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

Gokulan Ratnarajan; Wendy Newsom; Stephen A Vernon; Cecilia Fenerty; David Henson; Fiona Spencer; Yanfang Wang; Robert Harper; Andrew McNaught; Lisa Collins; Mike Parker; John Lawrenson; Robyn Hudson; Peng Tee Khaw; Richard Wormald; David Garway-Heath; Rupert Bourne

doi:10.1136/bmjopen-2013-002715

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

Gokulan Ratnarajan, Wendy Newsom, Stephen A Vernon, Cecilia Fenerty, David Henson, Fiona Spencer, Yanfang Wang, Robert Harper, Andrew McNaught, Lisa Collins, Mike Parker, John Lawrenson, Robyn Hudson, Peng Tee Khaw, Richard Wormald, David Garway-Heath, Rupert Bourne

Research output: Contribution to journal › Article › peer-review

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.

Original language	English
Article number	e002715
Journal	BMJ Open
Volume	3
Issue number	7
DOIs	https://doi.org/10.1136/bmjopen-2013-002715
Publication status	Published - 2013

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Journal Article

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10.1136/bmjopen-2013-002715

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Ratnarajan, G., Newsom, W., Vernon, S. A., Fenerty, C., Henson, D., Spencer, F., Wang, Y., Harper, R., McNaught, A., Collins, L., Parker, M., Lawrenson, J., Hudson, R., Khaw, P. T., Wormald, R., Garway-Heath, D., & Bourne, R. (2013). 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. BMJ Open, 3(7), Article e002715. https://doi.org/10.1136/bmjopen-2013-002715

@article{9e492b4f3d2e4d52acf4203af2bd79dc,

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",

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.",

keywords = "Journal Article",

author = "Gokulan Ratnarajan and Wendy Newsom and Vernon, {Stephen A} and Cecilia Fenerty and David Henson and Fiona Spencer and Yanfang Wang and Robert Harper and Andrew McNaught and Lisa Collins and Mike Parker and John Lawrenson and Robyn Hudson and Khaw, {Peng Tee} and Richard Wormald and David Garway-Heath and Rupert Bourne",

year = "2013",

doi = "10.1136/bmjopen-2013-002715",

language = "English",

volume = "3",

journal = "BMJ Open",

issn = "2044-6055",

publisher = "BMJ ",

number = "7",

}

Ratnarajan, G, Newsom, W, Vernon, SA, Fenerty, C, Henson, D, Spencer, F, Wang, Y, Harper, R, McNaught, A, Collins, L, Parker, M, Lawrenson, J, Hudson, R, Khaw, PT, Wormald, R, Garway-Heath, D & Bourne, R 2013, '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', BMJ Open, vol. 3, no. 7, e002715. https://doi.org/10.1136/bmjopen-2013-002715

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. / Ratnarajan, Gokulan; Newsom, Wendy; Vernon, Stephen A et al.
In: BMJ Open, Vol. 3, No. 7, e002715, 2013.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - The effectiveness of schemes that refine referrals between primary and secondary care--the UK experience with glaucoma referrals

T2 - the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project

AU - Ratnarajan, Gokulan

AU - Newsom, Wendy

AU - Vernon, Stephen A

AU - Fenerty, Cecilia

AU - Henson, David

AU - Spencer, Fiona

AU - Wang, Yanfang

AU - Harper, Robert

AU - McNaught, Andrew

AU - Collins, Lisa

AU - Parker, Mike

AU - Lawrenson, John

AU - Hudson, Robyn

AU - Khaw, Peng Tee

AU - Wormald, Richard

AU - Garway-Heath, David

AU - Bourne, Rupert

PY - 2013

Y1 - 2013

N2 - 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.

AB - 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.

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U2 - 10.1136/bmjopen-2013-002715

DO - 10.1136/bmjopen-2013-002715

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SN - 2044-6055

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