Search

Structured record keeping improves documentation in age-related macular degeneration; however, it may have a more limited effect on the management decisions of a group of already highly trained clinicians, especially in the context of other well-embedded clinical decision support tools. Structured record keeping has been associated with a range of advantages including improved history taking and communication, reduced number of unnecessary referrals, and enhanced diagnostic accuracy. The aim of this study was to examine the impact of a structured record keeping, quality improvement tool on recording, reporting and management congruency. A before and after retrospective record review study was performed in a single academic, intermediate-tier care institute in New South Wales, Australia. The structured record keeping tool intervention captured 31 items in addition to the prior pre-existing medical record: six items relating to historical risk factors, two items relating to patient activation, 13 items signifying core clinical signs, five items for change analysis and five items regarding the ongoing patient management plan. Two hundred medical records from 151 patients with age-related macular degeneration were analysed. There was a statistically significant improvement in the number of reports that explicitly specified the number of clinical structural risk factors (from 24 to 75%; Fisher's exact p < 0.001) and risk of progression to advanced disease (from 71 to 84%; p = 0.041); however, this documentation had no statistically significant effect on the report-recommended management plan and/or the final report-recommended review period. Disease-specific, structured record keeping improves the outgoing documentation of key clinical signs and is effective in prompting the transposition of these signs into a quantified risk progression score. It has limited value in improving management consistency among a group of highly trained eye care staff. [ABSTRACT FROM AUTHOR]

Background: In ageing populations, the prevalence of chronic diseases such as glaucoma is projected to increase, placing additional demands on limited health-care resources. In the UK, the demand for secondary care in hospital eye clinics was inflated by high rates of false positive glaucoma referrals. Collaborative care models incorporating referral refinement, whereby glaucoma suspect referrals are triaged by suitably trained optometrists through further testing, can potentially reduce false positive referrals. This study examined the impact of a referral refinement model on the accuracy of glaucoma referrals in Australia.Methods: Optometrist-initiated glaucoma suspect referrals to the Glaucoma Management Clinic (Sydney, Australia) were prospectively recruited. Glaucoma suspect referrals arising from two pathways were eligible for inclusion, either directly from a community optometrist (standard care) or following comprehensive assessment at the Centre for Eye Health (referral refinement). Main outcome measures were the positive predictive value and false positive rate of referrals. The impact of referral letter content on management outcomes was also investigated.Results: Of 464 referrals received between March 2015 and June 2018, 252 were for treatment of naïve glaucoma suspects and eligible for inclusion. Following ophthalmological assessment, 45.6 per cent (n = 115/252) were prescribed treatment for open angle glaucoma or ocular hypertension. Positive predictive value of community optometry referrals was 33.8 per cent (n = 25/74) and 50.6 per cent (n = 90/178) following referral refinement. The first visit discharge (false positive) rate was 26 per cent (n = 19/74) for community referrals compared to four per cent (n = 8/178) with referral refinement. Positive predictive value increased with the number of abnormal clinical examination findings associated with referral (χ2 test, p < 0.0001). The number of abnormal findings reported in referrals was significantly higher with referral refinement compared to without (n = 1.9 versus 1.5, t-test, p < 0.0001).Conclusion: Referral refinement can improve the diagnostic accuracy of optometry-initiated referrals for glaucoma suspects in Australia, thereby decreasing unnecessary referrals to hospital and other secondary clinics. [ABSTRACT FROM AUTHOR]