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Prospective study of glaucoma referrals across Europe: are we using resources wisely?
  1. Panayiota Founti1,2,
  2. Fotis Topouzis2,
  3. Gábor Holló3,
  4. Barbara Cvenkel4,
  5. Michele Iester5,
  6. Anna-Bettina Haidich6,
  7. Péter Kóthy3,
  8. Anneta Kiana2,
  9. Despoina Kolokotroni2,
  10. Ananth C Viswanathan7
  1. 1Glaucoma Unit, Moorfields Eye Hospital NHS Foundation Trust, London, UK
  2. 2Department of Ophthalmology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
  3. 3Glaucoma and Perimetry Unit, Department of Ophthalmology, Semmelweis University, Budapest, Hungary
  4. 4Department of Ophthalmology, University Medical Centre Ljubljana and Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
  5. 5Anatomical-Clinical Laboratory for Functional Diagnosis and Treatment of Glaucoma and Neuro-ophthalmological Diseases, Eye Clinic, DiNOGMI, University of Genoa, Genoa, Italy
  6. 6Department of Hygiene and Epidemiology, School of Medicine, Aristotle University of Thessaloniki, University Campus Thessaloniki, Thessaloniki, Greece
  7. 7NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, University College London, Institute of Ophthalmology, London, UK
  1. Correspondence to Dr Ananth C Viswanathan, Glaucoma Research Unit, Moorfields Eye Hospital, Glaucoma Research Unit, Moorfields Eye Hospital , City Road, London EC1V 2PD, UK; vis{at}ucl.ac.uk

Abstract

Background To investigate the outcomes of glaucoma referrals across different European countries.

Methods 250 patients newly referred to tertiary referral glaucoma specialist practices in the UK, Hungary, Slovenia, Italy and Greece were prospectively enrolled (50 consecutive patients per centre). Referral accuracy and predictive value of referral criteria for an intervention or further monitoring (positive predictive value) were analysed.

Results Same-day discharges occurred in 43% (95% CI 39% to 75%) (12/28) of optometrist-initiated referrals (UK only), 37% (95% CI 30% to 45%) (59/158) of ophthalmologist-initiated referrals (all centres) and 54% (95% CI 40% to 68%) (26/48) of self-referrals (Hungary, Italy and Greece). The percentages from all referral sources were 46% (95% CI 32% to 60%) in the UK, 56% (95% CI 44% to 70%) in Hungary, 30% (95% CI 17% to 43%) in Slovenia, 22% (95% CI 11% to 34%) in Italy and 60% (95% CI 46% to 74%) in Greece (p<0.001). Overall, the referring criterion was confirmed in 54% (95% CI 45% to 63%) (64/119) for intraocular pressure (IOP) >21 mm Hg, 56% (95% CI 43% to 69%) (33/59) for a suspicious optic disc and 61% (95% CI 45% to 77%) (22/36) for a suspicious visual field, with large between-country differences (p<0.05 for all comparisons). Of all referrals, 32% (95% CI 26% to 37%) were initiated on the basis of IOP >21 mm Hg only. By combining the IOP criterion with any other referring criterion, the positive predictive value increased from 56% (95% CI 45% to 67%) to at least 89% (95% CI 68% to 100%). In the UK, a hypothetical IOP threshold of >26 mm Hg, as a requirement for IOP-only referrals, would reduce IOP-only referrals by 44%, while not missing any definite glaucoma cases.

Conclusion The accuracy of referrals was poor in the UK and the other countries. Requiring a combination of criteria and raising the IOP threshold for IOP-only referrals are needed to cut waste in clinical care.

  • Glaucoma
  • Diagnostic Tests/investigation
  • Epidemiology
  • Intraocular Pressure
  • Optic Nerve

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Footnotes

  • Contributors Substantial contributions to the conception or design of the work: PF, FT, GH, BC, MI, ACV. Acquisition, analysis or interpretation of data for the work: PF, FT, GH, BC, MI, ABH, PK, AK, DK, ACV. Drafting the work: PF. Revising the work critically for important intellectual content: PF, FT, GH, BC, MI, ABH, PK, AK, DK, ACV. Final approval of the version to be published: PF, FT, GH, BC, MI, ABH, PK, AK, DK, ACV. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding All data were collected in the context of locally performed clinical audits.

  • Competing interests All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare no support from any organisation for the submitted work. PF is a contributor to the extant European Glaucoma Society Guidelines, and a contributor and chapter coauthor of the World Glaucoma Association consensus series published in 2016. FT reports grants and personal fees from Alcon, grants and personal fees from Novartis, grants and personal fees from Thea, personal fees from Bayer, personal fees from Allergan, grants and personal fees from Pfizer, personal fees from Santen, outside the submitted work. FT is a member and chapter editor of the extant European Glaucoma Society Guidelines Development Task Force, and a contributor and chapter editor of the extant World Glaucoma Association consensus series published in 2016. FT is also Lead of the Education Theme European Glaucoma Society (2016), Chair of Program Planning Committee of the European Glaucoma Society and Co-Chair of the Education Committee of the European Glaucoma Society (2012), Member of the International Council of Ophthalmology Residency Curriculum Panel (2012), General Secretary of the Greek Glaucoma Society Board (2013), Member of the Committee of the European Board of Ophthalmology (EBO) Glaucoma Subspecialty examination (2015), Section Leader Glaucoma Education Center of the American Academy of Ophthalmology (2016), Co-Chair in the Program Planning Committee of the Glaucoma Research Society (2016) and Associate Editor in the Journal of Glaucoma (2017). GH reports personal fees from Alcon, personal fees from Santen, non-financial support from Optovue, outside the submitted work. GH is a member of the National Liaison Committee and the Delivery of Care Committee of the European Glaucoma Society. BC reports personal fees from Alcon, Allergan and Thea, and non-financial support from Allergan, outside the submitted work. BC is a member and contributor of the extant European Glaucoma Society Guidelines. MI reports personal fees from Thea, grants from Sooft-Glaucoom and personal fees from Saten, outside the submitted work. MI is Member of the EGS Guidelines Development Task Force. ACV reports grants and personal fees from Allergan, personal fees from Alcon, personal fees from Bausch + Lomb and grants from Thea, outside the submitted work. ACV is author of the PROGRESSOR visual field software with royalties paid and is a member and chapter editor of the extant European Glaucoma Society Guidelines Development Task Force.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The full data set is available from the corresponding author at vis@ucl.ac.uk. All data were collected in the context of locally performed clinical audits so consent for data sharing was not obtained, but the presented data are anonymised and risk of identification is low.

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