PMID- 31609835
OWN - NLM
STAT- MEDLINE
DCOM- 20210923
LR  - 20210923
IS  - 1536-5166 (Electronic)
IS  - 1070-8022 (Linking)
VI  - 40
IP  - 4
DP  - 2020 Dec
TI  - Referral Patterns in Neuro-Ophthalmology.
PG  - 485-493
LID - 10.1097/WNO.0000000000000846 [doi]
AB  - BACKGROUND: Neuro-ophthalmologists specialize in complex, urgent, vision- and 
      life-threatening problems, diagnostic dilemmas, and management of complex 
      work-ups. Access is currently limited by the relatively small number of 
      neuro-ophthalmologists, and consequently, patients may be affected by incorrect 
      or delayed diagnosis. The objective of this study is to analyze referral patterns 
      to neuro-ophthalmologists, characterize rates of misdiagnoses and delayed 
      diagnoses in patients ultimately referred, and delineate outcomes after 
      neuro-ophthalmologic evaluation. METHODS: Retrospective chart review of 300 new 
      patients seen over 45 randomly chosen days between June 2011 and June 2015 in one 
      tertiary care neuro-ophthalmology clinic. Demographics, distance traveled, time 
      between onset and neuro-ophthalmology consultation (NOC), time between 
      appointment request and NOC, number and types of providers seen before referral, 
      unnecessary tests before referral, referral diagnoses, final diagnoses, and 
      impact of the NOC on outcome were collected. RESULTS: Patients traveled a median 
      of 36.5 miles (interquartile range [IQR]: 20-85). Median time from symptom onset 
      was 210 days (IQR: 70-1,100). Median time from referral to NOC was 34 days (IQR: 
      7-86), with peaks at one week (urgent requests) and 13 weeks (routine requests). 
      Median number of previous providers seen was 2 (IQR: 2-4; range:0-10), and 102 
      patients (34%) had seen multiple providers within the same specialty before 
      referral. Patients were most commonly referred for NOC by ophthalmologists (41% 
      of referrals). Eighty-one percent (242/300) of referrals to neuro-ophthalmology 
      were appropriate referrals. Of the 300 patients referred, 247 (82%) were complex 
      or very complex; 119 (40%) were misdiagnosed; 147 (49%) were at least partially 
      misdiagnosed; and 22 (7%) had unknown diagnoses. Women were more likely to be at 
      least partially misdiagnosed-108 of 188 (57%) vs 39 of 112 (35%) of men (P < 
      0.001). Mismanagement or delay in care occurred in 85 (28%), unnecessary tests in 
      56 (19%), unnecessary consultations in 64 (22%), and imaging misinterpretation in 
      16 (5%). Neuro-ophthalmologists played a major role in directing treatment, such 
      as preserving vision, preventing life-threatening complications, or avoiding 
      harmful treatment in 62 (21%) patients. CONCLUSIONS: Most referrals to 
      neuro-ophthalmologists are appropriate, but many are delayed. Misdiagnosis before 
      referral is common. Neuro-ophthalmologists often prevent vision- and 
      life-threatening complications.
FAU - Stunkel, Leanne
AU  - Stunkel L
AD  - Department of Ophthalmology (LS, BBB, NJN, VB), Emory University School of 
      Medicine, Atlanta, Georgia; Departments of Neurology, Ophthalmology, and 
      Neurosurgery (DDM), Indiana University School of Medicine, Indianapolis, Indiana; 
      and Departments of Neurology (BBB, NJN, VB), Epidemiology (BBB), and Neurological 
      Surgery (NJN), Emory University School of Medicine, Atlanta, Georgia.
FAU - Mackay, Devin D
AU  - Mackay DD
FAU - Bruce, Beau B
AU  - Bruce BB
FAU - Newman, Nancy J
AU  - Newman NJ
FAU - Biousse, Valerie
AU  - Biousse V
LA  - eng
GR  - R01 NS089694/NS/NINDS NIH HHS/United States
PT  - Journal Article
PT  - Multicenter Study
PT  - Research Support, N.I.H., Extramural
PL  - United States
TA  - J Neuroophthalmol
JT  - Journal of neuro-ophthalmology : the official journal of the North American 
      Neuro-Ophthalmology Society
JID - 9431308
SB  - IM
MH  - Female
MH  - Humans
MH  - Male
MH  - Middle Aged
MH  - Neurology/*methods
MH  - Ophthalmology/*methods
MH  - Referral and Consultation/*organization & administration
MH  - Retrospective Studies
EDAT- 2019/10/15 06:00
MHDA- 2021/09/24 06:00
CRDT- 2019/10/15 06:00
PHST- 2019/10/15 06:00 [pubmed]
PHST- 2021/09/24 06:00 [medline]
PHST- 2019/10/15 06:00 [entrez]
AID - 00041327-202012000-00006 [pii]
AID - 10.1097/WNO.0000000000000846 [doi]
PST - ppublish
SO  - J Neuroophthalmol. 2020 Dec;40(4):485-493. doi: 10.1097/WNO.0000000000000846.