Management of ophthalmology referral letters in the United Kingdom: are traditional methods the best?

Abstract

Traditionally referrals to ophthalmic units have been read and prioritised by a senior ophthalmologist. This has been seen as necessary due to the complex nature of the information contained within the referral, and to ensure that patients with sight threatening conditions are seen with appropriate speed. This well-established system is in the process of being challenged with the introduction of electronic booking in England (Choose and Book). This study undertook to establish whether non-consultant ophthalmic practitioners working in an eye clinic could grade referrals with an efficacy priority rating compatible with that of a consultant ophthalmologist. A total of 138 ophthalmic referral letters were read and prioritised using a 4 point scale by the consultant to whom they were addressed. They were then prioritised by three test readers, without knowledge of the consultant's decision. Agreement was evaluated using unweighted and linear weighted kappa analysis. A selection of the more controversial referrals (i.e. where agreement was equivocal) were also prioritised by four consultants. Weighted kappa analysis showed only a fair agreement between the scores given by the three test readers [Senior House Officer (SHO), Optometrist and Nurse Practitioner] and the consultant of 0.45, 0.48 and 0.37, respectively. However, in all cases, over 90% of scores were within one point of agreement with the Consultant score. Some letters were particularly difficult to interpret, leading to poor inter-consultant agreement on the more controversial letters (kappa = 0.30). Agreed clinical guidelines would make the prioritisation of most referral letters straightforward by a trained ophthalmic practitioner. However, traditional methods are inherently variable. To assist the untrained prioritiser there may need to be a priority scoring system, or availability of a triage assessment clinic.