Assessment of optometrists' referral accuracy and contributing factors: A review

Optometrists' Assessment of Pseudoexfoliation and Its Impact on Glaucoma Referrals

Purpose

To determine the frequency and accuracy of pseudoexfoliation syndrome (PEX) assessment in referrals from primary care optometrists before the new Swedish glaucoma guidelines were established, and to evaluate an optometrist's ability to assess PEX.

Patients and Methods

We studied PEX assessments in 95 referrals (95 patients,189 eyes) with elevated intraocular pressure (IOP) from optometrists to the Skåne University Hospital in Malmö, Sweden, in 2019. We reviewed the frequency and accuracy of PEX assessments in referrals and compliance of these referrals with the new guidelines. In addition, an optometrist's ability to identify PEX was evaluated and compared to that of an ophthalmologist specialized in glaucoma. Patients referred were examined at the hospital for PEX, first by the study's optometrist and then by the ophthalmologist.

Results

PEX was present in 17% of the patients (16 patients, 19 eyes). The optometrist in this study positively assessed PEX in 12 of 19 eyes (63%) before dilatation and in 14 of 19 eyes (74%) after dilatation. Seven referrals included a PEX assessment (3 assessed PEX and 4 assessed non-PEX), all of which were confirmed as correct. Of the 16 patients with PEX, 13 did not undergo a PEX assessment before referral. According to the new Swedish guidelines, three of the 13 referrals would not have been accepted, meaning that two patients requiring treatment would have been missed, one with pseudoexfoliation glaucoma and one with ocular hypertension with PEX.

Conclusion

Very few referrals from primary care optometrists included a PEX assessment (7%). According to the new guidelines, necessary referrals would therefore have been rejected. Still, the study's optometrist detected PEX in the majority of patients. The risk of missing high risk patients requiring glaucoma treatment would be reduced if primary care optometrists assess PEX before referral.

Effect of implementation of an electronic consult referral platform (eConsult) to triage retina referrals in Manitoba

OBJECTIVE

eConsult allows specialists to diagnose and recommend treatment plans for nonurgent conditions without the need for patient travel. Our purpose is to evaluate the effectiveness of eConsult in reducing unnecessary in-person retinal consultations in Manitoba.

DESIGN

Retrospective eConsult chart review.

PARTICIPANTS

Any person for whom an eConsult was submitted for a retina problem in Manitoba between November 2020 and October 2023 (n = 196).

METHODS

The primary objective was to quantify eConsults requiring no in-person referral, routine in-person referral, or urgent (within 4 weeks) in-person referral. Secondary objectives included describing characteristics of eConsults and quantifying the amount of time spent on the platform by both the referring provider and the specialist. On the basis of these variables, patient travel, consultation time, and specialist billings savings were calculated.

RESULTS

66.8% of eConsults did not require in-person assessment (n = 131), 24.5% required to be seen on a routine basis (n = 48), and 8.7% required to be seen within 4 weeks (n = 17). This translated to a net cost of $2,660.43 for the provincial government in billings over 3 years, but 81 990 km saved in patient travel. 99% of eConsults came from optometrists (n = 194). Referring providers spent an average of 10.6 ± 9.4 minutes on the platform per referral, and the specialist consultant spent 9.1 ± 6.6 minutes.

CONCLUSION

eConsult is a potentially cost-effective way to address increasing demand for retinal services, reduce wait times by reducing unnecessary referrals, and facilitate data sharing between optometrists and ophthalmologists.

Evaluating referrals of flashing lights and floaters coming into secondary care from primary care

CLINICAL RELEVANCE

Optometrists should look to take every opportunity to expand their knowledge, understanding and skills pertaining to vitreoretinal conditions.

BACKGROUND

Despite the existence of acute eye care schemes and the up-skilling of optometrists, many units are still noticing large numbers of poor-quality referrals with high false positive rates. The authors pondered whether these schemes are effective.

METHODS

At two different time points, a prospective analysis of patients took place, of all the flashing lights and floaters referrals coming into secondary care at the Royal Glamorgan Hospital, Wales, UK. The following data was captured: the exact source of the primary care referral, the diagnosis being queried, the secondary care diagnoses made and the secondary care management decisions. The accuracy of retinal break and Shafer's sign detection were also directly compared between primary care and secondary care using Cohen's Kappa Coefficient.

RESULTS

For the 2018 period, n = 51 patients were included. For the 2022-23 period n = 100 patients were included. The majority of referrals during both periods were from optometrists (>80%) via the WECS pathway. The most common diagnoses being queried were retinal breaks (~50%), followed by retinal detachments (~20%). Interestingly up to 20% of patients seen in secondary care were diagnosed as normal examinations and ~ 20%. Over 1/3 of patients were discharged after their first visit to the EEC. Statistically significant differences were found between the accuracy of retinal tear and Shafer's identification between the primary and secondary care settings.

CONCLUSION

A high number of false positive referrals are coming into secondary care from the WECS pathway and clear training and education needs have been identified.

Implementing a teleophthalmology referral platform in routine practice: Understanding a digital health intervention implementation using normalisation process theory

Objective

Digital health interventions have the potential to improve clinical processes and patient outcomes; however, many face challenges during the adoption and implementation stages, hindering their overall impact. Our study uses normalisation process theory (NPT) as a theoretical approach to explore the facilitators and barriers to the implementation of a teleophthalmology referral platform in the United Kingdom, as an illustrative case of the implementation of a digital health intervention in routine practice.

Methods

Semistructured interviews were conducted with 24 health professionals (18 optometrists and 6 ophthalmologists) involved in the implementation of a teleophthalmology referral platform. NPT guided data collection and analysis.

Results

Most participants were ready to engage with the teleophthalmology referral platform, recognising its potential value and benefits. However, during implementation, participants' perceptions varied; a major factor was whether their expectations from the technology were met, particularly regarding the feedback from the secondary eye care component of the referral platform. Several additional factors were identified that would influence the adoption of the platform. These included individual aspects (e.g. participants' IT skills), technology-related factors (e.g. the time required to complete referrals) and organisational factors (e.g. investment in community optometry services).

Conclusions

To successfully implement the teleophthalmology platform into routine practice, particularly on a large scale, multiple factors at different levels must be considered. This study highlights the complexity associated with implementing digital health interventions in routine practice and the contribution of NPT in untangling some of these complexities.

A review of UK primary care pathways for acute ophthalmic conditions

Care pathways for the management of acute ophthalmic conditions have developed and transformed significantly over recent years, owing to a combination of legislative changes, policy implementation and the pressing requirement to redistribute increased demand away from traditional secondary care providers through collaboration with primary care. Following UK healthcare devolution in 1999, each nation has developed and implemented their own strategies for managing the growing demands on acute ophthalmology services. Local commissioning across England has seen Enhanced Service Pathways develop to provide acute eye care by primary care optometrists, with provision and access dependent upon locality. Northern Ireland has seen the implementation of a nationwide Primary Eyecare Acute Referral Service, whilst in Scotland and Wales, the respective Governments have redesigned primary care optometry General Ophthalmic Service contracts to incorporate provision of extended investigations and management of acute conditions by optometrists across the nation, recognising the added benefit of optometrists with higher qualifications. This narrative review summarises both peer reviewed and appropriate grey literature articles reporting on acute eye care pathways in primary care. Despite significant progress, particularly during the global COVID-19 pandemic, there is arguably still a great deal of further research and evaluation required relating to pathway innovation, the role of professionals with higher qualifications, including independent prescribing, the role of telemedicine, reassurance around clinical safety, and how digital interconnectivity could potentially add value to collaborative schemes to meet the growing demand on acute eyecare.

Perceptions and Experiences of Key Informants in Eye Health on the Implementation of Eye Care Health Promotion Interventions in South Africa

Background: Eye care health promotion interventions aim to encourage the adoption of healthy behaviours that impact eye health and vision impairment, as well as increase the use of eye care services. Thus, this study aims to explore and describe the perceptions of eye care coordinators on the implementation of eye care health promotion interventions in rural Limpopo Province. Methods: This exploratory, descriptive qualitative study employed individual in-depth interviews to collect data from 10 district eye health coordinators. Participants were purposely sampled between June and July 2024. Data were analysed thematically using NVivo version 12. Results: The study revealed seven key themes: human resources in eye health, resource management, policy and governance, eye care services, innovation in eye health, community and patient engagement, and coordination and referral systems. Conclusions: In summary, our study offers important insights into the challenges and opportunities in implementing eye care health promotion interventions. A recommendation is made to address identified challenges such as workforce shortages, inadequate infrastructure, fragmented policies and outdated technologies. Policymakers and eye health professionals can work towards achieving the goals of universal health coverage (UHC) in eye health, ultimately improving eye health outcomes.

Investigating the impact of OCT imaging of the crystalline lens on the accuracy and precision of cataract assessment

PURPOSE

To determine if supplementing standard clinical assessments with Optical Coherence Tomography (OCT) imaging of the crystalline lens improves the accuracy and precision of lens opacity assessment and associated clinical management decisions by optometrists.

METHODS

Fifty optometrists registered in the UK or Éire undertook a clinical vignette study where participants graded lens opacities and made associated clinical management decisions based on the image(s)/information displayed. Three forms of vignettes were presented: (1) Slit-lamp (SL) images of the lens, (2) SL and OCT images and (3) SL, OCT and visual function measures. Vignettes were constructed using anonymised data from 50 patients with varying cataract severity, each vignette being presented twice in a randomised order (total vignette presentations = 300). The accuracy of opacity and management decisions were evaluated using descriptive statistics and non-parametric Bland-Altman analysis where assessments from experienced clinicians were the reference. The precision of assessments was examined for each vignette form using non-parametric Bland-Altman analysis.

RESULTS

All (n = 50) participants completed the study, with 36 working in primary eyecare (primary eyecare) settings and 14 in hospital eyecare services (HES). Agreement was highest where vignettes contained all clinical data (i.e., SL, OCT and visual function data-grading: 51.0%, management: 50.5%), and systematically reduced with decreasing vignette content (p < 0.001). A larger number of vignettes containing imaging and visual function measures exhibited below reference (i.e., less conservative) grading compared with vignettes containing imaging data alone (all p < 0.05). HES-based optometrists were more likely to grade lens opacities lower than clinicians working in primary eyecare (p < 0.001). Good measurement precision was evident for all vignettes, with a mean bias close to zero and limits of agreement below one grading step for all conditions.

CONCLUSIONS

The addition of anterior segment OCT to SL images improved the accuracy of lens opacity grading. Structural assessment alone yielded more conservative decision making, which reversed once visual functional data was available.

The effectiveness of interventions for optometric referrals into the hospital eye service: A review

PURPOSE

Ophthalmic services are currently under considerable stress; in the UK, ophthalmology departments have the highest number of outpatient appointments of any department within the National Health Service. Recognising the need for intervention, several approaches have been trialled to tackle the high numbers of false-positive referrals initiated in primary care and seen face to face within the hospital eye service (HES). In this mixed-methods narrative synthesis, we explored interventions based on their clinical impact, cost and acceptability to determine whether they are clinically effective, safe and sustainable. A systematic literature search of PubMed, MEDLINE and CINAHL, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), was used to identify appropriate studies published between December 2001 and December 2022.

RECENT FINDINGS

A total of 55 studies were reviewed. Four main interventions were assessed, where two studies covered more than one type: training and guidelines (n = 8), referral filtering schemes (n = 32), asynchronous teleophthalmology (n = 13) and synchronous teleophthalmology (n = 5). All four approaches demonstrated effectiveness for reducing false-positive referrals to the HES. There was sufficient evidence for stakeholder acceptance and cost-effectiveness of referral filtering schemes; however, cost comparisons involved assumptions. Referral filtering and asynchronous teleophthalmology reported moderate levels of false-negative cases (2%-20%), defined as discharged patients requiring HES monitoring.

SUMMARY

The effectiveness of interventions varied depending on which outcome and stakeholder was considered. More studies are required to explore stakeholder opinions around all interventions. In order to maximise clinical safety, it may be appropriate to combine more than one approach, such as referral filtering schemes with virtual review of discharged patients to assess the rate of false-negative cases. The implementation of a successful intervention is more complex than a 'one-size-fits-all' approach and there is potential space for newer types of interventions, such as artificial intelligence clinical support systems within the referral pathway.