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Carmichael J, Abdi S, Balaskas K, Costanza E, Blandford A. The effectiveness of interventions for optometric referrals into the hospital eye service: A review. Ophthalmic Physiol Opt 2023; 43:1510-1523. [PMID: 37632154 PMCID: PMC10947293 DOI: 10.1111/opo.13219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
PURPOSE Ophthalmic services are currently under considerable stress; in the UK, ophthalmology departments have the highest number of outpatient appointments of any department within the National Health Service. Recognising the need for intervention, several approaches have been trialled to tackle the high numbers of false-positive referrals initiated in primary care and seen face to face within the hospital eye service (HES). In this mixed-methods narrative synthesis, we explored interventions based on their clinical impact, cost and acceptability to determine whether they are clinically effective, safe and sustainable. A systematic literature search of PubMed, MEDLINE and CINAHL, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), was used to identify appropriate studies published between December 2001 and December 2022. RECENT FINDINGS A total of 55 studies were reviewed. Four main interventions were assessed, where two studies covered more than one type: training and guidelines (n = 8), referral filtering schemes (n = 32), asynchronous teleophthalmology (n = 13) and synchronous teleophthalmology (n = 5). All four approaches demonstrated effectiveness for reducing false-positive referrals to the HES. There was sufficient evidence for stakeholder acceptance and cost-effectiveness of referral filtering schemes; however, cost comparisons involved assumptions. Referral filtering and asynchronous teleophthalmology reported moderate levels of false-negative cases (2%-20%), defined as discharged patients requiring HES monitoring. SUMMARY The effectiveness of interventions varied depending on which outcome and stakeholder was considered. More studies are required to explore stakeholder opinions around all interventions. In order to maximise clinical safety, it may be appropriate to combine more than one approach, such as referral filtering schemes with virtual review of discharged patients to assess the rate of false-negative cases. The implementation of a successful intervention is more complex than a 'one-size-fits-all' approach and there is potential space for newer types of interventions, such as artificial intelligence clinical support systems within the referral pathway.
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Affiliation(s)
- Josie Carmichael
- University College London Interaction Centre (UCLIC), UCLLondonUK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCLInstitute of OphthalmologyLondonUK
| | - Sarah Abdi
- University College London Interaction Centre (UCLIC), UCLLondonUK
| | - Konstantinos Balaskas
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCLInstitute of OphthalmologyLondonUK
| | - Enrico Costanza
- University College London Interaction Centre (UCLIC), UCLLondonUK
| | - Ann Blandford
- University College London Interaction Centre (UCLIC), UCLLondonUK
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2
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Carmichael J, Abdi S, Balaskas K, Costanza E, Blandford A. Assessment of optometrists' referral accuracy and contributing factors: A review. Ophthalmic Physiol Opt 2023; 43:1255-1277. [PMID: 37395045 PMCID: PMC10946769 DOI: 10.1111/opo.13183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/14/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE In the UK, ophthalmology has the highest number of outpatient appointments within the National Health Service. False-positive referrals from primary care are one of the main factors contributing to the oversubscription of hospital eye services (HESs). We reviewed the accuracy of referrals originating from primary care optometrists and contributing factors, such as condition type and years since registration. RECENT FINDINGS Of the 31 studies included in the review, 22 were retrospective analyses of referrals and appointments at the HES. Eight were prospective studies, and one used online clinical vignettes. Seven assessed the accuracy of referrals for all ocular conditions. The remaining studies focused on glaucoma (n = 11), cataracts (n = 7), emergency conditions (n = 4), neovascular age-related macular degeneration (n = 1) and paediatric binocular vision (n = 1). The diagnostic agreement for suspected emergency ocular conditions was the lowest, with only 21.1% of referrals considered to require urgent attention in one study. For glaucoma, the first-visit discharge rate was high (16.7%-48%). Optometrist referral accuracy was overall 18.6% higher than General Medical Practitioners'; however, the two mainly referred different ocular conditions. Female optometrists made more false-positive referrals than males (p = 0.008). The proportion of false positives decreased by 6.2% per year since registration (p < 0.001). SUMMARY There was significant variation in referral accuracy across different ocular conditions, partly due to differences when defining accurate referrals. Optometrists working in primary care are generally more limited in their resources than the HES. Thus, choosing the cautious option of referral when they are unsure could be in the patients' best interests. The possible effect of increased use of advanced imaging on referrals requires evaluation. Although interventions such as refinement schemes have been put in place, these vary across regions, and their approaches such as virtual referral triaging may reduce unnecessary HES face-to-face appointments and promote communication between primary and secondary care.
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Affiliation(s)
- Josie Carmichael
- University College London Interaction Centre (UCLIC), UCLLondonUK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCLInstitute of OphthalmologyLondonUK
| | - Sarah Abdi
- University College London Interaction Centre (UCLIC), UCLLondonUK
| | - Konstantinos Balaskas
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCLInstitute of OphthalmologyLondonUK
| | - Enrico Costanza
- University College London Interaction Centre (UCLIC), UCLLondonUK
| | - Ann Blandford
- University College London Interaction Centre (UCLIC), UCLLondonUK
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Formichella P, Annoh R, Zeri F, Tatham AJ. The role of the disc damage likelihood scale in glaucoma detection by community optometrists. Ophthalmic Physiol Opt 2020; 40:752-759. [PMID: 32946144 DOI: 10.1111/opo.12734] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 08/21/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Recent guidelines recommend disc damage likelihood scale (DDLS) is recorded for all referrals of suspected glaucoma from community optometrists to hospital eye services (HES) in Scotland. This study aimed to determine whether lower DDLS grades were associated with higher rates of discharge at the first visit to HES. METHODS A retrospective analysis of 618 consecutive new referrals from community optometrists to a university hospital glaucoma service. 65 (10.5%) included DDLS graded by the community optometrist. A comprehensive eye examination and optical coherence tomography (OCT) was performed in the hospital glaucoma clinic and first visit discharge rate (FVDR) for different grades of DDLS compared. The relationship between DDLS and retinal nerve fibre layer (RNFL) thickness on OCT was also examined. RESULTS The FVDR for patients with DDLS recorded in the referral was 27.7% (18 of 65) compared to 25% (138 of 553) in those without DDLS (p = 0.631). The FVDR was 50% for those with a DDLS of 3 in the worse eye, decreasing to 32% and 21% for DDLS grades of 4 and 5 respectively. No patient with a DDLS ≥ 6 was discharged at the first visit and none with a DDLS < 4 (the cut off for consideration of referral in Scottish guidelines) were found to have glaucoma. There was a significant but weak inverse relationship between DDLS and RNFL thickness. The strongest relationship was with average RNFL thickness (r = -0.378, p < 0.01) followed by superotemporal (r = -0.359, p < 0.01) and inferotemporal (r = -0.353, p < 0.01) RNFL thickness. CONCLUSIONS In patients referred to HES with DDLS information included, lower DDLS grading was associated with higher odds of being discharged at the first visit. DDLS grading by community optometrists had a poor correlation with RNFL thickness measured using OCT.
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Affiliation(s)
- Paolo Formichella
- Princess Alexandra Eye Pavilion and Department of Ophthalmology, University of Edinburgh, Edinburgh, UK
| | - Roxanne Annoh
- Princess Alexandra Eye Pavilion and Department of Ophthalmology, University of Edinburgh, Edinburgh, UK
| | - Fabrizio Zeri
- Ophthalmic Research Group, School of Life and Health Sciences, Aston University, Birmingham, UK.,Research Centre in Optics and Optometry and Department of Material Science, University of Milano Bicocca, Milan, Italy
| | - Andrew J Tatham
- Princess Alexandra Eye Pavilion and Department of Ophthalmology, University of Edinburgh, Edinburgh, UK
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El-Abiary M, Loffler G, Young D, Strang N, Lockington D. Assessing the effect of Independent Prescribing for community optometrists and referral rates to Hospital Eye Services in Scotland. Eye (Lond) 2020; 35:1496-1503. [PMID: 32681093 DOI: 10.1038/s41433-020-1095-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Since 2010, General Ophthalmic Services (GOS) legislation and Independent Prescribing (IP) enable community optometrists to manage primary eye conditions. No studies have assessed the effect of IP. We wished to determine the distribution of IP optometrists and associated hospital referral rates across Scotland. METHODS In 2019, FOI requests (General Optical Council and NHS Education Scotland) identified all registered IP optometrists in Scotland and their registered postcodes. Data regarding community eye examinations and referrals to HES since 2010 were gathered via Information Services Division of NHS Scotland. RESULTS As of March 2019, there were 278 IP optometrists in Scotland (278/1189; 23.4%). Two hundred eighteen IP optometrists work in 293 practices across 11 of Scotland's 14 health boards. There was a strong correlation (r = +0.96) between population density and number of IP optometrists. Fifty-six percent of IP optometrists work in the two most deprived quintiles. Since IP's introduction, there has been a marked increase in anterior segment supplementary visits (+290%). Optometry referrals to GPs have reduced by 10.5%, but referrals to HES have increased by 118% (to 96,315). There was no correlation between quantity of IP optometrists and referral rates to HES (r = -0.06, 95% CI -0.64 to 0.56, p = 0.86). CONCLUSIONS This is the first analysis of IP optometrists and associated referral rates in Scotland. Despite good geographical distribution and increased supplementary attendances, optometric referrals to HES have doubled and continue to rise. We propose a ratio of primary, supplementary, non-referral and referral rates to discern the true impact of IP versus non-IP community optometric behaviour.
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Affiliation(s)
- Mariam El-Abiary
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, UK
| | - Gunter Loffler
- Department of Vision Sciences, School of Health and Life Sciences, Cowcaddens Road, Glasgow, G4 0BA, UK
| | - David Young
- Department of Mathematics and Statistics, University of Strathclyde, 16 Richmond Street, Glasgow, G1 1XQ, UK
| | - Niall Strang
- Department of Vision Sciences, School of Health and Life Sciences, Cowcaddens Road, Glasgow, G4 0BA, UK
| | - David Lockington
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, UK.
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Optometrist referrals to an emergency ophthalmology department: a retrospective review to identify current practise and development of shared care working strategies, in England. Eye (Lond) 2020; 35:1340-1346. [PMID: 32601501 DOI: 10.1038/s41433-020-1049-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 06/08/2020] [Accepted: 06/16/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Direct referrals from optometrists account for up to 10% eye casualty attendances. Despite this, there remains a paucity of literature on optometrist referrals to eye casualty. A better understanding of these referrals could be helpful in the development of shared care emergency pathways. Diagnostic agreement between optometrists and ophthalmologists for emergency referrals can be used to identify areas for development of shared care working strategies in emergency ophthalmology. METHODS A retrospective evaluation of 1059 consecutive optometric emergency referrals to Moorfields Eye Hospital was conducted. Referrals were only included when a letter or documentation for the reason for referral was provided. Diagnostic information from the referring optometrist and casualty doctor was summarised for each patient by an investigator (VMT) and recorded on a single spreadsheet. These clinical summaries were compared by a second independent investigator (IJ) and marked as agreeing, disagreeing or uncertain. Each clinical summary was then mapped to a diagnostic category using key word searches which were manually re-checked against the original summaries. Information on the timing of the referral and the outcome at the emergency department visit was also collated. Inter-observer agreement for diagnostic categories was measured using kappa coefficients. RESULTS Diagnostic agreement ranged between kappa 0.59 and 0.87. It was best for diagnoses within the red eye category (kappa 0.87). Compliance with College of Optometrists referral guidance ranged between 11 and 100%. More than half of referrals for elevated intra-ocular pressure were discharged at the eye casualty visit. Overall, 54% of patients were managed with advice alone, 39% required treatment following referral and 7% required onward referral from eye casualty. CONCLUSION The majority of patients referred by optometrists were managed with advice alone. A collaborative approach at the point referral could be helpful to improve referral efficiency.
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Anterior Chamber Angle Evaluation Using Gonioscopy: Consistency and Agreement between Optometrists and Ophthalmologists. Optom Vis Sci 2020; 96:751-760. [PMID: 31592958 DOI: 10.1097/opx.0000000000001432] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
SIGNIFICANCE In our intermediate-tier glaucoma care clinic, we demonstrate fair to moderate agreement in gonioscopy examination between optometrists and ophthalmologists, but excellent agreement when considering open versus closed angles. We highlight the need for increased consistency in the evaluation and recording of angle status using gonioscopy. PURPOSE The consistency of gonioscopy results obtained by different clinicians is not known but is important in moving toward practice modalities such as telemedicine and collaborative care clinics. The purpose of this study was to evaluate the description and concordance of gonioscopy results among different practitioners. METHODS The medical records of 101 patients seen within a collaborative care glaucoma clinic who had undergone gonioscopic assessment by two clinicians (one optometrist and either one general ophthalmologist [n = 50] or one glaucoma specialist [n = 51]) were reviewed. The gonioscopy records were evaluated for their descriptions of deepest structure seen, trabecular pigmentation, iris configuration, and other features. These were compared between clinicians (optometrist vs. ophthalmologist) and against the final diagnosis. RESULTS Overall, 51.9 and 59.8% of angles were graded identically in terms of deepest visible structure when comparing between optometrist versus general ophthalmologist and optometrist versus glaucoma specialist, respectively. The concordance increased when considering ±1 of the grade (67.4 and 78.5%, respectively), and agreement with the final diagnosis was high (>90%). Variations in angle grading other than naming structures were observed (2.0, 30, and 3.9% for optometrist, general ophthalmologist, and glaucoma specialist, respectively). Most of the time, trabecular pigmentation or iris configuration was not described. CONCLUSIONS Fair to moderate concordance in gonioscopy was achieved between optometrists and ophthalmologists in a collaborative care clinic in which there is consistent feedback and clinical review. To move toward unified medical records and a telemedicine model, improved consistency of record keeping and angle description is required.
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Positive predictive value of optic disc haemorrhages for open angle glaucoma. Eye (Lond) 2019; 34:2029-2035. [PMID: 31772382 DOI: 10.1038/s41433-019-0711-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 07/29/2019] [Accepted: 09/17/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To determine the positive predictive value (PPV) of disc haemorrhages (DHs) for the diagnosis of open angle glaucoma (OAG). METHODS A retrospective review of 618 consecutive new referrals by community optometrists to a hospital glaucoma service, including 54 patients with DHs. All patients had a comprehensive eye examination. The primary outcome was whether the patient was diagnosed with OAG in either eye, with a secondary outcome of whether they were discharged at the first visit (first visit discharge rate, FVDR). RESULTS 54 of 618 patients (8.7%) had a DH noted at the time of referral, including 21 referred with DH alone. 29 patients with DHs were diagnosed with OAG for a PPV of 54% (95% CI 40-67%), falling to 24% (95% CI 8-47%) in those with DH alone. The overall FVDR was 35%, increasing to 57% in those referred due to DH alone. The FVDR for those referred with DH alone was significantly higher than the FDVR of 25% among the 564 patients referred with suspected glaucoma without a DH (P = 0.001). The FVDR decreased to 35% for patients with a DH plus one other feature of glaucoma and to 0% for patients with a DH and at least two other features suggestive of glaucoma. CONCLUSIONS Almost 60% of patients referred due to isolated DHs were discharged at the first visit to the glaucoma clinic, however almost one in four was diagnosed with OAG. Patients with DH and other features suggestive of glaucoma had a higher probability of glaucoma diagnosis.
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8
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Care pathways for glaucoma detection and monitoring in the UK. Eye (Lond) 2019; 34:89-102. [PMID: 31700149 DOI: 10.1038/s41433-019-0667-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/11/2019] [Accepted: 10/11/2019] [Indexed: 11/08/2022] Open
Abstract
Glaucoma presents considerable challenges in providing clinically and cost-effective care pathways. While UK population screening is not seen as justifiable, arrangements for case finding have historically been considered relatively ineffective. Detection challenges include an undetected disease burden, whether from populations failing to access services or difficulties in delivering effective case-finding strategies, and a high false positive rate from referrals via traditional case finding pathways. The enhanced General Ophthalmic Service (GOS) in Scotland and locally commissioned glaucoma referral filtering services (GRFS) elsewhere have undoubtedly reduced false positive referrals, and there is emerging evidence of effectiveness of these pathways. At the same time, it is recognised that implementing GRFS does not intrinsically reduce the burden of undetected glaucoma and late presentation, and obvious challenges remain. In terms of diagnosis and monitoring, considerable growth in capacity remains essential, and non-medical health care professional (HCP) co-management and virtual clinics continue to be important solutions in offering requisite capacity. National guidelines, commissioning recommendations, and the Common Clinical Competency Framework have clarified requirements for such services, including recommendations on training and accreditation of HCPs. At the same time, the nature of consultant-delivered care and expectations on the glaucoma specialist's role has evolved alongside these developments. Despite progress in recent decades, given projected capacity requirements, further care pathways innovations appear mandated. While the timeline for implementing potential artificial intelligence innovations in streamlining care pathways is far from established, the glaucoma burden presents an expectation that such developments will need to be at the vanguard of future developments.
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Ho KC, Stapleton F, Wiles L, Hibbert P, Alkhawajah S, White A, Jalbert I. Systematic review of the appropriateness of eye care delivery in eye care practice. BMC Health Serv Res 2019; 19:646. [PMID: 31492128 PMCID: PMC6731572 DOI: 10.1186/s12913-019-4493-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/29/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Health care systems are continually being reformed, however care improvement and intervention effectiveness are often assumed, not measured. This paper aimed to review findings from published studies about the appropriateness of eye care delivery, using existing published evidence and/or experts' practice and to describe the methods used to measure appropriateness of eye care. METHODS A systematic search was conducted using Medline, Embase and CINAHL (2006 to September 2016). Studies reporting the processes of eye care delivery against existing published evidence and/or experts' practice were selected. Data was extracted from published reports and the methodological quality using a modified critical appraisal tool. The primary outcomes were percentage of appropriateness of eye care delivery. This study was registered with PROSPERO, reference CRD42016049974. RESULTS Fifty-seven studies were included. Most studies assessed glaucoma and diabetic retinopathy and the overall methodological quality for most studies was moderate. The ranges of appropriateness of care delivery were 2-100% for glaucoma, 0-100% for diabetic retinopathy and 0-100% for other miscellaneous conditions. Published studies assessed a single ocular condition, a sample from a single centre or a single domain of care, but no study has attempted to measure the overall appropriateness of eye care delivery. CONCLUSIONS These findings indicated a wide range of appropriateness of eye care delivery, for glaucoma and diabetic eye care. Future research would benefit from a comprehensive approach where appropriateness of eye care is measured across multiple conditions with a single methodology, to guide priorities within eye care delivery and monitor quality improvement initiatives.
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Affiliation(s)
- Kam Chun Ho
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, 2052, Australia.,Eye Health, Injury Division, The George Institute for Global Health, Sydney, Australia
| | - Fiona Stapleton
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, 2052, Australia
| | - Louise Wiles
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, 2052, Australia.,Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,Centre for Population Health Research, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Peter Hibbert
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, 2052, Australia.,Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,Centre for Population Health Research, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Sally Alkhawajah
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, 2052, Australia.,Optometry and Vision Science Department, King Saud University, Riyadh, Saudi Arabia
| | - Andrew White
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, 2052, Australia.,Save Sight Institute, University of Sydney, Westmead Hospital, Sydney, New South Wales, Australia.,Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney, Westmead Hospital, Sydney, New South Wales, Australia
| | - Isabelle Jalbert
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, 2052, Australia.
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10
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Jonuscheit S, Loffler G, Strang NC. General ophthalmic services in Scotland: value for (public) money? Ophthalmic Physiol Opt 2019; 39:225-231. [DOI: 10.1111/opo.12632] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sven Jonuscheit
- Department of Vision Sciences Glasgow Caledonian University Glasgow G4 0BA UK
| | - Gunter Loffler
- Department of Vision Sciences Glasgow Caledonian University Glasgow G4 0BA UK
| | - Niall C Strang
- Department of Vision Sciences Glasgow Caledonian University Glasgow G4 0BA UK
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11
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Phu J, Hennessy MP, Spargo M, Dance S, Kalloniatis M. A collaborative care pathway for patients with suspected angle closure glaucoma spectrum disease. Clin Exp Optom 2019; 103:212-219. [PMID: 31119793 DOI: 10.1111/cxo.12923] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/01/2019] [Accepted: 04/15/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Currently, no specific collaborative care pathway exists that distinguishes open angle glaucoma from narrow angle or angle closure disease. This study evaluates a newly developed referral and collaborative care pathway specifically for patients with angle closure spectrum disease. METHODS The medical records of consecutive patients referred to the Centre for Eye Health for glaucoma assessment were examined, six months before (Pre Suite) and after (Post Suite) the introduction of a novel referral pathway for anterior chamber angle assessment (Angle Suite). Patient demographic and clinical data, the referral letter and practitioner characteristics were extracted. RESULTS Angle Suite (n = 77) patients had an appointment much sooner compared to Pre (n = 383) and Post Suite (n = 425) patients (p < 0.0001). Following the introduction of Angle Suites, there was a reduction of incidental angle closure disease found in routine, non-angle closure glaucoma assessment. Onward referral was required by 36.4 per cent of patients referred for suspected angle closure disease, while the rest could be discharged back into the community (13.0 per cent) or reviewed at the Centre for Eye Health (50.6 per cent). Multinomial logistic regression found that the presence of an angle description in the referral letter improved the true positive rate for angle closure disease (p < 0.0001). CONCLUSIONS The clinical pathway may reduce the number of incidental angle closure patients and improved the timeliness of appropriate clinical care delivered to a subset of patients who may benefit from prompt medical attention. This pathway provides an opportunity for appropriately staffed and equipped collaborative care clinics to reduce the burden on tertiary level ophthalmic facilities.
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Affiliation(s)
- Jack Phu
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,School of Optometry and Vision Science, The University of New South Wales, Kensington, New South Wales, Australia
| | - Michael P Hennessy
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,Department of Ophthalmology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Matthew Spargo
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,Department of Ophthalmology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Samuel Dance
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,Department of Ophthalmology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Michael Kalloniatis
- Centre for Eye Health, The University of New South Wales, Kensington, New South Wales, Australia.,School of Optometry and Vision Science, The University of New South Wales, Kensington, New South Wales, Australia
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12
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Rotchford AP, Hughes J, Agarwal PK, Tatham AJ. Prevalence of treatment with glaucoma medication in Scotland, 2010-2017. Br J Ophthalmol 2019; 104:381-385. [PMID: 31097436 DOI: 10.1136/bjophthalmol-2019-314206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/10/2019] [Accepted: 05/03/2019] [Indexed: 11/04/2022]
Abstract
AIMS To report the number and demographic distribution of patients receiving intraocular pressure (IOP)-lowering medications across the whole population of Scotland for the years 2010-2017 and, using national census data, show how the observed changes compare with those predicted by the increasing age of the population structure over this period. METHODS Data were sourced from the Prescribing Information System of the NHS Information and Statistics Division for Scotland. The number of patients dispensed any IOP-lowering medication from a community pharmacy during each calendar year was collected by gender and by 5-year age bands. National census data were used to model the expected annual increase in treatment numbers due to population ageing. RESULTS The number of treated patients in 2017 was 61 249 which represents 1.13% of the whole population (or 2.16% over 40 years of age). The number increased from 48 178 in 2010-an increase over this period of 27.13% (3.88% per year).Prevalence increased with age, reaching 10.67% in those over 90 years. After age adjustment, more men were treated than women (OR 1.26).The expected number treated in 2017 based on census predictions was 54 075 (an increase of 5897 (12.24%) from 2010). The observed growth of 27.13% was 2.22-fold greater than the rate expected by population changes over the period 2010-2017. CONCLUSION The number of patients on medication for glaucoma and ocular hypertension in Scotland is increasing. The rate of increase cannot be explained by changes in the size and age structure of the population alone.
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Affiliation(s)
- Alan P Rotchford
- Ophthalmology, Tennent Institute of Ophthalmology, Gartnavel Hospital, Glasgow, UK
| | - John Hughes
- International Glaucoma Association, Ashford, Kent, UK
| | | | - Andrew J Tatham
- Ophthalmology, Princess Alexandra Eye Pavilion, Edinburgh, UK
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13
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Annoh R, Patel S, Beck D, Ellis H, Dhillon B, Sanders R. Digital ophthalmology in Scotland: benefits to patient care and education. Clin Ophthalmol 2019; 13:277-286. [PMID: 30799914 PMCID: PMC6371934 DOI: 10.2147/opth.s185186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Tackling visual impairment remains an important public health issue. Due to limited resources and the increasing demand on hospital eye services (HES), delivery of quality eye care within the community is essential. Training of clinical ophthalmic specialists and allied health-care professionals in the detection and management of common eye conditions can thus help to reduce the burden of eye disease and improve prognostic outcomes. Digital imaging has become a useful tool in facilitating eye-care delivery in both the community and hospital setting. In the last decade, the advent of electronic image exchange via a centralized referral unit in Scotland has revolutionized screening for ophthalmic disease, referrals, and shared care between community and HES clinicians. A government-led initiative known as the Scottish Eyecare Integration Project introduced electronic transfer of digital images within referrals from community optometrists to HES, which greatly reduced outpatient waiting times and improved patient satisfaction. The catalogue of live clinical information and digital images that resulted from the project led to the creation of a virtual learning platform through the University of Edinburgh. Participating professionals involved in eye care have interactive discussions about common eye conditions by sharing digital images of cases and investigations on a global online platform. This has received worldwide attention and inspired the creation of other university courses, e-learning platforms in eye-health education, and shared-care schemes in the screening of eye disease. We show that digital ophthalmology plays a vital role in the integration of community and HES partnership in delivery of patient care and in facilitating eye-health education to a global audience.
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Affiliation(s)
| | - Sirjhun Patel
- Ophthalmology Department, Ninewells Hospital, Dundee, UK
| | - Daniel Beck
- Princess Alexandra Eye Pavilion, Edinburgh, UK,
| | - Heather Ellis
- Ophthalmology Department, Lauriston Building, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | - Bal Dhillon
- Princess Alexandra Eye Pavilion, Edinburgh, UK,
- University of Edinburgh, Edinburgh, UK
| | - Roshini Sanders
- University of Edinburgh, Edinburgh, UK
- Queen Margaret Hospital, Dunfermline, UK
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Annoh R, Loo CY, Hogan B, Tan HL, Tang LS, Tatham AJ. Accuracy of detection of patients with narrow angles by community optometrists in Scotland. Ophthalmic Physiol Opt 2019; 39:104-112. [PMID: 30600544 DOI: 10.1111/opo.12601] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/27/2018] [Indexed: 11/29/2022]
Abstract
AIM To examine the accuracy of referrals by community optometrists for suspected primary angle closure, including primary angle closure suspects, primary angle closure and primary angle closure glaucoma. METHODS A retrospective review of 769 consecutive patients referred by community optometrists to the glaucoma clinic at a university hospital in Scotland. Ninety-five of 715 eligible subjects (13%) were referred due to suspected angle closure. All subjects had a comprehensive eye examination in the glaucoma clinic, including gonioscopy, with angle closure defined according to the International Society of Geographical and Epidemiological Ophthalmology classification as iridotrabecular contact over at least 270 degrees. RESULTS Fifty-nine of 95 subjects referred due to suspected angle closure were confirmed to have an occludable angle, while 36 of 95 (38%) had open angles (positive predictive value = 62%). Of 620 patients referred to the glaucoma clinic for reasons other than narrow angles, 601 (97%) had open angles on gonioscopy and 19 (3%) had narrow angles. Using the 620 patients referred with 'open angles' as a control group, sensitivity was estimated as 76% and specificity 94%. Eleven of 95 (12%) patients referred for possible angle closure were discharged at the first visit compared to 156 of 620 (25%) referred to the glaucoma clinic for other reasons (p = 0.003). In a multivariable model, suspect angle closure detected by the optometrist (OR = 56.0, 95% CI 35.2-89.2, p < 0.001) and female gender (OR = 1.9, 95% CI 1.2-3.1, p = 0.008) were associated with increased odds of angle closure on gonioscopy. CONCLUSION Community optometrists had good ability to detect eyes at risk of angle closure. There was also greater accuracy of referrals for suspected angle closure than for other glaucoma referrals.
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Affiliation(s)
- Roxanne Annoh
- Princess Alexandra Eye Pavilion and Department of Ophthalmology, University of Edinburgh, Edinburgh, UK
| | - Cheng Yi Loo
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Brian Hogan
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Huai Ling Tan
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Ling Shan Tang
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew J Tatham
- Princess Alexandra Eye Pavilion and Department of Ophthalmology, University of Edinburgh, Edinburgh, UK
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Abstract
BACKGROUND AND AIMS Idiopathic intracranial hypertension is a clinical syndrome of intracranial hypertension with normal cerebrospinal fluid in the absence of a mass lesion or hydrocephalus on brain imaging. Headache is the most common symptom of idiopathic intracranial hypertension, and about 10-15% of patients suffer from irreversible visual impairment. Previous estimates of the annual incidence of idiopathic intracranial hypertension vary worldwide from 0.03 to 2.2 per 100,000. The major risk factor implicated in idiopathic intracranial hypertension is body mass. Scotland has one of the worst records for obesity in the developed world, and the prevalence of obesity in Fife is higher than the Scottish average. Our aim was to record the incidence of idiopathic intracranial hypertension in NHS Fife over a one-year period. METHODS AND RESULTS Prospective study including every patient who was seen in the ophthalmology department in NHS Fife with a new diagnosis of idiopathic intracranial hypertension over a one-year period. Thirteen patients were seen with a new diagnosis of idiopathic intracranial hypertension from August 2013 to July 2014 giving an incidence of 3.56 per 100,000. Headache was the most common presenting symptom. Three patients were asymptomatic but were noted to have swollen optic discs during a routine sight test. One patient complained of visual symptoms. All patients were overweight. The mean BMI was 36 (range: 28-49). CONCLUSION The incidence of idiopathic intracranial hypertension in NHS Fife was significantly higher than previous estimates in the literature. This is probably due to a high level of obesity in Fife. Scotland is in the midst of an obesity epidemic and if this continues we may see increasing levels of idiopathic intracranial hypertension nationally with associated increasing incidence of visual impairment in young adults.
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Affiliation(s)
- Colin Goudie
- 1 Ophthalmology Registrar, Princess Alexandra Eye Pavilion, UK
| | - Jennifer Burr
- 2 Reader in Ophthalmology, St Andrews University, UK
| | - Andrew Blaikie
- 3 Consultant Ophthalmologist, NHS Fife, UK.,4 Honorary Senior Lecturer, Global Health Implementation Programme, University of St Andrews, UK
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Barrett C, Loughman J. Expanding the traditional role of optometry: Current practice patterns and attitudes to enhanced glaucoma services in Ireland. JOURNAL OF OPTOMETRY 2018; 11:252-261. [PMID: 29650469 PMCID: PMC6147747 DOI: 10.1016/j.optom.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 02/05/2018] [Accepted: 02/11/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE To investigate current diagnostic equipment availability and usage for glaucoma case-finding within community optometric practice, and to explore optometrists' attitudes towards an enhanced scope of clinical practice. METHODS An anonymous survey was developed, validated, and distributed to all optometrists in Ireland. RESULTS 199 optometrists (27% of registrants) responded to the survey. 87% had access to the traditional triad of tests necessary to conduct adequate glaucoma case finding. Standard automated perimetry was the most commonly absent (13%) of the three essential screening tests. 64% of respondents indicated that monocular direct ophthalmoscopy was their first choice technique for fundus examination. 47% of respondents had access to contact applanation tonometry, though just 14% used it as first choice during routine eye examinations. Among the 73 participants with access to both contact and non-contact tonometry (NCT), 80.8%, used NCT preferentially. The significant majority (98%) indicated an interest in enhanced glaucoma services with 57% agreeing that postgraduate training was an essential prerequisite to any increase in scope of practice. CONCLUSION Irish optometrists are well equipped with the traditional tests used in glaucoma detection. However, implementation of enhanced referral schemes or glaucoma monitoring or management services would require equipment upgrades and associated training in at least half of the surveyed practices. There is strong interest in furthering optometric professional development and expanding the traditional role boundaries of optometrists, incorporating further education as an essential prerequisite to an enhanced scope of practice.
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Affiliation(s)
- Catriona Barrett
- Dublin Institute of Technology, 19A Lower Kevin Street, Dublin 8, Ireland; DIT Centre for Eye Research Ireland, Environmental Sustainability and Health Institute, Dublin, Ireland.
| | - James Loughman
- Dublin Institute of Technology, 19A Lower Kevin Street, Dublin 8, Ireland; DIT Centre for Eye Research Ireland, Environmental Sustainability and Health Institute, Dublin, Ireland; African Vision Research Institute, University of KwaZulu Natal, South Africa
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Sii S, Nasser A, Loo CY, Croghan C, Rotchford A, Agarwal PK. The impact of SIGN glaucoma guidelines on false-positive referrals from community optometrists in Central Scotland. Br J Ophthalmol 2018; 103:369-373. [DOI: 10.1136/bjophthalmol-2017-311429] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 03/29/2018] [Accepted: 04/13/2018] [Indexed: 11/03/2022]
Abstract
BackgroundSince the introduction of National Institute for Health and Care Excellence glaucoma guidelines 2009, the number of referrals from community optometrists to hospital eye services has increased across the UK, resulting in increase in first visit discharge rates (FVDRs).AimTo assess the impact of Scottish Intercollegiate Guidelines Network (SIGN) 144 on quality of referrals from community optometrists.MethodologyA retrospective study of patient records who attended as new adult glaucoma referrals to clinics in Princess Alexandra Eye Pavilion, Edinburgh, and in Greater Glasgow and Clyde, was carried out across October–November 2014 (group 1) and September–October 2016 (group 2), before and after the introduction of SIGN 144. The primary outcome of this study is FVDRs. A secondary outcome is the extent of compliance to referral recommendations by SIGN guidelines.ResultsThree hundred and twelve and 325 patients were included in groups 1 and 2, respectively. There was a significant decline in FVDRs between these two periods from 29.2% to 19.2%. (p=0.004) (OR 0.58 (95%CI 0.40 to 0.84)). Post-SIGN guidelines, 87% of referrals were compliant to SIGN referral criteria while 13% remained non-compliant. The main reasons for non-compliance were no repeatable visual field defects (42.0%) and referrals due to high intraocular pressure were either not repeated or not interpreted in the context of age and central corneal thickness (36.8%).ConclusionPatients referred after the introduction of SIGN guidelines were 33.5% less likely to be discharged at the first visit. Although compliance to most recommendations in SIGN guidelines has improved, there is still a need to improve adherence to referral criteria
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18
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Labiris G, Panagiotopoulou EK, Kozobolis VP. A systematic review of teleophthalmological studies in Europe. Int J Ophthalmol 2018; 11:314-325. [PMID: 29487825 PMCID: PMC5824090 DOI: 10.18240/ijo.2018.02.22] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/08/2017] [Indexed: 11/23/2022] Open
Abstract
A systematic review of the recent literature regarding a series of ocular diseases involved in European telemedicine projects was performed based on the PubMed, Google Scholar and Springer databases in June 2017. Literature review returned 44 eligible studies; among them, emergency ophthalmology, diabetic retinopathy, glaucoma, age-related macular disease, cataract and retinopathy of prematurity. The majority of studies indicate teleophthalmology as a valid, reliable and cost-efficient method for care-provision in ophthalmology patients which delivers comparable outcomes to the traditional examination methods.
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Affiliation(s)
- Georgios Labiris
- Department of Ophthalmology, University Hospital of Alexandroupolis, Dragana, Alexandroupolis 68100, Greece
- Eye Institute of Thrace, Alexandroupolis 68100, Greece
| | | | - Vassilios P. Kozobolis
- Department of Ophthalmology, University Hospital of Alexandroupolis, Dragana, Alexandroupolis 68100, Greece
- Eye Institute of Thrace, Alexandroupolis 68100, Greece
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Ly A, Nivison-Smith L, Hennessy MP, Kalloniatis M. Collaborative care of non-urgent macular disease: a study of inter-optometric referrals. Ophthalmic Physiol Opt 2017; 36:632-642. [PMID: 27790767 PMCID: PMC5129555 DOI: 10.1111/opo.12322] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/25/2016] [Indexed: 11/30/2022]
Abstract
Purpose Diseases involving the macula and posterior pole are leading causes of visual impairment and blindness worldwide and may require prompt ophthalmological care. However, access to eye‐care and timely patient management may be limited due to inefficient and inappropriate referrals between primary eye‐care providers and ophthalmology. Optometrists with a special interest in macular disease may be useful as a community aid to better stratify and recommend best‐practice management plans for suitable patients. This study assesses such a notion by appraising the optometric referral patterns of patients with suspected macular disease to an intermediate‐tier optometric imaging clinic. Methods We performed a retrospective review of patient records and referrals using patients examined at Centre for Eye Health (CFEH) for an initial or follow up macular assessment between the 1/7/2013 and 30/6/2014 (n = 291). The following data were analysed: patient demographic characteristics, primary reason for referral, diagnosed/suspected condition, CFEH diagnosis and recommended management plan. Results The number of referrals stipulating a diagnosis, confirmed after evaluation at CFEH was 121 of 291 (42%). After evaluation at CFEH, the number of cases without a specific diagnosis was approximately halved (reduced from 47% to 23%), while the number of cases with no apparent defect or normal aging changes rose from 1% to 15%. Overall diagnostic congruency for specified macular conditions was high (58–94%); cases were seldom (30/291, 10%) found to have a completely different macular condition. 244 of 291 (84%) patients seen at CFEH were recommended ongoing optometric care: either with the referring optometrist or through recall to CFEH. Referral to an ophthalmologist was recommended in 47 instances (16%). Conclusions More widespread adoption of intermediate‐tier optometric eye‐care referral pathways in macular disease (following opportunistic primary care screening) has the potential to reduce the number of cases with non‐specific diagnoses and to increase those with a diagnosis of normal aging changes or no apparent disease. The majority of cases seen under this intermediate‐tier model required ongoing optometric care only and did not require face‐to‐face consultation with an ophthalmologist.
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Affiliation(s)
- Angelica Ly
- Centre for Eye Health, Sydney, Australia.,School of Optometry and Vision Science, UNSW Australia, Sydney, Australia
| | - Lisa Nivison-Smith
- Centre for Eye Health, Sydney, Australia.,School of Optometry and Vision Science, UNSW Australia, Sydney, Australia
| | - Michael P Hennessy
- Centre for Eye Health, Sydney, Australia.,Department of Ophthalmology, Prince of Wales Hospital, Randwick, Australia
| | - Michael Kalloniatis
- Centre for Eye Health, Sydney, Australia. .,School of Optometry and Vision Science, UNSW Australia, Sydney, Australia.
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20
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Goudie C, Pronin S, Court H, Pooley J, Tatham AJ. A national survey of the use of pachymeters by optometrists in Scotland: experience, views and barriers to use. Ophthalmic Physiol Opt 2017; 37:177-183. [DOI: 10.1111/opo.12352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/13/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Colin Goudie
- Princess Alexandra Eye Pavilion and Department of Ophthalmology; University of Edinburgh; Edinburgh UK
| | - Savva Pronin
- Princess Alexandra Eye Pavilion and Department of Ophthalmology; University of Edinburgh; Edinburgh UK
| | - Helen Court
- National Health Service (NHS) Education for Scotland; Edinburgh UK
| | - Janet Pooley
- National Health Service (NHS) Education for Scotland; Edinburgh UK
| | - Andrew J. Tatham
- Princess Alexandra Eye Pavilion and Department of Ophthalmology; University of Edinburgh; Edinburgh UK
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21
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Henderson R. Evidence for Scottish General Ophthalmic Services improving true-positive referral rate for Glaucoma. Ophthalmic Physiol Opt 2016; 37:113. [PMID: 28030878 DOI: 10.1111/opo.12336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lawrenson JG, Baker H, Ratnarajan G, Harper RA, Edgar DF. Authors' reply. Ophthalmic Physiol Opt 2016; 37:113-114. [PMID: 28030879 DOI: 10.1111/opo.12347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- John G Lawrenson
- Division of Optometry and Visual Science, City, University of London, London, UK
| | | | | | - Robert A Harper
- Manchester Academic Health Sciences Centre, Manchester Royal Eye Hospital, Manchester, UK
| | - David F Edgar
- Division of Optometry and Visual Science, City, University of London, London, UK
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Davey CJ, Scally AJ, Green C, Mitchell ES, Elliott DB. Factors influencing accuracy of referral and the likelihood of false positive referral by optometrists in Bradford, United Kingdom. JOURNAL OF OPTOMETRY 2016; 9:158-65. [PMID: 26614021 PMCID: PMC4911451 DOI: 10.1016/j.optom.2015.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/12/2015] [Accepted: 10/12/2015] [Indexed: 05/16/2023]
Abstract
AIMS Levels of false positive referral to ophthalmology departments can be high. This study aimed to evaluate commonality between false positive referrals in order to find the factors which may influence referral accuracy. METHODS In 2007/08, a sample of 431 new Ophthalmology referrals from the catchment area of Bradford Royal Infirmary were retrospectively analysed. RESULTS The proportion of false positive referrals generated by optometrists decreases with experience at a rate of 6.2% per year since registration (p<0.0001). Community services which involved further investigation done by the optometrist before directly referring to the hospital were 2.7 times less likely to refer false positively than other referral formats (p=0.007). Male optometrists were about half as likely to generate a false positive referral than females (OR=0.51, p=0.008) and as multiple/corporate practices in the Bradford area employ less experienced and more female staff, independent practices generate about half the number of false positive referrals (OR=0.52, p=0.005). CONCLUSIONS Clinician experience has the greatest effect on referral accuracy although there is also a significant effect of gender with women tending to refer more false positives. This may be due to a different approach to patient care and possibly a greater sensitivity to litigation. The improved accuracy of community services (which often refer directly after further investigation) supports further growth of these schemes.
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Affiliation(s)
| | - Andrew J Scally
- School of Health Studies, University of Bradford, Bradford, UK
| | - Clare Green
- Bradford Teaching Hospitals Foundation Trust, Bradford Royal Infirmary, Bradford, UK
| | - Edwin S Mitchell
- Shipley Ophthalmic Assessment Programme, Windhill Green Medical Centre, Shipley, UK
| | - David B Elliott
- Bradford School of Optometry and Vision Science, University of Bradford, Bradford, UK
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Affiliation(s)
- Michael Kalloniatis
- Centre for Eye Health. .,School of Optometry and Vision Science, University of New South Wales, Kensington, New South Wales, Australia.
| | - Christina Ly
- Centre for Eye Health.,School of Optometry and Vision Science, University of New South Wales, Kensington, New South Wales, Australia
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El-Assal K, Foulds J, Dobson S, Sanders R. A comparative study of glaucoma referrals in Southeast Scotland: effect of the new general ophthalmic service contract, Eyecare integration pilot programme and NICE guidelines. BMC Ophthalmol 2015; 15:172. [PMID: 26643710 PMCID: PMC4672504 DOI: 10.1186/s12886-015-0161-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 12/02/2015] [Indexed: 08/08/2023] Open
Abstract
Background Glaucoma is a progressive disease responsible for the second commonest cause of blindness in the UK. Identifying appropriate patients for hospital care remains an ongoing challenge for all UK hospital glaucoma services. The purpose of our study is to evaluate accuracy and outcome of community optometry referrals before and after implementation of the new general ophthalmic service contract in 2006, the Eyecare Integration Programme pilot in 2008 and the effect of NICE guidelines in glaucoma in 2009, over a 12-year period Methods A retrospective case analysis using a glaucoma electronic patient record was performed encompassing two six-year periods, 2000–2006 (Group A), and 2007–2012 (Group B). Results One thousand six hundred twenty-two new patients’ records were analysed. Waiting times reduced from 12.3 to 9.4 weeks. Significantly more patients kept first appointment (p = 0.0002) in group B. Glaucoma symptoms were significantly more in group A (p <0.0001) and only three patients lost Snellen’ visual acuity before appointment in group B compared to 12 in group A. Documentation of intraocular pressure was made in 74.1 % of Group A and 75.9 % of Group B, optic disc appearance in 85.4 % of Group A, and 93 % of Group B and visual fields in 84.4 % of Group A and 81.3 % of Group B. Significantly less normal (p < 0,0001), more glaucoma suspects (p < 0.0001), more open angle glaucoma (p = 0.0006) and fewer other conditions (p = 0.0024) were present in group B, compared to group A. Conclusion Patients were referred earlier with shorter waiting times for hospital appointments with the new Scottish general ophthalmic service and Eyecare Integration Programme. Additionally there were fewer false positive referrals with more diagnosis of glaucomatous disease. We discuss the benefits of these national screening and referral pathways together with their limitations and further refinements.
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Affiliation(s)
- Karim El-Assal
- Department of Ophthalmology, Queen Margaret Hospital, Whitefield Road, KY12 0SU, Dunfermline, Fife, UK.
| | | | - Stuart Dobson
- Medical Informatics, Queen Margaret Hospital, Dunfermline, Fife, UK
| | - Roshini Sanders
- Department of Ophthalmology, Queen Margaret Hospital, Whitefield Road, KY12 0SU, Dunfermline, Fife, UK
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Syrogiannis A, Rotchford AP, Agarwal PK, Kumarasamy M, Montgomery D, Burr J, Sanders R. Glaucoma-service provision in Scotland: introduction and need for Scottish Intercollegiate Guidelines Network guidelines. Clin Ophthalmol 2015; 9:1835-43. [PMID: 26491244 PMCID: PMC4599172 DOI: 10.2147/opth.s91818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To describe the pattern of glaucoma-service delivery in Scotland and identify areas for improvement, taking into account Scottish General Ophthalmic Services (GOS) arrangements and the Eye Care Integration project, and to design Scottish Intercollegiate Guidelines Network (SIGN) guidelines to refine the primary and secondary interface of glaucoma care. Materials and methods A glaucoma-survey questionnaire was sent to all consultant glaucomatologists in Scotland. The design of SIGN guidelines was based on the results of the questionnaire using SIGN methodology. Results Over 90% of Scottish glaucoma care is triaged and delivered within hospital services. Despite GOS referral, information is variable. There are no consistent discharge practices to the community. These results led to defined research questions that were answered, thus formulating the content of the SIGN guidelines. The guideline covers the assessment of patients in primary care, referral criteria to hospital, discharge criteria from hospital to community, and monitoring of patients at risk of glaucoma. Conclusion With increasing age and limitations to hospital resources, refining glaucoma pathways between primary and secondary care has become a necessity. Scotland has unique eye care arrangements with both the GOS and Eye Care Integration project. It is hoped that implementation of SIGN guidelines will identify glaucoma at the earliest opportunity and reduce the rate of false-positive referrals to hospital.
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Affiliation(s)
- Andreas Syrogiannis
- SIGN Working Group, SIGN Guidelines for Glaucoma Referral and Safe Discharge, Edinburgh, Scotland
| | | | - Pankaj Kumar Agarwal
- SIGN Working Group, SIGN Guidelines for Glaucoma Referral and Safe Discharge, Edinburgh, Scotland
| | - Manjula Kumarasamy
- SIGN Working Group, SIGN Guidelines for Glaucoma Referral and Safe Discharge, Edinburgh, Scotland
| | - Donald Montgomery
- SIGN Working Group, SIGN Guidelines for Glaucoma Referral and Safe Discharge, Edinburgh, Scotland
| | - Jennifer Burr
- SIGN Working Group, SIGN Guidelines for Glaucoma Referral and Safe Discharge, Edinburgh, Scotland
| | - Roshini Sanders
- SIGN Working Group, SIGN Guidelines for Glaucoma Referral and Safe Discharge, Edinburgh, Scotland ; Healthcare Improvement Scotland, Edinburgh, Scotland
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Ratnarajan G, Kean J, French K, Parker M, Bourne R. The false negative rate and the role for virtual review in a nationally evaluated glaucoma referral refinement scheme. Ophthalmic Physiol Opt 2015; 35:577-81. [DOI: 10.1111/opo.12224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 05/27/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Gokulan Ratnarajan
- Vision and Eye Research Unit; Anglia Ruskin University; Cambridge UK
- UCL Institute of Ophthalmology; University of London; London UK
- Oxford Eye Hospital; John Radcliffe Hospital; Oxford UK
| | - Jane Kean
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital; Huntingdon UK
| | - Karen French
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital; Huntingdon UK
| | - Mike Parker
- Postgraduate Medical Institute; Anglia Ruskin University; Cambridge UK
| | - Rupert Bourne
- Vision and Eye Research Unit; Anglia Ruskin University; Cambridge UK
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital; Huntingdon UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology; London UK
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Dabasia PL, Edgar DF, Garway-Heath DF, Lawrenson JG. A survey of current and anticipated use of standard and specialist equipment by UK optometrists. Ophthalmic Physiol Opt 2015; 34:592-613. [PMID: 25160893 DOI: 10.1111/opo.12150] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 07/22/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate current and anticipated use of equipment and information technology (IT) in community optometric practice in the UK, and to elicit optometrists' views on adoption of specialist equipment and IT. METHODS An anonymous online questionnaire was developed, covering use of standard and specialist diagnostic equipment, and IT. The survey was distributed to a random sample of 1300 UK College of Optometrists members. RESULTS Four hundred and thirty-two responses were received (response rate = 35%). Enhanced (locally commissioned) or additional/separately contracted services were provided by 73% of respondents. Services included glaucoma repeat measures (30% of respondents), glaucoma referral refinement (22%), fast-track referral for wet age-related macular degeneration (48%), and direct cataract referral (40%). Most respondents (88%) reported using non-contact/pneumo tonometry for intra-ocular pressure measurement, with 81% using Goldmann or Perkins tonometry. The most widely used item of specialist equipment was the fundus camera (74% of respondents). Optical Coherence Tomography (OCT) was used by 15% of respondents, up from 2% in 2007. Notably, 43% of those anticipating purchasing specialist equipment in the next 12 months planned to buy an OCT. 'Paperless' records were used by 39% of respondents, and almost 80% of practices used an electronic patient record/practice management system. Variations in responses between parts of the UK reflect differences in the provision of the General Ophthalmic Services contract or community enhanced services. There was general agreement that specialised equipment enhances clinical care, permits increased involvement in enhanced services, promotes the practice and can be used as a defence in clinico-legal cases, but initial costs and ongoing maintenance can be a financial burden. Respondents generally agreed that IT facilitates administrative flow and secure exchange of health information, and promotes a state-of-the-art practice image. However, use of IT may not save examination time; its dynamic nature necessitates frequent updates and technical support; the need for adequate training is an issue; and security of data is also a concern. CONCLUSION UK optometrists increasingly employ modern equipment and IT services to enhance patient care and for practice management. While the clinical benefits of specialist equipment and IT are appreciated, questions remain as to whether the investment is cost-effective, and how specialist equipment and IT may be used to best advantage in community optometric practice.
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Affiliation(s)
- Priya L Dabasia
- Centre for Public Health Research, School of Health Sciences, City University London, London, UK
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Keenan J, Shahid H, Bourne RR, White AJ, Martin KR. Cambridge community Optometry Glaucoma Scheme. Clin Exp Ophthalmol 2014; 43:221-7. [PMID: 25070417 DOI: 10.1111/ceo.12398] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 07/15/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND With a higher life expectancy, there is an increased demand for hospital glaucoma services in the United Kingdom. DESIGN The Cambridge community Optometry Glaucoma Scheme (COGS) was initiated in 2010, where new referrals for suspected glaucoma are evaluated by community optometrists with a special interest in glaucoma, with virtual electronic review and validation by a consultant ophthalmologist with special interest in glaucoma. PARTICIPANTS 1733 patients were evaluated by this scheme between 2010 and 2013. METHODS Clinical assessment is performed by the optometrist at a remote site. Goldmann applanation tonometry, pachymetry, monoscopic colour optic disc photographs and automated Humphrey visual field testing are performed. A clinical decision is made as to whether a patient has glaucoma or is a suspect, and referred on or discharged as a false positive referral. The clinical findings, optic disc photographs and visual field test results are transmitted electronically for virtual review by a consultant ophthalmologist. MAIN OUTCOME MEASURES The number of false positive referrals from initial referral into the scheme. RESULTS Of the patients, 46.6% were discharged at assessment and a further 5.7% were discharged following virtual review. Of the patients initially discharged, 2.8% were recalled following virtual review. Following assessment at the hospital, a further 10.5% were discharged after a single visit. CONCLUSIONS The COGS community-based glaucoma screening programme is a safe and effective way of evaluating glaucoma referrals in the community and reducing false-positive referrals for glaucoma into the hospital system.
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Affiliation(s)
- Jonathan Keenan
- Department of Ophthalmology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK
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Goudie C, Lunt D, Reid S, Sanders R. Ophthalmic digital image transfer: benefits to triage, patient care and resource. Ophthalmic Physiol Opt 2014; 34:628-35. [PMID: 25223370 DOI: 10.1111/opo.12154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/13/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE Hospital capacity in the UK is currently significantly challenged due to new treatments, targets and resource limitations. There have been significant improvements in training, equipment and shared care services in community primary care optometry services. Despite this the challenges to ophthalmic service delivery are considerable. One area of potential benefit is the effect on outcome when a clinical image is attached to a referral. We aimed to quantify the effect of attaching digital images to ophthalmic referrals. METHODS Retrospective analysis of 358 consecutive optometry referrals to the Hospital Eye Service in Dunfermline, Scotland using electronic referral with digital images. All images were screened by consultant ophthalmologists. RESULTS The patients were aged between 9 and 100 years (mean age 63.6 years). Sixty four (18%) referrals were deemed urgent (requiring appointment within 24-60 h), with the majority, 28 (8%) being wet macular degeneration. One hundred and seventy (48%) were deemed routine (appointment within 2-6 weeks), with categories including macular disease, glaucoma, cataract, optic disc and retinal abnormalities. Twenty seven (8%) patients were already attending the hospital eye service, or had been referred previously for the same condition. Categories were mainly glaucoma, diabetic retinopathy and cataract. Ninety-five (25%) were 'e-diagnosed' based on image and referral information (i.e. with no secondary eye care appointment). Diagnosis included glaucoma suspect (22, 6%), macular pathology (12, 3%), abnormal looking discs (9, 2.5%) and cataract (9, 2.5%). The overall 'did not attend' rate for those patients seen in the hospital eye service (254) was <1% (two patients). CONCLUSIONS The attachment of digital images improved the quality of referral triaging from optometry to secondary eye care in the hospital eye service. It allowed detection of sight threatening disease early and more appropriate allocation of patients to specific specialist clinics at first visit. They allowed safe and speedy 'e-diagnosis' of a subgroup, saving hospital capacity and minimising patient inconvenience. Indirectly the service also reduced the 'did not attend' rate. With recent improvements in camera and internet technology digital images will have an ever increasing role in secondary eye care as it continues to adapt to meet modern demands.
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Affiliation(s)
- Colin Goudie
- Department of Ophthalmology, Queen Margaret Hospital, Dunfermline, Scotland, UK
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Jamous KF, Kalloniatis M, Hayen A, Mitchell P, Stapleton FJ, Zangerl B. Application of clinical techniques relevant for glaucoma assessment by optometrists: concordance with guidelines. Ophthalmic Physiol Opt 2014; 34:580-91. [DOI: 10.1111/opo.12146] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/02/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Khalid F. Jamous
- School of Optometry and Vision Science; University of New South Wales; Sydney Australia
- Centre for Eye Health; University of New South Wales; Sydney Australia
- Department of Ophthalmology; Faculty of Medicine; King Saud University; Riyadh Saudi Arabia
| | - Michael Kalloniatis
- School of Optometry and Vision Science; University of New South Wales; Sydney Australia
- Centre for Eye Health; University of New South Wales; Sydney Australia
| | - Andrew Hayen
- School of Public Health and Community Medicine; University of New South Wales; Sydney Australia
| | - Paul Mitchell
- Centre for Vision Research; Department of Ophthalmology and Westmead Millennium Institute; University of Sydney; Sydney Australia
| | - Fiona J. Stapleton
- School of Optometry and Vision Science; University of New South Wales; Sydney Australia
| | - Barbara Zangerl
- School of Optometry and Vision Science; University of New South Wales; Sydney Australia
- Centre for Eye Health; University of New South Wales; Sydney Australia
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Ratnarajan G, Newsom W, French K, Kean J, Chang L, Parker M, Garway-Heath DF, Bourne RRA. The impact of glaucoma referral refinement criteria on referral to, and first-visit discharge rates from, the hospital eye service: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways project. Ophthalmic Physiol Opt 2013; 33:183-9. [DOI: 10.1111/opo.12029] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/03/2013] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Karen French
- Huntingdon Glaucoma Diagnostic & Research Centre; Hinchingbrooke Hospital; Huntingdon; UK
| | - Jane Kean
- Huntingdon Glaucoma Diagnostic & Research Centre; Hinchingbrooke Hospital; Huntingdon; UK
| | | | - Mike Parker
- Postgraduate Medical Institute; Anglia Ruskin University; Cambridge; UK
| | - David F Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology; London; UK
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Ratnarajan G, Newsom W, Vernon SA, Fenerty C, Henson D, Spencer F, Wang Y, Harper R, McNaught A, Collins L, Parker M, Lawrenson J, Hudson R, Khaw PT, Wormald R, Garway-Heath D, Bourne R. The effectiveness of schemes that refine referrals between primary and secondary care--the UK experience with glaucoma referrals: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project. BMJ Open 2013; 3:bmjopen-2013-002715. [PMID: 23878172 PMCID: PMC3717451 DOI: 10.1136/bmjopen-2013-002715] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES A comparison of glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and guidance. DESIGN Retrospective multisite review. SETTING The outcomes of clinical examinations by optometrists with a specialist interest in glaucoma (OSIs) were compared with optometrists with no specialist interest in glaucoma (non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, while Manchester and Gloucestershire reviewed OSI findings. PARTICIPANTS 1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 from Gloucestershire and 269 from Nottingham. RESULTS The first-visit discharge rate (FVDR) for all time periods for OSIs was 14.1% compared with 36.1% from non-OSIs (difference 22%, CI 16.9% to 26.7%; p<0.001). The FVDR increased after the April 2009 National Institute for Health and Clinical Excellence (NICE) glaucoma guidelines compared with pre-NICE, which was particularly evident when pre-NICE was compared with the current practice time period (OSIs 6.2-17.2%, difference 11%, CI -24.7% to 4.3%; p=0.18, non-OSIs 29.2-43.9%, difference 14.7%, CI -27.8% to -0.30%; p=0.03). Elevated intraocular pressure (IOP) was the commonest reason for referral for OSIs and non-OSIs, 28.7% and 36.1%, respectively, of total referrals. The proportion of referrals for elevated IOP increased from 10.9% pre-NICE to 28.0% post-NICE for OSIs, and from 19% to 45.1% for non-OSIs. CONCLUSIONS In terms of 'demand management', OSIs can reduce FVDR of patients reviewed in secondary care; however, in terms of 'patient safety' this study also shows that overemphasis on IOP as a criterion for referral is having an adverse effect on both the non-OSIs and indeed the OSIs ability to detect glaucomatous optic nerve features. It is recommended that referral letters from non-OSIs be stratified for risk, directing high-risk patients straight to secondary care, and low-risk patients to OSIs.
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Affiliation(s)
- Gokulan Ratnarajan
- The North East, North Central London and Essex Health Innovation & Education Cluster
- Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK
- UCL Institute of Ophthalmology, London, UK
| | - Wendy Newsom
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, Huntingdon, UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | | | - Cecilia Fenerty
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - David Henson
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Fiona Spencer
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Yanfang Wang
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Robert Harper
- Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Andrew McNaught
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Lisa Collins
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Mike Parker
- Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK
| | - John Lawrenson
- Division of Optometry and Visual Science, City University London, London, UK
| | - Robyn Hudson
- The North East, North Central London and Essex Health Innovation & Education Cluster
| | - Peng Tee Khaw
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Richard Wormald
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Rupert Bourne
- The North East, North Central London and Essex Health Innovation & Education Cluster
- Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK
- Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, Huntingdon, UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
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Borooah S, Grant B, Blaikie A, Styles C, Sutherland S, Forrest G, Curry P, Legg J, Walker A, Sanders R. Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign. Eye (Lond) 2012; 27:392-7. [PMID: 23258310 DOI: 10.1038/eye.2012.278] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively. METHOD A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction. RESULTS Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001). DISCUSSION Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.
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Affiliation(s)
- S Borooah
- Princess Alexandra Eye Pavilion, Edinburgh, UK.
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The Portsmouth-based glaucoma refinement scheme: a role for virtual clinics in the future? Eye (Lond) 2012; 26:1288-94. [PMID: 22766539 DOI: 10.1038/eye.2012.120] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Glaucoma referrals continue to impart a significant burden on Hospital Eye Services (HES), with a large proportion of these false positives. AIMS To evaluate the Portsmouth glaucoma scheme, utilising virtual clinics, digital technology, and community optometrists to streamline glaucoma referrals. METHOD The stages of the patient trail were mapped and, at each step of the process, 100 consecutive patient decisions were identified. The diagnostic outcomes of 50 consecutive patients referred from the refinement scheme to the HES were identified. RESULTS A total of 76% of 'glaucoma' referrals were suitable for the refinement scheme. Overall, 94% of disc images were gradeable in the virtual clinic. In all, 11% of patients 'attending' the virtual clinic were accepted into HES, with 89% being discharged for community follow-up. Of referrals accepted into HES, the positive predictive value (glaucoma/ocular hypertension/suspect) was 0.78 vs 0.37 in the predating 'unrefined' scheme (95% CI 0.65-0.87). The scheme has released 1400 clinic slots/year for HES, and has produced a £244 200/year cost saving for Portsmouth Hospitals' Trust. CONCLUSION The refinement scheme is streamlining referrals and increasing the positive predictive rate in the diagnosis of glaucoma, glaucoma suspect or ocular hypertension. This consultant-led practice-based commissioning scheme, if adopted widely, is likely to incur a significant cost saving while maintaining high quality of care within the NHS.
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de Vries MM, Stoutenbeek R, Müskens RPHM, Jansonius NM. Glaucoma screening during regular optician visits: the feasibility and specificity of screening in real life. Acta Ophthalmol 2012; 90:115-21. [PMID: 22268769 DOI: 10.1111/j.1755-3768.2011.02355.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To determine the feasibility and specificity of glaucoma screening during regular optician visits. METHODS In four optician shops, glaucoma screening was offered to 400 consecutive visitors aged 45 years or above. If the visitor agreed to participate, an intraocular pressure measurement and - in those with a pressure below 25 mmHg - a frequency-doubling perimeter (FDT) C20-1 visual field screening test were performed. Those with an elevated pressure or at least one reproducibly abnormal test location on FDT were referred to our hospital. RESULTS Three-hundred and fifty-two of 400 consecutive visitors (88%) were screened. Fifteen of the unscreened visitors were not screened because they were already regularly checked by an ophthalmologist related to glaucoma. Forty-two of 352 screened participants (12%) were referred. Of these 42 referrals, seven were diagnosed with glaucoma, 10 were diagnosed with ocular hypertension (OHT), 12 did not have any eye disease, seven had an eye disease other than glaucoma or OHT that was diagnosed previously and six were newly diagnosed with an eye disease other than glaucoma or OHT. The specificity of the screening protocol was 91% (95% confidence interval 88-94%). CONCLUSIONS Glaucoma screening at the optician shop was feasible, but the specificity of the screening protocol was rather low. With more stringent cut-off points (30 mmHg; at least two reproducibly abnormal test locations), the specificity could be improved to 96% (94-98%), apparently without a significant loss of sensitivity. This suggests that screening during regular optician visits might be a viable approach.
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Affiliation(s)
- Margriet M de Vries
- Department of Ophthalmology, University Medical Center Groningen, University of Groningen, 9700 R B Groningen, The Netherlands
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Theodossiades J, Myint J, Murdoch IE, Edgar DF, Lawrenson JG. Does optometrists’ self-reported practice in glaucoma detection predict actual practice as determined by standardised patients? Ophthalmic Physiol Opt 2012; 32:234-41. [DOI: 10.1111/j.1475-1313.2012.00898.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Parkins DJ, Edgar DF. Comparison of the effectiveness of two enhanced glaucoma referral schemes. Ophthalmic Physiol Opt 2011; 31:343-52. [DOI: 10.1111/j.1475-1313.2011.00853.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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O’Colmain U, Anijeet D, Vosoughi M, Sinclair A, Sanders R. Glaucoma blind registration in Fife (2000-2009) - a retrospective cohort study. Ophthalmic Physiol Opt 2011; 31:360-6. [DOI: 10.1111/j.1475-1313.2011.00849.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Myint J, Edgar DF, Kotecha A, Murdoch IE, Lawrenson JG. A national survey of diagnostic tests reported by UK community optometrists for the detection of chronic open angle glaucoma. Ophthalmic Physiol Opt 2011; 31:353-9. [DOI: 10.1111/j.1475-1313.2011.00844.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Myint J, Edgar DF, Kotecha A, Murdoch IE, Lawrenson JG. Barriers perceived by UK-based community optometrists to the detection of primary open angle glaucoma. Ophthalmic Physiol Opt 2010; 30:847-53. [DOI: 10.1111/j.1475-1313.2010.00792.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shah R, Edgar DF, Evans BJW. A comparison of standardised patients, record abstraction and clinical vignettes for the purpose of measuring clinical practice. Ophthalmic Physiol Opt 2010; 30:209-24. [PMID: 20444128 DOI: 10.1111/j.1475-1313.2010.00713.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND A recent review found standardised patient (SP) methodology to be the gold standard method for evaluating clinical care. Alternative methods include record abstraction and computerised clinical vignettes. SPs were compared to clinical records and to computerised vignettes in order to assess whether record abstraction and vignettes are accurate measures of clinical care provided within optometry. METHODS A total of 111 community optometrists in the south east of the UK consented to be visited by unannounced actors for an eye examination. The SPs received extensive training to enable accurate reporting of the content of the eye examinations using checklists. Clinical records were requested from optometrists who chose to receive feedback following the SP visits. The SP checklists were used as a guide to extract relevant information from the clinical records. An opportunity was made available to all UK qualified optometrists, through publicity in the College of Optometrists' monthly newsletter, the Association of Optometrists' monthly newsletter (Blink) and the UK optometry e-mail discussion list to complete three computerised clinical vignettes by performing a virtual eye examination using an on-line optometric record card. The average differences were calculated between the record abstraction and vignette results compared to the standardised patient encounter findings for different domains of an eye examination. Chi-square analyses were performed on the tests which were of the greatest clinical significance for each scenario. RESULTS The average overall difference for information gathered from record abstraction compared to the standardised patient encounter ranged from +2 to -26% (positive values indicate items that were recorded on the clinical records but not reported by the SP). For history and symptoms, the average difference ranged from -9 to -26%; for the proportion of tests performed during the examination this value ranged from +2 to -24% and for management issues the difference ranged from -1 to -4%. The average overall difference for the vignette data compared to the standardised patient encounter ranged from 0 to +26% (positive values indicate items that were not carried out in a clinical setting, as recorded by the SP, but were described by optometrists who completed the vignette as tests they would have carried out). For history and symptoms, the average difference for the vignette data ranged from +2 to +26%; from 0 to +20% for tests performed during the eye examination and from 0 to +11% for management. CONCLUSION Different methods of measuring clinical care capture different elements of clinical practice and are prone to different biases. This three-way comparison indicates that clinical records tend to under-estimate actual care provided, while vignette scores tend to over-estimate clinical performance. Low participation rates mean that the participating optometrists could be described as a 'self-selected sample'. This is a limitation of the research and the conclusions should be considered with this in mind. The significance of these findings for future research and for litigation and disciplinary cases is discussed.
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Affiliation(s)
- Rakhee Shah
- The Neville Chappell Research Clinic, The Institute of Optometry, Newington Causeway, London.
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Optometrists referrals for glaucoma assessment: a prospective survey of clinical data and outcomes. Eye (Lond) 2010; 24:1515-9. [PMID: 20559331 DOI: 10.1038/eye.2010.77] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
AIM The aim of this study is to determine the outcomes following referral for glaucoma from routine optometric practice and the positive predictive value (PPV). METHODS A prospective study of 441 referrals for glaucoma in the Portsmouth area was performed over 6 months. A positive outcome was defined when the patient had the diagnosis of glaucoma made or if there was a high index of suspicion of glaucoma requiring follow-up. The PPV was determined from positive outcome number/referral number. RESULTS The overall PPV was 0.37 (95% confidence interval 0.33-0.42). Open-angle glaucoma (OAG) was confirmed in 33 (7%) patients. A diagnosis of ocular hypertension was made in 49 (11%) patients and glaucoma suspect in 92 (21%) referrals. Two-thirds of optometrists recorded all 3 assessments: fields, intraocular pressure (IOP) and disc appearance, a figure representing 293 referrals (PPV 0.37). However the greatest referral accuracy was seen when only discs and IOPs were recorded (PPV 0.47). When all three tests were given as reasons for suspicion for glaucoma, the PPV was 0.71. The number of patients diagnosed with OAG from Portsea Island during the study period was 7, whereas the expected number of diagnosed patients was 29. CONCLUSION Wider use of perimetry by optometrists and increased reporting of all three tests has not led to an increase in PPV. There remain a considerable number of undiagnosed patients with glaucoma in the population.
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Shah R, Edgar DF, Evans BJW. How well does record abstraction quantify the content of optometric eye examinations in the UK? Ophthalmic Physiol Opt 2009; 29:383-96. [DOI: 10.1111/j.1475-1313.2009.00656.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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