Article Date: 6/1/2006

referrals
A Complete Guide To Referrals
The who, what, when, and why of O.D. referrals.
BY TOM MILLER, O.D., F.A.A.O.

While optometry has enjoyed an enhanced scope of practice in recent years, there are still times when we need to refer patients to specialists. But do you refer your patients for the wrong conditions, or to the wrong specialists? Like any responsible health care provider, we recognize the need to refer and do so without hesitation and probably sometimes without need. Too often, perhaps, we may refer the wrong problems to the wrong professional. This can create an unnecessary hassle and extra costs to our patients and to society in general, as well as perhaps a subtle loss of prestige for ourselves. I'll provide some guidelines here to help you when you're considering referring a patient.

When You Need Laboratory Testing

Below are some examples of tests you may need to order to diagnose various conditions: TEST: Erythrocyte sedimentation rate Ischemic optic neuropathy Giant cell arteritis Third nerve palsy TEST: C-Reactive Protein Ischemic optic neuropathy Amaurosis fugax TEST: Fasting blood glucose    Diabetes mellitus TEST: Hemoglobin A1C Diabetes mellitus TEST: Rheumatoid factor     Anterior uveitis secondary to suspected Juvenile rheumatoid arthritis TEST: Human leukocyte antigen (HLA-B27): Anterior uveitis, recurrent or bilateral Behcet's disease TEST: Fluorescent treponemal antibody absorption test (FTA-ABS): Behcet's disease TEST: Rapid plasma reagin (RPR) or Veneral disease research laboratory test (VDRL) Anterior uveitis, recurrent or bilateral TEST: Complete Blood Count (CBC) with differential     Giant cell arteritis Ischemic optic neuropathy Diabetes TEST: Lipid profile     Pre-senile corneal arcus

The when, what and who

One reason we may refer a patient is that he or she needs a procedure we are not licensed to perform, such as invasive surgery. We may also refer because we do not want, or do not feel qualified, to provide a particular type of care, such as low vision or specialty contact lens work. And, unfortunately, it may also be due to artificially-induced restrictions placed on us by insurance companies.

What follows are a few examples of wise referral patterns to help ensure prompt treatment of conditions that can be easily identified by O.D.s. They all may be co-managed. You can often start testing and initial treatment prior to referring. The box on page 78, "When You Need Laboratory Testing," offers some examples of conditions for which an optometrist may order tests.

The best way to find appropriate referral sources is from fellow optometrists in your area. Usually excellent practitioners are well known in any particular locale. If possible, you should develop a one-on-one relationship with other providers. Always stay in the loop by communicating both the intention of the consult or referral and your expectations (i.e., I will see this patient back in six months for a repeat dilated retinal exam). Don't assume the other provider will know your intentions. Visit labs and imaging centers and ask them for paperwork necessary for ordering tests. (For information on making referrals to other optometrists, see "Keeping It In The Family," on page 16.)

Labs and imaging centers

Many ophthalmic medical problems warrant further testing to confirm a diagnosis. Before you refer to a specialist, know that we can provide a great service to our patients by ordering, and in many cases interpreting, these tests. Additionally, you can speed proper treatment by having the results readily available to a specialist provider to whom you're referring. These include conditions such as ischemic optic neuropathy, ocular ischemic syndrome, Lyme disease, recurrent uveitis and unexplained vision loss. With these conditions, the proper blood work-up can greatly enhance your patients' level of care and expedite the proper diagnosis.

Other conditions may require imaging to arrive at the proper diagnosis and to guide you to the proper specialty clinician. Pseudotumor cerebri, optic disc swelling, nerve palsy and trauma are a few that frequently demand specialized imaging.

Unless specifically prohibited, you should find a good lab and imaging center in you community to which to send your patients. This is typically a benefit provided to those with hospital privileges, but it is also available to any O.D. who takes the time to learn the protocol. The lab will usually welcome your business with open arms.

Testing tips

Time for Imaging

Plain film x-ray Suspected orbital fracture Chest x-ray Anterior uveitis (recurrent or bilateral) Behcet's disease Computerized Tomography (CT) Scan Suspected orbital fracture with muscle entrapment Papilledema Orbital Cellulitis Graves orbitopathy Orbital tumors Demyelinating optic neuropathy Sinusitis Magnetic Resonance Imaging (MRI) Recent closed head trauma Pseudotumor cerebri/papilledema Orbital tumors Internuclear ophthalmoplegia Optic atrophy Acquired hemianopic or quadranopic field loss Third nerve palsy Chronic headache Magnetic Resonance Angiography (MRA) Suspected carotid/ophthalmic artery stenosis or dissection Suspected intracranial & orbital aneurysms Third nerve palsy

While proper and prudent referral for lab work or imaging is greatly beneficial in enhancing overall patient care, it's important that you are educated about what test to order and when to order it. Improper testing is not only expensive but can potentially delay proper treatment. See the box page 80 ("Time for Imaging") for a list of some common conditions that warrant imaging.

Follow-up is crucial

With all referral cases, it is vitally important from both a legal and a practice management standpoint to follow-up with the patient after he or she has seen the specialist. It's good practice to schedule the testing appointment while the patient is still in your office. Also, you should ensure that the specialist sends all of the patient's testing information to your office. If the specialist informs you that the patient missed the appointment, you need to contact the patient by some means. Many experts recommend a certified letter outlining the seriousness of the condition along with the possible outcome (sight loss, blindness, death, etc.).

Take charge

For the benefit of your patients and your practice, step up to the plate and take command of your patient's eye health. Our mission has evolved from that of a sight tester and eyeglass prescriber to that of a true "doctor of the eyes." Before automatically sending a patient to another clinician, it would often behoove us to fully investigate the problem, gathering all clinical information. At times, this will include requesting laboratory or imaging procedures.

No one will take better care of your patients than you will. Don't assume other practitioners will always do the right thing — be the captain of your patient's eye health. You will reap the rewards in both personal satisfaction and increased income from the referrals made by happy patients. Managing your patients' ocular care will greatly elevate you in their eyes. In this day of rushed, sloppy, inefficient and frequently haphazard medical care, they will appreciate your effort and concern probably more than you will ever know.

Find a good lab and imaging center in your community to which to send your patients.

Dr. Miller is in solo practice in Fayetteville, N.C. He graduated Southern College of Optometry in 2000 after serving in the U.S. Marine Corps. He was North Carolina's Young O.D. of the Year in 2002. E-mail him at tomeyeman@nc.rr.com.

 

 

When and Where to Refer

REFER TO AN INTERNIST  ■Mild diabetic retinopathy ■Mild hypertensive retinopathy ■Suggestive ocular signs of HIV/AIDS ■Ocular conditions suggestive of Lyme's Disease ■Myasthenia gravis REFER TO A NEUROLOGIST OR NEURO-OPHTHALMOLOGIST ■Optic neuritis suggestive of M.S. ■True papilledema ■Possible brain lesion or aneurysm shown on neuro-imaging ■Pseudotumor cerebri ■Unexplained anisocoria ■Unexplained nerve palsy REFERRAL TO A CARDIOLOGIST (OR INTERNIST) ■Ocular ischemic syndrome ■Hollenhorst plaque ■Retinal artery occlusion (for carotid artery evaluation) ■Amaurosis fugax REFER TO A RHEUMATOLOGIST ■Chronic uveitis with positive RH factor or antinuclear antibody (ANA) REFER TO A PEDIATRICIAN ■Cellulitis in children ■Severe allergies ■Suspect Attention Deficit Hyperactivity Disorder (ADHD) REFER TO A RETINAL SPECIALIST ■Arteritic ischemic optic neuropathy ■Retinal/Iris neovascularization ■Chronic idiopathic central serous chorioretinopathy (ISCR) requiring laser treatment ■Retinal tears or detachments needing repair REFER TO A GLAUCOMA SPECIALIST Advanced glaucoma needing surgery REFER TO A CORNEAL SPECIALIST ■Keratoplasty ■Severe central corneal ulcers REFER TO A GENERAL OPHTHALMOLOGIST ■Cataract surgery ■Yag capsulotomy

 

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Optometric Management, Issue: June 2006