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Jørgensen EP, Muttuvelu DV, Peto T, Natarajan S, Davies J, Keane PA, Ehlers LH. Implementing teleophthalmology services to improve cost-effectiveness of the national eye care system. Eye (Lond) 2024:10.1038/s41433-024-03156-4. [PMID: 38834842 DOI: 10.1038/s41433-024-03156-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 05/02/2024] [Accepted: 05/23/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Optometrist-assisted and teleophthalmology-enabled referral pathway (OTRP) for community optometry referrals has the potential to improve the capacity and efficiency of eye care delivery systems through risk stratification and limiting the number of improved referrals. This study investigates the expected future costs and benefits of implementing OTRP under various possible organizational set-ups relevant to a Danish context. METHODS A decision-analytic model (decision tree) with a one-year time horizon was constructed to portray alternative future patient referral pathways for people examined in optometry stores for suspected ocular posterior segment eye disease. The main outcomes were total healthcare costs per patient, average waiting time from eye examination in store until the start of treatment or end of referral pathway, and quality-adjusted life-years (QALY) gained. The economic evaluation compares the general ophthalmologist referral pathway (GO-RP) with a potential reimbursement model for the optometrist-assisted teleophthalmology referral pathways (R-OTRP) and a procurement model for the optometrist-assisted teleophthalmology referral pathways (P-OTRP). RESULTS The cost per individual with suspected ocular posterior segment eye disease was estimated to be £116 for GO-RP and £75 and £94 for P-OTRP and R-OTRP respectively. The average waiting time for diagnosis or end of referral pathway was 25 weeks for GO-RP and 5.8 and 5.7 for P-OTPR and R-OTPR respectively. QALY gain was 0.15 for P-OTRP/R-OTRP compared to 0.06 for GO-RP. CONCLUSION OTRP is effective in reducing unnecessary referrals and waiting times, increasing patients' HRQoL, and decreasing the costs of diagnosing individuals with suspected ocular posterior segment eye disease.
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Affiliation(s)
- E P Jørgensen
- Nordic Institute of Health Economics, Aarhus, Denmark
| | - D V Muttuvelu
- Department of Ophthalmology, Copenhagen University Hospital, Copenhagen, Denmark
- 2mitØje ApS, Aarhus, Denmark
| | - T Peto
- Queen's University Belfast, Belfast, UK
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
| | - S Natarajan
- Aditya Jyot Eye Hospital Pvt Ltd, Mumbai, Maharashtra, India
| | - J Davies
- Global Business School for Health, University College London, London, UK
| | - P A Keane
- University College London, London, UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
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Somerville JG, Strang NC, Jonuscheit S. Topical review: Task shifting and the recruitment and retention of eye health workers in underserved areas. Optom Vis Sci 2024; 101:143-150. [PMID: 38546755 DOI: 10.1097/opx.0000000000002118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Many populations experience difficulty accessing eye care, especially in rural areas. Implementing workforce recruitment and retention strategies, as well as task shifting through widening scope of practice, can improve eye care accessibility. This article provides novel evidence on the compatibility of these strategies aimed at enhancing ophthalmic workforce recruitment, retention, and efficacy. PURPOSE The global burden of blindness is unequally distributed, affects rural areas more, and is frequently associated with limited access to eye care. The World Health Organization has specified both task shifting and increasing human resources for eye health as instruments to improve access to eye care in underserved areas. However, it is uncertain whether these two instruments are sufficiently compatible to provide positive synergic effects. To address this uncertainty, we conducted a structured literature review and synthesized relevant evidence relating to task shifting, workforce recruitment, retention, and eye care. Twenty-three studies from across the globe were analyzed and grouped into three categories: studies exploring recruitment and retention in human resources for eye health in general, studies discussing the relationship between task shifting and recruitment or retention of health workers in general, and studies specifically discussing task shifting and recruitment or retention in eye care workers. FINDINGS Our findings demonstrate that incentives are effective for initiating task shifting and improving recruitment and retention in rural areas with a stronger effect noted in midlevel eye care professionals and trainees. Incentives can take various forms, e.g., financial and nonfinancial. The consideration of context-specific motivational factors is essential when designing strategies to facilitate task shifting and to improve recruitment and retention.
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Parkins DJ, Edgar DF, Evans BJW. Optometrist referral accuracy: Addressing the root causes of unwarranted variation. Ophthalmic Physiol Opt 2024; 44:229-230. [PMID: 37947239 DOI: 10.1111/opo.13248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Affiliation(s)
| | - David F Edgar
- Department of Optometry and Visual Sciences, School of Health & Psychological Sciences, City, University of London, London, UK
| | - Bruce J W Evans
- Institute of Optometry, London, UK
- Department of Optometry and Visual Sciences, School of Health & Psychological Sciences, City, University of London, London, UK
- School of Health and Social Care, London South Bank University, London, UK
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Evans BJW, Harvey K, Edgar DF. Referral replies to primary care optometrists: Technology must become a consistent enabler. Ophthalmic Physiol Opt 2023; 43:1587. [PMID: 37646478 DOI: 10.1111/opo.13224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Bruce J W Evans
- Institute of Optometry, London, UK
- School of Health and Social Care, London South Bank University, London, UK
- Department of Optometry and Visual Sciences, School of Health & Psychological Sciences, City, University of London, London, UK
| | - Krystynne Harvey
- Institute of Optometry, London, UK
- School of Health and Social Care, London South Bank University, London, UK
| | - David F Edgar
- Department of Optometry and Visual Sciences, School of Health & Psychological Sciences, City, University of London, London, UK
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Ong AY, Naughton A, Hornby S, Shwe-Tin A. Impact of an email advice service on filtering and refining ophthalmology referrals in England. Int Ophthalmol 2023; 43:4019-4025. [PMID: 37420128 DOI: 10.1007/s10792-023-02806-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Abstract
PURPOSE The growing capacity-demand imbalance has necessitated the accelerated digital transformation of eye care services. The role of Oxford Eye Hospital's (OEH) email advice service has become even more relevant in the post-Covid era. We sought to evaluate its impact on referrals to secondary care. METHODS The consultant-led OEH email advice service primarily targets primary eye care personnel (optometrists and GPs) requiring clinical advice on patient referral. Emails received between September and November 2020 were analysed for demographic data, contents, characteristics, and outcomes. Thematic analysis was performed. A user feedback survey was conducted. RESULTS A total of 828 emails were received over the 3-month study period (mean 9.1/day). They were predominantly from optometrists (77.9%) and general practitioners (16.1%). Of the 81.0% (671) relating to clinical advice, over half (54.8%) included images from a variety of modalities, and following review, over half (55.5%) were deemed suitable for management in the community, while 36.5% were referred directly to appropriate subspecialty clinics. Only 8.1% required urgent assessment in eye casualty. Thematic analysis showed that this service was most useful for retinal lesions, optical coherence tomography abnormalities, and borderline abnormal optic discs. No adverse events were identified. User feedback was very positive. CONCLUSION A secure email advice service is a safe and low-maintenance modality that provides direct and efficient two-way communication between primary and secondary eye care professionals. It allows rapid response to clinical queries, referral filtering and refinement, and streamlining of patient referral pathways. Users (predominantly optometrists) were overwhelmingly positive about its usefulness in clinical practice.
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Affiliation(s)
- Ariel Yuhan Ong
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK.
| | - Aoife Naughton
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Stella Hornby
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Audrey Shwe-Tin
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
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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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Blandford A, Abdi S, Aristidou A, Carmichael J, Cappellaro G, Hussain R, Balaskas K. Protocol for a qualitative study to explore acceptability, barriers and facilitators of the implementation of new teleophthalmology technologies between community optometry practices and hospital eye services. BMJ Open 2022; 12:e060810. [PMID: 35858730 PMCID: PMC9305899 DOI: 10.1136/bmjopen-2022-060810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Novel teleophthalmology technologies have the potential to reduce unnecessary and inaccurate referrals between community optometry practices and hospital eye services and as a result improve patients' access to appropriate and timely eye care. However, little is known about the acceptability and facilitators and barriers to the implementations of these technologies in real life. METHODS AND ANALYSIS A theoretically informed, qualitative study will explore patients' and healthcare professionals' perspectives on teleophthalmology and Artificial Intelligence Decision Support System models of care. A combination of situated observations in community optometry practices and hospital eye services, semistructured qualitative interviews with patients and healthcare professionals and self-audiorecordings of healthcare professionals will be conducted. Participants will be purposively selected from 4 to 5 hospital eye services and 6-8 affiliated community optometry practices. The aim will be to recruit 30-36 patients and 30 healthcare professionals from hospital eye services and community optometry practices. All interviews will be audiorecorded, with participants' permission, and transcribed verbatim. Data from interviews, observations and self-audiorecordings will be analysed thematically and will be informed by normalisation process theory and an inductive approach. ETHICS AND DISSEMINATION Ethical approval has been received from London-Bromley research ethics committee. Findings will be reported through academic journals and conferences in ophthalmology, health services research, management studies and human-computer interaction.
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Affiliation(s)
- Ann Blandford
- UCL Interaction Centre, University College London, London, UK
| | - Sarah Abdi
- UCL Interaction Centre, University College London, London, UK
| | | | - Josie Carmichael
- UCL Interaction Centre, University College London, London, UK
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Giulia Cappellaro
- School of Management, University College London, London, UK
- Department of Social and Political Sciences, Bocconi University, Milano, Italy
| | - Rima Hussain
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Institute of Ophthalmology, UCL, London, UK
| | - Konstantinos Balaskas
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Institute of Ophthalmology, UCL, London, UK
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Harvey K, Edgar DF, Agarwal R, Benwell MJ, Evans BJ. Referrals from community optometrists in England and their replies: A mixed methods study. Ophthalmic Physiol Opt 2022; 42:454-470. [PMID: 35106831 DOI: 10.1111/opo.12948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Community optometrists, through routine eye examinations, identify patients with disease or ocular abnormalities requiring referral to the Hospital Eye Service. In many cases no reply to the referral letter is received, resulting in some patients being re-referred unnecessarily, potentially increasing the number of other patients who lose sight whilst on hospital waiting lists. This study investigated, qualitatively and quantitatively, factors influencing optometric referrals and replies. METHODS The three-phase, sequential mixed methods study started with a literature review and qualitative phase, interviewing stakeholders to identify issues for exploration in subsequent phases. The second, quantitative phase, undertook documentary analysis of 349 patient referral records from three optometric practice modalities (domiciliary, independently owned, and corporate chain) in England. A final qualitative phase obtained views from stakeholders to explore unexplained findings from the first two phases. RESULTS Phase 1 identified communication, financial, professional and technological issues for further exploration. In Phase 2, the referral rate was 22.2% for domiciliary provider, 2.1% for independent practice and 2.5% for the corporate chain, with the variation most likely explained by patient age and associated ophthalmic disease, illness and disability. The referral reply rate was 5.7% for domiciliary provider, 25.0% for independent practice and 4.9% for the corporate chain. The community optometrist remained unaware of the outcome of their referral in 72.8% of cases. Qualitative analyses indicate the main factors influencing referral reply rates are technology, the General Medical Practitioner, community optometrists' utility to and utility of the National Health Service and patient mobilisation. CONCLUSIONS The low referral reply rate creates a break in the feedback loop required to raise the standard of referrals and avoid unnecessary re-referral. Of the factors identified that influence referral reply rates, technology is key in view of the increasing use of online referral platforms. Feedback to the referring optometrist should be embedded in such systems.
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Affiliation(s)
- Krystynne Harvey
- School of Health and Social Care, London South Bank University, London, UK.,Institute of Optometry, London, UK
| | - David F Edgar
- Division of Optometry and Visual Sciences, School of Health Sciences, City, University of London, London, UK
| | - Rishi Agarwal
- School of Health and Social Care, London South Bank University, London, UK.,Institute of Optometry, London, UK
| | - Martin J Benwell
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Bruce Jw Evans
- School of Health and Social Care, London South Bank University, London, UK.,Institute of Optometry, London, UK.,Division of Optometry and Visual Sciences, School of Health Sciences, City, University of London, London, UK
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Parkins DJ, Shah B, Benwell MJ, Evans BJW, Edgar DF. Design and use of vignettes to investigate referral decision-making by optometrists. JOURNAL OF OPTOMETRY 2021; 14:346-354. [PMID: 33967018 PMCID: PMC8569393 DOI: 10.1016/j.optom.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/04/2020] [Accepted: 09/15/2020] [Indexed: 06/12/2023]
Abstract
PURPOSE This study describes the design and application of a range of online clinical vignettes for measuring the impact of Continuing Education and Training (CET) and identifying unwarranted variation in optometric decision-making concerning referrals to secondary care. METHODS Twenty computerised vignettes were developed to assess clinical and referral management decisions taken in primary care optometry. The online system was specifically designed to present vignettes (ten pre-CET and ten post-CET) that avoided prompting correct answers. The main study group was qualified optometrists (N = 31) who chose any CET options available to United Kingdom optometrists over six months. Participants submitted a record of the CET undertaken, which was compared with an anonymised General Optical Council (GOC) reference sample. The vignettes were also completed by newly-qualified (N = 18) and pre-registration (N = 11) groups. RESULTS CET had no significant correlation (p = 0.37) with improvement in optometric clinical decision-making and referral practice (qualified group). Selection bias affected this group who had more CET points (p = 0.008) and peer discussion points (p = 0.003) than the GOC reference sample. Results were indicative due to small sample sizes. Newly-qualified practitioners were significantly more likely to refer than the qualified group (p = 0.004). Number of referrals decreased with time since qualification (p = 0.006). CONCLUSION Computerised vignettes are a useful tool for comparing referral decisions between groups. Recruiting clinicians for time-consuming vignette studies is challenging. Strategies to reduce unwarranted variation in optometry, including support for newly-qualified optometrists, require further investigation.
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Affiliation(s)
- David J Parkins
- London South Bank University, School of Health and Social Care, 103 Borough Road, London SE1 0AA, UK; Institute of Optometry, 56-62 Newington Causeway, London SE1 6DS, UK.
| | - Beju Shah
- Institute of Optometry, 56-62 Newington Causeway, London SE1 6DS, UK
| | - Martin J Benwell
- London South Bank University, School of Health and Social Care, 103 Borough Road, London SE1 0AA, UK
| | - Bruce J W Evans
- London South Bank University, School of Health and Social Care, 103 Borough Road, London SE1 0AA, UK; Institute of Optometry, 56-62 Newington Causeway, London SE1 6DS, UK; Division of Optometry & Visual Sciences, School of Health Sciences, City, University of London, Northampton Square, London EC1V 0HB, UK
| | - David F Edgar
- Division of Optometry & Visual Sciences, School of Health Sciences, City, University of London, Northampton Square, London EC1V 0HB, UK
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Shah R, Edgar DF, Khatoon A, Hobby A, Jessa Z, Yammouni R, Campbell P, Soteri K, Beg A, Harsum S, Aggarwal R, Evans BJW. Referrals from community optometrists to the hospital eye service in Scotland and England. Eye (Lond) 2021; 36:1754-1760. [PMID: 34363046 PMCID: PMC8344323 DOI: 10.1038/s41433-021-01728-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 07/05/2021] [Accepted: 07/28/2021] [Indexed: 12/26/2022] Open
Abstract
Objectives This audit assesses communication between community optometrists (COs) and hospital eye service (HES) in Scotland and England. Methods Optometric referrals and replies were extracted from six practices in Scotland and England. If no reply was found, replies/records were copied from HES records. De-identified referrals, replies and records were audited against established standards, evaluating whether referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated. Results From 905 de-identified referrals, RR ranged from 2.6 to 8.7%. From COs’ perspective, the proportion of referrals for which they received replies ranged from 37 to 84% (Scotland) and 26 to 49% (England). A total of 88–96% of referrals (Scotland) and 63–76% (England) were seen in the HES. Adjusting for cases when it is reasonable to expect replies, RRR becomes 45–92% (Scotland) and 38–62% (England) with RRR significantly greater in Scotland (P = 0.015). Replies were copied to patients in 0–21% of cases. Referrals were to the appropriate service and judged necessary in ≥90% of cases in both jurisdictions. Accuracy of referral ranged from 89 to 97% (Scotland) and 81 to 98% (England). The reply addressed the reason for referral in 94–100% of cases (Scotland) and 93–97% (England) and was meaningful in 95–100% (Scotland) and 94–99% (England). Conclusions Despite the interdisciplinary joint statement on sharing patient information, this audit highlights variable standard of referrals and deficits in replies to the referring COs, with one exception in Scotland. Replies from HES to COs are important for patient care, benefitting patients and clinicians and minimising unnecessary HES appointments.
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Affiliation(s)
- Rakhee Shah
- Centre for Applied Vision Research, City, University of London, London, UK.
| | - David F Edgar
- Centre for Applied Vision Research, City, University of London, London, UK
| | | | | | | | | | - Peter Campbell
- Centre for Applied Vision Research, City, University of London, London, UK
| | - Kiki Soteri
- University of Plymouth, Plymouth, UK.,Specsavers Opticians, St. Andrew, Guernsey
| | | | - Steven Harsum
- Epsom and St Helier University Hospitals NHS Trust, Epsom, UK
| | | | - Bruce J W Evans
- Centre for Applied Vision Research, City, University of London, London, UK.,Institute of Optometry, London, UK
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