Cwm Taf eye health equity profile
Author: Dr Rosalind Reilly, Specialty Registrar in Public Health and Dr Ciarán Humphreys, Consultant in Public Health/Health Intelligence
Date: 17 June 2011 / Version: 1
Publication/ Distribution:
· Cwm Taf Director of Public Health
· Royal National Institute of Blind People (RNIB)
· NHS Wales (Intranet)
· Public (Internet)
Review Date: N/A
Purpose and Summary of Document:
This eye health equity profile is intended to inform the development of the RNIB’s Community Engagement Project in the Cwm Taf Health Board area. It includes a description of the population of Cwm Taf; the epidemiology of the main eye conditions; the provision of services within Cwm Taf and considers the provision of services in relation to need. This document will also provide information for a wider eye health strategy for Cwm Taf Health Board with the aim of improving equity, outcomes and quality of life for people with or at risk of poor eye health.
Work Plan reference: HI46
Date: 17 June 2011 / Version: 1 (final) / Page: 81 of 81
Public Health Wales Observatory / Eye health equity profile
Acknowledgements
The authors would like to thank the following people for their contributions to this report:
Kerry Bailey, Sian Biddyr, Catey Bunce, Peter Garwood, Anne Hinchliffe, Martin Holloway, Ceri Jackson, Nicola John, Selwyn Jones, Rosemarie Keigwin-Harris, Shaun Leamon, Helen Lee, Nathan Lester, Marilyn Meecham, Margaret Munkley, Linda Morris, Bethan Patterson, Isabel Puscas, Raghu Ram, Jonathan Richards and Margaret Webber.
This report can be downloaded from the Observatory website: http://www.publichealthwales.wales.nhs.uk.
For any further information please contact us on:
.
© 2011 Public Health Wales NHS Trust.
Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context.
Acknowledgement to Public Health Wales NHS Trust to be stated.
Copyright in the typographical arrangement, design and layout belongs to Public Health Wales NHS Trust.
Abbreviations
APHO / Association of Public Health ObservatoriesARMD / Age-related macular degeneration
CEP / Community Engagement Project
CVI(W) / Certificate of visual impairment (Wales)
DRSSW / Diabetic Retinopathy Screening Service for Wales
EASR / European age-standardised rate
GOS / General Ophthalmic Services
LSOA / Lower layer super output area
NEHEM / National Eye Health Epidemiological Model
PEARS / Primary Eyecare Acute Referral Scheme
PEDW / Patient Episode Database for Wales
QOF / Quality and Outcomes Framework
RNIB / Royal National Institute for Blind People
USOA / Upper layer super output area
WAG / Welsh Assembly Government
WECHE / Welsh Eye Care Health Examination
WECI / Welsh Eye Care Initiative
WHS / Welsh Health Survey
WIMD / Welsh Index of Multiple Deprivation
Contents
Acknowledgements 2
Abbreviations 3
Summary 10
Background 14
1 Aims and objectives 14
1.1 Aims 14
1.2 Objectives 14
2 Methodology 15
3 Policy and strategic context 16
3.1 National 16
3.2 Local 19
4 Demography 19
4.1 Method 19
4.1.1 Data sources 19
4.1.2 Analysis 19
4.2 Results 20
4.2.1 Deprivation 20
4.2.2 Age and gender 22
4.2.3 Ethnicity 26
5 Epidemiology of eye conditions 26
5.1 Data sources 26
5.1.1 National Eye Health Epidemiological Model 26
5.1.2 GP annual prevalence survey 29
5.1.3 Quality and Outcomes Framework data 30
5.1.4 Association of Public Health Observatories and Welsh Health Survey data 30
5.2 Data analysis 30
5.2.1 National Eye Health Epidemiological Model 30
5.2.2 GP annual prevalence survey 31
5.2.3 Quality and Outcomes Framework data 31
5.2.4 Association of Public Health Observatories and Welsh Health Survey data 32
5.3 Results 32
5.3.1 Vision impairment 32
5.3.2 Diabetic retinopathy 34
5.3.3 Glaucoma 41
5.3.4 Cataracts 43
5.3.5 Age-related macular degeneration 46
6 Eye health service provision 48
6.1 Eye care in the Community 48
6.1.1 Optometry 48
6.1.2 Enhanced community eye care 51
6.1.3 Diabetic retinopathy screening 53
6.1.4 Ophthalmic primary care 53
6.1.5 Certificate of visual impairment and local authority registration 53
6.1.6 Pharmacy 54
6.2 Secondary care 54
7 Eye health service uptake 55
7.1 Primary and community care 55
7.1.1 Optometry and enhanced community eye care 55
7.1.2 Diabetic retinopathy screening 60
7.1.3 Certificate of visual impairment and local authority registration 67
7.1.4 Pharmacy data 70
7.2 Secondary care 71
7.2.1 Outpatients 71
7.2.2 Inpatients 75
8 Comparison of provision and need 79
8.1 Vision impairment 79
8.2 Diabetic retinopathy 81
8.3 Glaucoma 82
8.4 Cataracts 83
8.5 Age-related macular degeneration 86
9 Research and audit 87
10 Recommendations 87
10.1 Recommendations for the Community Engagement Project 87
10.2 Recommendations for local care pathways 88
10.2.1 Vision impairment 88
10.2.2 Diabetic retinopathy 88
10.2.3 Glaucoma 88
10.2.4 Cataracts 89
10.2.5 Age-related macular degeneration 89
10.3 Recommendations for Wales Eye Health Improvement Project Steering Group 89
11 Conclusion 89
12 References 91
Figures
Figure 1. Map of Cwm Taf with USOA boundaries and level of deprivation 21
Figure 2. Population pyramid by age and sex (per cent), Cwm Taf, 2009 22
Figure 3. Per cent change in population by age group, Cwm Taf, 2008-2033 25
Figure 4. Ethnic groups, Wales, Cwm Taf, Rhondda Cynon Taf and Merthyr Tydfil, 2007 26
Figure 5. Prevalence of diabetes mellitus, EASR and crude rate, health board level, 2009-2010 34
Figure 6. Prevalence of diabetes mellitus, EASR and crude rate, local authority level, 2009-2010 35
Figure 7. Prevalence of diabetes mellitus in GP practices, Wales 36
Figure 8. Management of diabetes: blood pressure <145/85, GP practices, 2009-2010 37
Figure 9. Management of diabetes: HbA1c <7 per cent, GP practices, 2009-2010 39
Figure 10. Management of diabetes: HbA1c <9 per cent, GP practices, 2009-2010 40
Figure 11. Age specific prevalence of glaucoma, 2007 43
Figure 12. Age specific prevalence of cataracts, 2007 46
Figure 13. Location of optometric practices, Cwm Taf 50
Figure 14. Location of optometric practices offering WECHE and PEARS examinations, Cwm Taf 52
Figure 15. Profile of diabetic retinopathy screening by health board, 2009-2010 61
Figure 16. Profile of diabetic retinopathy screening by local authority, 2009-2010 62
Figure 17. Control chart showing per cent of diabetic patients screened for diabetic retinopathy, GP practices, Wales, 2009-2010 63
Figure 18. Control chart showing per cent of qualifying diabetic patients screened for diabetic retinopathy in GP practices, Wales, 2009-2010 64
Figure 19. Attendance for new ophthalmology appointments, per 1,000 population, health board level, 2009 73
Figure 20. Attendance for new ophthalmology appointments, per 1,000 population, Cwm Taf USOA level, 2009 74
Figure 21. Cataract procedures, per 1,000 population, health board level, 2008 76
Figure 22. Cataract procedures, per 1,000, local authority level, 2008 77
Figure 23. Cataract procedures, per 1,000, Cwm Taf USOA level, 2008 78
Figure 24. Diabetes and diabetic retinopathy screening 82
Figure 25. Glaucoma: Estimates of need and provision relative to NEHEM 2009 estimate of need 83
Figure 26. Prevalence of cataract in comparison to crude rate of cataract operations, local authority level, 2008 84
Figure 27. Prevalence of cataract in comparison to cataract operations, Cwm Taf USOA level, 2008 85
Figure 28. EASR of cataract operations and level of deprivation, local authority level, 2008 86
Tables
Table 1. Population aged 60 years and over, Cwm Taf USOAs, Merthyr Tydfil, Rhondda Cynon Taf, Cwm Taf and Wales, 2009 23
Table 2. Population aged 65 years and over, Cwm Taf USOAs, Merthyr Tydfil, Rhondda Cynon Taf, Cwm Taf and Wales, 2009 24
Table 3. Prevalence of vision impairment, 2001 33
Table 4. Prevalence of vision impairment, 2009 34
Table 5. GP practices in Cwm Taf USOAs with significantly high or low EASRs of diabetes mellitus 36
Table 6. Estimates of prevalence of diabetes mellitus, Wales, Rhondda Cynon Taf and Merthyr Tydfil, 2009 37
Table 7. GP practices in Cwm Taf USOAs with significantly high or low per cent of diabetic patients with BP<145/85 38
Table 8. GP practices in Cwm Taf USOAs with significantly high or low per cent of diabetic patients with HbA1c <7 per cent 39
Table 9. GP practices in Cwm Taf USOAs with significantly high or low per cent of diabetic patients with HbA1c <9 per cent 40
Table 10. Prevalence of glaucoma, 2001 41
Table 11. Prevalence of glaucoma, 2009 42
Table 12. Estimated glaucoma prevalence, 2009 43
Table 13. Prevalence of cataracts, 2001 44
Table 14. Prevalence of cataracts, 2009 45
Table 15. Estimated cataracts prevalence, 2009 46
Table 16. Prevalence of age-related macular degeneration, 2001 47
Table 17. Prevalence of age-related macular degeneration, 2009 48
Table 18. Travel time to optometric practices, Cwm Taf, 2009 51
Table 19. WECHE, PEARS examinations and NHS funded sights tests, South East Wales, April 2009–March 2010 57
Table 20. Reasons for NHS funded sight tests in Cwm Taf and Wales, 2009-2010 58
Table 21. People aged 60 years and over receiving NHS funded sight tests 59
Table 22. People aged 15 years and under receiving NHS funded sight tests 59
Table 23. People on register for sight impairment and severe sight impairment receiving NHS funded sight tests 60
Table 24. People receiving jobseeker’s allowance and receiving NHS funded sight tests 60
Table 25. People receiving income support and receiving NHS funded sight tests 60
Table 26. GP practices in Cwm Taf with significantly high or low per cent of diabetic patients who received diabetic retinopathy screening 65
Table 27. GP practices in Cwm Taf with significantly high or low per cent of diabetic patients receiving diabetic retinopathy screening 66
Table 28. Certificates of visual impairment sent to Moorfields Eye Hospital 68
Table 29. Local authority register of people with sight impairment by local authority, 2009 69
Table 30. Local authority register of people with sight impairment by health board, 2009 69
Table 31. Minimum and maximum estimates of monthly ophthalmic glaucoma preparations, Merthyr Tydfil, Rhondda Cynon Taf, 2009-2010 data 71
Table 32. Local authority and NEHEM comparison of severe sight impairment, 2009 79
Table 33. Local authority and NEHEM comparison of sight impairment / low vision, 2009 80
Table 34. Glaucoma: Estimates of need and provision 83
Summary
This eye health equity profile has been used to inform the development of the Royal National Institute of Blind People’s (RNIB) Community Engagement Project (CEP). It is hoped that it can also be used to inform the development of an eye health strategy for Cwm Taf Health Board.
The Wales Vision Strategy Advisory Group set out in 2010 the priorities for meeting objectives of the UK Vision Strategy which has the overarching aim of eliminating avoidable blindness. The Wales Eye Health Improvement Project and the Welsh Eye Care Initiative (WECI) contribute to this agenda.
The quality of the available data on eye health is quite poor. Although prevalence models exist, these do not take into account factors such as deprivation. The models suggest that Cwm Taf has less need in terms of eye health care compared with Wales, but more deprived areas are likely to have greater need. The service data is also limited, and where available largely relates to items of service with little or no information about who is accessing these services. Local research and audit relating to eye health care in Cwm Taf was sought in this project. This identified one audit which has looked at the cataract pathway and one study which has looked at the presentation of people with cataracts across the health board area.
Cwm Taf has one of the most deprived populations in Wales. The highest levels of deprivation are in upper layer super output areas (USOAs) Merthyr02, RCT01, RCT03 and RCT04. Cwm Taf has a slightly lower proportion of older people (16.9 per cent people aged 65 years and over) compared to Wales (18.3 per cent). USOA RCT04 (19.0 per cent) has the highest proportion of older people and USOA RCT07 (14.4 per cent) has the lowest proportion of older people in Cwm Taf. A very low proportion of the population of Cwm Taf belong to a black or minority ethnic group (1.8 per cent).
Vision impairment
· There are an estimated 4,203 people aged 50 years and over with vision impairment in Cwm Taf and 47,386 in Wales
· The estimated prevalence of vision impairment in the population is slightly lower in Cwm Taf compared with Wales due to the lower proportion of older people in Cwm Taf
· Within Cwm Taf, the estimated prevalence of vision impairment in the population is higher in USOAs RCT04 and 06, where there is a higher proportion of older people
· The Welsh Eye Care Health Examination (WECHE) rate is variable in South East Wales and low in Rhondda Cynon Taf (2.9 per 1,000 in Rhondda Cynon Taf and 10.3 per 1,000 in Merthyr Tydfil)
· The crude rate of NHS funded sight tests in Cwm Taf (261.5 per 1,000) is slightly higher than that of Wales (245.5 per 1,000); the rate of NHS funded sight tests for people aged 60 years and over and aged 15 years and under is higher in Cwm Taf compared to Wales but the rate of NHS funded sight tests for sight impaired and severely sight impaired people and people receiving jobseeker’s allowance or income support is lower compared to Wales
· The reasons for NHS funded sight tests in Cwm Taf are less driven by income factors than might be expected
· The National Eye Health Epidemiological Model (NEHEM) predicts fewer severely sight impaired people (642) than the number on the local authority register (966), but predicts considerably more people with low vision (3,580) than are registered as sight impaired with the local authority (888). However, definitions do differ. Further work looking at this could be beneficial
· Data from the Welsh Health Survey shows that adults in the most deprived deprivation quintile were less likely to have visited an optician in the previous twelve months compared with people in the least deprived quintile
· The majority of Optometrists seem to be located in less deprived areas in Cwm Taf.
Diabetic retinopathy
· The estimated prevalence of diabetes is 4.7-6 per cent in Merthyr Tydfil, and 10 per cent when undiagnosed diabetes is included in the estimate
· There are an estimated 21,848 people with diagnosed and undiagnosed diabetes in Cwm Taf, and 221,777 in Wales