Study: Half of Tertiary Care Hospital Referrals for Ocular Concerns Deemed Unnecessary

Understandably, referring doctors did better at assessing trauma cases as needing tertiary care services. Still, this study finds many inefficiencies in the handoff of care from generalists to specialists when urgent attention is considered necessary.  Photo: Kristen Walton, OD. Click image to enlarge. Community-based hospitals and other healthcare facilities have continuously been stretched thin in their attempts to obtain coverage from specialists, placing an increased burden on academic medical centers to tend to patients transferred there as a last resort. This is evident in eye care, where studies show ophthalmic conditions represent only 1.5% of emergency room visits nationally, yet the proportion of transfers to tertiary or academic settings are reportedly as high as 24% and growing. What’s more, according to a study recently published in Ophthalmology, over half of transfer diagnoses at a given academic level 1 trauma hospital were inaccurate, and a majority of patients didn’t require admission or procedural intervention.The retrospective cross-sectional study looked at 685 total patients from outside hospitals, emergency departments (ED) and urgent care centers who were sent to the ophthalmology service at Harborview Medical Center in Seattle between February 2022 and January 2023. Of those patients, 6.1% received an in-person evaluation by an eyecare provider prior to being transferred, and 11.3% were discussed with an eyecare provider from the transferring facility. The most common transfer diagnoses were: rule out open globe injury (14.3%), rule out retinal detachment or tear (11%), orbital fracture (10.2%) and eyelid laceration (8.5%). Patients were most frequently transferred from level 2 trauma centers (25.8%) and facilities without any trauma level designation (25.8%). Referring providers predominantly held MD degrees (74.3%) and DO degrees (13.4%), followed by PA-C (4.7%), and ARNP (2.0%) degrees.According to the findings, only 48.9% of cases had accurate transfer diagnoses, and 50.2% of all transfers were discharged from the ED and underwent no procedural intervention within one month of transfer. Patients evaluated in-person by an eyecare provider prior to referral were more likely to have an accurate transfer diagnosis (90.5% vs. 66.3%) and more likely to require admission or procedural intervention (90.5% vs. 46.8%).The distribution by diagnostic accuracy category differed significantly between trauma and non-trauma diagnoses. This remained true after excluding patients for whom diagnostic accuracy could not be assessed. Trauma diagnoses were more likely to be accurate or partially accurate (vs. inaccurate) than non-trauma diagnoses (85.7% vs. 77.6%).With cost burdens in mind, the researchers also evaluated the methods of transportation used to get patients to the trauma center. Most patients (53.1%) were transported by ambulance or specialty vehicle, followed by their own automobile (35.6%) and airlift (6%). Of airlifted patients, 60% required admission, 53% required intervention and 20% were discharged without hospital admission or procedural intervention within one month of transfer. “Based on the reported literature on costs of inter-hospital transportation and emergency department visits, transfers to this single institution alone were associated with several millions of dollars of health care spending annually,” the authors wrote in Ophthalmology.The authors found it concerning that over 80% of transferred patients were not seen by or discussed with an eye provider before being transferred, writing that this “highlights a potentially growing emergency care crisis in which fewer ophthalmologists are available to provide on-call coverage at community hospitals.” Additionally, while only 6% of patients were evaluated in person, 11% were discussed with an outside on-call ophthalmologist, suggesting that even when ophthalmology call coverage is available, obtaining in-person emergent eye care remains challenging. “Proposed barriers to in-person examination by on-call eye providers include lack of equipment or outdated equipment in the ED, growth of ophthalmic subspecialization and concerns about malpractice liability in cases of diagnostic uncertainty,” they continued. “Further research is needed to better understand and address these barriers.”This study may be limited by its single-institution design, wrote the authors, which could hinder its generalizability. “Additionally, while we can assess pre-transfer diagnostic accuracy among transferred patients, we cannot assess the accuracy of outside diagnosis in cases that were ultimately not accepted for transfer. We were also limited in our ability to draw conclusions regarding differences in accuracy between those evaluated by ophthalmology and optometry due to the low number of patients evaluated by optometry prior to transfer.”Ultimately, this study supports the substantial time and cost burden for patients and the hospital system caused by patient transfers, which is further exacerbated by inaccurate diagnoses. “Implementing standardized pre-testing evaluation protocols, including in-person eyecare provider evaluations when available, could enhance diagnostic precision and optimize resource use,” the authors concluded.  Click here for the journal source. Hopkin, Blake et al. Assessing the efficacy of ophthalmic transfers to an academic level 1 trauma hospital: Diagnostic accuracy and intervention rates. August 11, 2025. [Epub ahead of print.]This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.