Impact of referral refinement on management of glaucoma suspects in Australia

Abstract

Background

In ageing populations, the prevalence of chronic diseases such as glaucoma is projected to increase, placing additional demands on limited health‐care resources. In the UK, the demand for secondary care in hospital eye clinics was inflated by high rates of false positive glaucoma referrals. Collaborative care models incorporating referral refinement, whereby glaucoma suspect referrals are triaged by suitably trained optometrists through further testing, can potentially reduce false positive referrals. This study examined the impact of a referral refinement model on the accuracy of glaucoma referrals in Australia.

Methods

Optometrist‐initiated glaucoma suspect referrals to the Glaucoma Management Clinic (Sydney, Australia) were prospectively recruited. Glaucoma suspect referrals arising from two pathways were eligible for inclusion, either directly from a community optometrist (standard care) or following comprehensive assessment at the Centre for Eye Health (referral refinement). Main outcome measures were the positive predictive value and false positive rate of referrals. The impact of referral letter content on management outcomes was also investigated.

Results

Of 464 referrals received between March 2015 and June 2018, 252 were for treatment of naïve glaucoma suspects and eligible for inclusion. Following ophthalmological assessment, 45.6 per cent (n = 115/252) were prescribed treatment for open angle glaucoma or ocular hypertension. Positive predictive value of community optometry referrals was 33.8 per cent (n = 25/74) and 50.6 per cent (n = 90/178) following referral refinement. The first visit discharge (false positive) rate was 26 per cent (n = 19/74) for community referrals compared to four per cent (n = 8/178) with referral refinement. Positive predictive value increased with the number of abnormal clinical examination findings associated with referral (χ² test, p < 0.0001). The number of abnormal findings reported in referrals was significantly higher with referral refinement compared to without (n = 1.9 versus 1.5, t‐test, p < 0.0001).

Conclusion

Referral refinement can improve the diagnostic accuracy of optometry‐initiated referrals for glaucoma suspects in Australia, thereby decreasing unnecessary referrals to hospital and other secondary clinics.

Key words:

• collaborative care
• glaucoma
• ophthalmologists
• optometrists
• referral

ACKNOWLEDGEMENTS

The authors would like to thank the clinical staff at the Centre for Eye Health for their assistance in data collection. This work was supported by the National Health and Medical Research Council (grant number 1033224) and Guide Dogs NSW/ACT who were a partner on the grant as well as provided salary support MY, AL, MK and BZ. JH is a PhD candidate supported by the Australian Government Research Training Program and Guide Dogs NSW/ACT.

Supporting information

Additional supporting information may be found in the online version of this article at the publisher’s website:

Figure S1. Referral form for community optometry (direct) referrals to the Glaucoma Management Clinic during the study period.

Table S1. The abnormal clinical examination findings identified in referrals across all referrals and according to referral pathway. IOP: intraocular pressure, ON: optic nerve, VF: visual field.

Additional information

Funding

National Health and Medical Research Council