Decision making in chronic glaucoma – optometrists vs ophthalmologists in a shared care service

Abstract

An audit model of decision-making in shared care is demonstrated that in this case supported the apprenticeship model of training utilised in the clinic.

Agreement between specially trained and accredited optometrists and glaucoma specialist consultant ophthalmologists in their management of glaucoma patients

“…This level of agreement increased to 90% when qualified agreements were included and decisions regarding medical management reached agreement levels of 96-97%. Previous hospital 4,11 and community 8 based studies have also reported good to nearly perfect levels of agreement for medical management. In our study, none of the optometrists' decisions was deemed unacceptable, although in two cases, the optometrists were judged to have been under cautious.…”

“…13 In 2006, a national survey identified 66 secondary care-led glaucoma shared care schemes in operation in England, 36 of which employed optometrists in some capacity (14 in the community and 22 'in-house'). 14 To our knowledge, there have been two previous studies that have compared the management decisions made by optometrists working within the hospital glaucoma service with those of consultant ophthalmologists 4,11 and three involving specially trained community optometrists assessing new referrals, 8 diagnosed glaucoma/glaucoma suspect patients 9 , or a combination of both. 10 Although all of these optometrists had undergone additional training, as far as we are aware, none had completed the College of Optometrists Diploma in Glaucoma and the hospital-based optometrists were working alongside the consultant ophthalmologist who was responsible for the patients.…”

“…The fact that the relatively high percentage agreement for optic-disc status was not reflected in the kappa value may have occurred because the majority of discs were classified as stable or probably stable. 15 None of the previous studies 4, [9][10][11] included an assessment of optic-disc stability and the results for VF analysis varied considerably, with Banes et al 4 reporting a fair level of agreement (55%, k ¼ 0.33) and Ho and Vernon 11 reporting an almost perfect level of agreement (90.2%, k ¼ 0.84)-a result that may have been influenced by the fact that the ophthalmologist was not masked to the optometrist's decisions. Notwithstanding, the difficulty in correctly identifying progressive optic disc and VF changes has previously been well documented and the agreement levels achieved by our optometrists are similar to those of other studies comparing glaucoma specialists.…”

“…4,[9][10][11] It has been shown that specially trained community optometrists are able to make satisfactory decisions regarding the diagnosis and initiation of treatment for glaucoma 8 and can help to reduce the number of false positive referrals into the Hospital Eye Service (HES) by up to 53%. [5][6][7] However, there remains a large number of individuals considered to be at risk of developing glaucoma who are still being monitored within the HES and, once a diagnosis of glaucoma is confirmed, follow-up becomes lifelong.…”

“…Although we acknowledge that our patient numbers are small compared with the majority of the previous studies, 4,9-11 all but one of these studies 4,10,11 required the ophthalmologists to make decisions based on a retrospective review of clinical data that had been collected by other health professionals. By adopting a similar methodology, it would have been possible to include a larger number of patients and provide a quantifiable measure of agreement between the two ophthalmologists-an advantage of the Banes study.…”