*4.4. Impact on Glaucoma Care*

4.4.1. QoC

#### New Patients (GSC and GAC)

In the GSC, 20.0% of patients were discharged wrongly by the GE, but only a minority required medical intervention, leading to a "significant" false rate of 4.0% [49]. The GSC missed two narrow angles with one requiring surgery [49]. In the GAC, the similarity of a GE's virtual assessment was "substantial" (κ = 0.72) to those made through a face-to-face assessment [48].

#### Follow-Up Patients (GCC, SMS, VC-PAEP, VC-MREH and VC-BEH, VC-REIP)

In the GCC, a "substantial" (κ = 0.69) agreement on triaging was found between the optometrists and supervising GEs [51]. In general, optometrists tended to be overcautious by considering patients more at risk. Still, the optometrists discharged 15.0% of the cases having glaucoma according to the GE. Another concern was the 6.5% of cases considered as low-risk by the optometrist who were identified as unstable by the GE [51]. Kotecha et al. compared the face-to-face assessment by a GE in the SMS with a virtual assessment by a different GE (inter-GE agreement) or by the same GE (intra-GE agreement) [57]. The inter-GE agreement was found to be "fair" (κ = 0.32). In this analysis, seven out of 14 unstable cases were detected during the virtual review (sensitivity of 50.0%). The other seven patients (3.4% of all patients) had been "misclassified" as stable during the virtual clinic assessment, two of whom (1.9%) having advanced VF loss. The sensitivity increased to 75.0% when only considering consultants and excluding fellows from the GE population [57]. Regarding the analysis made by the same GE, the intra-GE agreement was "fair" (κ = 0.26–0.27). The disagreements would only pose a risk for six patients (3.1% of all patients), since these were deemed as stable during the virtual review, but unstable at the face-to-face review by the same GE. The sensitivity amounted to 75.0% for the consultant and 60.0% for the fellow [57]. The study of Mostafa et al. showed that Goldmann applanation tonometry measurements only have moderate agreement when performed by different operators and that repeat Ocular Response Analyzer (ORA) IOP measurements were more consistent [53].

#### 4.4.2. Acceptance

Patients

According to Kotecha et al., patients with a low risk of progression were more open to a VC [59]. Patients were pleased with the reduced waiting time, the expertise of the staff and the productivity of the VC [57,59]. Court and Austin found that patients in the VC did not consider they were receiving inferior quality care compared to patients in StC [46]. However, some patients were disappointed by not receiving immediate feedback and not seeing a doctor on the same day [57]. Tatham et al. found no significant difference in knowledge of glaucoma between patients of VC-PAEP and StC-PAEP, suggesting that patients' knowledge is not disadvantaged by virtual clinics [52]. Study patients of Gunn et al. reported reduced waiting times as a key aspect of positive experiences [54]. These patients demonstrated high levels of trust in the staff performing tests in the glaucoma VC [53]. Spackman et al. evaluated patient satisfaction with the glaucoma VC in comparison with StC in The Royal Eye Infirmary Plymouth [55]. Overall, 98% of patients felt that the VC was the same or better than the StC [55].

## Staff

Gunn et al. [50] investigated the perspective of the GE; 92.9% of the respondents considered the VC as safe and efficient as StC, with 31.0% rating the efficiency as very good. The authors also identified the main reasons for not implementing a VC: insufficient staff, inadequate space, insufficient time or funding to train the non-medical staff, the risk of missing pathology and the lack of face-to-face discussion [50]. Later, Gunn et al. [54] investigated the perceptions of the technicians working in the glaucoma SC clinic. The technicians reported satisfaction in working within the glaucoma service. However, they commonly felt they would benefit from more detailed training, particularly around knowledge of the conditions and medications [54].

#### 4.4.3. Productivity

In the GSC, the GE discharged 62.0% of new glaucoma/OHT suspect referrals, sent 1.0% for an urgent same-day assessment with a GE, referred 6.0% to SMS and booked 31.0% for the consultant-led outpatient clinic [49]. In the GAC, 20.5% were discharged, after being diagnosed virtually as "normal" [48]. In the GCC, the GE discharged 3.7% of new glaucoma/OHT suspect referrals, which is 1.2% more than the number of patients that would have been discharged by the optometrists [51]. The virtual supervision by the GE also reduced the number of additional visits, e.g., the follow-up appointments, by 2.4% of the total number of visits [51]. The implementation of the SMS led to 13.0% of the patients

being discharged, 57.0% of the patients being rebooked in the SMS and 30.0% being sent to a GE for a face-to-face appointment [58].
