Agreement between optometrists and ophthalmologists on clinical management decisions for patients with glaucoma

Abstract

Background/aims: Although optometrists have become an accepted part of the team in many hospital glaucoma clinics, their decision making ability has not been assessed formally. This study aims to document the accuracy and safety of clinical work undertaken by optometrists in the hospital setting by investigating their management decisions on follow up of patients with glaucoma. Methods: Four optometrists and three medical clinicians examined 50 patients each. Clinical findings were recorded as usual in the hospital records but management decisions were documented separately on a specially designed data collection form. Subsequently, the patient records and clinical findings were reviewed retrospectively and independently by two consultant ophthalmologists, who were masked to the management decisions of the optometrists and medical clinicians. The consultants' management decisions were then compared with those made by the optometrists and medical clinicians. Percentage agreements were computed together with kappa (k), or weighted kappa, statistics where appropriate. Results: Agreement between consultants and optometrists was 55% (k = 0.33) for evaluation of visual field status, 79% (k = 0.67) for medical management, 72-98% for other aspects of patient management, and 78% (weighted k = 0.35) for scheduling of next clinic appointment. Very similar levels of agreement were found between consultants and medical clinicians. Conclusion: Agreement between optometrists and consultants, in glaucoma clinical decision making, was at least as good as that between medical clinicians and consultants. Within an appropriate environment, optometrists can safely work as part of the hospital glaucoma team in outpatient clinics.T he number of potential glaucoma sufferers is estimated to increase by about a third over the next 20 years.1 This has raised concerns about the personnel and financial resources required to provide a good standard of clinical care. One means of alleviating the burden on the hospital eye service is to involve non-medical eye care professionals, such as optometrists. Community optometrists already play a key part in the detection of glaucoma in the United Kingdom. They are responsible for more than 95% of glaucoma referrals to the hospital eye service and have the basic skills to detect glaucoma.2 Furthermore, optometrists are becoming increasingly involved in co-managed/shared care schemes and studies have been designed to assess their involvement. [3][4][5][6][7] Studies to date have examined the agreement between ophthalmologists and optometrists regarding individual aspects of the clinical examination-for example, optic disc and intraocular pressure assessment, [8][9][10][11] but, to our knowledge, not that regarding decision making for the management of glaucoma patients.This study was designed to evaluate this agreement between optometrists and two glaucoma subspecialist consultant ophthalmologists. As a benchmark, the same evaluation of agreement was undertaken for medical clinicians (associate special...

Agreement between specially trained and accredited optometrists and glaucoma specialist consultant ophthalmologists in their management of glaucoma patients

“…This level of agreement increased to 90% when qualified agreements were included and decisions regarding medical management reached agreement levels of 96-97%. Previous hospital 4,11 and community 8 based studies have also reported good to nearly perfect levels of agreement for medical management. In our study, none of the optometrists' decisions was deemed unacceptable, although in two cases, the optometrists were judged to have been under cautious.…”

“…13 In 2006, a national survey identified 66 secondary care-led glaucoma shared care schemes in operation in England, 36 of which employed optometrists in some capacity (14 in the community and 22 'in-house'). 14 To our knowledge, there have been two previous studies that have compared the management decisions made by optometrists working within the hospital glaucoma service with those of consultant ophthalmologists 4,11 and three involving specially trained community optometrists assessing new referrals, 8 diagnosed glaucoma/glaucoma suspect patients 9 , or a combination of both. 10 Although all of these optometrists had undergone additional training, as far as we are aware, none had completed the College of Optometrists Diploma in Glaucoma and the hospital-based optometrists were working alongside the consultant ophthalmologist who was responsible for the patients.…”

“…Notwithstanding, the difficulty in correctly identifying progressive optic disc and VF changes has previously been well documented and the agreement levels achieved by our optometrists are similar to those of other studies comparing glaucoma specialists. 4,[16][17][18] Differences in opinion regarding the stability of optic discs and VF will occur because of the subjective nature of such assessments but do not always lead to differences in management decisions. The fact that the consultant ophthalmologists initially disagreed with each other in more than half the cases that were retrospectively reviewed only serves to highlight the difficult and variable nature of glaucoma management, even in a population considered to be at low risk.…”

“…4,[9][10][11] It has been shown that specially trained community optometrists are able to make satisfactory decisions regarding the diagnosis and initiation of treatment for glaucoma 8 and can help to reduce the number of false positive referrals into the Hospital Eye Service (HES) by up to 53%. [5][6][7] However, there remains a large number of individuals considered to be at risk of developing glaucoma who are still being monitored within the HES and, once a diagnosis of glaucoma is confirmed, follow-up becomes lifelong.…”

“…Percentage agreement, kappa (k), and weighted kappa statistics were calculated for a range of parameters. Weighting was based on a system described by Banes et al, 4 that is, 1.0 for agreement, 0.75 for one-step away disagreement, 0.50 for two steps, 0.25 for three steps, and 0.00 for four or more steps.…”