Referrals and notifications by British optometrists

Referral Patterns in Neuro-Ophthalmology

BACKGROUND

Neuro-ophthalmologists specialize in complex, urgent, vision- and life-threatening problems, diagnostic dilemmas, and management of complex work-ups. Access is currently limited by the relatively small number of neuro-ophthalmologists, and consequently, patients may be affected by incorrect or delayed diagnosis. The objective of this study is to analyze referral patterns to neuro-ophthalmologists, characterize rates of misdiagnoses and delayed diagnoses in patients ultimately referred, and delineate outcomes after neuro-ophthalmologic evaluation.

METHODS

Retrospective chart review of 300 new patients seen over 45 randomly chosen days between June 2011 and June 2015 in one tertiary care neuro-ophthalmology clinic. Demographics, distance traveled, time between onset and neuro-ophthalmology consultation (NOC), time between appointment request and NOC, number and types of providers seen before referral, unnecessary tests before referral, referral diagnoses, final diagnoses, and impact of the NOC on outcome were collected.

RESULTS

Patients traveled a median of 36.5 miles (interquartile range [IQR]: 20-85). Median time from symptom onset was 210 days (IQR: 70-1,100). Median time from referral to NOC was 34 days (IQR: 7-86), with peaks at one week (urgent requests) and 13 weeks (routine requests). Median number of previous providers seen was 2 (IQR: 2-4; range:0-10), and 102 patients (34%) had seen multiple providers within the same specialty before referral. Patients were most commonly referred for NOC by ophthalmologists (41% of referrals). Eighty-one percent (242/300) of referrals to neuro-ophthalmology were appropriate referrals. Of the 300 patients referred, 247 (82%) were complex or very complex; 119 (40%) were misdiagnosed; 147 (49%) were at least partially misdiagnosed; and 22 (7%) had unknown diagnoses. Women were more likely to be at least partially misdiagnosed-108 of 188 (57%) vs 39 of 112 (35%) of men (P < 0.001). Mismanagement or delay in care occurred in 85 (28%), unnecessary tests in 56 (19%), unnecessary consultations in 64 (22%), and imaging misinterpretation in 16 (5%). Neuro-ophthalmologists played a major role in directing treatment, such as preserving vision, preventing life-threatening complications, or avoiding harmful treatment in 62 (21%) patients.

CONCLUSIONS

Most referrals to neuro-ophthalmologists are appropriate, but many are delayed. Misdiagnosis before referral is common. Neuro-ophthalmologists often prevent vision- and life-threatening complications.

Assessing the role of optometrists in the control of systemic hypertension in Saudi Arabia

The low level of awareness, treatment, and control of systemic hypertension is a global problem, but it is much more serious in Saudi Arabia. This study examines the contribution made by Saudi optometrists in detection and management of patients with systemic hypertension. We surveyed a sample of 250 optometrists practicing in Saudi Arabia to evaluate the level of knowledge and awareness of their role in combating systemic hypertension. A 48.4% response rate was obtained from practicing optometrists. Of those responding, optometrists were very positive towards the use of blood pressure (BP) monitors in optometric practice on a routine basis. Forty-six percent of the optometrists had access to a BP monitor, and about 93% of these respondents actually used the monitors during clinic consultations. Automated monitors were the most common (54%). Fifty-one percent and 49% of the optometrists reported that they did routinely question their patients about high BP and about their current BP medications, respectively. The less frequently asked question concerned the cholesterol level of the patient (21%). The tests most widely used by the optometrists while examining hypertensive patients was direct ophthalmoscopy with red free filter (56%) and the least was binocular indirect ophthalmoscopy (21%). Optometrists were more likely to refer patients suspected of systemic hypertension on the basis of elevated BP (74%) and presence of retinal hemorrhages (72%), but were less likely to refer patients with changes in arteriolar reflex (41%). The opinions were very positive towards the routine monitoring of BP within the Saudi optometry profession, as optometrists indicated that they had time within an eye examination to measure BP, it was financially rewarding (56% of respondents), and patients appreciated it (64% of respondents). Despite half of the optometrists having access to BP monitors (predominantly automated devices), many of the optometrists were unsure if they were trained enough to monitor BP in such patients. There is urgent need to train optometrists on the use of BP devices, interpretation of readings, and use of additional diagnostic tests during such eye examinations.

Referrals to ophthalmology: optometric and general practice comparison

PURPOSE

To assess referrals from primary care practitioners to an ophthalmological practice in order to determine whether any differences exist between the two primary care groups in the types of conditions referred, and in concurrence between reasons for referral and ophthalmological diagnosis.

METHODS

This study investigated patient referrals from general practitioners and optometrists to an ophthalmologist's practice in Belfast, over a period of 3 months from January 2007 to the end of March 2007. Anonymised data were divided into two groups depending on the referring practitioner. Within the two groups, patient numbers were sub-divided into 15 categories covering the range of diagnoses made. Preliminary diagnoses or reasons for referral were compared with the definitive diagnoses made by the ophthalmologist.

RESULTS

Optometrists contributed the greatest number of referrals (323) with 243 patients referred by general practitioners. Cataract was the most common condition referred by optometrists, and the second most common condition referred by general practitioners: agreement with ophthalmological diagnosis was high for both groups of primary care practitioners. Concurrence of referral reason with ophthalmological diagnosis for glaucoma was lower for general practitioners (56%) than for optometrists (76%), but optometrists referred more false positive patients for glaucoma than did general practitioners. The opposite was true for lid/tear duct/conjunctival conditions, the most common basis for referral by general practitioners.

CONCLUSIONS

The differences between the two primary care practitioner groups may reflect variations in training, skills and practice. Further investigation of the particular strengths of both groups, and how they can be optimised to promote effective shared care, is required.

Optimisation of outpatient resource utilisation in cataract management

PURPOSE

We assessed whether patients referred with a diagnosis of cataract require outpatient assessment before listing for surgery or whether the general practitioner could have direct access to the waiting list. We also studied whether pre-assessment clinics made a significant difference to management even when waiting times were long.

METHODS

Data about patients referred with a diagnosis of cataract to the Oxford Eye Hospital and associated hospitals were collected. Seventy-five patients were prospectively studied and 100 patient records were retrospectively analysed.

RESULTS

Twenty-six per cent of patients had a misdiagnosis or additional problems affecting management. Optometrists provided more information than general practitioners, but their diagnostic accuracy was equal (73% optometrists, 75% general practitioners). At the pre-assessment clinic pupil dilatation changed management in only 4% of patients.

CONCLUSION

Listing patients on the basis of referral letters would be inappropriate in 1 in 4 patients. Pre-assessment clinics rarely picked up a clinically relevant change. Thus if outpatient consultation included a decision on the exact surgical plan including implant power, then pre-assessment clinics may not be necessary.

Demand incidence and episode rates of ophthalmic disease in a defined urban population

OBJECTIVES

To estimate demand incidence and episode rates of ophthalmic disease in a defined urban population over one year.

DESIGN

Study of patients presenting with eye problems to general practice and eye casualty department.

SETTING

General practice and ophthalmic services in west Nottingham.

SUBJECTS

36,018 people from the combined practice lists of 17 Nottingham general practitioners.

MAIN OUTCOME MEASURES

Ophthalmic disorder, age and sex of patient, and where presented.

RESULTS

587 consultations were recorded for ophthalmic problems, 1771 with general practitioners and 816 with eye casualty. Most consultations to general practice were by females (1066 (60%)), whereas men aged 15-44 accounted for most work in eye casualty. These men commonly presented with trauma. Infective conjunctivitis, the commonest condition, had an episode rate of 13.5/1000 population/year. Demand incidence for cataracts was 1.9/1000 population/year. Demand incidence for chronic conditions increased with age.

CONCLUSIONS

As the average age of the population increases demand for ophthalmic services will rise. Planning and provision of resources to meet this increased demand should be considered now.

Referrals and notifications by optometrists within the UK: 1988 survey

In a survey of nearly 75,000 eye examinations, 6% of patients were referred to a medical doctor and the doctor was notified in a further 2% of cases. The level of referral was 2% higher than in 1986; 70% of referrals were the result of reminders or periodic attendances, and 80% of those referred were over 40 years of age. The general pattern of referral was broadly in agreement with a survey conducted in 1986 but indicates that some categories of eye conditions are being referred at a higher rate.