title: The effectiveness of schemes that refine referrals between primary and secondary care--the UK experience with glaucoma referrals: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project.
abstract: OBJECTIVE
  A comparison of glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and guidance.
  
  
  METHODS
  Retrospective multisite review.
  
  
  METHODS
  The outcomes of clinical examinations by optometrists with a specialist interest in glaucoma (OSIs) were compared with optometrists with no specialist interest in glaucoma (non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, while Manchester and Gloucestershire reviewed OSI findings.
  
  
  METHODS
  1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 from Gloucestershire and 269 from Nottingham.
  
  
  RESULTS
  The first-visit discharge rate (FVDR) for all time periods for OSIs was 14.1% compared with 36.1% from non-OSIs (difference 22%, CI 16.9% to 26.7%; p<0.001). The FVDR increased after the April 2009 National Institute for Health and Clinical Excellence (NICE) glaucoma guidelines compared with pre-NICE, which was particularly evident when pre-NICE was compared with the current practice time period (OSIs 6.2-17.2%, difference 11%, CI -24.7% to 4.3%; p=0.18, non-OSIs 29.2-43.9%, difference 14.7%, CI -27.8% to -0.30%; p=0.03). Elevated intraocular pressure (IOP) was the commonest reason for referral for OSIs and non-OSIs, 28.7% and 36.1%, respectively, of total referrals. The proportion of referrals for elevated IOP increased from 10.9% pre-NICE to 28.0% post-NICE for OSIs, and from 19% to 45.1% for non-OSIs.
  
  
  CONCLUSIONS
  In terms of 'demand management', OSIs can reduce FVDR of patients reviewed in secondary care; however, in terms of 'patient safety' this study also shows that overemphasis on IOP as a criterion for referral is having an adverse effect on both the non-OSIs and indeed the OSIs ability to detect glaucomatous optic nerve features. It is recommended that referral letters from non-OSIs be stratified for risk, directing high-risk patients straight to secondary care, and low-risk patients to OSIs.
authors.affiliation: The North East, North Central London and Essex Health Innovation & Education Cluster.
authors.forename: Gokulan
authors.initials: G
authors.lastname: Ratnarajan
authors.forename: Wendy
authors.initials: W
authors.lastname: Newsom
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Vernon
authors.forename: Cecilia
authors.initials: C
authors.lastname: Fenerty
authors.forename: David
authors.initials: D
authors.lastname: Henson
authors.forename: Fiona
authors.initials: F
authors.lastname: Spencer
authors.forename: Yanfang
authors.initials: Y
authors.lastname: Wang
authors.forename: Robert
authors.initials: R
authors.lastname: Harper
authors.forename: Andrew
authors.initials: A
authors.lastname: McNaught
authors.forename: Lisa
authors.initials: L
authors.lastname: Collins
authors.forename: Mike
authors.initials: M
authors.lastname: Parker
authors.forename: John
authors.initials: J
authors.lastname: Lawrenson
authors.forename: Robyn
authors.initials: R
authors.lastname: Hudson
authors.forename: Peng Tee
authors.initials: PT
authors.lastname: Khaw
authors.forename: Richard
authors.initials: R
authors.lastname: Wormald
authors.forename: David
authors.initials: D
authors.lastname: Garway-Heath
authors.forename: Rupert
authors.initials: R
authors.lastname: Bourne