Patients’ health jeopardized by failed ophthalmology follow-up

Failure to follow-up after ophthalmology appointments can damage patients’ health, a new study suggests.

Sixteen patients suffered serious incidents between July 2007 and November 2012 because they did not return for recommended appointments at the Moorfields Eye Hospital in London, according to investigators there.

“In our view, national consideration should be given to create targets for reporting how well providers are managing follow-up patients,” reported A Davis and colleagues in the journal Eye.

The problem is not limited to Moorfields. In 2009, the UK National Patient Safety Agency (NPSA) reported that 44 people with glaucoma experienced some harm as a result of delayed follow-up appointments from June 2005 to May 2009, including 13 patients who went blind.

In response to the concerns of the NPSA, Moorfields analysed the records of patients lost to follow-up over 5 years.

The researchers looked at the records of patients for whom no outcome was reported following an appointment. They identified 145,234 episodes as lost to follow-up. Most were within general ophthalmology and support services, such as optometry and orthoptics, and were judged to be low-risk.

They deemed the highest risk cases to be glaucoma, which made up 3.6% of the cases, and retinal cases, which made up 10.7%.

Next, they compared activity rates of subspecialty areas with rates of patients lost to follow-up. They found general ophthalmology, optometry, support services, and orthoptics had more unknown outcomes than expected. Glaucoma, medical retina, and external disease had lower rates than expected.

The investigators found 79,562 (54.8%) of the cases were for patients who had died. Senior clinical staff reviewed the electronic patient records and paper notes, and discharged another 50,519 (34.8%) with notes to the patients and their general practitioners.

They determined 15,153 (10.4%) required clinical review, and made appointments for 12,316 (8.5%).

The hospital staff could not close 2,837 (1.95%) of patient episodes, and were continuing to address them at the time the authors submitted their article.

Of these, 682 were episodes with appointments linked with support services. These patients remained under review in an ophthalmic subspecialty but were discharged from the support service.

Another 1146 were accident and emergency patients. The notes for these were offsite and were gradually being reviewed as they became available. A review of a sample set of 50 showed no clinical harm.

Another 246 patients were in the external disease service, so paper notes were also offsite and not initially available. The investigators could not find any clinical information either electronically or on paper. They wrote to the patients’ general practitioners for information, and offered future appointments to the patients. 

Reasons for lack of follow-up

Looking at the reasons patients did not return for follow-up, the researchers attributed the problem to “incomplete administrative processes to discharge the patients” in 79,652 cases (54.8%).

They found 18,098 (12.5%) resulted from patients not showing up for clinic appointments they had booked, and 47,574 (32.8%) resulted from appointments that were cancelled. They could not tell how many were cancelled by patients and how many by administrators, but data from the first 99,659 patient episodes found 5% of cancellations were due to the hospital and 9% due to the patients.

The researchers took a closer look at the 16 cases of patients who came to serious harm as a result of failure to follow-up. Fourteen of these were patients with glaucoma, one with a central vein occlusion and secondary glaucoma following a dexamethasone intravitreal implant. Another had a benign pleomorphic adenoma of the orbit.

Of the 14 glaucoma patients, 10 did not have follow-up appointments made after an outpatient visit. Another was seen in the accidents and emergency department, then referred to the glaucoma service, but no glaucoma appointment was made.

Of the other 4 patients, 1 patient did not show up for an appointment, and no new appointment was made. Another patient had no follow-up appointment made after a laser trabeculoplasty. A third did not receive an appointment after being referred by a general practitioner. The fourth was seen after the referral, attended an outpatient appointment, then did not return after that.

Evidence in the notes suggest that some of the glaucoma patients had particular obstacles to overcome. One had dementia, another had a poor memory due to a brain haemorrhage, and two had a record of poor compliance with therapy. The fourth had a record of poor attendance for diabetic retinal screening in addition to glaucoma appointments.

All of these patients suffered significant visual field loss as a result of this failure to follow-up. In three quarters of these cases, clinicians had clearly planned follow-up appointments, but in most cases these were changed, most often by the hospital. Lost notes, failure to book a procedure, and transfers from one subspecialty to another were also factors in some cases.

After reviewing literature from other specialties, Moorfields initiated new processes to minimize failures to follow-up.

These procedures include new written policies and training for administrative support to emphasize there must be an outcome for each patient at the end of clinic.

In addition, a log is kept of any patients for whom there are no outcomes, and senior clinicians now review the notes for patients who do not attend appointments, or whose appointments are cancelled.

Moorfields has also begun text reminders for all patients 2 days before appointments.

The hospital has taken steps to raise awareness in business, governance, and teaching meetings of the risks of failure to follow-up.

“There is further work to be done to ensure that patients referred internally to another ophthalmic subspecialty service have the appropriate appointment made,” the authors concluded.