Letter to the Editor: Accuracy of Referrals to Canadian Pediatric Ophthalmology Services

Optimizing timely access to tertiary health care has been a perpetual area of challenge and focus for most subspecialties in health care systems around the world. With relatively few subspecialists and an increasing population size, managing waitlists has been an ever-growing challenge that has been significantly exacerbated by the coronavirus disease 2019 pandemic. Specifically in the context of pediatric ophthalmology, there is little training for medical students and medical residents on the topic of ocular disorders and conditions, especially in children, leaving much of the burden of diagnosis and management of ophthalmic conditions on the shoulders of a relatively small group of pediatric ophthalmologists in Canada.1,2 Diagnosis of pediatric ocular conditions is often time sensitive. Children are not born with the ability to see perfectly; rather, visual development occurs over the first decade of life. Abnormal or absent visual stimulation due to conditions such as refractive errors, strabismus, and cataracts, among others, can lead to permanent visual impairment, that is, amblyopia. Furthermore, unlike adults who can voice concerns regarding their visual status, children may show no outward signs of visual impairment, especially in monocular conditions. As such, timely vision screening in young kids is paramount to pick up amblyogenic eye conditions to treat and prevent long-term vision loss. Lengthy wait times for children seeing a pediatric ophthalmologist are not just a matter of inconvenience for children and parents. Left untreated, ocular conditions may have a deleterious impact on not only the eye and the visual system but also the child's function and quality of life.3 There may also be lasting impacts on the patient's quality of life in adulthood, with psychosocial impacts and loss of function.3 To reduce the lengthy wait times children often endure before seeing a pediatric ophthalmologist,4 it is prudent to assess strategies of reducing referrals to pediatric ophthalmologists without compromising patient safety and improving delivery of eye care for all children. To devise potential strategies for improvement, we retrospectively evaluated referrals to our tertiary pediatric ophthalmology clinic to assess the diagnostic accuracy of different health care providers. Between 2016 and 2019, 1500 consecutive patients referred to the pediatric ophthalmology service at McMaster Children's Hospital in Ontario, Canada, were reviewed. Patients 18 years or younger were included. The presumed diagnosis as noted in the referral paperwork from general practitioners, pediatricians, and optometrists was correlated with the final diagnosis as determined by the staff pediatric ophthalmologist. Of the 1500 patient charts reviewed, 1241 met the inclusion criteria. Among these, 612 (49.3%) were from general practitioners, 316 (25.5%) from pediatricians, and 313 (25.2%) from optometrists. The 1241 included patients resulted in a total of 1382 referral diagnoses, as a patient could be referred for more than one ophthalmological reason. The pediatric ophthalmologist did not find any ocular abnormalities in 38% of children referred by both general practitioners and pediatricians (232 of 612 and 119 of 316, respectively) compared with only 15% of children referred from optometrists (48 of 313). The most common reason for referral in all three referral groups was strabismus, and within this category, the diagnostic accuracy rates were 51% among general practitioners, 50% among pediatricians, and 89% among optometrists (Table 1). Overall, the previous data demonstrate both the relatively low diagnostic accuracy rates of general practitioners and pediatricians and the relatively high diagnostic accuracy rate of optometrists. TABLE 1 - Diagnosis of referring health care professionals as compared with pediatric ophthalmologists General practitioners Pediatricians Optometrists No. patients referred No. patients where pediatric ophthalmologist agreed with diagnosis False-positive rate, % No. patients referred No. patients where pediatric ophthalmologist agreed with diagnosis False-positive rate, % No. patients referred No. patients where pediatric ophthalmologist agreed withdiagnosis False-positive rate, % Strabismus 261 133 49 135 67 50 148 132 11 Parental concern 126 54 57* 39 21 46† 44 19 57† Nasolacrimal duct obstruction 71 62 13 33 28 15 6 6 0 Lid lesion 51 47 8 13 10 23 6 6 0 Ptosis 20 18 10 21 20 5 3 2 33 Anterior segment anomaly 20 12 40 13 9 31 13 11 15 Amblyopia 15 11 27 15 8 47 74 66 11 Eye movement disorder 11 1 91 11 4 64 18 14 22 Red reflex anomaly 10 0 100 7 0 100 0 0 N/A Significant refractive error 9 8 11 4 3 25 46 45 2 Nystagmus 9 6 33 4 3 25 7 6 14 Conjunctivitis 6 3 50 4 2 50 3 3 0 Photophobia 4 2 50 1 0 100 2 2 0 Abnormal blinking 4 2 50 1 1 0 1 1 0 Cataracts 4 3 25 5 3 40 8 7 13 Periorbital cellulitis 3 2 33 1 1 0 0 0 N/A Epiphora 3 2 33 1 1 0 1 1 0 High intraocular pressure 2 2 0 2 1 50 3 1 67 Pupil abnormality 2 2 0 5 5 0 2 2 0 Torticollis 0 0 N/A 10 6 40 2 2 0 Posterior segment anomaly 0 0 N/A 1 1 0 16 12 22 Diplopia 0 0 N/A 0 0 N/A 4 3 25† Visual field defect 0 0 N/A 0 0 N/A 2 0 100 Optic nerve head cupping 0 0 N/A 0 0 N/A 2 2 0 Optic nerve head pallor 0 0 N/A 0 0 N/A 1 0 100 Optic nerve head swelling 0 0 N/A 7 1 86 6 6 0 *No ocular abnormalities found on examination. †No medical reason found for the diplopia. N/A = not applicable. Given the significant number of “false-positive” patients referred by general practitioners and pediatricians, directing primary referral patterns toward optometrists, when possible, would be beneficial. Further engagement with optometrists can help improve timely referral of those children who need pediatric ophthalmology input.5 These measures will reduce the volume of referrals to pediatric ophthalmology and the wait times for those children who do need to see a pediatric ophthalmologist while improving the detection and treatment of amblyogenic ocular conditions. Ophthalmology groups across the country should be encouraged to enhance awareness and provide guidance regarding common pediatric ophthalmic conditions to residency training programs, including those of emergency medicine, family practice, and pediatrics. Our retrospective review found that the most common reason for referral from all referring providers was strabismus, of which approximately 50% of patients had a normal examination. Often, these patients were found to have pseudostrabismus, specifically pseudoesotropia. If such cases of pseudostrabismus were diagnosed by the referring provider or, at a minimum, diverted to local optometrists, the burden of patients referred to pediatric ophthalmology and their lengthy wait times would be reduced. Improving eye care for children requires the collective team effort of all primary care providers such as general practitioners; specialists including pediatricians, optometrists, and ophthalmologists; and other stakeholders such as school boards and public health units. We hope that this letter acts as a stimulus for further dialogue between the interested parties, with the aim of improving eye care for children. Kim Vo, MDGrace Yeeun Lee, MPH, MHMYasmin Jindani, OD McMaster Pediatric Eye Research Group (McPERG) Department of Surgery McMaster University Hamilton, Ontario, CanadaHusayn Gulamhusein, MD, MPH Division of Ophthalmology Department of Surgery McMaster University Hamilton, Ontario, CanadaForough Farrokhyar, PhD, MPhil Office of Surgical Research Services Department of Surgery McMaster University Hamilton, Ontario, CanadaKourosh Sabri, MBChB Division of Ophthalmology Department of Surgery McMaster University Hamilton, Ontario, Canada [email protected]

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