bmj open · 19 medical institute (anglia ruskin university)7, nihr biomedical research centre at...

For peer review only

The effectiveness of schemes that refine referrals between primary and secondary care - the United Kingdom

experience with glaucoma referrals: The Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project.

Journal: BMJ Open

Manuscript ID: bmjopen-2013-002715

Article Type: Research

Date Submitted by the Author: 11-Feb-2013

Complete List of Authors: Ratnarajan, Gokulan; Anglia Ruskin University, Vision and Eye Research Unit; Health Innovation and Education Cluster, Newsom, Wendy; Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, ; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, Vernon, Stephen; Nottingham University Hospitals NHS Trust, Fenerty, Cecilia; Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Henson, David; Manchester Royal Eye Hospital and Manchester Academic

and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Spencer, Fiona; Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Wang, Yanfang; Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Harper, Robert; Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, McNaught, Andrew; Gloucestershire Hospitals NHS Foundation Trust,

Collins, Lisa; Gloucestershire Hospitals NHS Foundation Trust, Parker, Mike; Postgraduate Medical Institute, Anglia Ruskin University, Lawrenson, John; City University London, Hudson, Robyn; Health Innovation and Education Cluster, Khaw, Peng; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, Wormald, Richard; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, Garway-Heath, David; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, Bourne, Rupert; Anglia Ruskin University, Vision and Eye Research Unit;

Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital,

<b>Primary Subject Heading</b>:

Ophthalmology

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Secondary Subject Heading: Health services research

Keywords:

Glaucoma < OPHTHALMOLOGY, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Risk management < HEALTH SERVICES ADMINISTRATION & MANAGEMENT

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1

Title: 2

The effectiveness of schemes that refine referrals between primary and secondary 3

care - the United Kingdom experience with glaucoma referrals: The Health 4

Innovation & Education Cluster (HIEC) Glaucoma Pathways Project. 5

6

Authors: 7

Gokulan Ratnarajan1,2,9

, Wendy Newsom3,8

, Stephen A. Vernon4, Cecilia Fenerty

5, David 8

Henson5, Fiona Spencer

5, Yanfang Wang

5, Robert Harper

5, Andrew McNaught

6, Lisa Collins

6, 9

Mike Parker7, John Lawrenson

10, Robyn Hudson

1, Peng Tee Khaw

8, Richard Wormald

8, David 10

Garway-Heath8, Rupert Bourne

1,2,3,8 11

12

Author Affiliations: North East, North Central London and Essex Health Innovation & 13

Education Cluster1, Vision and Eye Research Unit (Postgraduate Medical Institute, Anglia 14

Ruskin University)2, Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke 15

Hospital3, Nottingham University Hospitals NHS Trust

4, Manchester Royal Eye Hospital and 16

Manchester Academic and Health Science Centre, Central Manchester University Hospitals 17

NHS Foundation Trust 5

, Gloucestershire Hospitals NHS Foundation Trust6, Postgraduate 18

Medical Institute (Anglia Ruskin University)7, NIHR Biomedical Research Centre at Moorfields 19

EyeHospital NHS Foundation Trust and UCL Institute of Ophthalmology 8, UCL Institute of 20

Ophthalmology9, Division of Optometry and Visual Science (City University London)

10.

21

22

23

Corresponding author: 24

Gokulan Ratnarajan 25

Vision & Eye Research Unit 26

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Postgraduate Medical Institute 27

Anglia Ruskin University 28

Cambridge 29

UK 30

[email protected] 31

+44 7976001102 32

More detailed information including appendices can be provided by the corresponding 33

author, Dr G Ratnarajan at [email protected]. 34

35

Word Count: 3003 words 36

37

Competing interest: None of the authors have received support from any organisation for 38

the submitted work; no financial relationships with any organisations that might have an 39

interest in the submitted work in the previous three years; no other relationships or 40

activities that could appear to have influenced the submitted. 41

42

I, Gokulan Ratnarajan, as the Corresponding Author has the right to grant on behalf of all 43

authors and does grant on behalf of all authors, an exclusive license on a worldwide basis to 44

the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be 45

published in BMJ editions and any other BMJPGL products and sublicenses to exploit all 46

subsidiary rights, as set out in their license. 47

48

Acknowledgements 49

We would like to acknowledge the optometrists and ophthalmologists involved in the 50

referral refinement schemes. 51

52

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The Health Innovation and Education Cluster provided funding for data collection. 53

All authors fully meet the criteria for authorship defined by the International Committee of 54

Medical Journal Editors. 55

56

Co-Authors qualifications: 57

58

Wendy Newsom BSc(Hons) MCOptom

59

Stephen A. Vernon MB CHB DM FRCS FRCOphth FCOptom(hon) DO

60

Cecilia Fenerty MD, MBChB, FRCOphth

61

David Henson PhD FRCOptom

62

Fiona Spencer MD, MBChB, FRCOphth

63

Yanfang Wang MSc, Bachelor of Medicine

64

Robert Harper DPhil MCOptom

65

Andrew McNaught MD FRCOphth

66

Lisa Collins BSc(Hons) MBA MCOptom 67

Mike Parker BSc MSc CStat

68

John Lawrenson BSc PhD MCOptom

69

Robyn Hudson BSc MBA

70

Peng Tee Khaw PhD FRCP FRCS FRCOphth CBiol FSB FCOptom (Hon) FRCPath 71

FMedSci

72

Richard Wormald MA MSc (Epid) FRCS FRCOphth

73

David Garway-Heath MD FRCOphth

74

Rupert Bourne MBBS BSc FRCOphth MD 75

76

77

78

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ABSTRACT 79

80

Objectives: A comparison of glaucoma referral refinement schemes (GRRS) in the UK during 81

a time period of considerable change in national policy and guidance. 82

83

Design: Retrospective multi-site review. 84

85

Setting: The outcomes of clinical examinations of optometrists with a specialist interest in 86

glaucoma (OSI) were compared to optometrists with no specialist interest in glaucoma (non-87

OSI). Data from Huntingdon and Nottingham assessed non-OSI findings, whilst Manchester 88

and Gloucestershire reviewed OSI findings. 89

90

Participants: 1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 91

from Gloucestershire and 269 from Nottingham. 92

93

Results: The overall first-visit discharge rate (FVDR) for all time periods for OSIs was 14.1% 94

compared to 36.1% from non-OSIs (difference 22.0% CI 16.9% to 26.7%, p < 0.001). The 95

FVDR increased after the April 2009 National Institute for Health and Clinical Excellence 96

(NICE) glaucoma guidelines compared to pre-NICE, which was particularly evident when pre-97

NICE was compared to the current practice time period (OSIs: 6.2% to 17.2%, difference 98

11.0%, CI -24.7% to 4.3%, p = 0.18, non-OSIs 29.2% to 43.9%, difference 14.7%, CI -27.8% to 99

-0.30%, p = 0.03). Elevated intra-ocular pressure (IOP) was the commonest reason for 100

referral for OSIs and non-OSIs, 28.7% and 36.1% of total referrals. The proportion of referrals 101

for elevated IOP increased from 10.9% pre-NICE to 28.0% post-NICE for OSIs, and from 102

19.0% to 45.1% for non-OSIs. 103

104

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Conclusions: In terms of ‘demand management’, OSIs can reduce the FVDR of patients 105

subsequently reviewed in secondary care, however in terms of ‘patient safety’ this study 106

also shows an overemphasis on IOP as a criterion for referral is having an adverse effect on 107

both the non-OSI’s and indeed the OSI’s ability to detect glaucomatous optic nerve features. 108

It is recommended that referral letters from non-OSIs be stratified for risk, directing high risk 109

patients straight to secondary care, and low risk patients to OSIs for efficient assessment. 110

111

ARTICLE SUMMARY 112

Article focus 113

• Can specialist trained optometrists reduce the first-visit discharge rate of patients 114

identified in primary care as being at risk of glaucoma and therefore reduce the 115

burden on the hospital eye service? 116

• What is the temporal trend in first-visit discharge rates? 117

• What is a safe model of glaucoma referral refinement that can be used to establish a 118

national framework? 119

120

Key messages 121

• Specialist trained optometrists can reduce the first-visit discharge rate of patients 122

subsequently reviewed in secondary care compared to direct referrals from non-123

specialist optometrists (36.1% vs 14.1% difference 22% CI 16.9% to 26.7%, p < 0.001). 124

However in terms of ‘patient safety’ this study also shows that the overemphasis on 125

IOP as a criterion for referral is having an adverse effect on both the specialist and 126

non-specialist optometrist’s ability to detect glaucomatous optic nerve features. 127

• First-visit discharge rates have increased in the time periods post National Institute 128

for Health and Clinical Excellence (NICE) glaucoma guideline publication, and are 129

continuing to increase, particularly for non-OSIs. 130

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• It is the author’s recommendation that patients with a high chance of being 131

diagnosed with glaucoma based on the examination findings of the non-specialist 132

optometrist should be referred directly to secondary care and those at lower risk 133

could effectively be reviewed by a specialist trained optometrists carrying out a 134

comprehensive eye examination. 135

136

Strengths and limitations 137

• This is the first multi-site review of glaucoma referral refinement schemes in the UK. 138

• The time frame for the study has encompassed all the major changes in clinical 139

guidelines and practice since 2009. 140

• The false negative, or percentage of patients that were inappropriately discharged 141

by the specialist and non-specialist optometrist, is not known. This will be addressed 142

in an upcoming prospective study using the recommendations of this report. 143

144

145

146

147

148

149

150

151

152

153

154

155

156

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INTRODUCTION 157

158

Glaucoma is the world’s leading cause of irreversible blindness.1 This progressive optic 159

neuropathy is characterised by damage to the optic nerve head and nerve fibre layer, with 160

visual field loss which is usually asymptomatic until the disease becomes advanced. Up to 161

twenty percent of referrals to ophthalmology clinics in the UK are for suspected glaucoma, 162

with the annual cost for monitoring patients with this chronic, and potentially blinding 163

condition estimated to be £22,469,000.2,3

164

165

In the UK, most referrals for suspected glaucoma are generated through opportunistic 166

surveillance during sight-tests by primary care optometrists (hereafter referred to as an 167

Optometrist with no Specialist Interest in glaucoma, non-OSI). 4-6

168

169

As part of a sight-test, the non-OSI is required to perform an examination of the optic disc 170

using fundoscopy. If clinically indicated they may measure the intra-ocular pressure (IOP) 171

typically using ‘air puff’ non-contact tonometry (NCT) which is prone to higher variability and 172

over-estimating the IOP (in individuals with thick corneas) compared to Goldmann contact 173

tonometry used in hospital ophthalmology departments.7 Visual field testing is also carried 174

out if clinically indicated and completes the established triad of examinations/tests to detect 175

glaucoma. 176

177

The number of patients being referred to ophthalmology departments is rapidly increasing 178

due to an ageing population, advances in diagnostic and screening tools such as visual field 179

testing, and changes in national and professional guidance with regard to glaucoma care. 180

181

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The National Institute for Health and Clinical Excellence (NICE) guidelines for the diagnosis 182

and management of chronic open glaucoma and ocular hypertension (OHT; elevated IOP but 183

no signs of glaucomatous optic disc damage or visual field loss) was published in April 184

2009.8,9,10

These guidelines however did not include in its remit guidance on the detection 185

and referral of suspected glaucoma by community optometrists as it was felt this would 186

make the guidelines unmanageably large.11

187

188

The professional representative organisations for optometry practice, the Association of 189

Optometrists (AOP), response to these guidelines was as follows: 190

191

“English and Welsh PCTs and Health Boards may not have the resources to cope with the 192

numbers of referrals – many of which, because they will have had their pressures taken using NCT, 193

will be false positives. Nevertheless, in the absence of funding to repeat pressures using Goldmann, 194

the AOP believes strongly that optometrists have no choice other than to refer a patient who has a 195

sign of ocular hypertension – e.g. pressures measured at over 21 mmHg, using whatever tonometer 196

they choose. To identify a sign of OHT and then not to act on it could be considered to be 197

unprofessional, especially when the correct course of action has been well researched, by a panel of 198

experts in the field, using evidence-based methods, and has been officially published by NICE.” 12

199

Prior to this, an optometrist would use their clinical judgement as to whether a 200

patient with normal ocular examination and a borderline IOP warranted referral based on 201

other risk factors such as age and family history. However, after the AOP’s recommendation, 202

all of these patients are now being referred with a resultant surge in the number of referrals 203

for suspected glaucoma and, consequently, an increase in first-visit discharges .10,13-15

204

205

In December 2009, an attempt by the Royal College of Ophthalmologists and College of 206

Optometrists to reduce the total number of first-visit discharges was made by issuing Joint 207

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College Guidance (JCG) in relation to OHT patients with low risk of significant visual field loss 208

in their lifetime. It was recommended that optometrists consider not referring patients aged 209

over 80 years with an IOP of less than 26mmHg with an otherwise normal ocular 210

examination. For patients aged between 65 and 80 this IOP criterion was less than 25mmHg, 211

as current NICE guidance does not recommend offering treatment to these subsets of 212

patients. For the latter group, it was recommended that these individuals be reviewed 213

annually by a community optometrist.16

214

215

216

Glaucoma Referral Refinement schemes (GRRS) have proliferated across the country over 217

the past decade, often demonstrating marked variation in pathway design, referral criteria 218

as well as the level of competency and training required by the participating optometrists.17-

219

23 The relatively few reports published on this subject have demonstrated that this serves as 220

an effective method of reducing first-visit discharges to the hospital, but opinion is divided 221

on the question of optimal pathway design, triaging and referral criteria, to ensure efficiency 222

but also patient safety. This question was addressed by The North East, North Central 223

London and Essex Health Innovation and Education Cluster (NECLES HIEC) Glaucoma 224

pathway project, by way of a multi-site review of established organisationally distinct GRRS 225

across the UK, with the objective of establishing a national framework for glaucoma referral 226

refinement.24

227

228

METHODS 229

230

The outcomes of GRRS in Huntingdon, Manchester, Gloucestershire and Nottingham were 231

retrospectively analysed during four 2 month time periods: pre NICE (March and April 2009), 232

post NICE (November and December 2009), post JCG (August and September 2010) and 233

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current practice (March and April 2011). Ethical approval at each trust was obtained prior to 234

data collection. 235

236

Each scheme is organisationally distinct and reflects the range of variation between schemes 237

nationally (Figure 1). The Huntingdon, Manchester and Gloucestershire schemes are all 238

community based, whereas the Nottingham scheme is hospital based. A more detailed 239

description of each scheme and a summary table (table 1) is found in an appendix. 240

241

Each scheme requires participating optometrists to gain local accreditation of core 242

optometric competencies (such as Goldmann contact tonometry, slit-lamp binocular indirect 243

ophthalmoscopy and visual field interpretation) through a hospital approved training 244

scheme. A specialist qualification in glaucoma is not a prerequisite.25-27

245

246

247

In Huntingdon and Nottingham the data from the non-OSI referral as well the subsequent 248

findings from the next eye health professional were collected (for Nottingham and low risk 249

Huntingdon patients this was the optometrist with specialist interest in glaucoma, OSI, and 250

for high risk Huntingdon patients this was a glaucoma consultant). In Manchester and 251

Gloucestershire the data from the OSI referral and the hospital visit were analysed. 252

253

254

Statistical Analysis 255

256

Data from electronic and paper patient records and paper referral letters were collated 257

using Microsoft Excel; statistical analysis was performed in R (version 2.15.1, The R 258

foundation for statistical computing, Vienna, Austria). Percentages of first-visit discharge 259

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rate (FVDR) were compared using Fisher’s Exact Test, and confidence limits for the 260

differences between percentages were calculate using Newcombe’s Hybrid Score Interval 261

Method. Confidence limits and P-values within a set of factor levels have been corrected for 262

multiplicity using the Dunn Sidak method. 263

264

The FVDR was the main outcome metric for this analysis and is defined as the percentage of 265

referrals from an OSI or a non-OSI that was discharged at the first visit to the final provider. 266

This is analogous to the ‘false positive rate’ which is the chosen outcome metric in the 267

published literature on this topic. Agreement rates on diagnostic accuracy and referral 268

appropriateness always use the diagnosis given by the final clinician, and assumes their 269

finding to be the gold standard. 270

271

272

RESULTS 273

274

Data of 1086 patients were analysed: 190 (17.5%) pre NICE, 338 (35.7%) post NICE, 287 275

(26.4%) post JCG and 271 (25.0%) from the current practice group. 434 (40.0%) patients 276

were from Huntingdon (304 high and 130 low risk), 179 (16.5%) from Manchester, 204 277

(18.8%) from Gloucestershire and 269 (24.8%) from Nottingham. 278

279

56.1% of patients referred from OSIs were male as compared to 43.7% from non-OSIs. 280

Mean age of patients referred by the OSIs was 63.2 years compared to 62.0 years for non-281

OSIs. 282

283

284

285

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Reason for Referral from non-OSI and OSI optometrists 286

287

The most common reason for non-OSI referral across all observation periods was for an 288

elevated IOP-only (36.1%). In the pre NICE timeframe, IOP-only referrals accounted for 289

19.0% of referrals, increasing to 45.1% in the post NICE period. This was coupled with a 290

decrease in many other stated reasons for referral by the non-OSI, particularly those not 291

including IOP, exemplified by disc only referrals which reduced from 15.9% pre NICE to 6.1% 292

post NICE. 293

294

The most common reason for OSI referral across all observation periods was also for raised 295

IOP only (28.8%), though a less marked increase (10.9% versus 28.0%) post NICE was 296

observed compared to non-OSIs. 297

298

First-visit discharge rate associated with non-OSI and OSI optometrists 299

300

The overall FVDR for non-OSI referrals was 36.1% and for OSI referrals was 14.1% (difference 301

22% CI 16.9% to 26.7%, p < 0.001). The FVDR for combination of each site and time period is 302

given in table 1. When interpreting these data it is important to note that for Nottingham 303

and Huntingdon the FVDR is for referrals from a non-OSI, while for Manchester and 304

Gloucestershire the FVDR is that of referrals from an OSI. 305

The FVDR pre-NICE was 21.9% compared to 35.4% in the current practice time period 306

(difference 13.5%, CI -23.8% to -2.4%, p = 0.006). For OSIs, the FVDR was 6.2% pre-NICE and 307

17.2% current practice (difference 11.0%, CI -24.7% to 4.3%, p = 0.18) and for non-OSIs the 308

FVDR was 29.2% pre NICE and 43.9% current practice (difference 14.7%, CI -27.8% to -0.30%, 309

p = 0.03). 310

311

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312

Table 1: First-visit discharge rate by site and by time period. 313

(OSI denotes optometrist with specialist interest in glaucoma. Non-OSI denotes optometrist with no 314

specialist interest in glaucoma. NICE denotes National Institute for Health and Clinical Excellence, JCG 315

denotes Joint College Guidance). 316

317

Site (professional

initiating referral)

First-visit discharge rate by period

All periods Pre NICE Post NICE Post JCG Current

practice

Nottingham (non-OSI) 19.5 32.8 25.3 53.7 33.5

Huntingdon (non-OSI) 33.3 37.6 42.1 38.3 38.0

Mean non-OSI 29.2 35.0 34.7 43.9 36.1

Manchester (OSI) 4.9 6.5 16.9 3.0 8.9

Gloucestershire (OSI) 8.7 20.3 12.5 25.9 18.6

Mean OSI 6.3 15.2 15.0 17.2 14.1

Mean overall 21.9 27.8 27.6 35.4 28.6

318

319

Outcomes of referrals from non-OSI and OSI optometrists based on reason for referral 320

321

A referral for suspected glaucoma is characteristically based on the finding of an elevated 322

IOP, an abnormal optic disc appearance, an abnormal visual field or a combination of these 323

findings. These patients are then classified as either having glaucoma, a suspicion of 324

glaucoma (‘glaucoma suspect’) or as being normal. The largest source of first-visit discharges 325

for both non-OSIs and OSIs were for IOP-only related referrals, with 83.5% and 55.0% of 326

these, respectively, being discharged. Referrals based on more than one criterion, such as 327

those for abnormal IOP, optic disc and visual fields, resulted in fewer first-visit discharges 328

(40.8% non-OSI and 25.7% OSI). More details are given in Figure 2. 329

330

331

332

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DISCUSSION 333

334

The main rationale for the refinement of referrals for suspected glaucoma has been to 335

reduce the overall number of referrals to the hospital eye services whilst simultaneously 336

increasing the quality and accuracy of the referral process.

337

338


340

Both non-OSIs and OSIs demonstrated similar stated reasons for referral with IOP-only 341

referrals being the largest category for referral, 36.1% and 28.7% respectively, followed by 342

referrals for elevated IOP and abnormal optic disc, 12.8% and 19.6% respectively. Disc-only 343

referrals and disc and VF referrals were the next largest categories in both groups, with the 344

smallest category being for elevated IOP and a suspicious VF. 345

346

In contrast, the temporal trend observed among the stated reasons for referral for the non-347

OSI and OSI displayed marked variation. All non-OSI referral categories not involving IOP as a 348

referral criterion demonstrated a decline post NICE compared to pre NICE. The reverse was 349

seen for referrals involving IOP, particularly IOP-only referrals which increased from 19.0% to 350

45.1%. The AOP’s response to the NICE Guidelines seems to have had much less effect on 351

the temporal trend in referrals generated by OSIs. Exceptions being IOP-only referrals which 352

showed a less dramatic rise than that of the non-OSI, 10.9% pre NICE to 28.0% post NICE, 353

and referrals citing IOP, optic disc and visual fields which decreased from 26.6% to 6.4%. This 354

would suggest that, post-NICE, optometrists initiating referrals concentrate more on IOP as a 355

reason for referral with less emphasis being placed on concurrent assessment of the optic 356

nerve and visual field. 357

358

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It would seem that the introduction of JCG was successful in reducing the proportion of non-359

OSI referrals for only a raised IOP (45.1% to 32.0%) after the large increase post NICE. This 360

trend was not observed in the OSI group where the proportion of referrals for raised IOP-361

only actually increased from 28.0% to 41.5%. This may seem surprising but may reflect the 362

improved quality of referrals from non-OSIs. 363

364

365


367

The overall FVDR for non-OSI referrals was statistically significantly higher than that for OSIs, 368

suggesting superior concordance of the OSI findings with the final provider. 369

370

The lack of legal indemnity for optometrists not complying with the AOP’s recommendation 371

interestingly has proved to be a really effective way of changing optometry practice, though 372

unfortunately this directly resulted in more inappropriate referrals. 373

374

The introduction of JCG did not lower the FVDR in either group, as would have been 375

expected, with FVDRs unchanged from the post NICE period. This may be because the undue 376

perception of the importance of IOP over other aspects of the ocular examination still 377

remained. 378

379

For both OSIs and non-OSIs, the highest FVDRs were in the current practice time period, with 380

the latter group reaching a statistical significant increase in FVDR compared to pre-NICE. This 381

suggests the need for further multi-stakeholder guidance (such as the JCG) regarding 382

detection and referral of suspected glaucoma to be used in conjunction with the NICE 383

guidance on the diagnosis and management of glaucoma and OHT. In addition, if the AOP’s 384

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recommendation were withdrawn, this may have a significant impact on improving the 385

quality of referrals and therefore lowering the FVDR. 386

387

The lower IOP threshold for referral to ophthalmology recommended in the NICE guidelines 388

may explain the rise in the FVDR for the OSI post NICE, but also may reflect a culture by 389

optometrists, OSI and non-OSI, to adopt a more risk averse approach to the clinical 390

assessment of patients with suspected glaucoma with a lower threshold for referral in 391

keeping with the AOP’s recommendation. This is speculative, but the maintenance of the 392

FVDR for the OSI in the post JCG and current practice periods imply that whatever factors 393

caused the increase in first-visit discharges post NICE remained there for the duration of this 394

analysis. 395

396

Features of the ocular examination performed at the referral refinement consultation that 397

best predict a diagnosis of glaucoma 398

399

The width-adjusted bar graphs of outcome of referral based on reason for referral (Figure 2) 400

demonstrate the large proportion of IOP-only referrals and its low diagnostic yield. In the 401

non-OSI referrals, only 16.5% of these patients were given a follow-up appointment, with 402

just 3.5% diagnosed with primary open angle glaucoma. These values were considerably 403

higher for the OSI-initiated referrals (45% and 14.7%, respectively). 404

405

These findings highlight that IOP-only referrals represent a waste of hospital out-patient 406

resource. However, 14.7% of these IOP-only referrals were subsequently diagnosed with 407

glaucoma implying the referring clinician had missed or not examined in sufficient detail to 408

identify glaucomatous optic disc pathology, which by definition needs to be present to 409

diagnose glaucoma. 410

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411

79.7% of OSI referrals for solely a suspicious optic disc appearance were followed up by the 412

hospital, but only 5.8% were diagnosed with glaucoma at the first review, the remainder 413

being classified as glaucoma suspect. In contrast, only 49.4% of non-OSI disc-suspect 414

referrals were followed-up by the hospital. This suggests the extra training received by OSIs 415

resulted in more accurate referrals. 416

417

Multiple-criterion referrals by the OSI, such as an abnormal IOP, optic disc and visual field, 418

resulted a higher percentage of patients being diagnosed with glaucoma, 45.7%. This leads 419

the authors to question the effectiveness of the OSI in such referrals as a substantial 420

proportion will be subsequently referred to secondary care. The scheme in Huntingdon has 421

adopted risk stratification through a paper triage of the non-OSI referrals carried out by the 422

hospital, with only patients found to have one risk factor deemed low risk and therefore 423

suitable for glaucoma referral refinement. Our findings would suggest that the stratification 424

of the referral letter according to risk, a strategy that could be incorporated across all 425

medical specialities, could be an effective method to ensure patients with a high probability 426

of having glaucoma are seen directly by secondary care without the need for the additional 427

examination by an OSI. This is reflected by the most recent glaucoma publication from NICE 428

in March 2012: The NICE commissioners guide ‘services for people at risk of developing 429

glaucoma’ which was produced to provide commissioners of eye services guidance as to how 430

to safely and effectively manage patients at risk of glaucoma.28

It recommends that patients 431

with an IOP of greater than 30mmHg should be referred directly to secondary care. 432

433

434

435

436

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Limitations 437

438

There are some limitations of this study which are important to consider. The false negative, 439

or percentage of patients that were inappropriately discharged by the non-OSI and OSI, is 440

not known. This will be addressed in an upcoming prospective study using the 441

recommendations of this report. 442

443

The final provider in the schemes was not always a consultant ophthalmologist, and 444

therefore a reference standard can not be applied across all the schemes that were 445

evaluated. Again this will be addressed in the upcoming prospective study. 446

447

OSIs are not performing opportunistic screening and therefore their referrals are more likely 448

to be appropriate compared to the non-OSI. However, the FVDR is the most appropriate 449

metric to measure the ‘added diagnostic value’ an OSI introduces to the referral pathway in 450

GRRS compared to the traditional referral pathway in which a non-OSI directly refers to the 451

HES. 452

453

454

Recommendations 455

456

This report of activity from four established referral refinement schemes of differing design 457

has highlighted a continually increasing FVDR post-NICE. This study has also demonstrated 458

that specialist trained optometrists (OSIs) can successfully refine the referrals from non-OSIs 459

for suspected glaucoma leading to a statistically significant reduction in the FVDR. It is the 460

authors recommendation that patients with a high chance of being diagnosed with glaucoma 461

based on the examination findings of the non-OSI should be referred directly to secondary 462

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care and those at lower risk could effectively be reviewed by an OSI carrying out a 463

comprehensive eye examination. The results of this analysis lead us to recommend that ‘low 464

risk’ should be defined as referrals based on IOP only, optic disc only, VF only and IOP and VF, 465

with all other referrals including any reference to a shallow anterior chamber angle better 466

suited to a direct referral to secondary care. 467

468

The inclusion of VF and disc examination is clearly associated with a lower FVDR and, 469

therefore, the authors recommend that detailed disc and VF examination form part of the 470

referral refinement in conjunction with Goldmann/Perkins tonometry for measuring the IOP. 471

Using the referral criteria of the JCG will crucially allows the optometrist to operate within a 472

professional and legal framework. 473

474

FUNDING 475

None 476

CONTRIBUTORSHIP 477



DATA SHARING 480



COMPETING INTERESTS 483

None 484

485

486

487

488

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489

490

491

492

493

494

495

496

497

498

References: 499

500

1. Quigley HA. Number of people with glaucoma worldwide. Br J Ophthalmol 1986; 80: 501

389-393. 502

2. www.nice.org.uk/nicemedia/live/12145/44043/44043.pdf 503

3. Davey CJ, Green C, Elliott DB. Assessment of referrals to the hospital eye service by 504

optometrists and GPs in Bradford and Airedale. Ophthalmic Physiol Opt. 2011; 31: 505

23-28. 506

4. Bowling B, Chen SD, Salmon JF. Outcomes of referrals by community optometrists to 507

a hospital glaucoma service. Br J Ophthalmol 2005; 89: 1102-1104. 508

5. Burr JM, Mowatt G, Hernández R et al. The Clinical effectiveness and cost-509

effectiveness of screening for open angle glaucoma: a systematic review and 510

economic evaluation. Health Technol Assess 2007; 11: 1-190. 511


optometrists and GP’s in Bradford and Airedale. Ophthalmic Physiol Opt 2011; 31: 513

23-28. 514

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7. Shields MB. The Non-contact tonometer. Its value and Limitations. Surv Ophthalmol 515

1980; 24: 211-219. 516

8. http://guidance.nice.org.uk/CG85/NiceGuidance/pdf/English 517

9. Vernon SA. The changing pattern of glaucoma referrals by optometrists. Eye 1998; 518

854-857. 519

10. Shah S, Murdoch IE. NICE – impact on glaucoma case detection. Ophthalmic Physiol 520

Opt 2011; 31: 339-342. 521

11. Sparrow JM. How nice in NICE? Br J Ophthalmol 2013; 97: 116-117. 522

12. Association of Optometrists. 2010. Advice on NICE glaucoma guidelines. (online) 523

http://www.aop.org.uk/practitioner-advice/enhanced-services/glaucoma-nice-524

guidelines/ 525

13. Ratnarajan G, Newsom W, French K et al. Unnecessary referral rate and the risk 526

stratification analysis of the Community and Hospital Allied Network Glaucoma 527

Evaluation Scheme (CHANGES) - The Health Innovation & Education Cluster (HIEC) 528

Glaucoma Pathways project. Submitted to Br J Ophthalmol (bjophthalmol-2012-529

302359). 530

14. Ratnarajan G, Newsom W, French K et al. The effect of changes in referral behaviour 531

following NICE Guideline publication on agreement of examination findings between 532

professionals in an established glaucoma referral refinement pathway. The Health 533

Innovation & Education Cluster (HIEC) Glaucoma Pathways project. Accepted by Br J 534

Ophthalmol (doi:10.1136/bjophthalmol-2012-302352). 535

15. Edgar D, Romanay T, Lawrenson J et al. Referral Behaviour Among Optometrists: 536

Increase in the Number of Referrals from Optometrists Following the Publication of 537

the April 2009 NICE Guidelines for the Diagnosis and Management of COAG and OHT 538

in England and Wales and its Implications. Optometry in Practice 2010; 11: 33 – 38. 539

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16. http://www.college-optometrists.org/en/utilities/document-540

summary.cfm/docid/B7251E0C-2436-455A-B15F1E43B6594206 541

17. Bourne RRA, French KA, Chang L et al. Can a community optometrist-based referral 542

refinement scheme reduce false-positive glaucoma hospital referrals without 543

compromising quality of care? The Community and hospital allied network glaucoma 544

evaluation scheme (CHANGES). Eye 2010; 24: 881-887. 545

18. Henson DB, Spencer AF, Harper R et al. Community refinement of glaucoma referrals. 546

Eye 2003; 17: 21-26. 547

19. Parkins DJ, Edgar DF. Comparison of the effectiveness of two enhanced glaucoma 548

referral schemes. Ophthalmic Physiol Opt 2011; 31: 343-352. 549

20. Syam P, Rughani K, Vardy SJ et al. The Peterborough scheme for community 550

specialist optometrists in glaucoma: a feasibility study. Eye 2010; 24: 1156-1164 551

21. Devarajan N, Williams GS, Hopes M et al. The Carmarthenshire Glaucoma Referral 552

Refinement Scheme, a safe and efficient screening service. Eye 2011; 25: 43-49. 553

22. Ang GS, Ng WS, Azuara-Blanco A. The influence of the new general ophthalmic 554

services (GOS) contract in optometrist referrals for glaucoma in Scotland. Eye 2009; 555

23: 351-355. 556

23. LOCSU glaucoma pathways, 557

http://www.locsu.co.uk/uploads/enhanced_pathways_2012/locsu_glaucoma_rr_oh558

t_monitoring_pathway_rev_june_2012.pdf 559

24. http://www.necles.org.uk/whatwedo/eyesvision/index.html 560


summary.cfm?docid=2E04330D-91F6-48DB-B39DC69D6737EF6A 562

26. http://www.wopec.co.uk/courses 563

27. http://www.city.ac.uk/courses/cpd/glaucoma#course-detail=0 564

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28. http://www.nice.org.uk/usingguidance/commissioningguides/glaucoma/glaucoma.js565

p 566

29. Schuman JS. Glaucoma care: the patients’ perspective. What do patients want? Br J 567

Ophthalmol 2008; 92: 1571-1572. 568

569

570

571

572

573

574

Figure 1: Schematic flow chart of the organizational structure of each of the 4 glaucoma 575

referral refinement schemes (HES denotes Hospital Eye Service) 576

577

Figure 2: The outcomes of patients referred by non-OSIs (top) and OSIs (bottom). The width 578

of each bar is representative of the proportion of the total referral base. 579


specialist interest in glaucoma.) 581

582

583

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Figure 1: Schematic flow chart of the organizational structure of each of the 4 glaucoma referral refinement schemes (HES denotes Hospital Eye Service)

296x419mm (300 x 300 DPI)

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Figure 2: The outcomes of patients referred by non-OSIs (top) and OSIs (bottom). The width of each bar is representative of the proportion of the total referral base.

(OSI denotes optometrist with specialist interest in glaucoma. Non-OSI denotes optometrist with no

specialist interest in glaucoma.)

254x190mm (72 x 72 DPI)

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1

Appendix 1 1

2

Huntingdon 3

4

The Community and Hospital Allied Network Glaucoma Evaluation Scheme (CHANGES) was 5

established in 2006 and involves an initial triage of the referral letter by a hospital based 6

optometrist into either low or high risk according to a protocol. A referral is deemed low risk 7

if only one/none of the following risk factors were noted for either eye: abnormal optic disc, 8

abnormal visual field, abnormal IOP (22-28mmHg or IOP asymmetry). All other referrals 9

were deemed high risk (including any reference to a shallow anterior chamber). Low risk 10

patients are seen by one of 8 community based OSIs and high risk patients are seen directly 11

in the hospital’s specialist glaucoma clinic. Only those low risk patients with a normal ocular 12

examination (IOP less than 22mmHg, normal optic disc and visual fields) are discharged by 13

the OSI. 14

15

Manchester 16

17

The Manchester glaucoma referral refinement scheme was established in 2000. All referrals 18

to Manchester Royal Eye Hospital (MREH) for patients who are registered with a GP in 19

central Manchester Primary Care Trust are reviewed by one of 12 OSIs. The current IOP 20

criteria necessitating referral to MREH are a modification of the original to reflect the JCG. 21

Other single referral criteria include unequivocal pathological cupping of the optic disc noted 22

after pupil dilation or visual field loss consistent with a diagnosis of glaucoma confirmed at a 23

second visit. Combined referral criteria include IOP ≥22 mmHg plus a suspicious optic disc 24

appearance or optic disc asymmetry. An abnormal optic disc and corresponding visual field 25

defect irrespective of the IOP necessitates a referral. Additional referral criteria include 26

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anterior segment signs of secondary glaucoma with IOP >22 mmHg on two occasions, or 27

suspected angle closure (symptoms of sub-acute attacks or occludable angle and IOP >22 28

mmHg). 29

30

Gloucestershire 31

32

The Gloucestershire glaucoma referral refinement scheme was established in 2008. All 33

community optometrists were offered the opportunity to participate and become accredited 34

to the scheme (for consistency in nomenclature, accredited community optometrists will 35

subsequently also be referred to as OSI). Patients who are registered with a Gloucestershire 36

GP practice are seen by one of 103 (85% of the total number of optometrists in this area) 37

OSIs and have their referral refined by the same OSI. The optometrist is only reimbursed for 38

referral of those patients who meet the following NICE-compliant referral criteria: patients 39

younger than 65 years with IOP in either eye of ≥ 22mmHg, patients aged 65 years or older 40

with an IOP ≥ 25mmHg, measured twice on each of 2 separate patient visits. If initial 41

measurement is ≥ 30mmHg and/or angle closure is suspected, repeated IOP measurements 42

on the same patient visit are sufficient for referral. Regardless of IOP, patients are referred if 43

the optic disc appearance is glaucomatous and/or a reproducible visual field defect (evident 44

on two separate occasions) is noted with automated perimetry. When a patient attends a 45

non-accredited optometrist, a referral is made in the usual way, without refinement, via the 46

patient’s GP to the hospital. 47

48

Nottingham 49

50

The glaucoma referral refinement scheme based at Queens Medical Centre was established 51

in 2009. All new referrals for suspected glaucoma are assessed by one of 3 hospital-based 52

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3

optometrists. Patients found to have a normal ocular examination by these optometrists are 53

discharged. Those patients that are found to have unequivocal glaucoma and who require 54

urgent treatment or who are identified as having occludable anterior chamber angles are 55

discussed with a consultant on the same day with a treatment plan established and an 56

appropriate prescription issued if necessary. Those with advanced glaucoma (Mean 57

deviation of >12dB on visual field testing or a visual field defect within 10 degrees of 58

fixation) are directed to a specialist glaucoma clinic. Patients diagnosed as ocular 59

hypertensive, with less severe glaucoma or in whom glaucoma is suspected are given a 60

review appointment in a general clinic, which may or may not be run by a glaucoma 61

specialist. 62

Table 1 : Summary of the 4 glaucoma referral refinement schemes (GRRS) 63

(VF denotes visual field) 64

65

Huntingdon Manchester Gloucestershire Nottingham

All glaucoma referrals seen

in GRRS

No Yes No Yes

Setting of GRRS Community Community Community Hospital

Contact

(Goldmann/Perkins)

tonometry required

Yes Yes Yes Yes

Dilated disc assessment

required

Yes Yes At discretion of

refining optometrist

Yes

VF machine requirement

Humphrey Any Suprathreshold Any Suprathreshold Humphrey

Year of introduction 2006 2000 2008 2009

Number of GRR

optometrists involved

8 12 103 3

Cost of GRR appointment

(£)

50.00 46.50 50.00 (only if

referred)

118.08

Hospital accreditation of

optometrist

Yes Yes Yes Yes

Specialist qualification in

glaucoma

Preferred, not

essential

Preferred, not

essential

Preferred, not

essential

Preferred, not

essential

66

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The effectiveness of schemes that refine referrals between primary and secondary care - the United Kingdom

experience with glaucoma referrals: The Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project.

Journal: BMJ Open

Manuscript ID: bmjopen-2013-002715.R1

Article Type: Research

Date Submitted by the Author: 29-Apr-2013

Complete List of Authors: Ratnarajan, Gokulan; Anglia Ruskin University, Vision and Eye Research Unit; Health Innovation and Education Cluster, Newsom, Wendy; Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, ; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, Vernon, Stephen; Nottingham University Hospitals NHS Trust, Fenerty, Cecilia; Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Henson, David; Manchester Royal Eye Hospital and Manchester Academic

and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Spencer, Fiona; Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Wang, Yanfang; Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Harper, Robert; Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, McNaught, Andrew; Gloucestershire Hospitals NHS Foundation Trust,

Collins, Lisa; Gloucestershire Hospitals NHS Foundation Trust, Parker, Mike; Postgraduate Medical Institute, Anglia Ruskin University, Lawrenson, John; City University London, Hudson, Robyn; Health Innovation and Education Cluster, Khaw, Peng; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, Wormald, Richard; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, Garway-Heath, David; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, Bourne, Rupert; Anglia Ruskin University, Vision and Eye Research Unit;

Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital,

<b>Primary Subject Heading</b>:

Ophthalmology


BMJ Open on M

ay 28, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

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J Open: first published as 10.1136/bm

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nloaded from



Secondary Subject Heading: Health services research

Keywords:

Glaucoma < OPHTHALMOLOGY, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Risk management < HEALTH SERVICES ADMINISTRATION & MANAGEMENT

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1

1

Title: 2




6

Authors: 7


, Wendy Newsom3,8


5, David 8


5, Yanfang Wang

5, Robert Harper

5, Andrew McNaught

6, Lisa Collins

6, 9


10, Robyn Hudson

1, Peng Tee Khaw

8, Richard Wormald

8, David 10


1,2,3,8 11

12












10.

21

22

23




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2



Cambridge 29

UK 30


+44 7976001102 32



35


37





42






48

Acknowledgements 49



52

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56


58

Wendy Newsom BSc(Hons) MCOptom

59

Stephen A. Vernon MB CHB DM FRCS FRCOphth FCOptom(hon) DO

60

Cecilia Fenerty MD, MBChB, FRCOphth

61

David Henson PhD FRCOptom

62

Fiona Spencer MD, MBChB, FRCOphth

63

Yanfang Wang MSc, Bachelor of Medicine

64

Robert Harper DPhil MCOptom

65

Andrew McNaught MD FRCOphth

66


Mike Parker BSc MSc CStat

68

John Lawrenson BSc PhD MCOptom

69

Robyn Hudson BSc MBA

70


FMedSci

72

Richard Wormald MA MSc (Epid) FRCS FRCOphth

73

David Garway-Heath MD FRCOphth

74


76

77

78

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ABSTRACT 79

80



83


85

Setting: The outcomes of clinical examinations by optometrists with a specialist interest in 86

glaucoma (OSIs) were compared to optometrists with no specialist interest in glaucoma 87

(non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, whilst 88

Manchester and Gloucestershire reviewed OSI findings. 89

90



93










19.0% to 45.1% for non-OSIs. 103

104

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5







111

ARTICLE SUMMARY 112

Article focus 113







120

Key messages 121










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• It is the authors’ recommendation that patients with a high chance of being 131



could effectively be reviewed by a specialist trained optometrist carrying out a 134


136



• The time series for the study was carefully selected to encompass all the major 139

changes in clinical guidelines and practice since 2009. However, by definition a 140

retrospective observational time series study will not provide data on all time points. 141

• The false negative rate, or percentage of patients that were inappropriately 142

discharged by the specialist and non-specialist optometrists, is not known. This will 143

be addressed in an upcoming prospective study using the recommendations of this 144

report. 145

146

147

148

149

150

151

152

153

154

155

156

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157

158

INTRODUCTION 159

160







166

167


surveillance during sight tests by primary care optometrists (hereafter referred to as an 169

Optometrist with no Specialist Interest in glaucoma, non-OSI). 4-6

170

171

As part of a sight test, the non-OSI is required to perform an examination of the optic disc 172

using fundoscopy. If clinically indicated they may measure the intra-ocular pressure (IOP) 173

typically using ‘air puff’ non-contact tonometry (NCT) which is prone to higher variability and 174

over-estimating the IOP (in individuals with thick corneas) compared to Goldmann contact 175

tonometry used in hospital ophthalmology departments.7 Visual field testing is also carried 176

out if clinically indicated and completes the established triad of examinations/tests to detect 177

glaucoma. 178

179




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183


and management of chronic open angle glaucoma and ocular hypertension (OHT; elevated 185

IOP but no signs of glaucomatous optic disc damage or visual field loss) were published in 186

April 2009.8,9,10

These guidelines however did not include in their remit guidance on the 187

detection and referral of suspected glaucoma by community optometrists as it was felt this 188

would make the guidelines unmanageably large.11

189

190

The representative organisation for the optometry profession and individual optometrists, 191

the Association of Optometrists (AOP), response to these guidelines was as follows: 192

193








experts in the field, using evidence-based methods, and has been officially published by NICE.” 12

201




many of these patients are now being referred with a resultant surge in the number of 205

referrals for suspected glaucoma and, consequently, an increase in first-visit discharges .10,13-

206

15 207

208

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The most recent JCG, published in March 2013, 217

recommended introduction of repeat IOP measurement schemes to reduce false-positive 218

referrals to the hospital eye service, and recommended where possible to facilitate the 219

implementation of glaucoma referral refinement schemes (GRRS) to further reduce the 220

false-positive referral rate. 17

221

222

GRRS have proliferated across the country over the past decade, often demonstrating 223

marked variation in pathway design, referral criteria as well as the level of competency and 224

training required by the participating optometrists.18-25

This study, the largest and only multi-225

site review of GRRS in the UK, aimed to investigate if specialist trained optometrists can 226

effectively reduce the first-visit discharge rate (FVDR) of patients identified in primary care 227

as being at risk of glaucoma and therefore reduce the burden on the hospital eye service. 228

Using the data from this report, a safe and efficient model of glaucoma referral refinement is 229

described that can be used to establish a much-needed national framework for GRRS? This 230

study was carried out by the Department of Health’s initiative called The North East, North 231

Central London and Essex Health Innovation and Education Cluster (HIEC) Glaucoma 232

pathway project.26

233

234

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METHODS 235

236


retrospectively analysed during four 2 month time periods: pre NICE (March and up to 22nd

238

April 2009, when the guidelines were published), post NICE (November and December 2009), 239

post JCG (August and September 2010) and current practice (March and April 2011). Ethical 240

approval at each trust was obtained prior to data collection. 241

242





247





251

252

The inclusion criteria for Huntingdon and Nottingham were referrals from non-OSIs as well 253

the subsequent findings from the next eye health professional (for Nottingham and low risk 254

Huntingdon patients this was the optometrist with specialist interest in glaucoma, OSI, and 255

for high risk Huntingdon patients this was a glaucoma consultant). The inclusion criteria for 256

Manchester and Gloucestershire were referrals from OSIs and the subsequent hospital visit. 257

Referrals from any other source were excluded. 258

259

260

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262



foundation for statistical computing, Vienna, Austria). Percentages of FVDR were compared 265

using Fisher’s Exact Test, and confidence limits for the differences between percentages 266

were calculated using Newcombe’s Hybrid Score Interval Method. Confidence limits and P-267

values within a set of factor levels have been corrected for multiplicity using the Dunn Sidak 268

method. 269

270

The FVDR, the main outcome metric for this analysis, is defined as the percentage of 271

referrals from an OSI or a non-OSI that was discharged at the first visit to the final provider. 272

FVDR was chosen in preference to ‘false positive rate’, the chosen outcome metric in the 273

published literature on this topic to date, as no inference of the appropriateness or falseness 274

of referral is implied as this may be governed by local policy. 275

Agreement rates on diagnostic accuracy and FVDR always use the diagnosis given by the 276

final clinician, and assumes their finding to be the gold standard. For Nottingham and low 277

risk Huntingdon this is the OSI, and for Manchester, Gloucestershire and high risk 278

Huntingdon this was the consultant Ophthalmologist 279

280

281

RESULTS 282

283

Data of 1086 patients (48% male, mean age 63 years) were analysed: 190 (17.5%) pre NICE, 284

338 (35.7%) post NICE, 287 (26.4%) post JCG and 271 (25.0%) from the current practice 285

group. 434 (42% male, mean age 62 years) patients were from Huntingdon (304 high and 286

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130 low risk), 179 (57% male, mean age 62 years ) from Manchester, 204 (55% male, mean 287

age 64 years) from Gloucestershire and 269 (46% male, mean age 62 years) from 288

Nottingham. 289

290



OSIs. 293

294

295

296


298

The most common reason for referral by a non-OSI across all observation periods was for an 299

elevated IOP-only (36.1%). In the pre NICE timeframe, IOP-only referrals accounted for 300

19.0% of referrals, increasing to 45.1% in the post NICE period. This was coupled with a 301

decrease in many other stated reasons for referral by the non-OSI, particularly those not 302

including IOP, exemplified by disc only referrals which reduced from 15.9% (20 referrals) pre 303

NICE to 6.1% (12 referrals) post NICE. 304

305



observed compared to non-OSIs. However, in terms of rate of increase for IOP only referrals 308

post NICE this was similar for both groups ( x 2.6 increase for OSIs and x 2.4 increase for non-309

OSIs). 310

311

312

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314

The overall FVDR for referrals by a non-OSI was 36.1% and for OSI referrals was 14.1% 315

(difference 22% CI 16.9% to 26.7%, p < 0.001). The FVDR for combination of each site and 316

time period is given in table 1. When interpreting these data it is important to note that for 317

Nottingham and Huntingdon the FVDR is for referrals from non-OSIs, while for Manchester 318

and Gloucestershire the FVDR is that of referrals from OSIs. 319





p = 0.03). 324

325

326





331

Site



practice



Mean non-OSI 29.2 35.0 34.7 43.9 36.1

Manchester (OSI) 4.9 6.5 16.9 3.0 8.9


Mean OSI 6.3 15.2 15.0 17.2 14.1

Mean overall 21.9 27.8 27.6 35.4 28.6

332

333

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335









344

345

346

DISCUSSION 347

348



increasing the quality and accuracy of the referral process.

351

352


354

Both non-OSIs and OSIs demonstrated a similar trend for the stated reasons for referral with 355

IOP-only referrals being the largest category for referral, 36.1% and 28.7% respectively, 356

followed by referrals for elevated IOP and abnormal optic disc, 12.8% and 19.6% respectively. 357

Disc-only referrals and disc and VF referrals were the next largest categories in both groups, 358

with the smallest category being for elevated IOP and a suspicious VF. 359

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360


OSI and OSI displayed marked variation. All referral categories by a non-OSI not involving IOP 362

as a referral criterion demonstrated a decline post NICE compared to pre NICE. The reverse 363

was seen for referrals involving IOP, particularly IOP-only referrals which increased from 364

19.0% (24 referrals) to 45.1% (96 referrals). The AOP’s response to the NICE Guidelines 365

seems to have had much less effect on the temporal trend in referrals generated by OSIs. 366

Exceptions being IOP-only referrals which increased 2.6 fold post NICE (10.9% pre NICE to 367

28.0% post NICE), and referrals citing IOP, optic disc and visual fields which decreased from 368

26.6% (16 referrals) to 6.4% (7 referrals). This would suggest that, post-NICE, optometrists 369

initiating referrals concentrate more on IOP as a reason for referral with less emphasis being 370

placed on concurrent assessment of the optic nerve and visual field. 371

372

It would seem that the introduction of JCG was successful in reducing the proportion of 373

referrals by a non-OSI for only a raised IOP (45.1% to 32.0%) after the large increase post 374

NICE. This trend was not observed in the OSI group where the proportion of referrals for 375

raised IOP-only actually increased from 28.0% to 41.5%. This may seem surprising but may 376

reflect the improved quality of referrals from non-OSIs. 377

378

379


381

The overall FVDR for referrals by a non-OSI was statistically significantly higher than that for 382

OSIs (particularly the Mancheter GRRS), suggesting superior concordance of the OSI findings 383

with the final provider. 384

385

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389




remained. However, the current practice FVDR in the Manchester scheme did reduce to 3% 393

from 16.9% in the post JCG time period, and may represent a delay in the full 394

implementation of JCG criteria by its participating OSIs. Despite this for both OSIs and non-395

OSIs as a whole, the highest FVDRs were in the current practice time period, with the latter 396

group reaching a statistical significant increase in FVDR compared to pre-NICE. This suggests 397

the need for further multi-stakeholder guidance (such as the JCG) regarding detection and 398

referral of suspected glaucoma to be used in conjunction with the NICE guidance on the 399

diagnosis and management of glaucoma and OHT. In addition, if the AOP’s recommendation 400

were withdrawn, this may have a significant impact on improving the quality of referrals and 401

therefore lowering the FVDR. 402

403






FVDR in the post JCG and current practice periods, with the exception of Manchester, imply 409

that whatever factors caused the increase in first-visit discharges post NICE remained there 410

for the duration of this analysis. 411

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412



415



referrals by a non-OSI, only 16.5% of these patients were given a follow-up appointment, 418

with just 3.5% diagnosed with primary open angle glaucoma. These values were 419

considerably higher for the OSI-initiated referrals (45% and 14.7%, respectively). These 420

findings highlight that IOP-only referrals represent a waste of hospital out-patient resource. 421

However, 14.7% of these IOP-only referrals by OSIs were subsequently diagnosed with 422

glaucoma. This implies either the OSI had missed glaucomatous optic disc pathology, or the 423

extra expertise of the consultant Ophthalmologist assisted by additional imaging modalities 424

available in the hospital was able to identify the optic disc pathology. 425

426

79.7% of OSI referrals compared to only 49.4% of non-OSI referrals for solely a suspicious 427

optic disc appearance were followed up by the hospital, which suggests,the extra training 428

received by OSIs resulted in more accurate referrals. However, the percentage of patients 429

actually diagnosed with glaucoma at the hospital eye service was low both OSI and non-OSI, 430

5.8% and 9.0% respectively. This demonstrates that the consultant Ophthalmologist 431

classified the majority of these referrals as glaucoma suspect. 432

433





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adopted risk stratification through a paper triage of the referrals by a non-OSI carried out by 438

the hospital, with only patients found to have one risk factor deemed low risk and therefore 439

suitable for glaucoma referral refinement. Our findings would suggest that the stratification 440

of the referral letter according to risk, a strategy that could be incorporated across all 441

medical specialities, could be an effective method to ensure patients with a high probability 442

of having glaucoma are seen directly by secondary care without the need for the additional 443

examination by an OSI. This is reflected by the most recent glaucoma publication from NICE 444

in March 2012: The NICE commissioners guide ‘services for people at risk of developing 445

glaucoma’ which was produced to provide commissioners of eye services guidance as to how 446

to safely and effectively manage patients at risk of glaucoma.30

It recommends that patients 447

with an IOP of greater than 30mmHg should be referred directly to secondary care. 448

449

450

451

452

Limitations 453

454

There are some limitations of this study which are important to consider. The false negative 455

rate, or percentage of patients that were inappropriately discharged by non-OSIs and OSIs, is 456

not known. This will be addressed in an upcoming prospective study using the 457


459




463

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to be appropriate compared to non-OSIs. However, the FVDR is the most appropriate metric 465

to measure the ‘added diagnostic value’ an OSI introduces to the referral pathway in GRRS 466

compared to the traditional referral pathway in which a non-OSI directly refers to the 467

hospital eye service. 468

469

The time series for the study was carefully selected to encompass all the major changes in 470

clinical guidelines and practice since 2009. However, by definition a retrospective 471

observational time series study will not provide data on all time points. 472

473

474

Recommendations 475

476





authors’ recommendation that patients with a high chance of being diagnosed with 481

glaucoma based on the examination findings of the non-OSI should be referred directly to 482

secondary care and those at lower risk could effectively be reviewed by an OSI carrying out a 483





488

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therefore, the authors’ recommend that detailed disc and VF examination form part of the 490


Using the referral criteria of the 2009 JCG will crucially allow the optometrist to operate 492

within a professional and legal framework, and can lower the FVDR as shown by the 493

Manchester GRRS in the current practice time frame. 494

495

496

497

498

499

500

501

502

503

504

505

506

507

508

509

510

511

512

513

514

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515

516

References: 517

518


389-393. 520




23-28. 524








23-28. 532

7. Vincent SJ, Vincent RA, Shields D RA, et al. Comparison of intraocular pressure 533

measurement between rebound, non-contact and Goldmann applanation tonometry 534

in treated glaucoma patients. Clin Experiment Ophthalmol. 2012; 40:e163-70. 535



854-857. 538


Opt 2011; 31: 339-342. 540

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guidelines/ 544

13. Ratnarajan G, Newsom W, French K et al. impact of glaucoma referral refinement 545

criteria on referral to, and first-visit discharge rates from, the hospital eye service: 546

the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways project. 547

Ophthalmic Physiol Opt 2013; 33:183-189. 548




Innovation & Education Cluster (HIEC) Glaucoma Pathways project. Br J Ophthalmol. 552

2013; 97: 210-214. 553





16. Guidance on the referral of Glaucoma suspects by community optometrists. The 558

College of Optometrists and Royal College of Ophthalmologists. 2010. 559

http://www.college-optometrists.org/en/utilities/document-560


17. Commissioning better eye care. The College of Optometrists and Royal College of 562

Ophthalmologists. 2013. http://www.college-optometrists.org/en/utilities/document-563

summary.cfm/4B0BE038-E6B2-49B4-B913529D58F2F038 564

18. Bourne RRA, French KA, Chang L et al. Can a community optometrist-based referral 565

refinement scheme reduce false-positive glaucoma hospital referrals without 566

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compromising quality of care? The Community and hospital allied network glaucoma 567

evaluation scheme (CHANGES). Eye 2010; 24: 881-887. 568

19. Henson DB, Spencer AF, Harper R et al. Community refinement of glaucoma referrals. 569

Eye 2003; 17: 21-26. 570

20. Parkins DJ, Edgar DF. Comparison of the effectiveness of two enhanced glaucoma 571

referral schemes. Ophthalmic Physiol Opt 2011; 31: 343-352. 572

21. Syam P, Rughani K, Vardy SJ et al. The Peterborough scheme for community 573


22. Devarajan N, Williams GS, Hopes M et al. The Carmarthenshire Glaucoma Referral 575

Refinement Scheme, a safe and efficient screening service. Eye 2011; 25: 43-49. 576

23. Ang GS, Ng WS, Azuara-Blanco A. The influence of the new general ophthalmic 577

services (GOS) contract in optometrist referrals for glaucoma in Scotland. Eye 2009; 578

23: 351-355. 579

24. LOCSU glaucoma pathways, 580



25. Hawley C, Albrow H, Sturt J et al. UK Eye Care Services Project. College of 583

Optometrists. http://www.college-optometrists.org/en/research/commissioned-584

research-2/index.cfm/ServicesProject 585

586

26. http://www.necles.org.uk/whatwedo/eyesvision/index.html 587



28. http://www.wopec.co.uk/courses 590

29. http://www.city.ac.uk/courses/cpd/glaucoma#course-detail=0 591

30. http://www.nice.org.uk/usingguidance/commissioningguides/glaucoma/glaucoma.js592

p 593

594

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Figure legends: 595

596



599





604

605

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1

1

Title: 2




6

Authors: 7


, Wendy Newsom3,8


5, David 8


5, Yanfang Wang

5, Robert Harper

5, Andrew McNaught

6, Lisa Collins

6, 9


10, Robyn Hudson

1, Peng Tee Khaw

8, Richard Wormald

8, David 10


1,2,3,8 11

12












10. 21

22

23




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2



Cambridge 29

UK 30


+44 7976001102 32



35


37





42






48

Acknowledgements 49



52

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56


58

Wendy Newsom BSc(Hons) MCOptom 59

Stephen A. Vernon MB CHB DM FRCS FRCOphth FCOptom(hon) DO 60

Cecilia Fenerty MD, MBChB, FRCOphth 61

David Henson PhD FRCOptom 62

Fiona Spencer MD, MBChB, FRCOphth 63

Yanfang Wang MSc, Bachelor of Medicine 64

Robert Harper DPhil MCOptom 65

Andrew McNaught MD FRCOphth 66


Mike Parker BSc MSc CStat 68

John Lawrenson BSc PhD MCOptom 69

Robyn Hudson BSc MBA 70


FMedSci 72

Richard Wormald MA MSc (Epid) FRCS FRCOphth 73

David Garway-Heath MD FRCOphth 74


76

77

78

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ABSTRACT 79

80



83


85

Setting: The outcomes of clinical examinations byof optometrists with a specialist interest in 86

glaucoma (OSIs) were compared to optometrists with no specialist interest in glaucoma 87

(non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, whilst 88

Manchester and Gloucestershire reviewed OSI findings. 89

90



93










19.0% to 45.1% for non-OSIs. 103

104

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111

ARTICLE SUMMARY 112

Article focus 113







120

Key messages 121










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• It is the author’s’ recommendation that patients with a high chance of being 131



could effectively be reviewed by a specialist trained optometrists carrying out a 134


136



• The time seriesframe for the study has was carefully selected to encompassed all the 139

major changes in clinical guidelines and practice since 2009. However, by definition a 140

retrospective observational time series study will not provide data on all time points. 141

• The false negative rate,, or percentage of patients that were inappropriately 142

discharged by the specialist and non-specialist optometrists, is not known. This will 143

be addressed in an upcoming prospective study using the recommendations of this 144

report. 145

146

147

148

149

150

151

152

153

154

155

156

Comment [GR1]: Reposne to reviewer 2.

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157

158

INTRODUCTION 159

160







166

167


surveillance during sight-testsight tests by primary care optometrists (hereafter referred to 169

as an Optometrist with no Specialist Interest in glaucoma, non-OSI). 4-6 170

171

As part of a sight-testsight test, the non-OSI is required to perform an examination of the 172

optic disc using fundoscopy. If clinically indicated they may measure the intra-ocular 173

pressure (IOP) typically using ‘air puff’ non-contact tonometry (NCT) which is prone to higher 174

variability and over-estimating the IOP (in individuals with thick corneas) compared to 175

Goldmann contact tonometry used in hospital ophthalmology departments.7 Visual field 176

testing is also carried out if clinically indicated and completes the established triad of 177

examinations/tests to detect glaucoma. 178

179




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183


and management of chronic open angle glaucoma and ocular hypertension (OHT; elevated 185

IOP but no signs of glaucomatous optic disc damage or visual field loss) wereas published in 186

April 2009.8,9,10

These guidelines however did not include in theirits remit guidance on the 187

detection and referral of suspected glaucoma by community optometrists as it was felt this 188

would make the guidelines unmanageably large.11

189

190

The professional representative organisations for optometry practicerepresentative 191

organisation for the optometry profession and individual optometrists, the Association of 192

Optometrists (AOP), response to these guidelines was as follows: 193

194








experts in the field, using evidence-based methods, and has been officially published by NICE.” 12 202




manyall of these patients are now being referred with a resultant surge in the number of 206

referrals for suspected glaucoma and, consequently, an increase in first-visit discharges .10,13-207

15 208

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209










The most recent JCG, published in March 2013, 218

recommended introduction of repeat IOP measurement schemes to reduce false-positive 219

referrals to the HES, and recommended where possible to facilitate the implementation of 220

glaucoma referral refinement schemes (GRRS) to further reduce the false-positive referral 221

rate. 17

222

223

224

Glaucoma Referral Refinement schemes (GRRS) have proliferated across the country over 225

the past decade, often demonstrating marked variation in pathway design, referral criteria 226

as well as the level of competency and training required by the participating optometrists.187-227

253 The relatively few reports published on this subject have demonstrated that this serves as 228

an effective method of reducing first-visit discharges fromto the hospital, but opinion is 229

divided on the question of optimal pathway design, triaging and referral criteria, to ensure 230

efficiency but also patient safety. This question was addressed by the Department of 231

Health’s initiative called The North East, North Central London and Essex Health Innovation 232

and Education Cluster (NECLES HIEC) Glaucoma pathway project, which carried out, by way 233

of a multi-site review of established organisationally distinct GRRS across the UK, with the 234 Comment [GR2]: In response to reviewer’s 1

comment about explaining HIEC glaucoma

pathways project in title.

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objective of establishing a national framework for glaucoma referral refinement.264

235

236

METHODS 237

238


retrospectively analysed during four 2 month time periods: pre NICE (March and up to 22nd

240

April 2009, when the guidelines were )published), post NICE (November and December 241

2009), post JCG (August and September 2010) and current practice (March and April 2011). 242

Ethical approval at each trust was obtained prior to data collection. 243

244





249





253

254

The iInclusion criteria for Huntingdon and Nottingham the data from thewere referrals from 255

non-OSIs referral as well the subsequent findings from the next eye health professional were 256

collected (for Nottingham and low risk Huntingdon patients this was the optometrist with 257

specialist interest in glaucoma, OSI, and for high risk Huntingdon patients this was a 258

glaucoma consultant). The inclusion criteria forIn Manchester and Gloucestershire the data 259

Formatted: Superscript

Comment [GR3]: Response to reviewer 2

Comment [GR4]: This paragraph has been

amended to follow reviewer 2 recommendation.

Comment [GR5]: Reponse to reviewer 2 about

making this term clearer, this has been

amended throughout the manuscript.

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11

from thewere referrals from OSIs referral and the subsequent hospital visit were analysed. 260

Referrals from any other source were excluded. 261

262

263


265



foundation for statistical computing, Vienna, Austria). Percentages of first-visit discharge 268

rate (FVDR) were compared using Fisher’s Exact Test, and confidence limits for the 269

differences between percentages were calculated using Newcombe’s Hybrid Score Interval 270

Method. Confidence limits and P-values within a set of factor levels have been corrected for 271

multiplicity using the Dunn Sidak method. 272

273

The FVDR, was the main outcome metric for this analysis, and is defined as the percentage 274

of referrals from an OSI or a non-OSI that was discharged at the first visit to the final 275

provider. TFVDRhis was chosen in preference tois analogous to the ‘false positive rate’ , 276

which is the chosen outcome metric in the published literature on this topic to date, as no 277

inference of the appropriateness or falseness of referral is implied as this may be governed 278

by local policy. 279

Agreement rates on diagnostic accuracy and referral appropriatenessFVDR always use the 280

diagnosis given by the final clinician, and assumes their finding to be the gold standard. For 281

Nottingham and low risk Huntingdon this is the OSI, and for Manchester, Gloucestershire 282

and high risk Huntingdon this was the consultant Ophthalmologist 283

284

285

Comment [GR6]: Paragraph amended in

response to reviewer 2 comments.

Comment [GR7]: Added as suggested by

reviewer 3

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RESULTS 286

287

Data of 1086 patients (48% male, mean age 63 years) were analysed: 190 (17.5%) pre NICE, 288

338 (35.7%) post NICE, 287 (26.4%) post JCG and 271 (25.0%) from the current practice 289

group. 434 (42% male, mean age 62 years40.0%) patients were from Huntingdon (304 high 290

and 130 low risk), 179 (57% male, mean age 62 years 16.5%) from Manchester, 204 (55% 291

male, mean age 64 years18.8%) from Gloucestershire and 269 (46% male, mean age 62 292

years24.8%) from Nottingham. 293

294



OSIs. 297

298

299

300


302

The most common reason for non-OSI referralreferral by a non-OSI across all observation 303

periods was for an elevated IOP-only (36.1%). In the pre NICE timeframe, IOP-only referrals 304

accounted for 19.0% of referrals, increasing to 45.1% in the post NICE period. This was 305

coupled with a decrease in many other stated reasons for referral by the non-OSI, 306

particularly those not including IOP, exemplified by disc only referrals which reduced from 307

15.9% (20 referrals) pre NICE to 6.1% (12 referrals) post NICE. 308

309



Comment [GR8]: Addition of participant

demographic information, including numbers in each site and each time period as requested

by reviewer 2

Comment [GR9]: Added raw values as

requested by reviewer 3

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observed compared to non-OSIs. However, in terms of rate of increase for IOP only referrals 312

post NICE this was similar for both groups ( x 2.6 increase for OSIs and x 2.4 increase for non-313

OSIs). 314

315

316


318

The overall FVDR for non-OSI referralsreferrals by a non-OSI was 36.1% and for OSI referrals 319

was 14.1% (difference 22% CI 16.9% to 26.7%, p < 0.001). The FVDR for combination of each 320

site and time period is given in table 1. When interpreting these data it is important to note 321

that for Nottingham and Huntingdon the FVDR is for referrals from a non-OSIs, while for 322

Manchester and Gloucestershire the FVDR is that of referrals from an OSIs. 323





p = 0.03). 328

329

330





335

Comment [GR10]: Added sentence in response

to reviewer 3

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14

Site (professional

initiating referral)



practice



Mean non-OSI 29.2 35.0 34.7 43.9 36.1

Manchester (OSI) 4.9 6.5 16.9 3.0 8.9


Mean OSI 6.3 15.2 15.0 17.2 14.1

Mean overall 21.9 27.8 27.6 35.4 28.6

336

337


339









348

349

350

DISCUSSION 351

352



increasing the quality and accuracy of the referral process. 355

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356


358

Both non-OSIs and OSIs demonstrated a similar trend for the stated reasons for referral with 359

IOP-only referrals being the largest category for referral, 36.1% and 28.7% respectively, 360

followed by referrals for elevated IOP and abnormal optic disc, 12.8% and 19.6% respectively. 361

Disc-only referrals and disc and VF referrals were the next largest categories in both groups, 362

with the smallest category being for elevated IOP and a suspicious VF. 363

364


OSI and OSI displayed marked variation. All referral non-OSI referral categories by a non-OSI 366

not involving IOP as a referral criterion demonstrated a decline post NICE compared to pre 367

NICE. The reverse was seen for referrals involving IOP, particularly IOP-only referrals which 368

increased from 19.0% (24 referrals) to 45.1% (96 referrals). The AOP’s response to the NICE 369

Guidelines seems to have had much less effect on the temporal trend in referrals generated 370

by OSIs. Exceptions being IOP-only referrals which increased 2.6 fold post NICE showed a 371

less dramatic rise than that of the non-OSI, (10.9% pre NICE to 28.0% post NICE), and 372

referrals citing IOP, optic disc and visual fields which decreased from 26.6% (16 referrals) to 373

6.4% (7 referrals). This would suggest that, post-NICE, optometrists initiating referrals 374

concentrate more on IOP as a reason for referral with less emphasis being placed on 375

concurrent assessment of the optic nerve and visual field. 376

377

It would seem that the introduction of JCG was successful in reducing the proportion of non-378

OSI referralsreferrals by a non-OSI for only a raised IOP (45.1% to 32.0%) after the large 379

increase post NICE. This trend was not observed in the OSI group where the proportion of 380

Comment [GR11]: In response to reviewer 3

Comment [GR12]: I have kept this sentence

unchanged as I have now added raw values

(above) as suggested by reviewer 3.

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referrals for raised IOP-only actually increased from 28.0% to 41.5%. This may seem 381

surprising but may reflect the improved quality of referrals from non-OSIs. 382

383

384


386

The overall FVDR for non-OSI referralsreferrals by a non-OSI was statistically significantly 387

higher than that for OSIs (particularly the Mancheter GRRS), suggesting superior 388

concordance of the OSI findings with the final provider. 389

390




394




remained. However, the current practice FVDR in the Manchester scheme did reduce to 3% 398

from 16.9% in the post JCG time period, and may represent a delay in the full 399

implementation of JCG criteria by its participating OSIs. Despite this f 400

401

For both OSIs and non-OSIs as a whole, the highest FVDRs were in the current practice time 402

period, with the latter group reaching a statistical significant increase in FVDR compared to 403

pre-NICE. This suggests the need for further multi-stakeholder guidance (such as the JCG) 404

regarding detection and referral of suspected glaucoma to be used in conjunction with the 405

NICE guidance on the diagnosis and management of glaucoma and OHT. In addition, if the 406


comment.


comments.

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AOP’s recommendation were withdrawn, this may have a significant impact on improving 407

the quality of referrals and therefore lowering the FVDR. 408

409






FVDR for the OSI in the post JCG and current practice periods, with the exception of 415

Manchester, imply that whatever factors caused the increase in first-visit discharges post 416

NICE remained there for the duration of this analysis. 417

418



421



non-OSI referralsreferrals by a non-OSI, only 16.5% of these patients were given a follow-up 424

appointment, with just 3.5% diagnosed with primary open angle glaucoma. These values 425

were considerably higher for the OSI-initiated referrals (45% and 14.7%, respectively). 426

427

These findings highlight that IOP-only referrals represent a waste of hospital out-patient 428

resource. However, 14.7% of these IOP-only referrals by OSIs were subsequently diagnosed 429

with glaucoma. This implyiimplies eitherng the referring clinicianOSI had missed or not 430

examined in sufficient detail to identify glaucomatous optic disc pathology, or the extra 431

expertise of the consultant Ophthalmologist assisted by additional imaging modalities 432

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available in the HES was able to identify the optic disc pathologywhich by definition needs to 433

be present to diagnose glaucoma. 434

435

79.7% of OSI referrals compared to only 49.4% of non-OSI referrals for solely a suspicious 436

optic disc appearance were followed up by the hospital, which suggests,, but only 5.8% were 437

diagnosed with glaucoma at the first review, the remainder being classified as glaucoma 438

suspect. In contrast, only 49.4% of non-OSI disc-suspect referrals were followed-up by the 439

hospital. This suggests tthe extra training received by OSIs resulted in more accurate 440

referrals. However, the percentage of patients actually diagnosed with glaucoma at the HES 441

was low both OSI and non-OSI, 5.8% and 9.0% respectively. This demonstrates that the 442

consultant Ophthalmologist classified the majority of these referrals as glaucoma suspect. 443

444





adopted risk stratification through a paper triage of the non-OSI referralsreferrals by a non-449

OSI carried out by the hospital, with only patients found to have one risk factor deemed low 450

risk and therefore suitable for glaucoma referral refinement. Our findings would suggest that 451

the stratification of the referral letter according to risk, a strategy that could be incorporated 452

across all medical specialities, could be an effective method to ensure patients with a high 453

probability of having glaucoma are seen directly by secondary care without the need for the 454

additional examination by an OSI. This is reflected by the most recent glaucoma publication 455

from NICE in March 2012: The NICE commissioners guide ‘services for people at risk of 456

developing glaucoma’ which was produced to provide commissioners of eye services 457

guidance as to how to safely and effectively manage patients at risk of glaucoma.3028

It 458


Comment [GR15]: This sentence has been

altered in view of reviewer 3 comments.


Comment [GR16]: Sentence added in response

to reviewer 3

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recommends that patients with an IOP of greater than 30mmHg should be referred directly 459

to secondary care. 460

461

462

463

464

Limitations 465

466

There are some limitations of this study which are important to consider. The false negative 467

rate, or percentage of patients that were inappropriately discharged by the non-OSIs and 468

OSIs, is not known. This will be addressed in an upcoming prospective study using the 469


471




475


to be appropriate compared to the non-OSIs. However, the FVDR is the most appropriate 477

metric to measure the ‘added diagnostic value’ an OSI introduces to the referral pathway in 478

GRRS compared to the traditional referral pathway in which a non-OSI directly refers to the 479

HES. 480

481

The time series for the study was carefully selected to encompass all the major changes in 482

clinical guidelines and practice since 2009. However, by definition a retrospective 483

observational time series study will not provide data on all time points. 484

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Comment [GR17]: Reposne to reviewer 2.


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485

486

Recommendations 487

488





authors’ recommendation that patients with a high chance of being diagnosed with 493

glaucoma based on the examination findings of the non-OSI should be referred directly to 494

secondary care and those at lower risk could effectively be reviewed by an OSI carrying out a 495





500


therefore, the authors’ recommend that detailed disc and VF examination form part of the 502


Using the referral criteria of the 2009 JCG will crucially allows the optometrist to operate 504

within a professional and legal framework, and can lower the FVDR as shown by the 505

Manchester GRRS in the current practice time frame. 506

507

508

509

510

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511

512

513

514

515

516

517

518

519

520

521

522

523

524

525

526

527

528

References: 529

530


389-393. 532




23-28. 536

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22








23-28. 544

7. Shields MB. The Non-contact tonometer. Its value and Limitations. Surv Ophthalmol 545

1980; 24: 211-219.Vincent SJ, Vincent RA, Shields D RA, Shields D et al. Comparison 546

of intraocular pressure measurement between rebound, non-contact and Goldmann 547

applanation tonometry in treated glaucoma patients. Clin Experiment Ophthalmol. 548

2012; 40:e163-70. 549



854-857. 552


Opt 2011; 31: 339-342. 554




guidelines/ 558

14.13. Ratnarajan G, Newsom W, French K et al. impact of glaucoma referral 559

refinement criteria on referral to, and first-visit discharge rates from, the hospital 560

eye service: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways 561

project. Ophthalmic Physiol Opt 2013; 33:183-189. 562


Formatted: Font: +Headings (Calibri), 11 pt, NotBold


Comment [GR18]: Updated reference as

suggested by reviewer 2



Formatted: Bullets and Numbering





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Innovation & Education Cluster (HIEC) Glaucoma Pathways project. Br J Ophthalmol. 566

2013; 97: 210-214. 567

14. Accepted by Br J Ophthalmol (doi:10.1136/bjophthalmol-2012-302352). 568





16. Guidance on the referral of Glaucoma suspects by community optometrists. The 573

College of Optometrists and Royal College of Ophthalmologists. 2010. 574

http://www.college-optometrists.org/en/utilities/document-575


17. Commissioning better eye care. The College of Optometrists and Royal College of 577

Ophthalmologists. 2013. http://www.college-optometrists.org/en/utilities/document-578

summary.cfm/4B0BE038-E6B2-49B4-B913529D58F2F038 579

17.18. Bourne RRA, French KA, Chang L et al. Can a community optometrist-based 580

referral refinement scheme reduce false-positive glaucoma hospital referrals 581

without compromising quality of care? The Community and hospital allied network 582

glaucoma evaluation scheme (CHANGES). Eye 2010; 24: 881-887. 583

18.19. Henson DB, Spencer AF, Harper R et al. Community refinement of glaucoma 584

referrals. Eye 2003; 17: 21-26. 585

19.20. Parkins DJ, Edgar DF. Comparison of the effectiveness of two enhanced 586

glaucoma referral schemes. Ophthalmic Physiol Opt 2011; 31: 343-352. 587

Formatted: English (U.S.)


Formatted: Font color: CustomColor(RGB(20,20,19))






Formatted: French (France)

Formatted: Font: (Default) Calibri, 11 pt, French(France)

Formatted: Font: (Default) Calibri, 11 pt, Italic,French (France)

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Formatted: No underline, Font color: Auto, English(U.S.)


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20.21. Syam P, Rughani K, Vardy SJ et al. The Peterborough scheme for community 588


21.22. Devarajan N, Williams GS, Hopes M et al. The Carmarthenshire Glaucoma 590

Referral Refinement Scheme, a safe and efficient screening service. Eye 2011; 25: 591

43-49. 592

22.23. Ang GS, Ng WS, Azuara-Blanco A. The influence of the new general 593

ophthalmic services (GOS) contract in optometrist referrals for glaucoma in Scotland. 594

Eye 2009; 23: 351-355. 595

23.24. LOCSU glaucoma pathways, 596



25. Hawley C, Albrow H, Sturt J et al. UK Eye Care Services Project. College of 599 Optometrists. http://www.college-optometrists.org/en/research/commissioned-600 research-2/index.cfm/ServicesProject 601

602 24.26. http://www.necles.org.uk/whatwedo/eyesvision/index.html 603

25.27. http://www.college-optometrists.org/en/utilities/document-604


26.28. http://www.wopec.co.uk/courses 606

27.29. http://www.city.ac.uk/courses/cpd/glaucoma#course-detail=0 607

28.30. http://www.nice.org.uk/usingguidance/commissioningguides/glaucoma/gla608

ucoma.jsp 609

29.Schuman JS. Glaucoma care: the patients’ perspective. What do patients want? Br J 610

Ophthalmol 2008; 92: 1571-1572. 611

612

613



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616





621

622

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Figure 1: Schematic flow chart of the organizational structure of each of the 4 glaucoma referral refinement schemes (HES = Hospital Eye Service)

90x95mm (300 x 300 DPI)

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Figure 2: The outcomes of patients referred by non-OSIs (top) and OSIs (bottom). The width of each bar is representative of the proportion of the total referral base.

(OSI denotes optometrist with specialist interest in glaucoma. Non-OSI denotes optometrist with no

specialist interest in glaucoma.)

90x142mm (300 x 300 DPI)

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1

Appendix 1 1

2

Huntingdon 3

4

The Community and Hospital Allied Network Glaucoma Evaluation Scheme (CHANGES) was 5

established in 2006 and involves an initial triage of the referral letter by a hospital based 6

optometrist into either low or high risk according to a protocol. A referral is deemed low risk 7

if only one/none of the following risk factors were noted for either eye: abnormal optic disc, 8

abnormal visual field, abnormal IOP (22-28mmHg or IOP asymmetry). All other referrals 9

were deemed high risk (including any reference to a shallow anterior chamber). Low risk 10

patients are seen by one of 8 community based OSIs and high risk patients are seen directly 11

in the hospital’s specialist glaucoma clinic. Only those low risk patients with a normal ocular 12

examination (IOP less than 22mmHg, normal optic disc and visual fields) are discharged by 13

the OSI. 14

15

Manchester 16

17

The Manchester glaucoma referral refinement scheme was established in 2000. All referrals 18

to Manchester Royal Eye Hospital (MREH) for patients who are registered with a GP in 19

central Manchester Primary Care Trust are reviewed by one of 12 OSIs. The current IOP 20

criteria necessitating referral to MREH are a modification of the original to reflect the JCG. 21

Other single referral criteria include unequivocal pathological cupping of the optic disc noted 22

after pupil dilation or visual field loss consistent with a diagnosis of glaucoma confirmed at a 23

second visit. Combined referral criteria include IOP ≥22 mmHg plus a suspicious optic disc 24

appearance or optic disc asymmetry. An abnormal optic disc and corresponding visual field 25

defect irrespective of the IOP necessitates a referral. Additional referral criteria include 26

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2

anterior segment signs of secondary glaucoma with IOP >22 mmHg on two occasions, or 27

suspected angle closure (symptoms of sub-acute attacks or occludable angle and IOP >22 28

mmHg). 29

30

Gloucestershire 31

32

The Gloucestershire glaucoma referral refinement scheme was established in 2008. All 33

community optometrists were offered the opportunity to participate and become accredited 34

to the scheme (for consistency in nomenclature, accredited community optometrists will 35

subsequently also be referred to as OSIs). Patients who are registered with a Gloucestershire 36

GP practice are examinedseen by one of 103 (85% of the total number of optometrists in 37

this area) OSIs and have their referral refined by the same OSI. The optometrist is only 38

reimbursed for referral of those patients who meet the following NICE-compliant referral 39

criteria: patients younger than 65 years with IOP in either eye of ≥ 22mmHg, patients aged 40

65 years or older with an IOP ≥ 25mmHg, measured twice on each of 2 separate patient 41

visits. If initial measurement is ≥ 30mmHg and/or angle closure is suspected, repeated IOP 42

measurements on the same patient visit are sufficient for referral. Regardless of IOP, 43

patients are referred if the optic disc appearance is glaucomatous and/or a reproducible 44

visual field defect (evident on two separate occasions) is noted with automated perimetry. 45

When If a patient attends a non-accredited optometrist (15% of the total number of 46

optometrists practicing in this area), a referral is made in the usual way, without refinement, 47

via the patient’s GP to the hospital. 48

49

Nottingham 50

51

Comment [GR1]: Clarification made as per

reviewer 3 comments

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3

The glaucoma referral refinement scheme based at Queens Medical Centre was established 52

in 2009. All new referrals for suspected glaucoma are assessed by one of 3 hospital-based 53

optometrists. Patients found to have a normal ocular examination by these optometrists are 54

discharged. Those patients that are found to have unequivocal glaucoma and who require 55

urgent treatment or who are identified as having occludable anterior chamber angles are 56

discussed with a consultant on the same day with a treatment plan established and an 57

appropriate prescription issued if necessary. Those with advanced glaucoma (Mean 58

deviation of >12dB on visual field testing or a visual field defect within 10 degrees of 59

fixation) are directed to a specialist glaucoma clinic. Patients diagnosed as ocular 60

hypertensive, with less severe glaucoma or in whom glaucoma is suspected are given a 61

review appointment in a general clinic, which may or may not be run by a glaucoma 62

specialist. 63

Table 21 : Summary of the 4 glaucoma referral refinement schemes (GRRS) 64

(VF denotes visual field) 65

66

Huntingdon Manchester Gloucestershire Nottingham

All glaucoma referrals seen in GRRS

No Yes No Yes

Setting of GRRS Community Community Community Hospital

Contact (Goldmann/Perkins) tonometry required

Yes Yes Yes Yes

Dilated disc assessment required

Yes Yes At discretion of refining optometrist

Yes

VF machine requirement

Humphrey Any Suprathreshold Any Suprathreshold Humphrey

Year of introduction 2006 2000 2008 2009

Number of GRR optometrists involved

8 12 103 3

Cost of GRR appointment (£)

50.00 46.50 50.00 (only if appropriately

referred)

118.08

Hospital accreditation of optometrist

Yes Yes Yes Yes

Specialist qualification in glaucoma

Preferred, not essential




67

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