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Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions 2013 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/ Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.

Abstract

Objectives

A comparison of glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and guidance.

Design

Retrospective multisite review.

Setting

The outcomes of clinical examinations by optometrists with a specialist interest in glaucoma (OSIs) were compared with optometrists with no specialist interest in glaucoma (non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, while Manchester and Gloucestershire reviewed OSI findings.

Participants

1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 from Gloucestershire and 269 from Nottingham.

Results

The first-visit discharge rate (FVDR) for all time periods for OSIs was 14.1% compared with 36.1% from non-OSIs (difference 22%, CI 16.9% to 26.7%; p<0.001). The FVDR increased after the April 2009 National Institute for Health and Clinical Excellence (NICE) glaucoma guidelines compared with pre-NICE, which was particularly evident when pre-NICE was compared with the current practice time period (OSIs 6.2–17.2%, difference 11%, CI −24.7% to 4.3%; p=0.18, non-OSIs 29.2–43.9%, difference 14.7%, CI −27.8% to −0.30%; p=0.03). Elevated intraocular pressure (IOP) was the commonest reason for referral for OSIs and non-OSIs, 28.7% and 36.1%, respectively, of total referrals. The proportion of referrals for elevated IOP increased from 10.9% pre-NICE to 28.0% post-NICE for OSIs, and from 19% to 45.1% for non-OSIs.

Conclusions

In terms of ‘demand management’, OSIs can reduce FVDR of patients reviewed in secondary care; however, in terms of ‘patient safety’ this study also shows that overemphasis on IOP as a criterion for referral is having an adverse effect on both the non-OSIs and indeed the OSIs ability to detect glaucomatous optic nerve features. It is recommended that referral letters from non-OSIs be stratified for risk, directing high-risk patients straight to secondary care, and low-risk patients to OSIs.

Details

Title
The effectiveness of schemes that refine referrals between primary and secondary care—the UK experience with glaucoma referrals: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project
Author
Ratnarajan, Gokulan 1 ; Newsom, Wendy 2 ; Vernon, Stephen A 3 ; Fenerty, Cecilia 4 ; Henson, David 4 ; Spencer, Fiona 4 ; Wang, Yanfang 4 ; Harper, Robert 4 ; McNaught, Andrew 5 ; Collins, Lisa 5 ; Parker, Mike 6 ; Lawrenson, John 7 ; Hudson, Robyn 8 ; Khaw, Peng Tee 9 ; Wormald, Richard 9 ; Garway-Heath, David 9 ; Bourne, Rupert 10 

 The North East, North Central London and Essex Health Innovation & Education Cluster; Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK; UCL Institute of Ophthalmology, London, UK 
 Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, Huntingdon, UK; NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK 
 Nottingham University Hospitals NHS Trust, Nottingham, UK 
 Manchester Royal Eye Hospital and Manchester Academic and Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK 
 Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK 
 Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK 
 Division of Optometry and Visual Science, City University London, London, UK 
 The North East, North Central London and Essex Health Innovation & Education Cluster 
 NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK 
10  The North East, North Central London and Essex Health Innovation & Education Cluster; Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK; Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, Huntingdon, UK; NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK 
First page
e002715
Section
Ophthalmology
Publication year
2013
Publication date
2013
Publisher
BMJ Publishing Group LTD
e-ISSN
20446055
Source type
Scholarly Journal
Language of publication
English
ProQuest document ID
1785356622
Copyright
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions 2013 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/ Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.