title: The false negative rate and the role for virtual review in a nationally evaluated glaucoma referral refinement scheme.
abstract: OBJECTIVE
  To establish the safety of the CHANGES glaucoma referral refinement scheme (GRRS).
  
  
  METHODS
  The CHANGES scheme risk stratifies glaucoma referrals, with low risk referrals seen by a community based specialist optometrist (OSI) while high risk referrals are referred directly to the hospital. In this study, those patients discharged by the OSI were reviewed by the consultant ophthalmologist to establish a 'false negative' rate (Study 1). Virtual review of optic disc photographs was carried out both by a hospital-based specialist optometrist as well as the consultant ophthalmologist (Study 2).
  
  
  RESULTS
  None of these 34 discharged patients seen by the consultant were found to have glaucoma or started on treatment to lower the intra-ocular pressure. Five of the 34 (15%) were classified as 'glaucoma suspect' based on the appearance of the optic disc and offered a follow-up appointment. Virtual review by both the consultant and optometrist had a sensitivity of 80%, whilst the false positive rate for the optometrist was 3.4%, and 32% for the consultant (p < 0.05).
  
  
  CONCLUSIONS
  The false negative rate of the OSIs in the CHANGES scheme was 15%, however there were no patients where glaucoma was missed. Virtual review in experienced hands can be as effective as clinical review by a consultant, and is a valid method to ensure glaucoma is not missed in GRRS. The CHANGES scheme, which includes virtual review, is effective at reducing referrals to the hospital whilst not compromising patient safety.
authors.affiliation: Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, UK.|UCL Institute of Ophthalmology, University of London, London, UK.|Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK.
authors.forename: Gokulan
authors.initials: G
authors.lastname: Ratnarajan
authors.affiliation: Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, Huntingdon, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Kean
authors.affiliation: Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, Huntingdon, UK.
authors.forename: Karen
authors.initials: K
authors.lastname: French
authors.affiliation: Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK.
authors.forename: Mike
authors.initials: M
authors.lastname: Parker
authors.affiliation: Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, UK.|Huntingdon Glaucoma Diagnostic & Research Centre at Hinchingbrooke Hospital, Huntingdon, UK.|NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK.
authors.forename: Rupert
authors.initials: R
authors.lastname: Bourne
mesh_terms: D000328:Adult; D000368:Aged; D005188:False Negative Reactions; D005260:Female; D005901:Glaucoma / Q000175:diagnosis*; D006801:Humans; D007429:Intraocular Pressure; D008297:Male; D008875:Middle Aged; D009798:Ocular Hypertension / Q000175:diagnosis; D009907:Optometry / Q000592:standards*; D012017:Referral and Consultation / Q000592:standards; D014065:Tonometry, Ocular; D006113:United Kingdom; D015351:Vision Screening / Q000592:standards*; D058609:Visual Field Tests; D014794:Visual Fields
keywords: false negative rate; glaucoma; optometrists with specialist interest in glaucoma; referral refinement; virtual review