Avoiding misplacement of blame for medical maloccurrence

Vitreous haemorrhage without obvious cause: national survey of management practices

AIM

We undertook a national survey to establish the management of dense vitreous haemorrhage without obvious cause.

METHODS DESIGN

Cross-sectional anonymous self-reporting survey of ophthalmic practitioners within three target groups: vitreoretinal specialists (VRS), nonvitreoretinal specialists (NVRS), and associate specialists (AS).

INTERVENTION

Presentation of the hypothetical scenario of a patient presenting with recent onset (fresh) vitreous haemorrhage with no retinal view and no apparent cause on history taken at presentation.

OUTCOME MEASURES

The relative importance assigned by respondents to eight examination techniques at presentation. The proportion of respondents stating that they would review patients and perform B-scan examination at or prior to 2 weeks after presentation. The stated time to surgical intervention by VRS, and the time to referral by NVRS and AS.

RESULTS

VRS ranked B-scan examination higher than AS (P<0.001). A total of 98.1% of VRS indicated that they would next review patients within 2 weeks of presentation, this figure fell to 86.5% for NVRS and 47% for AS (P<0.001). A 98.1% of VRS indicated that they would next perform B-scan ultrasound within 2 weeks of presentation, this figure fell to 88.9% for NVRS and 70.6% for AS (P<0.001). The mean time to surgical intervention by VRS was 9.5 weeks without retinal tear demonstrated on B-scan, 1.7 weeks with retinal tear demonstrated on B-scan and 1 week with retinal detachment demonstrated on B-scan. The mean time to referral by NVRS was 6.7 weeks and by AS was 11.9 weeks.

CONCLUSIONS

Vitreoretinal specialists considered B-scan the most important examination tool, and typically perform B-scan early and frequently after presentation. Non-VR ophthalmologists (particularly associate specialists) review patients and perform B-scan ultrasound later and less often than vitreoretinal specialists. We recommend early referral to VR specialists, as reported referral even in uncomplicated cases would often be outside the timeframe within which VR specialists would typically choose to operate.

Maloccurrence in oculoplastic surgery related to the managed care environment

Conflicts between specialties abound in problems of the periorbita with different specialties claiming expertise in this area. These conflicts include both the diagnosis and the treatment of oculoplastic problems. Cases are presented in which such conflicts have arisen leading to less than optimal care for the patients. Engendering these conflicts are the Managed Care fiats of both insurance companies and hospital territorial conflicts. Ideas are presented for the ethical resolution of both the physician conflicts and for the recognition that managed care induced conflicts lead ultimately to less than optimal care.