A comparative study of glaucoma referrals in Southeast Scotland: effect of the new general ophthalmic service contract, Eyecare integration pilot programme and NICE guidelines

Abstract

BackgroundGlaucoma is a progressive disease responsible for the second commonest cause of blindness in the UK. Identifying appropriate patients for hospital care remains an ongoing challenge for all UK hospital glaucoma services. The purpose of our study is to evaluate accuracy and outcome of community optometry referrals before and after implementation of the new general ophthalmic service contract in 2006, the Eyecare Integration Programme pilot in 2008 and the effect of NICE guidelines in glaucoma in 2009, over a 12-year periodMethodsA retrospective case analysis using a glaucoma electronic patient record was performed encompassing two six-year periods, 2000–2006 (Group A), and 2007–2012 (Group B).ResultsOne thousand six hundred twenty-two new patients’ records were analysed. Waiting times reduced from 12.3 to 9.4 weeks. Significantly more patients kept first appointment (p = 0.0002) in group B. Glaucoma symptoms were significantly more in group A (p <0.0001) and only three patients lost Snellen’ visual acuity before appointment in group B compared to 12 in group A. Documentation of intraocular pressure was made in 74.1 % of Group A and 75.9 % of Group B, optic disc appearance in 85.4 % of Group A, and 93 % of Group B and visual fields in 84.4 % of Group A and 81.3 % of Group B. Significantly less normal (p < 0,0001), more glaucoma suspects (p < 0.0001), more open angle glaucoma (p = 0.0006) and fewer other conditions (p = 0.0024) were present in group B, compared to group A.ConclusionPatients were referred earlier with shorter waiting times for hospital appointments with the new Scottish general ophthalmic service and Eyecare Integration Programme. Additionally there were fewer false positive referrals with more diagnosis of glaucomatous disease. We discuss the benefits of these national screening and referral pathways together with their limitations and further refinements.

The impact of SIGN glaucoma guidelines on false-positive referrals from community optometrists in Central Scotland

“…To our knowledge, this study is the third analysis of glaucoma referrals from optometrists in Scotland after the study by Ang et al 7 which examined the impact of the new GOS contract in 2006 and El-Assal et al 6 which assessed the impact of both GOS and NICE guidance in 2010.…”

“…In part, this is a consequence of our lower rates of discharge for other types of referral (particularly raised IOP). But it may also be due to the fact that disc interpretation is a difficult and subjective technical skill6 which was shared by a substantial number of Optometrists with Specialist Interests (OSIs) in Ratnarajan et al ’s study 4 5. Their study also showed OSIs had higher accuracy in diagnosing based on optic disc findings 5…”

“…The strength of the referral pathway in Scotland centres upon encouraging public uptake of screening through the existence of the General Ophthalmic Service (GOS) contract, (2006) whereby all residents are entitled to receive free biennial eye checks by community optometrists 6. This contract supported enhanced diagnostic assessment through supplementary payments and resulted in a marked improvement in the true-positive rate of glaucoma referrals 7.…”

General ophthalmic services in Scotland: value for (public) money?

“…A number of peer‐reviewed studies have evaluated aspects of the new Scottish GOS contract including the quality of referrals, access to and distribution of services, the use of clinical equipment and practitioner preferences relating to the management of ocular conditions. One particular area that has attracted the attention of researchers is the impact of the new GOS contract on the quality of glaucoma referrals . Comparing the quality of more than 300 glaucoma referrals before and after the new GOS, Ang et al .…”

“…showed that outcomes and quality of glaucoma referrals have improved based on an increased rate of true positives and fewer cases of false positive referrals. El‐Assal et al used hospital glaucoma patient data from more than 1600 patients over a 12‐year period (2000–2012), with the introduction of the new GOS at the midpoint of this period. This study showed that with the new GOS contract in place, patients with glaucoma were correctly referred at an earlier point, allowing timely intervention.…”