770
Journal of the Royal Society of Medicine Volume 83 December 1990
General practitioner referrals to a-neye hospital:
a standard referral form
N P Jones FRcs I C Lloyd FRCS J Kwartz DO University Department of Ophthalmology,
Manchester, Royal Eye Hospital Oxford Road; Maihester Mi1 9WH
Kewords: general practitioner referral; hospital eye service; standard-ireferrl ferm
Summary
To assess general practitioner (GP) referrals to an
eye hospital, 500 consecutive referral letters were
analysed for content, diagnosis, ocular examination,
and medical and drug history. Inadequate infortion
was provided. Visual acuity was measured by general
practitioners in only 3.7% of referrals. The standard
of ocular examination compared unfavourably with
that of ophthalmic opticians. A standard ophthalmic
referral form is proposed, and referral protocols are
desirable. Undergraduate education in ophthalmology
is inadequate and requires more curricular time.
Introduction
The quality of communication between the hospital
services and general practitioners has recently
come under scrutiny1-10. The discharge letter from a
hospital unit to a general practitioner is an example
of a method of communication often considered to be
in need of improvement8-10. Although the principles
of referral from general practitioner (GP) to hospital
specialist have been addressed2-5, the quality of the
referral letter itself is not so frequently considered6.
Ophthalmology is a busy outpatient specialty with,
in some cases, long waiting times for a first hospital
appointment. With increasing demand, and with a
high prevalence of ocular disease in an ageing
population"1, such problems are unlikely to decrease.
Appropriate, concise and informed referrals from GP
to hospital will do much to- smooth the consultation
process.
At Manchester Royal Eye Hospital, incoming
referral letters are received centrally in the medical
records department and distributed to consultant
firms. The letters are scrutinized by the consultant
or senior registrar, and a decision on priority is
made for the patient's first appointment, based upon
the clinical information contained in the letter. The
quality of referral letters are extremely variable. This
study quantifies this variability and comments on the
effects upon patient triage. Protocols for referral
information are suggested, and the introduction of a
standard referral letter is proposed.
Methods
Five hundred consecutive patient referrals made by
post to the Manchester Royal Eye Hospital were
analysed. Patients referred urgently with letters by
hand to the Accident & Emergency Department were
excluded, as were internal referrals from other
hospital doctors.
Referrals to the hospital were initiated either by the
GP or by an ophthalmic optician (00) via referral
form GOS 18. The content and quality ofthe referral
letters were analysed in terms of presentation,
information provided and the need for priority.
Comparison was made between the information
presented by GP and 00 where appropriate. No
comparison was made between the su s diagnis
of the referring doctor or optician, and the final
diagnosis of the ophthalmologist. The ophthalmologist
scrutinizing the referrals does not have this luxury
and must base his decisions on the information
provided by the referring source.
Form GOS 18 refers a patient from 00 to GP. The
form contains a section for completion by the GP if
referral to an ophthalmologist is considered necessary.
The provision of further relevant information by the
GP in this circumstance, was analysed.
Results
All 500 patients were referred to the hospital by a GP.
Of these referrals, 245 (49.0%) were initiated by the
GP and 255 (51.0%) by an ophthalmic optician. A
diagnosis or suggested diagnosis was made in 409
cases (81.8%). Table 1 shows the spectrum of diagnoses
Tablek . Diagnoses requiring examination ofeyelids, adnexae,
anterior segment or posterior segment
Diagnosis
Number Number
(GP)
(00)
Diagnoses requiringqexandrton
of eyelids and adne
Eyelid lesions for minor surgery
Limal problems
Problems with ocular prostheses
79
12
0
3
2
0
of anterior segment:
Coijunctival and corneal problems 20
38
Cataract
14
74
.
Diagnoses requiring examination
Diagnoses requiring examination
of posterior segment:
Possible glaucoma
Macular degeneration
Diabetic retinopathy
Hypertensive retinopathy
Other fundus problems
2
2
2
0
0
47
18
6
5
14
23
1
3
50
10
20
2
3
41
9
Diagnoses requiring neurological
or orthoptic aesment
Orthoptic problems
Ptosis
Intracranial problems
No diagnosis made
Miscellaneous
0141-0768/90/
120770.03/02.00/0
0 1990
The Royal
Society of
Medicine
Journal of the Royal Society of Medicine Volume 83 December 1990
Table 2. Diagnosis in referral letter: patients with reduced
vision
Diagnosis
Number (GP) Number (00)
2
Amblyopia
35 (44.3%)
Cataract
2
Corneal problems
2
Diabetic retinopathy
2
Glaucoma
2
Macular degeneration
Retinal vascular problems 1
2
Others
No diagnosis made
31 (39.2%)
Total
79
3
70 (54.2%)
4
3
2
15
3
6
23 (17.8%)
129
Table 3. Ocular examination performed by general
practitioners (GP) and ophthalmic opticians (00) as recorded
in the referral letter
Form of examination
Measurement of visual
acuity
External/anterior segment
examination
Examination of fundus
Comprehensive examination
including acuity, anterior
and posterior segment
No record of examination
Patient
Patient
nos. (GP)
nos. (00)
9 (3.7%)
183 (71.7%)
131 (53.5%) 129 (50.6%)
15 (6.1%)
3 (1.2%)
74 (29.0%)
27 (10.6%)
107 (43.7%)
42 (16.5%)
for referrals initiated by GP and 00. For those
patients with symptoms of visual deterioration, the
suggested diagnoses are shown in Table 2.
Where definite evidence was included in the referral
letter of some form of ocular examination having
taken place, this information was recorded. The
examinations performed by GP and 00 are recorded
in Table 3. General practitioners measured the
visual acuity in only 3.7% of referrals initiated by
themselves, and for patients with visual loss, the
proportion rose to 6.3%.
The presentation ofreferral from the GP varied. In
313 cases (62.6%) there was a typed letter. In 92 cases
(18.4%) the referral was in the form of a legible
handwritten letter. It was not possible to read the
letter in 22 cases (4.4%) owing to illegibility or
incomprehensibility.
In 305 referral letters (61.0%) the patient's symptoms
were recorded or were implied by the diagnosis.
Information on the duration of symptoms was
provided by the GP in 54 cases (10.8%). A past ocular
history was provided in 50 cases (10.0%) and
information on topical treatment already prescribed
in 30 (6.0%). Some information on general health was
included in 112 referrals (22.4%) and this proportion
rose to 27.5% for those 127 patients complaining of
loss of vision. A note of currently prescribed drugs was
included in 67 cases (13.4%).
For those 255 patients referred initially by the 00,
an accompanying letter was sent by the GP in 74
(29.0%) cases in addition to the form GOS 18. In 132
referrals (51.8%) form GOS 18 alone was sent, with
or without further information included. In 49 (19.2%)
instances a letter was sent but form GOS 18 was not
enclosed. For those patients referred initially by
the 00, the following additional information was
supplied by the GP: ocular history 24 (9.4%); present
ocular medication 2 (0.8%); past medical history
62 (24.3%); drug history 36 (14.1%). In 166 referrals
(65.0%), no clinical patient information was supplied
by the GP.
Discussion
The spectrum ofdiagnoses shown in Table 1 illustrates
patients' perceptions of the roles of GPs and opticians.
It also reflects opticians' greater knowledge of
ophthalmology and greater skill in ophthalmoscopy.
Both professionals have an active part to play in the
primary care of ocular problems. Ocular complaints
account for 2.7% of all GP consultations12, yet
undergraduate medical education in ophthalmology
does not adequately reflect this. There is much room
for improvement.
Clearly, a referring doctor is selective about what
is included in a referral letter. For this reason
it should not be assumed that failure to include
evidence of an ocular examination, indicates that
no examination has taken place. However, for the
ophthalmologist such information is important and
the inclusion of normal findings is relevant. It is
therefore disappointing that 43.7% of referrals from
GPs contained no evidence of an ocular examination,
and that only 6.1% of patients from this source had
their optic discs or maculae examined. It is also of
some concern that only 29% of patients referred by
QOs included any comment on the posterior segment,
despite the fact that examination of the optic discs
is a statutory part of a refraction test.
The measurement of visual acuity is, for the
ophthalmologist and optician, the first part of any
ophthalmic examination. This need not be the case
for the general practitioner, but should be mandatory
if the patient complains of visual loss or other visual
symptoms. The test is not time-consuming and every
general practice should be able to provide a Snellen
chart for this purpose. It is of concern that even for
patients with visual loss, only 6.3% of patients had
visual acuity measured by their GP. The figure of
71.7% for opticians was surprisingly low.
The importance of providing a medical background
for a patient with visual loss was appreciated in only
the minority ofreferrals (27.5%). In only 13.4% was any
drug information provided. Information on currently
prescribed drugs is of great importance in any
referral, and no less so because the recipient is an
ophthalmologist. Many ophthalmological patients
are elderly, and it is in this age group where
much inaccuracy in drug reporting is found7. Some
drugs can cause ocular disease (eg prednisolone,
chloroquine). Others can interact with topical ophthalmological drugs (eg Verapamil with ,8-blockers)
whereas some can potentiate drugs used in ophthalmological practice (eg potassium-losing diuretics
and aceta7nlamide). Some have important implications
for surgery, and this includes minor eyelid surgery
(eg warfarin). Drug information includes topical
treatment, and in only 6% of this study was such
information included. We are aware that by no means
all patients will have used topical treatment, but it
is common for such information to be absent when
treatment has been given. The information is
important especially where an antibiotic has already
771
772
Journal of the Royal Society of Medicine Volume 83 December 1990
been tried, and is crucial if a topical steroid has been
prescribed.
For those patients initially referred by their
optician, 65% had no further information supplied
before the referral was forwarded to the
ophthalmologist. It was also disappointing that in
19.2%, form GOS 18 was not sent on by the GP. With
this referral route, both optician and GP have
impQrtant information to divulge. Form GOS 18
contains a refraction and details of an ophthalmic
examination which will be comprehensible to an
ophthalmologist but often not to a GP. This form
should always be included. Similarly, many patients
with ocular complaints will have underlying medical
problems unknown to their optician, which can be
placed into perspective by their general practitioner.
This opportunity should not be missed. Suggestions
that opticians refer directly to ophthalmologists
should be resisted for this reason, except in the
occasional purely ophthalmic emergency such as
acute glaucoma.
The question of screening for ocular diseases,
especially glaucoma, has been raised in the past
and the suggestion has been made that general
practitioners have a role to play13. Opticians are
however better placed to do this. They are better
trained in ophthalmology (though this is a
condemnation of undergraduate medical training), are
more likely to be accurate in their diagnosis614"5 and
have access to tonometry and visual field testing,
which is necessary to make a better assessment of the
patient than is possible by mere examination of the
optic discs16. That opticians are already more active
in this field is supported by this study, in which GPs
referred two glaucoma suspects, and opticians 47.
In an attempt to improve the quality and layout
of information provided in a hospital discharge
Practice stamp
Date
Dear
DOB
Re:
Address:
Occupation:
Now Patient
Eye Hosp No:
Symptoms:
Duration:
Treatment:
Exasination:
Best Visual acuity
R
L
Diagnosis:
Hedical History:
Current drugs:
Priority:
Routine
Some priority
Urgent
Reason:
Yours
Figure 1. Proposed format for a standard referral letter
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summary, a standard format has been suggested8.
The concept can equally be applied to a referral letter,
and an example is given in Figure 1. The letter
contains practice and patient details, and is followed
by a concise list of information which would enable
rapid and accurate assessment of the patient's needs
by the ophthalmologist. These details include some
statement on symptoms and their duration, the
essentials of ocular examination, and supporting
information on past medical history and prescribed
drugs. The widespread usage of such forms, together
with the mutual development of referral protocols as
suggested by Marinker et aL3 can only improve the
standard ofreferral and therefore the service provided
to patients. The provision of a similar section along
these lines would also enhance the GOS 18 referral
form.
Acknowledgments: We are grateful for the willing help of
the staff of the Medical Records Department, Manchester
Royal Eye Hospital.
References
1 Fair JF. Hospital discharge and death communications.
Br J Hosp Med 1989;42:59-61
2 McGlade KJ, Bradley T, Murphy GJ, Lundy GP.
Referrals to hospital by general practitioners: a study
of compliance and communication. BMJ 1988;297:
1246-8
3 Marinker M, Wilkin D, Metcalfe DH. Referral to
hospital: can we do better? BMJ 1988;297:461-4
4 Hull FM, Westerman RF. Referral to medical outpatients department at teaching hospitals in Birmingham
and Amsterdam. BMJ 1986;293:311-14
5 Coulter A, Noone A, Goldacre M. General practitioners'
referrals to specialist outpatient clinics. BMJ 1989:304-8
6 Harrison RJ, Wild JM, Hobley AJ. Referral patterns to
an ophthalmic outpatient clinic by general practitioners
and ophthalmic opticians and the role of these professionals in screening for ocular disease. BMJ 1988;
297:1162-7
7 Gilchrist WJ, Lee YC, Tam HC, MacDonald JB,
Williams BO. Prospective study of drug reporting by
general practitioners for an elderly population referred
to a geriatric service. BMJ 1987;294:289-91
8 Penney TM. How to do it. Dictate a discharge sutmmary.
BMJ 1989;28:1084-5
9 Penney TM. Delayed communication between hospitals
and general practitioners: where does the problem lie?
BMJ 1988;297:28-9
10 Mageean RJ. Study of "discharge communications" from
hospital. BMJ 1986;293:1283-4
11 Gibson JM, Rosenthal AR, Lavery J. A study of'the
prevalence of eye disease in the elderly in an English
community. Trans Ophthalmol Soc UK 1985;104:
196-203
12 Dart JK. Eye disease at a community health centre.
BMJ 1986;293:1477-80
13 Hitchings RA. Visual disability and the elderly. BMJ
1989;298:1126-7
14 Clearkin L, Harcourt B. Referral pattern of true and
suspected glaucoma to an adult ophthalmic outpatient
clinic. Trans Ophthalmol Soc UK 1983;103:284-7
15 Brittain GP, Austin DJ, Kelly SP. A prospective survey
to determine sources and diagnostic accuracy of
glaucoma referrals. Health Trendls 1988;20:43-4
16 Wood CM, Bosanquet RO. Limitations of direct ophthalmoscopy in screening for glaucoma. BMJ 1987;294:
1587-8
(Accepted 8 May 1990)