GP Dr Tim Smith describes his in-house ophthalmology clinic which has reduced waiting times for an opinion and cut inappropriate referrals


   

Ophthalmic care is generally perceived by GPs as a difficult area in which they lack confidence. One survey1 found that 50% of the GPs shared this view, yet consultation rates in general practice for eye problems are not uncommon, ranging from 1.5% to 5.0%.2–4

Long waits for a first appointment at an ophthalmology outpatient clinic, inappropriate referrals to routine and urgent clinics, GPs' lack of confidence in diagnosis and management and expense all add up to a poor deal for patients with eye problems and the NHS.

Research findings (see Box 1, below) suggest that more could be done at the primary care level.

Box 1: Issues around referral for eye problems

Eye clinics are often full of normal people inappropriately referred and the emergency department full of urgent cases often presenting too late because they could not get access to the outpatients.5

Long waits, often well in excess of 6 months, for a first appointment at an ophthalmology outpatient clinic are not unusual. The demand for secondary ophthalmic care is high and likely to increase with demographic change.6, 7

At secondary care level, advances in ophthalmic techniques, the lowest number of ophthalmologists per capita in the European Union8 and rising demand are likely to increase the already long waiting lists.

The long waiting lists are compounded by inappropriate referrals to routine and urgent clinics.2 In one paper, analysis of referral routes and diagnostic accuracy in cases of suspected glaucoma showed that only 32% were confirmed as having glaucoma, fewer than 23% had ocular hypertension, and 29% were normal; additionally, 99% had originated from an optimetric visit.9

Another study found that of 149 cases referred by ophthalmic opticians following ocular screening, 70 (47%) had glaucoma or incomplete features of glaucoma, but 10 patients referred by GPs were normal.10

One study6 proposed that a consultant $phthalmologist seeing approximately 10 patients per week in a primary care centre was cost-effective and would meet the routine needs of seven GPs, but not all urgent problems would be catered for.

Another study11 found that of 1309 patients referred to an outreach clinic provided by a specialist ophthalmic team on a monthly basis to 17 general practices in London, 480 (37%) required onward referral. Also, the annual referral rates to outpatients from the study practices was much lower (3.8/1000 registered patients vs 9.5/10000 for the control practices). However, the cost per patient seen in the outreach clinic (£48.09) was about three times the cost per patient seen in the outpatient clinic (£15.71).

 

Ours is a large general practice, with 12 full-time, two job-sharing and two part-time principals, in the market town of Melton Mowbray. The population of 33 000 has a national average age/sex distribution.12

On request I initiated an 'in-house' eye clinic to offer advice on primary management and appropriateness of secondary referral. Partners were still free to manage eye problems themselves. I have had formal training in ophthalmology with 10 year's experience as a clinical assistant for one session a week in retinopathy and general ophthalmology clinics.

Patients were referred to the in-house clinic by the partners, opticians via the GOS 18 form, the in-house diabetes clinic (for screening), and the local outpatient ophthalmology clinic (for follow-up).

 

An evaluation of the clinic for the period May 1996 to May 1997 was subsequently undertaken.

A total of 439 consecutive patients were seen in the clinic. The data were analysed retrospectively 6 months later. A post-fellowship registrar in ophthalmology helped to analyse the data and, on the basis of the presenting symptoms, clinical findings anm final diagnosis, categorised each referral as normally being suitable for primary care or secondary care.

If the 439 patients referred, 200 (46%) were initiated by GPs, 136 (31%) by opticians, 42 (10%) from outpatients for follow-up or as an 'in-between' visit, 42 (10%) from in-house diabetes clinics and 19 (4%) were miscellaneous.

Table 1 (below) shows the source of referrals and their degree of urgency. It is notable that of those classified urgent, 68 (80%) were from GPs and only 9 (11%) were from opticians. Of the 439 patients seen, 217 (49%) required one visit, 188 (43%) two visits, and 34 (8%) three to nine visits.

Table 1: Source of referral to in-house ophthalmology clinic and degree of urgency
Source Routine referral
No. (%)
Urgent referral
No. (%)
Total
No. (%)
GP 132 (30) 68 (16) 200 (46)
Optician 127 (29) 9 (2) 136 (31)
Outpatient department 42 (10) 0 (0) 42 (10)
In-house diabetes clinic 39 (9) 3 (0.7) 42 (10)
Self 12 (3) 3 (0.7) 15 (3)
Nurse 1 (0.2) 2 (0.5) 3 (0.7)
Missing data 1 (0.2) 0 (0) 1 (0.2)

Total

354 (81) 85 (19) 439 (100)

Waiting times for the in-house clinic were measured: 65% of the routine referrals were seen within 2 weeks and 85% within 28 days. Of the urgent referrals, 77% were seen within 24 hours and 97% within 7 days.

Onward referrals from the in-house clinic included 17 (25%) of the GP urgent referrals and 28 (22%) of the routine referrals. Onward referral of patients from the opticians included 58 (46%) of their routine referrals. Six of their nine urgent referrals were referred onwards.

Presenting symptoms were classified as shown in Table 2 (below). The range of patients referred by GPs was fairly wide compared with those referred by opticians, who tended to refer patients with suspected glaucoma, query cataract and maculopathy. The 'clinic' referrals were mainly from the practice diabetes clinic. The source of acute eye problems was very much biased towards GPs.

Table 2: Source of referral to the in-house ophthalmology clinic by diagnostic category

Reason for referral No. (%) Optician
No. (%)
GP
No. (%)
Clinic
No. (%)
OPD
No. (%)
Eyelid 32 (7) 3 (0.7) 29 (7) 0 (0) 0 (0)
Foreign body/trauma 9 (2) 0 (0) 7 (2) 0 (0) 0 (0)
Corneal 14 (3) 10 (2) 3 (0.7) 0 (0) 1 (0.2)
Watering/discharge 18 (4) 0 (0) 18 (4) 0 (0) 0 (0)
Painful eye 33 (8) 2 (0.5) 25 (6) 0 (0) 2 (0.5)
Red eye 25 (6) 1 (0.2) 23 (5) 0 (0) 0 (0)
Visual loss/disturbance:
Acute
Chronic

42 (10)
51 (12)

6 (1)
20 (5)


32 (7)
26 (6)


0 (0)
1 (0.2)

0 (0)
1 (0.2)
Query cataract 37 (8) 19 (4) 11 (3) 0 (0) 1 (0.2)
Suspected glaucoma 66 (15) 43 (10) 4 (0.9) 9 (2) 9 (2)
Query retinopathy 51 (12) 0 (0) 3 (0.7) 27 (6) 4 (0.9)
Query maculopathy 24 (5) 19 (4) 3 (0.7) 4 (0.9) 2 (0.5)
Other 27 (6) 11 (3) 15 (3) 0 (0) 17 (4)
Data missing 9 (2) 2 (0.5) 1 (0.2) 1 (0.2) 5 (1)

Total

439 (100) 136 (31) 200 (46) 42 (10) 42 (10)

Table 3 (below) shows the final diagnosis at 6 months after the end of the study period. When the ophthalmologist assessed the referral pattern, he classified 316 (72%) as possibly requiring secondary care, whereas in this clinic only 133 (30%) were referred on during the study period.

Of the 439 patients, 56 (13%) were considered normal. Most of these were suspected glaucoma; 10 required onward referral for confirmation of normality, with the remainder continuing to be followed up.

Table 3: Primary diagnoses and onward referral patterns
Primary diagnosis No. (%) Routine referral
No. (%)
Urgent referral
No. (%)
Not referred
No. (%)
Eyelid problems 70 (16) 10 (2) 1 (0.2) 59 (13)
Normal 56 (13) 9 (2) 1 (0.2) 46 (11)
Age-related macular degeneration 41 (9) 9 (2) 6 (1) 26 (6)
Suspected glaucoma 37 (8) 10 (2) 0 (0) 27 (6)
Lens opacities 35 (8) 23 (5) 0 (0) 12 (3)
Neuro-ophthalmic problems 27 (6) 5 (1) 3 (0.7) 19 (4)
Corneal disorders 29 (7) 5 (1) 3 (0.7) 21 (5)
Diabetic retinopathy/maculopathy 24 (6) 8 (2) 1 (0.2) 15 (3)
Open-angle glaucoma 23 (5) 8 (2) 1 (0.2) 14 (3)
Acute anterior uveitis/iritis 21 (5) 3 (0.7) 3 (0.7) 15 (3)
Conjunctival disorders 19 (4) 3 (0.7) 0 (0) 16 (4)
Retinal/macular lesions 14 (3) 3 (0.7) 5 (1) 6 (2)
Retinal vascular disorders 14 (3) 4 (0.9) 3 (0.7) 7 (2)
Posterior vitreous detachment 13 (3.0) 2 (0.5) 0 (0) 11 (3)
Miscellaneous problems 14 (3) 2 (0.5) 0 (0) 12 (3)
Missing data 2 (0.5) 1 (0.2) 1 (0.2) 0 (0)
Total 439 (100) 105 (24) 28 (6) 306 (70)
Eyelid problems Blepharitis 15, dry eye 15, blocked tear duct 14, chalazion 10, stye 5, cysts 4, ptosis 3, trichiasis 2, ectropion 1, dacryocystitis 1
Lens opacities Cataract 31, posterior capsular thickening 4
Neuro-ophthalmic disorders Amblyopia 10, migraine 8, optic neuritis 3, anterior ischaemic neuropathy 3, Bell's palsy 1, swollen optic disc 1, disc haemorrhage 1
Corneal disorders Foreign body 7, dystrophy 4, herpes simplex 4, ulcer 4, abrasion 3, herpes zoster 2, other keratitis 5
Diabetic retinopathy/maculopathy Maculopathy 14, background 10
Uveitis/iritis Acute anterior 10, postoperative 7, Fuchs 2, herpes simplex 1, chronic 1
Conjunctival/scleral disorders Allergic 5, viral 3, bacterial 1, chlamydial 2, haemorrhage 1, episcleritis 4, pterygium 2, other 1
Retinal/macula lesions Vitreous haemorrhage 4, macula hole 2, retinal fold 1, angioid streak 1, telangiectasia 1, detachment 1, naevus 1, macula cyst 1, retinitis pigmentosa 1, cellophane maculopathy 1
Retinal vascular disorders Central vein occlusion 8, branch vein occlusion 5, retinal haemorrhage 1

Miscellaneous problems

Myopia 3, side-effects of drops 3, squint 2, physiological cupping 2, eye trauma 2, hypotony 1, removal of sutures 1

 

Table 4 (below) shows an analysis of the costs of the in-house clinic per patient, given various referral options. In calculating the outpatient costs, one follow-up visit per patient has been assumed, as exact data are not available.

Table 4: Comparison of costs
Estimated annual running costs of the in-house clinic £
Capital cost of equipment assuming depreciation over 10 years: 1453.00
Cost of reagents for 439 initial and 242 follow-up examinations: 710.00
  2163.00

Model 1: Estimated cost of in-house clinic:

Cost of referring to the outpatients 133 patients at £72.00 per first visit and £33.00 per follow-up assuming one follow-up per year:
13965.00
Cost of referrals for visual fields (£31.00 x 42):
1302.00
Annual running costs of in-house clinic:

 

2163.00

Total:
17430.00
Therefore cost per patient per year (£17430.00/439):
39.70

Model 2: Estimated cost if all patients were referred:

Cost of referring to the outpatients 439 patients at £72.00 per first visit and £33.00 per follow-up assuming one follow-up per year: 46095.00
Therefore cost per patient per year (£46095.00/439): 105.00
Costs of clinic including payment from health authority
Payment by health authority for 439 patients at £35.54 for a first visit and £23.02 for a follow-up visit to the in-house clinic: 21729.90
Total cost of clinic (£17430.00 + £21729.90): 39159.90

Therefore cost per patient per year (£39159.90/439):

89.20

Fourteen patients had a discrepancy of diagnosis at 6 months, but none of these was of major importance.

In this study, an in-house clinic based on a partner with subspecialty experience in ophthalmology was the suggested solution. It was hoped that this would provide a better service, but its cost-effectiveness was also considered important.

The referral patterns in our study (46% by GPs and 31% by opticians) were comparable to those found in other studies of referral patterns (e.g. 49% and 39% respectively10).

The majority of urgent referrals to our in-house clinic came from GPs, which suggests that patients with acute eye symptoms present to their GP rather than their optician.

In Harrison et al's study,10 visual disturbance accounted for 31% of referrals, and in our study it accounted for 28% of referrals by GPs and opticians.

The overall onward referral rate in this study was 30% (24% routinely and 6% urgently). This is comparable to that found in the outreach clinic study (37%),11 but this included 4% for minor surgery, which we do in house.

In the in-house clinic, 'normal' accounted for 13% of final diagnoses, as in another community study.6

The remainder of final diagnoses show a significant range of eye problems. Of the common significant eye diagnoses, open-angle glaucoma was diagnosed in 5%, and cataract significant enough to be referred in 5%, which is similar to that found in other community studies.2, 3

The cost analysis suggests that, given the payment by the health authority, the cost to the NHS of providing the in-house clinic is little different from the costs of an outpatient clinic.

Benefits to the patient are a much shorter waiting time for an opinion and a shorter distance to travel, which is a significant consideration for older patients.

For urgent problems the benefit to the patient may be even greater. These cases were mostly seen the same day and could often be assessed as urgent and requiring action straightaway, fairly urgent and fast tracking into an outpatient clinic, or normal/non-urgent.

We conclude that an effective 'filter' can be provided at the primary care level by a non-specialist and that this care is safe, effective, cost-effective and beneficial to both primary and secondary care.

 

  1. Featherstone PI, James C, Hall MS, Williams A. General practitioners' confidence in diagnosing and managing eye conditions: a survey in south Devon. Br J Gen Pract 1992; 42: 21-4.
  2. Sheldrick JH, Wilson AD, Vernon SA, Sheldrick CM. Management of ophthalmic disease in general practice. Br J Gen Pract 1993; 43: 459-62.
  3. Dart JKG. Eye disease at a community health centre. Br Med J 1986: 293: 1477-80.
  4. McDonnell PJ. How do general practitioners manage eye disease in the community? Br J Ophthalmol 1988: 72: 733-6.
  5. Griffiths PG. A surfeit of screening? Br Med J 1997: 315: 318.
  6. Sheldrick JH, Vernon SA, Wilson A, Read SJ. Demand incidence and episode rates of ophthalmic disease in a defined urban population. Br Med J 1992; 305: 933-6.
  7. Hillman J. Audit of elderly people's eye problems and non-attendance at hospital eye service. Br Med J 1994; 308: 953.
  8. Royal College of Ophthalmologists' data, 1996.
  9. Sheldrick JH, Ng C, Austin DJ, Rosenthal AR. An analysis of referral routes and diagnostic accuracy in cases of suspected glaucoma. Ophthalmic Epidemiol 1994; 1(1): 31-9.
  10. Harrison RJ, Wild JM, Hobley AJ. Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease. Br Med J 1995; 297: 1162-7.
  11. Gillam SJ, Ball M, Prasad M, Dunne H, Cohen S, Vafidis G. Investigation of benefits and costs of an ophthalmic outreach clinic in general practice. Br J Gen Pract 1995; 45: 649-52.
  12. Jagger C, Clarke M, Clarke S. Getting older – feeling younger. The changing health profile of the elderly. Int J Epidemiol 1991; 20: 234-8.

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Guidelines in Practice, December 2001, Volume 4(12)
© 2001 MGP Ltd
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