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

Abstract

ObjectivesA comparison of glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and guidance.DesignRetrospective multisite review.SettingThe 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.Participants1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 from Gloucestershire and 269 from Nottingham.ResultsThe 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.ConclusionsIn 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.

Prospective study of glaucoma referrals across Europe: are we using resources wisely?

“…By combining the IOP criterion with any other JCG criterion,12 the predictive value increased substantially, and this is in agreement with previously published data 3 6 13. Thus, our findings support the statement that ‘IOP-only referrals represent a waste of hospital outpatient resource’ 13. Interestingly, family history of glaucoma had a low positive predictive value, even when it was combined with other referring criteria.…”

Automated imaging technologies for the diagnosis of glaucoma: a comparative diagnostic study for the evaluation of the diagnostic accuracy, performance as triage tests and cost-effectiveness (GATE study)

“…There are emerging models of eye care in the community that try to reduce the number of false-positive referrals to hospital eye services. [53][54][55] Their effectiveness, efficiency and acceptability need to be evaluated in primary research before implementing change. The GATE study provides robust data on how such services might be reconfigured.…”

Optic nerve head and fibre layer imaging for diagnosing glaucoma

“…Ratnarajan 2013 has recently reported on suspected glaucoma referral patterns by optometrists with or without special interest in glaucoma in the UK. They concluded that a referral for suspected glaucoma is based characteristically on nding an elevated IOP, an abnormal optic disc appearance, an abnormal visual field, or a combination of these.…”