Barrett Catriona, O'Brien Colm, Loughman James
Department of Optometry, Dublin Institute of Technology (DIT), Dublin, Ireland.
DIT Centre for Eye Research Ireland, Environmental Sustainability and Health Institute, Dublin, Ireland.
Ophthalmic Physiol Opt. 2018 Jul;38(4):400-410. doi: 10.1111/opo.12446. Epub 2018 Feb 28.
Glaucoma referral refinement (GRR) has proven a successful demand management strategy for glaucoma suspect cases in the United Kingdom (UK). A GRR clinic was established in Dublin, Ireland to investigate the clinical viability of this pathway outside the UK's National Health Service (NHS) structures, and away from the influence of National Institute for Clinical Excellence (NICE) guidance.
Glaucoma suspect patients were recruited into the scheme following referral from community optometrists in the greater Dublin area. The GRR exam protocol was designed in consultation with the participating ophthalmology department. The refinement scheme optometrist, trained through apprenticeship style experience at a hospital outpatient clinic, made a tentative management decision after carrying out the GRR exam. The final management decision was made in a 'virtual clinic' by a glaucoma specialist consultant ophthalmologist.
Two hundred and twenty-five glaucoma suspect patients were seen in the scheme. After their first GRR visit, 28% were discharged back to their own optometrist, 42% were monitored in the GRR clinic, and 30% were referred to ophthalmology. After this monitoring cohort were further assessed, a total of 38% of the patients seen within the scheme required referral to ophthalmology. Sixteen percent of the total participant group (n = 225) were lost to follow up. Cohen's κ was used to determine the level of agreement between the scheme optometrist and ophthalmologist. There was substantial agreement, with κ = 0.63 for the first visit management decisions (n = 225). Agreement increased for subsequent monitoring visits with κ = 0.85 for second visits (n = 65), and κ = 0.69 for all management decisions within the scheme (n = 301). We received management outcomes for 44 of the 86 patients referred to ophthalmology. Of these 44, 57% received medical treatment for glaucoma, 34% were monitored without treatment, 2% were discharged, and 7% had comorbidities that were assessed and managed.
Of the patients seen within the scheme, 62% did not require referral onward to ophthalmology, thus releasing the significant majority of hospital clinic slots that would previously have been required to examine such patients. The high level of inter-professional decision agreement likely reflects the benefits of pre-scheme apprenticeship style training and ongoing hospital clinic participation by the scheme optometrist. The rate of loss to follow up compares favourably with ophthalmology led, hospital based, glaucoma clinics. Nevertheless, the losses indicate that patient education remains a key priority for future planning.
青光眼转诊优化（GRR）已被证明是英国青光眼疑似病例成功的需求管理策略。在爱尔兰都柏林设立了一个GRR诊所，以调查该途径在英国国家医疗服务体系（NHS）结构之外、不受国家临床优化研究所（NICE）指南影响的临床可行性。
从都柏林大区的社区验光师转诊而来的青光眼疑似患者被纳入该计划。GRR检查方案是与参与的眼科部门协商设计的。通过在医院门诊以学徒方式培训的GRR验光师在进行GRR检查后做出初步管理决策。最终管理决策由青光眼专科顾问眼科医生在“虚拟诊所”中做出。
该计划共诊治了225例青光眼疑似患者。首次GRR就诊后，28%的患者被转回其自己的验光师处，42%在GRR诊所接受监测，30%被转诊至眼科。对该监测队列进行进一步评估后，该计划内就诊的患者中共有38%需要转诊至眼科。总参与者群体中有16%（n = 225）失访。使用Cohen's κ来确定该计划验光师与眼科医生之间的一致性水平。一致性程度较高，首次就诊管理决策的κ值为0.63（n = 225）。后续监测就诊的一致性有所提高，第二次就诊的κ值为0.85（n = 65），该计划内所有管理决策的κ值为0.69（n = 301）。我们收到了转诊至眼科的86例患者中44例的管理结果。在这44例中，57%接受了青光眼药物治疗，34%在未治疗的情况下接受监测，2%被出院，7%有合并症并得到评估和处理。
在该计划内就诊的患者中，62%不需要进一步转诊至眼科，从而腾出了以前检查此类患者所需的大部分医院门诊时段。专业间决策的高度一致性可能反映了该计划验光师在计划前以学徒方式培训以及持续参与医院门诊的益处。失访率与以眼科为主导的、基于医院的青光眼诊所相比具有优势。然而，失访情况表明患者教育仍是未来规划的关键优先事项。
