Elsevier

Ophthalmology

Volume 121, Issue 1, January 2014, Pages 126-133
Ophthalmology

Original article
Assessment of the Quality of Glaucoma Referral Letters Based on a Survey of Glaucoma Specialists and a Glaucoma Guideline

Presented at: the American Glaucoma Society 23rd Annual Meeting, March 2, 2013, San Francisco, California; Association for Research in Vision and Ophthalmology, May 8, 2013, Seattle, Washington; Canadian Ophthalmological Society Annual Meeting, June 2013, Montreal, Quebec, Canada.
https://doi.org/10.1016/j.ophtha.2013.08.027Get rights and content

Objective

To assess the quality of glaucoma referral letters and to report on the results of a survey of glaucoma specialists about referral letter content.

Design

Cross-sectional study.

Participants

A survey of 135 glaucoma specialists and audit of 200 consecutive referral letters to a tertiary glaucoma unit.

Methods

An online questionnaire was sent to members of the Canadian and American Glaucoma Societies asking what they considered the most important data to be included in a glaucoma referral. Consecutive referral letters to a tertiary glaucoma unit were assessed for legibility and content on the basis of the survey results and information items in current guidelines.

Main Outcome Measures

Survey outcome and proportion of included content items in referral letters.

Results

The survey revealed that the top 5 most important data that glaucoma specialists would like to be included in a referral letter for progressive glaucoma were serial visual fields (VFs), current glaucoma therapy, current intraocular pressure (IOP), maximum IOP, and serial disc imaging. These items often were omitted in the referral letters audited. A total of 200 referral letters were assessed, 46% from ophthalmologists, 42% from optometrists, 10% from family practitioners, and 2% from other sources. Reasons for referral were diagnosis of glaucoma (37%), unstable glaucoma (25%), angle assessment (17%), and others (21%). Some 26% of the referral letters were deemed illegible (18% from ophthalmologists vs. 6% from optometrists; P < 0.01). Degree of urgency was mentioned in 27% of referrals. Optometrists were more likely than ophthalmologists to provide visual acuity (VA), IOP, refraction, and VFs (P < 0.01 for each). Some 24% of referrals for progression included more than 10 of the 14 information points suggested by the Canadian glaucoma guidelines, and 34% included fewer than 8 of the 14 points.

Conclusions

Referral letters frequently did not include important information, with 34% of referral letters deemed substandard. Optometrist referrals were better than ophthalmologist referrals in terms of content and legibility. A checklist of clinical details for referring physicians is suggested, which includes maximum and current IOP, disc evaluation, serial VFs, and serial disc imaging.

Section snippets

Methods

An e-mail was sent to members of the Canadian Glaucoma Society and American Glaucoma Society inviting them to participate in an electronic questionnaire regarding glaucoma referral letters. The following 2 questions were asked:

1. When receiving a glaucoma referral letter from an ophthalmologist OR an optometrist for consideration of GLAUCOMA PROGRESSION or SURGERY, what are the top 5 most important pieces of information you would like to know?

2. When receiving a glaucoma (suspect) referral

Results

A total of 200 referral letters were evaluated during the study period. Table 1 summarizes the sources and reasons for referral. The majority of referrals were from ophthalmologists (46%) and optometrists (42%) followed by FPs (10%) and others (2%; 1 each from an emergency physician, general physician, dermatologist, and neurologist). The most common reason for referral was for the diagnosis of glaucoma (37%), of which the majority were from optometrists (47%). The second most common reason was

Discussion

The Canadian Medical Association has stated that improving the referral and consultation process is one of its current priorities. In a survey of 5500 secondary and tertiary physicians,6 less than half (47%) reported that referral letters contained enough information to triage a patient. Inadequate referral information may result in irreversible vision loss and a potential liability for physicians from delayed treatment.7 Failure to communicate is a common cause of complaints and medicolegal

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    Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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