title: The effect of changes in referral behaviour following NICE guideline publication on agreement of examination findings between professionals in an established glaucoma referral refinement pathway: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways project.
abstract: OBJECTIVE
  To investigate whether the publication of the National Institute for Health and Clinical Excellence (NICE) glaucoma guidelines had an effect on the agreement of examination findings between professionals involved in an established glaucoma referral refinement pathway.
  
  
  METHODS
  To report inter-professional agreement for the clinical examination findings of optometrists with a special interest in glaucoma (OSI), optometrists with no specialist interest in glaucoma (non-OSI) and a glaucoma consultant. Part 1 investigated agreement between an OSI and consultant and part 2 investigated agreement of clinical findings between the non-OSI and a specialist clinician (OSI or consultant).
  
  
  RESULTS
  Part 1: Agreement between OSI and consultant in determining an abnormal intraocular pressure (IOP) (>21 mm Hg) expressed as a percentage positive predictive value (PPPV) was no different pre-NICE (60.6%) and post-NICE (61.4%, p=0.51) guidelines. PPPV for identification of an abnormal optic disc was better pre-NICE (60.6%) than post-NICE (42.7%, p=0.02). The appropriate referral rate for patients referred by an OSI was higher pre-NICE (69.6%) than post-NICE (61.2%) (p=0.07). Part 2: The PPPV between non-OSI and specialist clinician for an abnormal IOP was better pre-NICE (62.5%) than post-NICE (50.9%, p=0.12). This was also observed for abnormal optic discs, 70.0% pre-NICE and 52.9% post-NICE (p=0.04).
  
  
  CONCLUSIONS
  The accuracy for detecting an abnormal IOP by the OSI has remained unchanged post-NICE, but there was a reduction in accuracy in detecting an abnormal optic disc as well as the appropriate referral rate. For the non-OSI, there was a decline in both IOP and optic disc assessment accuracy.
authors.affiliation: Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, East Road, Cambridge, CB1 1PT, UK. g.ratnarajan@gmail.com
authors.forename: Gokulan
authors.initials: G
authors.lastname: Ratnarajan
authors.forename: Wendy
authors.initials: W
authors.lastname: Newsom
authors.forename: Karen
authors.initials: K
authors.lastname: French
authors.forename: Jane
authors.initials: J
authors.lastname: Kean
authors.forename: Lydia
authors.initials: L
authors.lastname: Chang
authors.forename: Mike
authors.initials: M
authors.lastname: Parker
authors.forename: David F
authors.initials: DF
authors.lastname: Garway-Heath
authors.forename: Rupert Richard Alexander
authors.initials: RR
authors.lastname: Bourne
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D005260:Female; D005901:Glaucoma / Q000175:diagnosis*; D006266:Health Education / Q000592:standards*; D006801:Humans; D007429:Intraocular Pressure; D008297:Male; D008875:Middle Aged; D009907:Optometry / Q000592:standards*; D017410:Practice Guidelines as Topic; D012372:ROC Curve; D012017:Referral and Consultation; D012189:Retrospective Studies; D006113:United Kingdom