Rakhee Shah

Measuring clinical practice

The goals of this paper are to review techniques for measuring clinical practice within healthcare professions and to discuss possible applications of these techniques to primary care optometry. A review of the literature suggests a lack of systematic research investigating standards of clinical practice within optometry. It is argued that evidence‐based research to determine the content of typical optometric eye examinations would be valuable for several reasons: to evaluate the service provided to the public by the profession; setting priorities and assessing the outcomes of continuous education and training; to influence governmental and professional policy decisions; National Health Service General Ophthalmic Services issues; the equitable management of clinicolegal matters and consumer complaints; setting appropriate professional guidelines and developing undergraduate training. Evidence‐based studies within other healthcare professions have evaluated the content of clinical consultations. The literature reviewed reveals three main approaches: (1) abstraction of medical records, (2) use of clinical vignettes and (3) use of standardized patients (SPs) who present unannounced to clinics. In this review, we compare and contrast the use of these different methods in assessing the content of clinical consultations. It is clear from the literature reviewed that the use of SPs is the ‘gold standard’ methodology. Clinical vignettes can also provide useful data, especially if computerized.

A comparison of standardised patients, record abstraction and clinical vignettes for the purpose of measuring clinical practice

Background:  A recent review found standardised patient (SP) methodology to be the gold standard method for evaluating clinical care. Alternative methods include record abstraction and computerised clinical vignettes. SPs were compared to clinical records and to computerised vignettes in order to assess whether record abstraction and vignettes are accurate measures of clinical care provided within optometry.

Standardized Patient Methodology to Assess Refractive Error Reproducibility

Purpose. Standardized patient (SP) methodology is the gold standard for evaluating clinical practice. This approach was used to investigate the content of typical optometric eyecare in England and the reproducibility of refractive error measurement using prescriptions obtained by three SPs. Methods. The three SPs were independently examined by three to four expert optometric clinicians to obtain “benchmark” estimates of refractive error. One hundred two community optometrists consented to be visited by three SPs who were trained to provide accurate responses during the examinations. The spectacle prescriptions obtained by the SPs were analyzed for spherical equivalent refraction, spherical power and cylindrical power using astigmatic decomposition. Results. The spherical equivalent refractions were found to be within ±0.25 D of the benchmark on average 81% of the time and within ±0.50 D 97% of the time. The spherical power was within ±0.25 D 90% of the time and within ±0.50 D 98% of the time. The cylindrical power agreed within ±0.25 D 93% of the time and within ±0.50 D 100% of the time. Based on reproducibility limits data obtained for all six eyes, any two optometrists would differ in their estimation of spherical equivalent refraction by no more than 0.75 D in 95% of repeated measures. The astigmatic data (C0 and C45) show that optometrists will differ in their estimation of the C0 component by between 0.25 and 0.61 D and for the C45 component by between 0.22 and 0.47 D in 95% of repeated measures. Conclusions. The agreement between our data and the results of other similar studies support the conclusions that subjective refractive findings are reproducible to approximately ±0.75 D when performed by multiple optometrists in patients of different age groups and levels of ametropia. SPs are an effective way of measuring reproducibility of refractive error and should be considered for further comparative analysis in different age groups and different levels of ametropia.

Glaucoma detection: the content of optometric eye examinations for a presbyopic patient of African racial descent.

Aims: Standardised patient (SP) methodology is the gold standard for evaluating clinical practice. We investigated the content of optometric eyecare for an early presbyopic SP of African racial descent, an “at-risk” patient group for primary open-angle glaucoma (POAG). Methods: A trained actor presented unannounced as a 44-year-old patient of African racial descent, complaining of recent near vision difficulties, to 100 community optometrists for an audio-recorded eye examination. The eye examinations were subsequently assessed via a checklist based on evidence-based POAG reviews, clinical guidelines and expert panel opinion. Results: Ninety-five per cent of optometrists carried out optic disc assessment and tonometry, which conforms to the UK College of Optometrists’ advice that those patients aged >40 years should receive at least two of the following tests: tonometry, optic disc assessment, visual field testing. Thirty-five per cent of optometrists carried out all of these tests and 6% advised the SP of increased POAG risk in those of African racial descent. Conclusion: SP encounters are an effective measure of optometric clinical practice. As in other healthcare disciplines, there are substantial differences between optometrists in the depth of their clinical investigations, challenging the concept of a “standard sight test”. There is a need for continuing professional development (CPD) in glaucoma screening, in which the increased risk of POAG in those of African racial descent should be emphasised.

The content of optometric eye examinations for a young myope with headaches

Background:  A recent review found standardised patient (SP) methodology to be the gold standard methodology for evaluating clinical care. We used this to investigate the content of optometric eye care for a young myopic patient with headaches suggestive of migraine.

A survey of the availability of state-funded primary eye care in the UK for the very young and very old

Background:  The National Health Service (NHS) provides General Ophthalmic Services (GOS) to eligible patients in the UK. Nearly all community optical practices have a contract with the NHS via local primary care organisations (primary care trusts in England) allowing the practices to provide NHS sight tests to eligible patients.

The content of optometric eye examinations for a presbyopic patient presenting with symptoms of flashing lights

Background:  Standardised patients (SPs) are the gold standard methodology for evaluating clinical care. This approach was used to investigate the content of optometric eyecare for a presbyopic patient who presented with recent photopsia.

How well does record abstraction quantify the content of optometric eye examinations in the UK

Background:  A recent review found standardised patient (SP) methodology to be the gold standard method for evaluating clinical care. We compared the clinical records describing the content of optometric eye examinations with the actual content, as revealed by SPs.

Technical Note: A comparison of a novel direct ophthalmoscope, the OptyseTM, to conventional direct ophthalmoscopes

Despite the current popularity of binocular indirect ophthalmoscopy, direct ophthalmoscopes are still commonly used by clinicians for fundus examination. They are considered to be expensive, however, and it has been suggested that this cost can prevent their use by healthcare professionals in developing countries. The OptyseTM Lens Free Ophthalmoscope is a novel direct ophthalmoscope, without a lens focus system, that allows for comparatively inexpensive manufacture and supply. We compared the clarity of view with the OptyseTM to that with standard direct ophthalmoscopes, over a sequential cohort of patients with a variety of refractive errors and ocular conditions. The grade of clarity of view with the OptyseTM Lens Free Ophthalmoscope was less than conventional ophthalmoscopes (Wilcoxon signed rank test, p < 0.0001). This grade of clarity of view was not associated with the ametropia of the ophthalmoscopic observation (Spearman r ≤ 0.03, p ≥ 0.28) but was with the presence of cataracts (χ2 test, p < 0.0001) with both the OptyseTM and the conventional ophthalmoscopes. Despite its limitations, the retinal view with OptyseTM was often within acceptable clinical limits suggesting that this relatively inexpensive ophthalmoscope may have a place when cost prohibits any other type of ophthalmoscope use.

The videm summit: Developing patient, carer, and clinician driven research priorities for concurrent visual impairment and dementia.

P4-277 THE VIDEM SUMMIT: DEVELOPING PATIENT, CARER, AND CLINICIAN DRIVEN RESEARCH PRIORITIES FOR CONCURRENT VISUAL IMPAIRMENTAND DEMENTIA. Michael Bowen, Sarah Buchanan, Susan Maskell, James Pickett, Katherine Cowan, David Edgar, Beverley Hancock, Rosa Pepe, Rakhee Shah, The College of Optometrists, London, United Kingdom; The Thomas Pocklington Trust, London, United Kingdom; PPI Representative, Lincoln, United Kingdom; Alzheimer’s Society, London, United Kingdom; James Lind Alliance, National Institute for Health Research Evaluation Trials & Studies Coordinating Centre, Southampton, United Kingdom; City University London, London, United Kingdom; The Outside Clinic, Swindon, United Kingdom. Contact e-mail: michael. bowen@college-optometrists.org