Improving the Diagnostic accuracy of referrals for Papilloedema (The DIPP study) from primary care: A qualitative study of GP perspectives.

Problem

Papilloedema refers to optic nerve swelling from raised intracranial pressure and could signify life-threatening disease, e.g., brain tumours. There is little research that examines how GPs manage direct and indirect referral (via community optometry services) for suspected papilledema or benign variants (pseudopapilloedema). Inaccurate referrals can have a negative effect on service delivery and NHS funding as well as patient experience. As part of a programme of work to improve this referral pathway, we used a questionnaire and semi-structured interviews to understand how GPs in England manage people with suspected papilloedema.

Approach

GPs completed an online questionnaire in REDCap via the NIHR Clinical Research Network (June-October 2023). The questionnaire was based on 2 case vignettes with colour fundal photos: one case consulted their GP with headaches and pseudopapilloedema; the second had asymptomatic papilloedema picked up by their optometrist during a routine sight test. In their consent form, GPs could volunteer to be interviewed via zoom. GP interviews were audio-recorded, the transcripts were transcribed then coded by three independent researchers.

Findings

Forty-five GPs completed the questionnaire. For case 1, 21/45 (47%) mistook pseudopapilloedema for papilloedema, but only 11/21 (52%) were confident with their diagnosis and their management varied: 8/21 (38%) suggested a sight test at an optician practice; 8/21 (38%) suggested immediate referral to a hospital service. For case 2, most 26/45 (57.7%) said they would consult the patient, 8/45 (17.8%) would urgently forward the letter to the hospital eye service; 7/45 (15.5%) would refer immediately to hospital. GPs’ suggestions to improve current referral pathways, included: clearer guidelines and referral forms; direct access from community optometrists to specialist services. Some GPs commented that papilloedema rarely presents to them and their environment (room lighting) and available equipment (lack of cycloplegic eyedrops) contribute to their diagnostic uncertainty. Interviews were conducted with five GPs regarding their management of patients with suspected papilloedema; five main themes emerged: (i) Competence and Capabilities (practitioners described their experience, knowledge or lack thereof and relevant training), (ii) History, Examination and Diagnosis (important signs and symptoms, misdiagnoses and prevalence), (iii) Barriers and Limitations (available facilities, time to assess and diagnose, systems setbacks), (iv) Health Professional Opinions (confidence levels, practitioner satisfaction and suggestions), (v) Decision Making and Patient Follow-Up (referral process, current protocol and team discussions).

Consequences

GP perspectives will help us develop clinical guidelines and educational materials to improve the diagnostic accuracy of community referrals for suspected papilloedema. It will reduce hospital waiting times so that patients with serious health problems, like brain tumours, are treated more quickly and with better outcomes.