally who frequently encounter patients with a learning disability in their hospital practice and knowing where to start when creating referral criteria or KPIs may create a barrier to services becoming established. In order to address this gap in experience, we set about developing a set of consensus statements regarding referral thresholds for ocular conditions commonly encountered in adults with learning disability. METHOD: A series of video interviews were undertaken with eye health professionals with a range of experience in eye care for people with learning disability. Each contributor commented on the usability and clarity of each element of the referral criteria. In addition, each contributor was asked to express the overriding principles by which they make decisions regarding referral thresholds for patients with learning disability. These were collated into the final document which was circulated and agreed by all participants. RESULTS: A table setting out referral thresholds for commonly encountered eye conditions in adults with learning disabilities is presented. CONCLUSION: We have presented a succinct set of consensus statements relating referral thresholds for common presentations of visual problems in adults with learning disability in the UK distilled from the collective experience of a group of eye health professionals. The intention was not to present a comprehensive review of management of each condition. Rather, the consensus statements may form the starting point from which each area could develop locally agreed criteria, as is suggested by the LOCSU pathway guidance.

Findings from an opt-in eye examination service in English special schools. Is vision screening effective for this population?

Our objective was to present the findings of an opt-in, school-based eye care service for children attending 11 special schools in England and use these findings to determine whether a vision screening programme would be appropriate for this population. Data from eye examinations provided to 949 pupils (mean age 10.7 years) was analysed to determine the prevalence and aetiology of visual deficiencies and reported eye care history. For 46.2% (n = 438) of pupils, a visual deficiency was recorded. 12.5% of all the children seen (n = 119) had a visual deficiency that was previously undiagnosed. Referral for a medical opinion was made for 3.1% (n = 29) of pupils seen by the service. Spectacle correction was needed for 31.5% (n = 299) of pupils; for 12.9% (122) these were prescribed for the first time. 3.7% (n = 11) of parents/carers of pupils needing spectacles chose not to use the spectacle dispensing service offered in school. Eye care history was available for 847 pupils (89.3%). Of the pupils for whom an eye care history was available, 44% (n = 373) reported no history of any previous eye care and10.7% (n = 91) reported a history of attending a community optical practice/opticians. Only one pupil from the school entry 4-5 age group (0.6% of age group n = 156) would have passed vision screening using current Public Health England screening guidelines. Children with a diagnosis of autism were significantly less likely to be able to provide a reliable measurement of visual acuity. This study supports previously published evidence of a very high prevalence of visual problems in children with the most complex needs and a significant unmet need in this group. It demonstrates routine school entry vision screening using current Public Health England guidelines is not appropriate for this group of children and very low uptake of community primary eye care services.

Eye care in young children: a parent survey exploring access and barriers.

BACKGROUND: A questionnaire was designed to investigate the attitudes of parents toward eye care for their young children (4-6-year-olds) and possible barriers to accessing eye care for this age group. An exploration was undertaken to determine whether these beliefs and barriers are influenced by certain demographic factors such as ethnicity, level of parental income, level of parental education, confidence with speaking English and a reported family history of eye problems. METHODS: A total of 1,317 questionnaires (hard copies) were distributed to parents of children in primary school reception and year one classes (ages four to six) from 14 schools across five London boroughs. Ninety online surveys were sent to parents at two further London schools. All questionnaires were anonymous. RESULTS: A total of 384 completed questionnaires were analysed (27 per cent response rate). Three hundred and thirty-eight parents (24 per cent) completed the 'parental knowledge' section of the questionnaire. Of all responses, 65 per cent (n = 249) were from parents whose children attended a school where a program of school entry vision screening took place. Of these, 15 per cent (n = 36) of parents reported that they were aware of the screening program. Barriers to accessing eye care for their children were reported by 38 per cent (n = 153) of parents/carers who responded. Twelve per cent (n = 47) reported not knowing how to access an eye test for their child and 12 per cent (n = 47) reported that they were concerned their child would be given glasses that were not needed. When compared to parents from White ethnic groups, parents from African/Afro-Caribbean ethnic groups were more likely to report not knowing how to access an age-appropriate eye test for their child (p = 0.001). Parents of African/Afro-Caribbean ethnic origins were statistically more likely to report barriers to eye care (p = 0.001). CONCLUSION: The study provides evidence of some parental misconceptions around eye care for young children and some barriers to access. Possible solutions to this are discussed.

More than just perception-action recalibration: walking through a virtual environment causes rescaling of perceived space.

Egocentric distances in virtual environments are commonly underperceived by up to 50 % of the intended distance. However, a brief period of interaction in which participants walk through the virtual environment while receiving visual feedback can dramatically improve distance judgments. Two experiments were designed to explore whether the increase in postinteraction distance judgments is due to perception-action recalibration or the rescaling of perceived space. Perception-action recalibration as a result of walking interaction should only affect action-specific distance judgments, whereas rescaling of perceived space should affect all distance judgments based on the rescaled percept. Participants made blind-walking distance judgments and verbal size judgments in response to objects in a virtual environment before and after interacting with the environment through either walking (Experiment 1) or reaching (Experiment 2). Size judgments were used to infer perceived distance under the assumption of size-distance invariance, and these served as an implicit measure of perceived distance. Preinteraction walking and size-based distance judgments indicated an underperception of egocentric distance, whereas postinteraction walking and size-based distance judgments both increased as a result of the walking interaction, indicating that walking through the virtual environment with continuous visual feedback caused rescaling of the perceived space. However, interaction with the virtual environment through reaching had no effect on either type of distance judgment, indicating that physical translation through the virtual environment may be necessary for a rescaling of perceived space. Furthermore, the size-based distance and walking distance judgments were highly correlated, even across changes in perceived distance, providing support for the size-distance invariance hypothesis.

Paediatric community vision screening with combined optometric and orthoptic care: a 64-month review.

We report a new model of community-based secondary vision screening and demonstrate that a high proportion of children can be effectively managed in such a clinic without referral to the hospital eye service (HES). We performed a 64-month retrospective study of a secondary vision screening clinic providing the combined skills of an optometrist and orthoptist in a community setting. Particular attention was given to the diagnosis and management of children not referred to the HES. During this period, 1755 children were sent appointments and 74% (1300) attended the clinic. The community orthoptist and school nurses referred 53% of the patients and health visitors, general practitioners and community medical officers made 32% of the clinic referrals. Spectacles were prescribed for 41% of the children and 8% were prescribed patching. Sixteen per cent of the children were referred on to the HES. This model of care using the combined expertise of the orthoptist and optometrist is able to diagnose and manage the majority of children who have failed primary vision screening and avoids unnecessary referrals to the HES.