C L I N I C A L
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E X P E R I M E N T A L
OPTOMETRY RESEARCH PAPER
Australian optometric and ophthalmologic referral pathways for people with age-related macular degeneration, diabetic retinopathy and glaucoma Clin Exp Optom 2014; 97: 248–255 Khalid F Jamous*§ BSc(Optom) MOptom Isabelle Jalbert* OD MPH PhD Michael Kalloniatis*† MSc(Optom) PhD Mei Ying Boon* BOptom(Hons) PhD * School of Optometry and Vision Science and † Centre for Eye Health, University of New South Wales, Kensington, Australia § Department of Ophthalmology, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia E-mail: [email protected]
Submitted: 13 March 2013 Revised: 6 September 2013 Accepted for publication: 14 September 2013
DOI:10.1111/cxo.12119 Background: This study investigated the referral pathways offered to patients with agerelated macular degeneration (AMD), diabetic retinopathy (DR) or glaucoma (GL) by ophthalmologists and optometrists. Methods: Australian ophthalmologists and optometrists were surveyed regarding referral decisions to other eye-care specialists (inter- or intra-professional), general medical practitioners (GPs), low vision rehabilitation (LVR) and support services. Thematic analysis and concept mapping were applied to highlight current and ideal referral pathways. Results: The survey was completed by 155 optometrists and 50 ophthalmologists and deemed representative of their respective professions in Australia. Not surprisingly, the vast majority of the participating optometrists (97 to 99 per cent) referred to ophthalmologists regardless of the underlying condition. Clear differences (Chi-square: p < 0.05) were observed in the referral patterns of optometrists and ophthalmologists to GPs and support services. General medical practitioner services were almost exclusively used for patients with DR, while AMD triggered a significantly higher referral rate to low vision rehabilitation and support services than the other two disorders. Conclusion: While ophthalmologists predominantly referred patients with AMD, DR or GL to low vision rehabilitation services, optometrists’ referrals were highly skewed toward ophthalmology. Referrals to other supporting services by the two groups were not greatly used. The perceived referral pathways by the two eye-care professionals suggested a unidirectional route, potentially highlighting the need for a more collaborative approach that facilitates optimal use of eye health care and allied services.
Key words: age-related macular degeneration, diabetic retinopathy, glaucoma, low vision rehabilitation, ophthalmologist, optometrist, referral pathways
High-quality eye care involves optometrists and ophthalmologists working together with general practitioners (GPs), orthoptists and allied health care workers or professionals working for organisations providing low vision rehabilitation (LVR) and support services.1–3 In Australia, this part of the health-care system is under substantial pressure due to the growing number of people with chronic eye disease, such as age-related macular degeneration (AMD), diabetic retinopathy (DR) and glaucoma (GL).4–6 In addition, the ‘fragmented’ nature of the health-care system results in people with complex and chronic conditions frequently navigating through many potential routes to care on their own and reducing the efficiency of health-care delivery.7 Comanagement between different eye-care Clinical and Experimental Optometry 97.3 May 2014
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professionals was suggested as key to more efficient delivery of ocular health care.8 Suitable and timely delivery of eye health care can reduce visual loss and health-care costs, as preventative eye care is significantly less costly than subsequent disability.9–11 Optometrists encompass a wide range of care, including performing vision and eye assessments, screening for, monitoring and treating eye disease, prescribing and supplying spectacles, contact lenses, low vision aids and therapeutic drugs.12 They also initiate referrals for specialty care, rehabilitative and ancillary services in relation to health and function of the visual system,13–15 making them essential in the development of co-management plans. Between optometrists and ophthalmologists in Australia, co-management plans have been proposed
based on their respective training and areas of expertise. For example, proposed ‘shared care’ between local optometrists and hospital-based ophthalmologists can reduce patient waiting time for review and foster working partnerships to provide localised care for the benefit of patients.16 Because of the systemic nature of some eye diseases, such as DR, GPs may also need to be included in patient management for further medical attention, such as diabetes control. In Australia, GPs can also facilitate referral to psychological counselling services and falls prevention clinics, so optometrists may wish to refer to GPs, particularly as visual impairment is associated with depression and increased falls risk.17–19 Australian eye-care professionals are well placed to participate in a joint effort between © 2013 The Authors
Clinical and Experimental Optometry © 2013 Optometrists Association Australia
Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
ophthalmologists and optometrists.20,21 Referrals should facilitate easy access to different services and enhance early detection and management of ocular disease. Three prevalent eye diseases, AMD, DR and GL were used to investigate these points. Our study is the first attempt to sample attitudes of the two eye-care professional groups to determine whether the traditional referral processes for people with AMD, DR and GL are generally consistent and interactive. It should benefit the patient by highlighting early intervention, avoiding duplication of services and instituting cost-effective care. It should benefit the practitioners in building confidence in the referral process and ensuring that no patient ‘falls through the cracks’. It should benefit the health-care system in minimising costs and expensive hospital or ophthalmology time without sacrificing quality of care.
METHODS
Survey design A two-part questionnaire consisting of openended and closed questions was developed to survey Australian optometrists and ophthalmologists (Appendix 1). Section 1 explored the demographic characteristics of clinicians, including age, gender, mode and location of practice and whether they provided low vision services in their practice or consider themselves as low vision service providers. Section 2 determined the clinicians’ referral patterns and referral criteria to other eye-care and allied services for people with AMD, DR or GL. To determine the referral pathway to low vision rehabilitation services, a list of the major organisations in Australia (for example, Vision Australia, Guide Dogs Australia et cetera) was included. Similarly, to determine the referral pathway to support services, a list was included of the major support organisations in Australia that are known to provide information and advice in relation to specific conditions (for example, Diabetes Australia, Glaucoma Australia and Macular Degeneration Foundation).
email list of Optometrists Association Australia (OAA). A total of 2,092 optometrists were invited electronically to participate in the survey through a link to the online questionnaire. Ophthalmologists were randomly selected from the Yellow Pages business telephone directory of Australia and public directories of the major public hospitals in Australia. A letter including a hard copy of the questionnaire, reply paid envelope and an invitation letter with the option to complete the questionnaire online was posted to 353 ophthalmologists. All ophthalmologists who participated in this study replied by hard copy.
Analysis Data were analysed using a mixed-methods strategy.22 Quantitative data obtained from closed-ended data was analysed using SPSS 20 software (Version 20; SPSS Inc, Chicago, IL, USA) to conduct descriptive statistics. Chi-square analysis was used to determine significant differences among referrals to different services for AMD, DR or GL, with p-values of less than 0.05 being considered significant. Qualitative data were analysed for common themes reported by participants. For example, answers reported by optometrists that had a common idea such as ‘visual field check up’, ‘assessment of visual field’ and ‘field testing’ were coded under one theme—‘visual field testing’. Coded data were then entered into a database as factors and frequencies of occurrence analysed.23 The perceptions of the ideal referral pathways for the three ocular conditions were analysed with concept mapping. The relationships between different concepts (that is, GPs, optometrists, ophthalmologists, low vision rehabilitation services) were demonstrated using a diagram, where concepts were enclosed in circles or boxes and connected with arrows. This method is a valid scientific tool of analysis in educational research for visualising ideas or processes.24,25
RESULTS
Sampling strategy
Participant characteristics
Hard copy and online versions of the survey were approved by the Human Research Ethics Advisory (HREA) panel at the University of New South Wales. Optometrists were recruited from the 2009 members’ directory
Of 2,042 invitations confirmed to have been delivered to optometrists, 155 responses were received, resulting in a response rate of eight per cent. For ophthalmologists, 344 were successfully delivered and 50 responses
© 2013 The Authors Clinical and Experimental Optometry © 2013 Optometrists Association Australia
were returned producing a response rate of 15 per cent. The mean age and gender of participating optometrists and ophthalmologists matched national averages.26 Although ophthalmologists who responded were primarily from New South Wales, there were no significant differences between our cohorts and the national averages. The responding ophthalmologists were mostly classified as general ophthalmologists or those with multiple subspecialties (60 per cent), followed by retinal specialists (12 per cent) and anterior segment specialists (eight per cent). None of the above characteristics had a significant influence on the survey outcome (Table 1). Although the overall characteristics of the replying cohorts were comparable to national averages, the lower than expected response rates may have resulted in an incomplete assessment regarding the nation as a whole. As data were generally consistent, it was considered an important representation of the investigated attitudes among eye-care specialists. We also assessed the patient encounter rates for participating optometrists and ophthalmologists for each condition. The majority of optometrists see five to nine AMD patients per month and one to four patients with DR or GL (Table 2A). Comparable distributions were obtained for ophthalmologists (p = 0.91, 0.99 and 0.99 for AMD, DR and GL, respectively) when assessed on an encounter per day rate (Table 2B).
Referral patterns for individuals with AMD, DR or GL Regardless of the underlying condition, optometrists referred the majority of patients to ophthalmologists (Chi-square: p = 0.14) but rarely to another optometrist (Chi-square: p = 0.08; Figure 1A). Referrals to other providers were significantly dependent on the disorder (Chi-square: p < 0.05). GPs were consulted for only diabetic patients, while AMD patients mostly referred to low vision rehabilitation and support services. Ophthalmologists’ referral behaviour was not significantly different from that of optometrists (Figure 1B) with the exception of referrals to other ophthalmologists (2-tailed, paired Student’s t-test, p = 0.002). Overall, only the referral pattern to optometrists differed significantly between the two eye-care professions (Chi-square: p < 0.05). With regard to referral to low vision rehabilitation services, the proportion of ophthalmologists referring patients with AMD to low vision rehabilitation services was Clinical and Experimental Optometry 97.3 May 2014
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Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
Demographic information
Optometrists National average
Total number of practitioners Age (years)
Ophthalmologists Survey
4,414
155
National average 887
Survey 50
Average
40.0
44.4
51.6
49.6
Male
n.a.*
47.0
n.a.*
49.6
Female
n.a.*
41.1
n.a.*
47.0
Male
55.8
55.5
84.3
86.0
Female
44.2
44.5
15.7
14.0
Location of practice (%)
Metropolitan
78.8
66.5
84.4
96.0
Rural/remote
21.2
33.5
15.6
4.0
State/Territory of location (%)
New South Wales
37.7
38.0
36.4
52.0
Victoria
22.1
26.5
25.9
24.0
Queensland
20.0
19.3
17.0
8.0
Gender (%)
Western Australia
8.2
6.5
9.2
4.0
South Australia
6.1
5.2
7.3
10.0
Tasmania
2.7
1.9
2.2
0.0
Australian Capital Territory
1.9
2.6
0.3
0.0
Northern Territory
1.1
0.0
n.a.*
2.0
* n.a. = No data available
Table 1. Demographic characteristics of participating optometrists and ophthalmologists compared to national averages26
A
B
Patients seen per month
AMD
DR
GL
Rarely
9%
19%
6%
1–4
19%
46%
48%
5–9
31%
22%
30%
10–14
25%
9%
11%
≥ 15
16%
4%
5%
Patients seen per day
AMD
DR
GL
Rarely
12%
20%
10%
1–4
52%
58.7%
33.3%
5–9
23.2%
18.5%
37.9%
6%
3.6%
9.2%
6.8%
1.2%
9.6%
10–14 ≥ 15
Table 2. For each of the three investigated disorders (A) optometrists and (B) ophthalmologists indicated a range most closely representing the numbers of patients seen. Percentages of practitioners are shown for age-related macular degeneration (AMD), diabetic retinopathy (DR) and glaucoma (GL).
significantly greater than the proportion referring patients with DR or GL (Chisquare: p < 0.05). Vision Australia was the most commonly used organisation by ophthalmologists (80/58/60 per cent for AMD/ Clinical and Experimental Optometry 97.3 May 2014
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DR/GL, respectively) and optometrists (67/ 47/44 per cent for AMD/DR/GL, respectively), followed by disease-specific groups— Macular Degeneration Foundation for AMD (14 per cent of ophthalmologists, 37 per
cent of optometrists), Diabetes Australia for DR (8 per cent of ophthalmologists, 28 per cent of optometrists) and Glaucoma Australia for GL (26 per cent of ophthalmologists, 32 per cent of optometrists). Guide Dogs NSW/ACT was referred to by six to 14 per cent of the practitioners. Ophthalmologists also used the Royal Society for the Blind (10 to 14 per cent) while optometrists favoured the Association for the Blind (8 to 12 per cent). A number of other organisations were used at much lower levels.
Referral criteria for individuals with AMD, DR or GL Optometrists’ referral criteria to ocular health care and supporting services for the three conditions were analysed thematically and for frequency of occurrence (Table 3). Optometrists’ referral criteria to ophthalmology were reported by many respondents for all three conditions (AMD = 134; DR = 135; GL = 130) and mainly based on further investigation or confirmation of a diagnosis, medical or surgical interventions and treatment. Up to 110 responses indicated referring to ophthalmologists for reduced or altered vision or visual acuity. Few optometrists reported their criteria for © 2013 The Authors
Clinical and Experimental Optometry © 2013 Optometrists Association Australia
Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
A
AMD
100%
97%
DR
GL 99%
99%
*
88%
*
80%
67% 57%
*
52%
49%
60%
40%
20%
29%
27%
8% 4%
5% 4%
4%
0%
B
AMD
DR
*
GL
94%
100%
72%
68%
80%
60% 28%
40%
28%
26%
20%
16% 14% 20%
8% 8%
10% 4%
2% 0%
Ophthalmologists
Optometrists
GPs
LVR services
Support services
Figure 1. Distribution of referral decisions The proportions of (A) optometrists (n = 155) and (B) ophthalmologists (n = 50) who refer patients with age-related macular degeneration (AMD), diabetic retinopathy (DR) or glaucoma (GL) to other health-care and allied services. (CI = 95%, *p < 0.05)
referring to the other services except for DR, where 90 respondents reported referral criteria to GPs for control of diabetes. Agreement between optometrists and ophthalmologists was observed regarding referral criteria for low vision rehabilitation and support services, including areas targeting the effect of visual impairment (responses in bold and italics indicate criteria that were considered important by ophthalmologists). In particular, optometrists and ophthalmologists particularly focused on the use of adjunct services based on the remaining visual function as a consequence of any of the three investigated disorders (Table 4).
Ideal service pathways for patients with AMD, DR and GL Fifty-nine per cent (n = 91) of optometrists described an ideal referral pathway for patients with AMD, DR and GL, while only 10 per cent of the ophthalmologists reported
an opinion on this question. Responses were categorised as ‘unidirectional’, if the individual service provider appeared in a distinct order and patients were channelled from one to the next. ‘Multidirectional’ pathways referred to those scenarios where several other services were activated by the same provider. Lastly, patients that were comanaged and thus repeatedly transferred between services, were labelled as ‘circular’. There was complete agreement between optometrists and ophthalmologists that optometrists or GPs should initiate these pathways across the investigated disorders. GPs were preferred as initiators in 24.0 per cent of scenarios and consequently triggered eye-specific care through referral to an optometrist. A particular deviation was observed with regard to DR (5.0 per cent of the above 24.0 per cent), for which multidirectional pathways included consultations with podiatrists, endocrinologists and nutritionists at the same time. Of the remainder,
© 2013 The Authors Clinical and Experimental Optometry © 2013 Optometrists Association Australia
optometrists and GPs were presumed equally important as primary care providers in 2.7 per cent, while the balance was attributed to optometrists as suggested first responder to problems related to AMD, DR and GL. The majority (88.6 per cent) of reported ideal pathways included ophthalmologists subsequent to the optometric assessment. This interaction was described as unidirectional by 64.6 per cent, while 24.0 per cent envisioned optometrists remaining the main carers through back-referral by the ophthalmologists. Alternatively, there was a suggestion that optometrists were to refer to low vision rehabilitation services only (8.7 per cent) or they are seen as equivalent with ophthalmologists, creating a circular referral pathway also including low vision rehabilitation services (2.7 per cent; AMD only). Finally, all proposed patient management plans resulted in referrals to either low vision rehabilitation services only (62.4 per cent) or a combination of low vision rehabilitation and support services (37.6 per cent). This step was supposed to be initiated by optometrists in 45.6 per cent of ideal pathway solutions, by ophthalmologists in 51.7 per cent or by either for the remainder. It should be noted that 80 per cent of the ophthalmologists suggested this step to be initiated by them rather than an optometrist. Interestingly, low vision rehabilitation and support services were reported as the final destination in a linear manner in 60.4 per cent of scenarios, while only 39.6 per cent integrated them as part of a multidirectional (36.9 per cent) or circular (2.7 per cent) step, while consulting with other specialists at the same time. DISCUSSION Previous studies indicate that more than 90 per cent of referrals initiated by optometrists were to ophthalmological services for the management of AMD, DR or GL.27–29 This is likely to be influenced by the nature of these conditions, significantly affecting a patient’s vision and primarily requiring management and treatment by an ophthalmologist.30–32 Considering the shortage of practising ophthalmologists in Australia, high referral rates to ophthalmologists is likely to compound the current shortfalls in the eye-care system.33 Rowe, MacLean and Shekelle34 indicated that many chronic cases may not require ophthalmological management or Clinical and Experimental Optometry 97.3 May 2014
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Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
To optometrists Age-realed macular degeneration (AMD) (n = 10)
Diabetic retinopathy (n = 9)
Glaucoma (n = 6)
Further eye testing (optical coherence tomography (OCT)
Further eye testing (OCT or retinal photography) (7)
Visual field testing (5)
or retinal photography) (8)
Dilated fundoscopy (5)
Low vision aids (3)
Dilated fundoscopy (5)
Monitoring of diabetic retinopathy (2)
Monitoring of glaucoma (1)
Low vision aids (4) To ophthalmologists AMD (n = 134) Reduction or change in vision or visual acuity (110)
Diabetic retinopathy (n = 135)
Glaucoma (n = 130)
Clinical sign of fundus changes (88)
Abnormal status of optic disc (98)
Clinical sign of fundus changes (76)
Proliferative diabetic retinopathy (61)
Abnormal (IOP) (94)
Diagnosis or suspicion of wet AMD (57)
Moderate to severe non-proliferative diabetic retinopathy (33)
Visual field defects (67)
Diagnosis and treatment (44)
Diagnosis and treatment
Diagnosis and treatment (44)
Further testing (OCT or angiogram) (37)
Further testing (OCT or angiogram) (31)
Further testing (OCT or pachymetry) (14)
NHMRC guidelines on DR (11)
The NHMRC guidelines on glaucoma (7) A family history of glaucoma (2)
To general medical practitioners AMD (n = 5)
Diabetic retinopathy (n = 90)
Glaucoma (n = 5)
Provision of dietary supplements (3)
For diabetes control (79)
General health issues (4)
General health issues (3)
General health issues (17)
For medical report (1)
Arranging for further services, such as community support services (1)
Arranging for further services, such as counselling (6)
To support services (n = 68) AMD (n = 68)
Diabetic retinopathy (n = 46)
Glaucoma (n = 36)
Information & support (58)
Information & support (37)
Information & support (31)
Patient’s request (25)
Patient’s request (14)
Patient’s request (10)
To low vision rehabilitation services AMD (n = 124)
Diabetic retinopathy (n = 74)
Glaucoma (n = 68)
Visual acuity problems (86)
Visual acuity problems (40)
Vision problems (46)
Vision problems (36)
Vision problems (22)
Visual acuity problems (27)
Low vision aids (31)
Low vision aids (19)
Orientation and mobility (22)
Difficulties to perform activities of daily living (26)
Difficulties to perform activities of daily living (16)
Low vision aids (11)
Orientation and mobility (11)
Orientation and mobility (7)
Need for help in home (3)
Occupational therapy (7)
Occupational therapy (2)
Need for help with social issues (2)
Need for counselling (7) Patient or family’s request (6)
Table 3. Referral criteria Criteria reported by optometrists influencing decisions for referrals to health and eye-care providers, indicating the total of responses received in brackets (multiple responses were allowed). Responses in italics indicate criteria that were considered important by ophthalmologists. n = number of participants replying to the respective category (please note that this does not correspond to the total number of participants responding to the survey).
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© 2013 The Authors Clinical and Experimental Optometry © 2013 Optometrists Association Australia
Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
Vision and visual acuity problems AMD
Diabetic retinopathy
Glaucoma
Visual acuity (VA) (86)
VA (40)
VA (27)
VA worse than 6/12 (85)
VA worse than 6/12 (35)
VA worse than 6/12 (24)
Near VA less than N5 (1)
Poor VA (5)
VA too poor to correct with regular glasses (3)
Vision problems (36)
Vision problems (22)
Vision problems (46)
Significant visual loss affecting independence and functional vision (32)
Significant visual loss affecting independence and functional vision (18)
Significant visual field loss (less than 20 degree field of view remaining) (n = 42)
Poor prognosis of vision recovery (3)
Inability of patients to cope with regular eyeglasses alone (4)
Visual difficulties beyond the scope of spectacles and simple magnifiers (2)
Reduced contrast sensitivity (1)
Peripheral field loss affecting mobility (1) Field loss crossing horizontal meridian (i.e. any inferior field loss) (1)
Table 4. Particular concerns regarding vision and visual acuity problems The reported visual parameters used as referral criteria to low vision rehabilitation services for patients with age-related macular degeneration (AMD), diabetic retinopathy or glaucoma.
treatment if a condition is controlled. Optometrists could manage these controlled conditions, thereby reducing the patient load on ophthalmological services.12 The proportions of optometrists referring patients to GPs were very low except for patients with DR (67 per cent). This is likely to be due to optimal treatment of DR requiring active management of systemic diabetes and cardiovascular risk factors.35 GPs also provide access to adjunct services, such as counselling or falls prevention programs, which may benefit vision-impaired patients and thus, low referral rates for AMD and GL to GPs suggest that these patients may be missing out on these services.36 Even though we did not define levels of visual loss in our study, referrals to low vision rehabilitation and support services were primarily initiated for people with AMD (Figure 1). This may be a consequence of the higher number of patients with AMD compared to DR and GL seen by eye-care specialists (Table 2), as well as the potential for rapid deterioration of vision with AMD progression.37–40 AMD is also associated with significant functional loss requiring multidisciplinary evaluation, especially among elderly patients.41 Education and awareness campaigns generated
by the Macular Degeneration Foundation in Australia may also have a significant contribution.42 Visual field was a major criterion in the involvement of low vision rehabilitation (Table 4), as were visual fields in concordance with recommendations that difficulties with mobility arise, if the visual field is less than 70° circular diameter and rehabilitation should be initiated once it is constricted to 15°.43 This criterion may not be sufficient, as patients with GL may encounter difficulties with mobility even though their visual fields and visual acuities are relatively intact.44 Similarly, a study suggested that low vision rehabilitation may be an effective strategy to help people with DR to cope with difficulties in daily living activities.45 This suggests that these services are underused to improve quality of life for people with DR and GL.
Envisioned referral pathway Two-thirds of the proposed referral pathways did not distinguish between disorders and centred on the unidirectional optometrist to ophthalmologist relationship. GPs were included as primary care specialists in 25 per cent of the scenarios but not taken
© 2013 The Authors Clinical and Experimental Optometry © 2013 Optometrists Association Australia
into consideration as referrers to low vision rehabilitation or support services. If they were, this would open additional resources to the patient.46 Additional specialists such as endocrinologists, podiatrists and nutritionists were considered only in conjunction with a DR-specific pathway.47,48 Although that can be attributed to the systemic nature of the disease, a lack of collaboration between specialists will result in isolated symptomatic treatments. Mapped pathways reflected unidirectional thinking, suggesting there is not much space for comparing notes and feedbacks. Most noticeably, regardless of the initiating party, allied health services, established to support core professionals, were considered as an end point rather than an integrated step during diagnosis and treatment of disorders of vision. Together with the main focus of referral criteria on visual acuity and function, these services are likely to be involved late in the patient’s disease progression and therefore, may not provide full benefits to the patients.
CONCLUSION Our study indicated that there is recognition of all the major players contributing to the referral process for the three investigated conditions. Referrals by optometrists were highly skewed toward ophthalmologists, suggesting that other eye-care players, such as GPs, other optometrists, low vision rehabilitation and support services, may be underused. In addition, the perceived referral pathways were mostly unidirectional, highlighting the need for a more collaborative approach that facilitates optimal use of eye healthcare and allied service for the management and treatment of age-related macular degeneration, diabetic retinopathy and glaucoma. ACKNOWLEDGEMENTS
Khalid F Jamous was supported by a scholarship from King Saud University at Riyadh, Saudi Arabia. This paper was presented in part at the American Academy of Optometry Annual meeting in Boston, USA in October 2011. We thank Drs Andrew Whatham, Barbara Zangerl and Lisa Nivison-Smith for their valuable contribution in reviewing the manuscript. REFERENCES 1. Ratnarajan G, Newsom W, French K, Kean J, Chang L, Parker M, Garway-Heath DF et al. The impact of
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16. O’Connor PM, Harper CA, Brunton CL, Clews SJ, Haymes SA, Keeffe JE. Shared care for chronic eye diseases: perspectives of ophthalmologists, optometrists and patients. Med J Aust 2012; 196: 646–650. 17. Department of Health and Ageing. National Framework for Action to promote eye health and prevent avoidable blindness and vision loss. 2005. Available from: http://www.health.gov.au/ internet/main/publishing.nsf/Content/ EA9F52585145B878CA2572DD000C19FF/$File/ ehframwork.pdf. [Accessed 14 July 2012]. 18. Lord SR, Tiedemann A, Chapman K, Munro B, Murray SM, Gerontology M, Ther GR et al. The effect of an individualized fall prevention program on fall risk and falls in older people: a randomized, controlled trial. J Am Geriatr Soc 2005; 53: 1296– 1304. 19. Black AA, Wood JM, Lovie-Kitchin JE. Inferior visual field reductions are associated with poorer functional status among older adults with glaucoma. Ophthalmic Physiol Opt 2011; 31: 283–291. 20. Martin DP, Diehr P, Price KF, Richardson WC. Effect of a gatekeeper plan on health services use and charges: a randomized trial. Am J Public Health 1989; 79: 1628–1632. 21. Kim JJ, Kim CM. Models for joint ophthalmology– optometry patient management. Curr Opin Ophthalmol 2011; 22: 256–260. 22. Johnson RB, Onwuegbuzie AJ, Turner LA. Toward a definition of mixed methods research. J Mixed Methods Res 2007; 1: 112–133. 23. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook: Thousand Oaks, California: Sage Publications, 1994. 24. Novak JD. Concept mapping: A useful tool for science education. J Res Sci Teach 1990; 27: 937–949. 25. Davies M. Concept mapping, mind mapping and argument mapping: what are the differences and do they matter? Higher Educ 2011; 62: 279–301. 26. AIHW. Australian Institute of Health and Welfare. Eye health labour force in Australia. Cat. no. PHE 116. Canberra: AIHW, 2009. 27. Wood J, Jeffery M, Tame S. Glaucoma screening by optometrists. Clin Exp Optom 1993; 76: 199–207. 28. 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: 31–39. 29. Pooley JE, Frost EC. Optometrists’ referrals to the Hospital Eye Service. Ophthalmic Physiol Opt 1999; 19 Suppl 1: S16–S24. 30. O’Shea JG. Age-related macular degeneration: a leading cause of blindness. Med J Aust 1996; 165: 561. 31. Infeld DA, O’Shea JG. Glaucoma: diagnosis and management. Postgrad Med J 1998; 74 (878): 709– 715. 32. Barber AJ. A new view of diabetic retinopathy: a neurodegenerative disease of the eye. Prog Neuropsychopharmacol Biol Psychiatry 2003; 27: 283– 290. 33. Pick ZS, Stewart J, Elder MJ. The New Zealand ophthalmology workforce 2008. Clin Experiment Ophthalmol 2008; 36: 762–766. 34. Rowe S, MacLean CH, Shekelle PG. Preventing visual loss from chronic eye disease in primary care. JAMA 2004; 291: 1487–1495. 35. Gardner TW, Antonetti DA, Barber AJ, LaNoue KF, Levison SW. Diabetic retinopathy: more than meets the eye. Surv Ophthalmol 2002; 47, Suppl 2: S253–S262.
36. Sims J, Kerse N, Naccarella L, Long H. Health promotion and older people: the role of the general practitioner in Australia in promoting healthy ageing. Aust N Z J Public Health 2000; 24: 356–359. 37. Green J, Siddall H, Murdoch I. Learning to live with glaucoma: a qualitative study of diagnosis and the impact of sight loss. Soc Sci Med 2002; 55: 257–267. 38. Chu J, Ali Y. Diabetic retinopathy: a review. Drug Develop Res 2008; 69: 1–14. 39. Chopdar A, Chakravarthy U, Verma D. Age-related macular degeneration. Br Med J 2003; 326 (7387): 485–488. 40. Klein R, Klein BE, Linton KL. Prevalence of agerelated maculopathy. The Beaver Dam Eye Study Ophthalmol 1992; 99: 933–943. 41. Lamoureux EL, Pallant JF, Pesudovs K, Rees G, Hassell JB, Keeffe JE. The effectiveness of low-vision rehabilitation on participation in daily living and quality of life. Invest Ophthalmol Vis Sci 2007; 48: 1476–1482. 42. Macular Degeneration Foundation. Macular Degeneration Awareness Week, 2009. Available from: http://www.mdfoundation.com.au/mdawpast.aspx. [Accessed13 April 2011]. 43. Lovie-Kitchin JE, Soong GP, Hassan SE, Woods RL. Visual field size criteria for mobility rehabilitation referral. Optom Vis Sci 2010; 87: E948–E957. 44. Noe G, Ferraro J, Lamoureux E, Rait J, Keeffe JE. Associations between glaucomatous visual field loss and participation in activities of daily living. Clin Experiment Ophthalmol 2003; 31: 482–486. 45. Lamoureux EL, Hassell JB, Keeffe JE. The impact of diabetic retinopathy on participation in daily living. Arch Ophthalmol 2004; 122: 84–88. 46. Khan SA, Das T, Kumar SM, Nutheti R. Low vision rehabilitation in patients with age-related macular degeneration at a tertiary eye care centre in southern India. Clin Experiment Ophthalmol 2002; 30: 404– 410. 47. Pomeroy SEM, Cant RP. General practitioners’ decision to refer patients to dietitians: insight into the clinical reasoning process. Aust J Prim Health 2010; 16: 147–153. 48. Woods CA. Working better with GPs: Lessons to be learned from a study of health care networks in the management of diabetes. Clin Exp Optom 2006; 89: 1–2.
© 2013 The Authors Clinical and Experimental Optometry © 2013 Optometrists Association Australia
Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
APPENDIX 1 Abbreviated version of questionnaire The questionnaire was identical for optometrists and ophthalmologists except for question 3, where ophthalmologists were asked for their subspecialty (general ophthalmologists, retina, glaucoma, refractive surgery, cataract surgeon, neuropathology, paediatric, oculoplastic surgeon, anterior segment, other). Additionally, questions 6, 9 and 12 of the questionnaire were asked in terms of patients per day, rather than per month on the ophthalmological version of the questionnaire to account for the anticipated larger number of patients. The full-length questionnaire includes appropriate space to answer each question and also a list of low vision rehabilitation organisations and support services. Section 1 (Demographic information) 1. Age: 20–29 30–39 40–49 50–59 2. Gender: Male Female 3. Mode of practice: (Tick all that apply) Associate/Partner Sole practitioner Franchisee Independent Corporate/Franchise Other 4. State or territory of practice? ACT NSW NT QLD SA TAS 5. Which areas do you provide services for? Metropolitan Rural Remote
≥60
VIC
Section 2: Age-related macular degeneration (AMD): 6. On average, how many patients do you see in a month with AMD? Rarely 1–2 3–5 6–10 11–20 ≥20 7. Which service(s) do you refer a patient with AMD to? Optometrists Ophthalmologists LVR services Support services 8. What are your criteria for referring patients with AMD to such services? Diabetic retinopathy (DR): 9. On average, how many patients do you see in a month with DR? Rarely 1–2 3–5 6–10 11–20 ≥20 10. Which service(s) do you refer a patient with DR to? Optometrists Ophthalmologists LVR services Support services GPs
WA
GPs
Other;
Other;
11. What are your criteria for referring patients with DR to such services? Glaucoma: 12. On average, how many patients do you see in a month with glaucoma? Rarely 1–2 3–5 6–10 11–20 ≥20 13. Which service(s) do you refer a patient with glaucoma to? Optometrists Ophthalmologists LVR services Support services GPs Other; 14. What are your criteria for referring patients with glaucoma to such services? 15. When you refer patients with any one of these visual conditions (AMD, DR or glaucoma), do you provide them with information or advice about the service or organisation that they are referred to? 16. Can you describe what you would consider is an ideal referral pathway for patients with AMD? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 17. Can you describe what you would consider is an ideal referral pathway for patients with DR? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 18. Can you describe what you would consider is an ideal referral pathway for patients with glaucoma? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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A N D
E X P E R I M E N T A L
OPTOMETRY RESEARCH PAPER
Australian optometric and ophthalmologic referral pathways for people with age-related macular degeneration, diabetic retinopathy and glaucoma Clin Exp Optom 2014; 97: 248–255 Khalid F Jamous*§ BSc(Optom) MOptom Isabelle Jalbert* OD MPH PhD Michael Kalloniatis*† MSc(Optom) PhD Mei Ying Boon* BOptom(Hons) PhD * School of Optometry and Vision Science and † Centre for Eye Health, University of New South Wales, Kensington, Australia § Department of Ophthalmology, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia E-mail: [email protected]
Submitted: 13 March 2013 Revised: 6 September 2013 Accepted for publication: 14 September 2013
DOI:10.1111/cxo.12119 Background: This study investigated the referral pathways offered to patients with agerelated macular degeneration (AMD), diabetic retinopathy (DR) or glaucoma (GL) by ophthalmologists and optometrists. Methods: Australian ophthalmologists and optometrists were surveyed regarding referral decisions to other eye-care specialists (inter- or intra-professional), general medical practitioners (GPs), low vision rehabilitation (LVR) and support services. Thematic analysis and concept mapping were applied to highlight current and ideal referral pathways. Results: The survey was completed by 155 optometrists and 50 ophthalmologists and deemed representative of their respective professions in Australia. Not surprisingly, the vast majority of the participating optometrists (97 to 99 per cent) referred to ophthalmologists regardless of the underlying condition. Clear differences (Chi-square: p < 0.05) were observed in the referral patterns of optometrists and ophthalmologists to GPs and support services. General medical practitioner services were almost exclusively used for patients with DR, while AMD triggered a significantly higher referral rate to low vision rehabilitation and support services than the other two disorders. Conclusion: While ophthalmologists predominantly referred patients with AMD, DR or GL to low vision rehabilitation services, optometrists’ referrals were highly skewed toward ophthalmology. Referrals to other supporting services by the two groups were not greatly used. The perceived referral pathways by the two eye-care professionals suggested a unidirectional route, potentially highlighting the need for a more collaborative approach that facilitates optimal use of eye health care and allied services.
Key words: age-related macular degeneration, diabetic retinopathy, glaucoma, low vision rehabilitation, ophthalmologist, optometrist, referral pathways
High-quality eye care involves optometrists and ophthalmologists working together with general practitioners (GPs), orthoptists and allied health care workers or professionals working for organisations providing low vision rehabilitation (LVR) and support services.1–3 In Australia, this part of the health-care system is under substantial pressure due to the growing number of people with chronic eye disease, such as age-related macular degeneration (AMD), diabetic retinopathy (DR) and glaucoma (GL).4–6 In addition, the ‘fragmented’ nature of the health-care system results in people with complex and chronic conditions frequently navigating through many potential routes to care on their own and reducing the efficiency of health-care delivery.7 Comanagement between different eye-care Clinical and Experimental Optometry 97.3 May 2014
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professionals was suggested as key to more efficient delivery of ocular health care.8 Suitable and timely delivery of eye health care can reduce visual loss and health-care costs, as preventative eye care is significantly less costly than subsequent disability.9–11 Optometrists encompass a wide range of care, including performing vision and eye assessments, screening for, monitoring and treating eye disease, prescribing and supplying spectacles, contact lenses, low vision aids and therapeutic drugs.12 They also initiate referrals for specialty care, rehabilitative and ancillary services in relation to health and function of the visual system,13–15 making them essential in the development of co-management plans. Between optometrists and ophthalmologists in Australia, co-management plans have been proposed
based on their respective training and areas of expertise. For example, proposed ‘shared care’ between local optometrists and hospital-based ophthalmologists can reduce patient waiting time for review and foster working partnerships to provide localised care for the benefit of patients.16 Because of the systemic nature of some eye diseases, such as DR, GPs may also need to be included in patient management for further medical attention, such as diabetes control. In Australia, GPs can also facilitate referral to psychological counselling services and falls prevention clinics, so optometrists may wish to refer to GPs, particularly as visual impairment is associated with depression and increased falls risk.17–19 Australian eye-care professionals are well placed to participate in a joint effort between © 2013 The Authors
Clinical and Experimental Optometry © 2013 Optometrists Association Australia
Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
ophthalmologists and optometrists.20,21 Referrals should facilitate easy access to different services and enhance early detection and management of ocular disease. Three prevalent eye diseases, AMD, DR and GL were used to investigate these points. Our study is the first attempt to sample attitudes of the two eye-care professional groups to determine whether the traditional referral processes for people with AMD, DR and GL are generally consistent and interactive. It should benefit the patient by highlighting early intervention, avoiding duplication of services and instituting cost-effective care. It should benefit the practitioners in building confidence in the referral process and ensuring that no patient ‘falls through the cracks’. It should benefit the health-care system in minimising costs and expensive hospital or ophthalmology time without sacrificing quality of care.
METHODS
Survey design A two-part questionnaire consisting of openended and closed questions was developed to survey Australian optometrists and ophthalmologists (Appendix 1). Section 1 explored the demographic characteristics of clinicians, including age, gender, mode and location of practice and whether they provided low vision services in their practice or consider themselves as low vision service providers. Section 2 determined the clinicians’ referral patterns and referral criteria to other eye-care and allied services for people with AMD, DR or GL. To determine the referral pathway to low vision rehabilitation services, a list of the major organisations in Australia (for example, Vision Australia, Guide Dogs Australia et cetera) was included. Similarly, to determine the referral pathway to support services, a list was included of the major support organisations in Australia that are known to provide information and advice in relation to specific conditions (for example, Diabetes Australia, Glaucoma Australia and Macular Degeneration Foundation).
email list of Optometrists Association Australia (OAA). A total of 2,092 optometrists were invited electronically to participate in the survey through a link to the online questionnaire. Ophthalmologists were randomly selected from the Yellow Pages business telephone directory of Australia and public directories of the major public hospitals in Australia. A letter including a hard copy of the questionnaire, reply paid envelope and an invitation letter with the option to complete the questionnaire online was posted to 353 ophthalmologists. All ophthalmologists who participated in this study replied by hard copy.
Analysis Data were analysed using a mixed-methods strategy.22 Quantitative data obtained from closed-ended data was analysed using SPSS 20 software (Version 20; SPSS Inc, Chicago, IL, USA) to conduct descriptive statistics. Chi-square analysis was used to determine significant differences among referrals to different services for AMD, DR or GL, with p-values of less than 0.05 being considered significant. Qualitative data were analysed for common themes reported by participants. For example, answers reported by optometrists that had a common idea such as ‘visual field check up’, ‘assessment of visual field’ and ‘field testing’ were coded under one theme—‘visual field testing’. Coded data were then entered into a database as factors and frequencies of occurrence analysed.23 The perceptions of the ideal referral pathways for the three ocular conditions were analysed with concept mapping. The relationships between different concepts (that is, GPs, optometrists, ophthalmologists, low vision rehabilitation services) were demonstrated using a diagram, where concepts were enclosed in circles or boxes and connected with arrows. This method is a valid scientific tool of analysis in educational research for visualising ideas or processes.24,25
RESULTS
Sampling strategy
Participant characteristics
Hard copy and online versions of the survey were approved by the Human Research Ethics Advisory (HREA) panel at the University of New South Wales. Optometrists were recruited from the 2009 members’ directory
Of 2,042 invitations confirmed to have been delivered to optometrists, 155 responses were received, resulting in a response rate of eight per cent. For ophthalmologists, 344 were successfully delivered and 50 responses
© 2013 The Authors Clinical and Experimental Optometry © 2013 Optometrists Association Australia
were returned producing a response rate of 15 per cent. The mean age and gender of participating optometrists and ophthalmologists matched national averages.26 Although ophthalmologists who responded were primarily from New South Wales, there were no significant differences between our cohorts and the national averages. The responding ophthalmologists were mostly classified as general ophthalmologists or those with multiple subspecialties (60 per cent), followed by retinal specialists (12 per cent) and anterior segment specialists (eight per cent). None of the above characteristics had a significant influence on the survey outcome (Table 1). Although the overall characteristics of the replying cohorts were comparable to national averages, the lower than expected response rates may have resulted in an incomplete assessment regarding the nation as a whole. As data were generally consistent, it was considered an important representation of the investigated attitudes among eye-care specialists. We also assessed the patient encounter rates for participating optometrists and ophthalmologists for each condition. The majority of optometrists see five to nine AMD patients per month and one to four patients with DR or GL (Table 2A). Comparable distributions were obtained for ophthalmologists (p = 0.91, 0.99 and 0.99 for AMD, DR and GL, respectively) when assessed on an encounter per day rate (Table 2B).
Referral patterns for individuals with AMD, DR or GL Regardless of the underlying condition, optometrists referred the majority of patients to ophthalmologists (Chi-square: p = 0.14) but rarely to another optometrist (Chi-square: p = 0.08; Figure 1A). Referrals to other providers were significantly dependent on the disorder (Chi-square: p < 0.05). GPs were consulted for only diabetic patients, while AMD patients mostly referred to low vision rehabilitation and support services. Ophthalmologists’ referral behaviour was not significantly different from that of optometrists (Figure 1B) with the exception of referrals to other ophthalmologists (2-tailed, paired Student’s t-test, p = 0.002). Overall, only the referral pattern to optometrists differed significantly between the two eye-care professions (Chi-square: p < 0.05). With regard to referral to low vision rehabilitation services, the proportion of ophthalmologists referring patients with AMD to low vision rehabilitation services was Clinical and Experimental Optometry 97.3 May 2014
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Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
Demographic information
Optometrists National average
Total number of practitioners Age (years)
Ophthalmologists Survey
4,414
155
National average 887
Survey 50
Average
40.0
44.4
51.6
49.6
Male
n.a.*
47.0
n.a.*
49.6
Female
n.a.*
41.1
n.a.*
47.0
Male
55.8
55.5
84.3
86.0
Female
44.2
44.5
15.7
14.0
Location of practice (%)
Metropolitan
78.8
66.5
84.4
96.0
Rural/remote
21.2
33.5
15.6
4.0
State/Territory of location (%)
New South Wales
37.7
38.0
36.4
52.0
Victoria
22.1
26.5
25.9
24.0
Queensland
20.0
19.3
17.0
8.0
Gender (%)
Western Australia
8.2
6.5
9.2
4.0
South Australia
6.1
5.2
7.3
10.0
Tasmania
2.7
1.9
2.2
0.0
Australian Capital Territory
1.9
2.6
0.3
0.0
Northern Territory
1.1
0.0
n.a.*
2.0
* n.a. = No data available
Table 1. Demographic characteristics of participating optometrists and ophthalmologists compared to national averages26
A
B
Patients seen per month
AMD
DR
GL
Rarely
9%
19%
6%
1–4
19%
46%
48%
5–9
31%
22%
30%
10–14
25%
9%
11%
≥ 15
16%
4%
5%
Patients seen per day
AMD
DR
GL
Rarely
12%
20%
10%
1–4
52%
58.7%
33.3%
5–9
23.2%
18.5%
37.9%
6%
3.6%
9.2%
6.8%
1.2%
9.6%
10–14 ≥ 15
Table 2. For each of the three investigated disorders (A) optometrists and (B) ophthalmologists indicated a range most closely representing the numbers of patients seen. Percentages of practitioners are shown for age-related macular degeneration (AMD), diabetic retinopathy (DR) and glaucoma (GL).
significantly greater than the proportion referring patients with DR or GL (Chisquare: p < 0.05). Vision Australia was the most commonly used organisation by ophthalmologists (80/58/60 per cent for AMD/ Clinical and Experimental Optometry 97.3 May 2014
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DR/GL, respectively) and optometrists (67/ 47/44 per cent for AMD/DR/GL, respectively), followed by disease-specific groups— Macular Degeneration Foundation for AMD (14 per cent of ophthalmologists, 37 per
cent of optometrists), Diabetes Australia for DR (8 per cent of ophthalmologists, 28 per cent of optometrists) and Glaucoma Australia for GL (26 per cent of ophthalmologists, 32 per cent of optometrists). Guide Dogs NSW/ACT was referred to by six to 14 per cent of the practitioners. Ophthalmologists also used the Royal Society for the Blind (10 to 14 per cent) while optometrists favoured the Association for the Blind (8 to 12 per cent). A number of other organisations were used at much lower levels.
Referral criteria for individuals with AMD, DR or GL Optometrists’ referral criteria to ocular health care and supporting services for the three conditions were analysed thematically and for frequency of occurrence (Table 3). Optometrists’ referral criteria to ophthalmology were reported by many respondents for all three conditions (AMD = 134; DR = 135; GL = 130) and mainly based on further investigation or confirmation of a diagnosis, medical or surgical interventions and treatment. Up to 110 responses indicated referring to ophthalmologists for reduced or altered vision or visual acuity. Few optometrists reported their criteria for © 2013 The Authors
Clinical and Experimental Optometry © 2013 Optometrists Association Australia
Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
A
AMD
100%
97%
DR
GL 99%
99%
*
88%
*
80%
67% 57%
*
52%
49%
60%
40%
20%
29%
27%
8% 4%
5% 4%
4%
0%
B
AMD
DR
*
GL
94%
100%
72%
68%
80%
60% 28%
40%
28%
26%
20%
16% 14% 20%
8% 8%
10% 4%
2% 0%
Ophthalmologists
Optometrists
GPs
LVR services
Support services
Figure 1. Distribution of referral decisions The proportions of (A) optometrists (n = 155) and (B) ophthalmologists (n = 50) who refer patients with age-related macular degeneration (AMD), diabetic retinopathy (DR) or glaucoma (GL) to other health-care and allied services. (CI = 95%, *p < 0.05)
referring to the other services except for DR, where 90 respondents reported referral criteria to GPs for control of diabetes. Agreement between optometrists and ophthalmologists was observed regarding referral criteria for low vision rehabilitation and support services, including areas targeting the effect of visual impairment (responses in bold and italics indicate criteria that were considered important by ophthalmologists). In particular, optometrists and ophthalmologists particularly focused on the use of adjunct services based on the remaining visual function as a consequence of any of the three investigated disorders (Table 4).
Ideal service pathways for patients with AMD, DR and GL Fifty-nine per cent (n = 91) of optometrists described an ideal referral pathway for patients with AMD, DR and GL, while only 10 per cent of the ophthalmologists reported
an opinion on this question. Responses were categorised as ‘unidirectional’, if the individual service provider appeared in a distinct order and patients were channelled from one to the next. ‘Multidirectional’ pathways referred to those scenarios where several other services were activated by the same provider. Lastly, patients that were comanaged and thus repeatedly transferred between services, were labelled as ‘circular’. There was complete agreement between optometrists and ophthalmologists that optometrists or GPs should initiate these pathways across the investigated disorders. GPs were preferred as initiators in 24.0 per cent of scenarios and consequently triggered eye-specific care through referral to an optometrist. A particular deviation was observed with regard to DR (5.0 per cent of the above 24.0 per cent), for which multidirectional pathways included consultations with podiatrists, endocrinologists and nutritionists at the same time. Of the remainder,
© 2013 The Authors Clinical and Experimental Optometry © 2013 Optometrists Association Australia
optometrists and GPs were presumed equally important as primary care providers in 2.7 per cent, while the balance was attributed to optometrists as suggested first responder to problems related to AMD, DR and GL. The majority (88.6 per cent) of reported ideal pathways included ophthalmologists subsequent to the optometric assessment. This interaction was described as unidirectional by 64.6 per cent, while 24.0 per cent envisioned optometrists remaining the main carers through back-referral by the ophthalmologists. Alternatively, there was a suggestion that optometrists were to refer to low vision rehabilitation services only (8.7 per cent) or they are seen as equivalent with ophthalmologists, creating a circular referral pathway also including low vision rehabilitation services (2.7 per cent; AMD only). Finally, all proposed patient management plans resulted in referrals to either low vision rehabilitation services only (62.4 per cent) or a combination of low vision rehabilitation and support services (37.6 per cent). This step was supposed to be initiated by optometrists in 45.6 per cent of ideal pathway solutions, by ophthalmologists in 51.7 per cent or by either for the remainder. It should be noted that 80 per cent of the ophthalmologists suggested this step to be initiated by them rather than an optometrist. Interestingly, low vision rehabilitation and support services were reported as the final destination in a linear manner in 60.4 per cent of scenarios, while only 39.6 per cent integrated them as part of a multidirectional (36.9 per cent) or circular (2.7 per cent) step, while consulting with other specialists at the same time. DISCUSSION Previous studies indicate that more than 90 per cent of referrals initiated by optometrists were to ophthalmological services for the management of AMD, DR or GL.27–29 This is likely to be influenced by the nature of these conditions, significantly affecting a patient’s vision and primarily requiring management and treatment by an ophthalmologist.30–32 Considering the shortage of practising ophthalmologists in Australia, high referral rates to ophthalmologists is likely to compound the current shortfalls in the eye-care system.33 Rowe, MacLean and Shekelle34 indicated that many chronic cases may not require ophthalmological management or Clinical and Experimental Optometry 97.3 May 2014
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Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
To optometrists Age-realed macular degeneration (AMD) (n = 10)
Diabetic retinopathy (n = 9)
Glaucoma (n = 6)
Further eye testing (optical coherence tomography (OCT)
Further eye testing (OCT or retinal photography) (7)
Visual field testing (5)
or retinal photography) (8)
Dilated fundoscopy (5)
Low vision aids (3)
Dilated fundoscopy (5)
Monitoring of diabetic retinopathy (2)
Monitoring of glaucoma (1)
Low vision aids (4) To ophthalmologists AMD (n = 134) Reduction or change in vision or visual acuity (110)
Diabetic retinopathy (n = 135)
Glaucoma (n = 130)
Clinical sign of fundus changes (88)
Abnormal status of optic disc (98)
Clinical sign of fundus changes (76)
Proliferative diabetic retinopathy (61)
Abnormal (IOP) (94)
Diagnosis or suspicion of wet AMD (57)
Moderate to severe non-proliferative diabetic retinopathy (33)
Visual field defects (67)
Diagnosis and treatment (44)
Diagnosis and treatment
Diagnosis and treatment (44)
Further testing (OCT or angiogram) (37)
Further testing (OCT or angiogram) (31)
Further testing (OCT or pachymetry) (14)
NHMRC guidelines on DR (11)
The NHMRC guidelines on glaucoma (7) A family history of glaucoma (2)
To general medical practitioners AMD (n = 5)
Diabetic retinopathy (n = 90)
Glaucoma (n = 5)
Provision of dietary supplements (3)
For diabetes control (79)
General health issues (4)
General health issues (3)
General health issues (17)
For medical report (1)
Arranging for further services, such as community support services (1)
Arranging for further services, such as counselling (6)
To support services (n = 68) AMD (n = 68)
Diabetic retinopathy (n = 46)
Glaucoma (n = 36)
Information & support (58)
Information & support (37)
Information & support (31)
Patient’s request (25)
Patient’s request (14)
Patient’s request (10)
To low vision rehabilitation services AMD (n = 124)
Diabetic retinopathy (n = 74)
Glaucoma (n = 68)
Visual acuity problems (86)
Visual acuity problems (40)
Vision problems (46)
Vision problems (36)
Vision problems (22)
Visual acuity problems (27)
Low vision aids (31)
Low vision aids (19)
Orientation and mobility (22)
Difficulties to perform activities of daily living (26)
Difficulties to perform activities of daily living (16)
Low vision aids (11)
Orientation and mobility (11)
Orientation and mobility (7)
Need for help in home (3)
Occupational therapy (7)
Occupational therapy (2)
Need for help with social issues (2)
Need for counselling (7) Patient or family’s request (6)
Table 3. Referral criteria Criteria reported by optometrists influencing decisions for referrals to health and eye-care providers, indicating the total of responses received in brackets (multiple responses were allowed). Responses in italics indicate criteria that were considered important by ophthalmologists. n = number of participants replying to the respective category (please note that this does not correspond to the total number of participants responding to the survey).
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Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
Vision and visual acuity problems AMD
Diabetic retinopathy
Glaucoma
Visual acuity (VA) (86)
VA (40)
VA (27)
VA worse than 6/12 (85)
VA worse than 6/12 (35)
VA worse than 6/12 (24)
Near VA less than N5 (1)
Poor VA (5)
VA too poor to correct with regular glasses (3)
Vision problems (36)
Vision problems (22)
Vision problems (46)
Significant visual loss affecting independence and functional vision (32)
Significant visual loss affecting independence and functional vision (18)
Significant visual field loss (less than 20 degree field of view remaining) (n = 42)
Poor prognosis of vision recovery (3)
Inability of patients to cope with regular eyeglasses alone (4)
Visual difficulties beyond the scope of spectacles and simple magnifiers (2)
Reduced contrast sensitivity (1)
Peripheral field loss affecting mobility (1) Field loss crossing horizontal meridian (i.e. any inferior field loss) (1)
Table 4. Particular concerns regarding vision and visual acuity problems The reported visual parameters used as referral criteria to low vision rehabilitation services for patients with age-related macular degeneration (AMD), diabetic retinopathy or glaucoma.
treatment if a condition is controlled. Optometrists could manage these controlled conditions, thereby reducing the patient load on ophthalmological services.12 The proportions of optometrists referring patients to GPs were very low except for patients with DR (67 per cent). This is likely to be due to optimal treatment of DR requiring active management of systemic diabetes and cardiovascular risk factors.35 GPs also provide access to adjunct services, such as counselling or falls prevention programs, which may benefit vision-impaired patients and thus, low referral rates for AMD and GL to GPs suggest that these patients may be missing out on these services.36 Even though we did not define levels of visual loss in our study, referrals to low vision rehabilitation and support services were primarily initiated for people with AMD (Figure 1). This may be a consequence of the higher number of patients with AMD compared to DR and GL seen by eye-care specialists (Table 2), as well as the potential for rapid deterioration of vision with AMD progression.37–40 AMD is also associated with significant functional loss requiring multidisciplinary evaluation, especially among elderly patients.41 Education and awareness campaigns generated
by the Macular Degeneration Foundation in Australia may also have a significant contribution.42 Visual field was a major criterion in the involvement of low vision rehabilitation (Table 4), as were visual fields in concordance with recommendations that difficulties with mobility arise, if the visual field is less than 70° circular diameter and rehabilitation should be initiated once it is constricted to 15°.43 This criterion may not be sufficient, as patients with GL may encounter difficulties with mobility even though their visual fields and visual acuities are relatively intact.44 Similarly, a study suggested that low vision rehabilitation may be an effective strategy to help people with DR to cope with difficulties in daily living activities.45 This suggests that these services are underused to improve quality of life for people with DR and GL.
Envisioned referral pathway Two-thirds of the proposed referral pathways did not distinguish between disorders and centred on the unidirectional optometrist to ophthalmologist relationship. GPs were included as primary care specialists in 25 per cent of the scenarios but not taken
© 2013 The Authors Clinical and Experimental Optometry © 2013 Optometrists Association Australia
into consideration as referrers to low vision rehabilitation or support services. If they were, this would open additional resources to the patient.46 Additional specialists such as endocrinologists, podiatrists and nutritionists were considered only in conjunction with a DR-specific pathway.47,48 Although that can be attributed to the systemic nature of the disease, a lack of collaboration between specialists will result in isolated symptomatic treatments. Mapped pathways reflected unidirectional thinking, suggesting there is not much space for comparing notes and feedbacks. Most noticeably, regardless of the initiating party, allied health services, established to support core professionals, were considered as an end point rather than an integrated step during diagnosis and treatment of disorders of vision. Together with the main focus of referral criteria on visual acuity and function, these services are likely to be involved late in the patient’s disease progression and therefore, may not provide full benefits to the patients.
CONCLUSION Our study indicated that there is recognition of all the major players contributing to the referral process for the three investigated conditions. Referrals by optometrists were highly skewed toward ophthalmologists, suggesting that other eye-care players, such as GPs, other optometrists, low vision rehabilitation and support services, may be underused. In addition, the perceived referral pathways were mostly unidirectional, highlighting the need for a more collaborative approach that facilitates optimal use of eye healthcare and allied service for the management and treatment of age-related macular degeneration, diabetic retinopathy and glaucoma. ACKNOWLEDGEMENTS
Khalid F Jamous was supported by a scholarship from King Saud University at Riyadh, Saudi Arabia. This paper was presented in part at the American Academy of Optometry Annual meeting in Boston, USA in October 2011. We thank Drs Andrew Whatham, Barbara Zangerl and Lisa Nivison-Smith for their valuable contribution in reviewing the manuscript. REFERENCES 1. Ratnarajan G, Newsom W, French K, Kean J, Chang L, Parker M, Garway-Heath DF et al. The impact of
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36. Sims J, Kerse N, Naccarella L, Long H. Health promotion and older people: the role of the general practitioner in Australia in promoting healthy ageing. Aust N Z J Public Health 2000; 24: 356–359. 37. Green J, Siddall H, Murdoch I. Learning to live with glaucoma: a qualitative study of diagnosis and the impact of sight loss. Soc Sci Med 2002; 55: 257–267. 38. Chu J, Ali Y. Diabetic retinopathy: a review. Drug Develop Res 2008; 69: 1–14. 39. Chopdar A, Chakravarthy U, Verma D. Age-related macular degeneration. Br Med J 2003; 326 (7387): 485–488. 40. Klein R, Klein BE, Linton KL. Prevalence of agerelated maculopathy. The Beaver Dam Eye Study Ophthalmol 1992; 99: 933–943. 41. Lamoureux EL, Pallant JF, Pesudovs K, Rees G, Hassell JB, Keeffe JE. The effectiveness of low-vision rehabilitation on participation in daily living and quality of life. Invest Ophthalmol Vis Sci 2007; 48: 1476–1482. 42. Macular Degeneration Foundation. Macular Degeneration Awareness Week, 2009. Available from: http://www.mdfoundation.com.au/mdawpast.aspx. [Accessed13 April 2011]. 43. Lovie-Kitchin JE, Soong GP, Hassan SE, Woods RL. Visual field size criteria for mobility rehabilitation referral. Optom Vis Sci 2010; 87: E948–E957. 44. Noe G, Ferraro J, Lamoureux E, Rait J, Keeffe JE. Associations between glaucomatous visual field loss and participation in activities of daily living. Clin Experiment Ophthalmol 2003; 31: 482–486. 45. Lamoureux EL, Hassell JB, Keeffe JE. The impact of diabetic retinopathy on participation in daily living. Arch Ophthalmol 2004; 122: 84–88. 46. Khan SA, Das T, Kumar SM, Nutheti R. Low vision rehabilitation in patients with age-related macular degeneration at a tertiary eye care centre in southern India. Clin Experiment Ophthalmol 2002; 30: 404– 410. 47. Pomeroy SEM, Cant RP. General practitioners’ decision to refer patients to dietitians: insight into the clinical reasoning process. Aust J Prim Health 2010; 16: 147–153. 48. Woods CA. Working better with GPs: Lessons to be learned from a study of health care networks in the management of diabetes. Clin Exp Optom 2006; 89: 1–2.
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Australian optometric and ophthalmologic referral pathways Jamous, Jalbert, Kalloniatis and Boon
APPENDIX 1 Abbreviated version of questionnaire The questionnaire was identical for optometrists and ophthalmologists except for question 3, where ophthalmologists were asked for their subspecialty (general ophthalmologists, retina, glaucoma, refractive surgery, cataract surgeon, neuropathology, paediatric, oculoplastic surgeon, anterior segment, other). Additionally, questions 6, 9 and 12 of the questionnaire were asked in terms of patients per day, rather than per month on the ophthalmological version of the questionnaire to account for the anticipated larger number of patients. The full-length questionnaire includes appropriate space to answer each question and also a list of low vision rehabilitation organisations and support services. Section 1 (Demographic information) 1. Age: 20–29 30–39 40–49 50–59 2. Gender: Male Female 3. Mode of practice: (Tick all that apply) Associate/Partner Sole practitioner Franchisee Independent Corporate/Franchise Other 4. State or territory of practice? ACT NSW NT QLD SA TAS 5. Which areas do you provide services for? Metropolitan Rural Remote
≥60
VIC
Section 2: Age-related macular degeneration (AMD): 6. On average, how many patients do you see in a month with AMD? Rarely 1–2 3–5 6–10 11–20 ≥20 7. Which service(s) do you refer a patient with AMD to? Optometrists Ophthalmologists LVR services Support services 8. What are your criteria for referring patients with AMD to such services? Diabetic retinopathy (DR): 9. On average, how many patients do you see in a month with DR? Rarely 1–2 3–5 6–10 11–20 ≥20 10. Which service(s) do you refer a patient with DR to? Optometrists Ophthalmologists LVR services Support services GPs
WA
GPs
Other;
Other;
11. What are your criteria for referring patients with DR to such services? Glaucoma: 12. On average, how many patients do you see in a month with glaucoma? Rarely 1–2 3–5 6–10 11–20 ≥20 13. Which service(s) do you refer a patient with glaucoma to? Optometrists Ophthalmologists LVR services Support services GPs Other; 14. What are your criteria for referring patients with glaucoma to such services? 15. When you refer patients with any one of these visual conditions (AMD, DR or glaucoma), do you provide them with information or advice about the service or organisation that they are referred to? 16. Can you describe what you would consider is an ideal referral pathway for patients with AMD? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 17. Can you describe what you would consider is an ideal referral pathway for patients with DR? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 18. Can you describe what you would consider is an ideal referral pathway for patients with glaucoma? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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