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R. R. Bourne, W. Newsom, K. French, L. Chang; The CHANGES Scheme (Community and Hospital Allied Network Glaucoma Evaluation Scheme). Invest. Ophthalmol. Vis. Sci. 2008;49(13):4999.
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Glaucoma healthcare delivery needs to adapt flexibly to the community it serves and the demands of the National Health Service in the United Kingdom. False positive referrals occupy a significant proportion of new patient consultation time. CHANGES was developed to address these issues with a community-based scheme, a collaboration between optometrists & hospital clinicians and communication with an electronic patient record (EPR).
Between March and August 2006, 8 community optometrists with a special interest in glaucoma (OSIs) were trained in glaucoma detection with a university course and with hospital-based practical and didactic teaching. All other local optometrists were invited to the hospital-based teaching. 2 hospital-based OSIs triaged all referral letters (from original referring optometrists) into high and low risk. Low risk referrals booked an appointment with their choice of OSI who performed a comprehensive glaucoma evaluation - discharging or referring the patient to the hospital glaucoma service (supervised virtually by the hospital glaucoma team using an EPR).
27 glaucoma-related referrals were assessed by OSIs between August to December 2006. Of these, 9 were discharged and 18 referred to the hospital.The original referring optometrist false positive rate = 41%. The OSI false positive rate = 27.8% and false negative rate = 33.3%. 38 glaucoma-related referrals were assessed by OSIs between January to June 2007. Of these, 9 were discharged and 29 referred to the hospital. The original referring optometrist false positive rate = 39%. The OSI false positive rate = 13.8% and false negative rate = 11.1%. Agreement between consultant glaucomatologist (gold standard) and OSIs in judging an optic disc abnormal achieved a sensitivity of 91% and specificity of 50%. For an abnormal intraocular pressure (>21mmHg), these values were 79% and 78%, and for detection of an occludable anterior chamber angle, 67% and 87%.
The referral refinement behaviour of all optometrists has improved as a result of this community glaucoma scheme, in particular that of the OSIs. Low false negative rates when assessing agreement between ophthalmologist and OSI are important in reassuring clinicians that cases of glaucoma are not missed in the community. Reduction of false positive glaucoma referrals to the hospital glaucoma service has led to a more efficient service which benefits from closer collaboration with the optometrist referral base.
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