Examining referral patterns to neuro-ophthalmologists

Objective: To analyze referral patterns to neuro-ophthalmologists, characterize rates of misdiagnoses and delayed diagnoses in patients referred, and to identify characteristics of referrals likely to benefit most from neuro-ophthalmologic evaluation. 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 a relatively small number of neuro-ophthalmologists, and patients may be affected by incorrect or delayed diagnosis of these conditions. Design/Methods: Retrospective chart review of 300 new patients seen over 45 randomly-chosen days between 06/2011–06/2015 in one tertiary care neuro-ophthalmology clinic. Date range was chosen to use comprehensive paper charting. Demographics, distance traveled, time between onset and consultation, time between appointment request and consultation, providers seen before referral, unnecessary tests before referral, referral diagnoses, final diagnoses, and impact of the neuro-ophthalmologist on outcome were collected. Results: Patients traveled a median 36.5 miles (IQR: 20–85). Median time from onset was 210 days (IQR: 70–1100). Median time from referral to visit was 34 days (IQR: 7–86), with peaks at one week (urgent requests) and 3 months. 82% (247/300) were complex/very complex. 81% (242/300) were appropriate referrals. Median number of previous providers seen was 2 (IQR: 2–4; range: 0–10). 40% (119/300) were misdiagnosed; 49% (147/300) were at least partially misdiagnosed; 7% (22/300) had unknown diagnoses. Women were more likely to be at least partially misdiagnosed—57% (87/153) versus 35% (39/112) of men. Mismanagement or delay in care was present in 28% (85/300), unnecessary tests in 19% (56/300), unnecessary consultations in 22% (65/300), and imaging misinterpretation in 15% (6/300). In 59% (178/300) neuro-ophthalmologists provided a diagnosis and directed treatment, and in 21% (62/300) neuro-ophthalmologists played a major role in preserving vision/preventing life-threatening complications/avoiding harmful treatment. Conclusions: Most referrals to neuro-ophthalmologists were appropriate, but many were delayed. Misdiagnosis prior to referral was common. Neuro-ophthalmologists often prevented vision and life-threatening complications. Disclosure: Dr. Stunkel has nothing to disclose. Dr. Mackay has nothing to disclose. Dr. Bruce has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with MedImmune, Bayer, Jensen Law Group. Dr. Newman has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with GenSight Biologics and Quark Pharmaceuticals. Dr. Newman has received research support from GenSight Biologics and Santhera Pharmaceuticals. Dr. Biousse has received personal compensation in an editorial capacity for Up to Date Neurology.