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An Evidence-Based Investigation of the Content of Optometric Eye Examinations in the UK

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An Evidence-Based Investigation of the Content of Optometric Eye Examinations in the UK Shah, Rakhee (2009). An Evidence-Based Investigation of the Content of Optometric Eye Examinations in the UK. (Unpublished Doctoral thesis, City University London) City Research Online Original citation: Shah, Rakhee (2009). An Evidence-Based Investigation of the Content of Optometric Eye Examinations in the UK. (Unpublished Doctoral thesis, City University London) Permanent City Research Online URL: http://openaccess.city.ac.uk/12445/ Copyright & reuse City University London has developed City Research Online so that its users may access the research outputs of City University London's staff. Copyright © and Moral Rights for this paper are retained by the individual author(s) and/ or other copyright holders. All material in City Research Online is checked for eligibility for copyright before being made available in the live archive. URLs from City Research Online may be freely distributed and linked to from other web pages. Versions of research The version in City Research Online may differ from the final published version. Users are advised to check the Permanent City Research Online URL above for the status of the paper. Enquiries If you have any enquiries about any aspect of City Research Online, or if you wish to make contact with the author(s) of this paper, please email the team at [email protected]. An Evidence-Based Investigation of the Content of Optometric Eye Examinations in the UK Rakhee Shah Doctor of Philosophy Henry Wellcome Laboratories for Vision Sciences, The Department of Optometry and Visual Science, City University, Northamptom Square, London. EC1V 0HB, UK. Research conducted at: The Institute of Optometry, 56-62 Newington Causeway, London. SE1 6DS, UK. May 2009 Contents Page Tables 1-5 Figures and Illustrations 6-8 Acknowledgements 9 Declaration 11 Thesis Abstract 12 Chapter 1 Literature Review and Introduction 13 1.1 Background 13 1.2 Why do we need to measure clinical practice? 17 1.3 Methods of measuring clinical practice 21 1.4 Comparisons of the methods of measuring clinical care 24 1.5 Literature review of use of standardised patients (SPs) 26 1.6 Conclusions from literature review 34 1.7 Aims of the research study 36 Chapter 2 Study 1: Telephone Survey: A Survey of the 37 Availability of State Funded Primary Eyecare in the UK for the Very Young and Very Old 2.1 Aims of study 1 37 2.2 General Introduction 37 2.3 General Methods 40 2.4 Scenario 1: A child aged one year 41 2.5 Scenario 2: A patient aged 90 years with Dementia 46 2.6 General Discussion 51 2.7 Chapter Summary 54 Chapter 3 An Overview of Study 2: The Standardised Patient 56 Study 3.1 Aims of Study 2: The standardised patient study 56 3.2 Choice of standardised patient profiles 57 3.3 General Methods 58 3.4 Introduction to results 73 3.5 Chapter Summary 74 Chapter 4 Scenario 1: The Content of Optometric Eye 75 Examinations for a Young Myope Presenting with Headaches 4.1 Introduction 75 4.2 Methods 78 4.3 Results 83 4.4 Discussion 91 4.5 Chapter Summary 96 Chapter 5 Scenario 2: The Content of Optometric Eye 97 Examinations for a Presbyopic Patient of African Racial Descent 5.1 Introduction 97 5.2 Methods 103 5.3 Results 109 5.4 Discussion 115 5.5 Chapter Summary 121 Chapter 6 Scenario 2: The Content of Optometric Eye 123 Examinations for a Presbyopic Patient Presenting with Flashing Lights 6.1 Introduction 123 6.2 Methods 127 6.3 Results 134 6.4 Discussion 143 6.5 Chapter Summary 150 Chapter 7 The Reproducibility of Refractive Error Measurement 151 7.1 Introduction 151 7.2 Methods 157 7.3 Results 160 7.4 Discussion 172 7.5 Chapter Summary 180 Chapter 8 How Well Does Record Abstraction Quantify the 181 Content of Optometric Eye Examinations in the UK? A Comparison of Standardised Patients to Clinical Record Cards 8.1 Introduction 181 8.2 Methods 182 8.3 Results 184 8.4 Discussion 190 8.5 Chapter Summary 200 Chapter 9 General Discussion of Study 2 202 9.1 General Discussion 202 9.2 Limitations of Standardised Patient Research 205 9.3 Chapter Summary 206 Chapter 10 Study 3: Clinical Vignettes in Assessing Clinical Care 207 within Optometry 10.1 Introduction 207 10.2 Methods 208 10.3 Results 211 10.4 Discussion 222 10.5 Chapter Summary 233 Chapter 11 A Comparison of Standardised Patients, Record 234 Abstraction and Clinical Vignettes 11.1 Introduction 234 11.2 Methods 234 11.3 Results 235 11.4 Discussion 252 11.5 Chapter Summary 259 Chapter 12 Ideas for Further Research and Final Summary 260 12.1 Ideas for further research 260 12.2 Final Summary & Conclusion 261 Appendices & Supporting Published Work 270 Appendices Summary 271 Supporting Published Work Summary 272 References 273 Tables Page Table 1.1 Optometric practice is legislated in the Opticians Act (1989), 14-5 professional guidelines are provided by the General Optical Council (GOC) and the College of Optometrists, and regulations are issued by the National Health Service (General Ophthalmic Services). This table, while not a complete list of these documents, concentrates on those that influence the standards of professional practice relevant to the present research. Table 1.2 A hierarchy of methods used to assess clinical practice. 27 Miller’s pyramid of clinical competence is illustrated in Figure 1.1. The limitations of the standardised patient (SP) design, with solutions, are discussed in more detail in this chapter. A Hawthorne effect occurs when a practitioner behaves differently because they are being observed. Table 1.3 Important characteristics of Standardised Patients (SPs). 30 Table 2.1 Categories of people eligible for NHS sight tests in the UK. 38 Table 2.2 Terms of Service for General Ophthalmic Services (GOS). This 39 is not a complete list, but is an overview concentrating on the Terms of Service relevant to this study. Table 2.3 Questions asked in Scenario 1. 42 Table 2.4 Responses to the questions: “We have a family history of “lazy 43 eye”/ “squint”. Should my son have an eye test?” and “Can it be done at your opticians?” Table 2.5 Questions asked in Scenario 2. 48 Table 3.1 A table highlighting specific Stage 2 Core competencies 60 relating to the three different scenarios Table 4.1 The MIPCA/MAA eight item headache Diagnostic Screening 77 Questionnaire (DSQ) [Reproduced with permission from the Optician]. Table 4.2 Diagnostic algorithm used with the DSQ for patients who 77 answer ‘yes’ to questions 1-3. [Reproduced with permission from the Optician]. Table 4.3 An overview of the first standardised patient’s symptoms, and 79 answers to questions asked during the eye examination. Table 4.4 Primary and secondary research objectives relating to 82-3 scenario 1. Table 4.5 Questions appropriate to identifying the significant nature of 84 the patient’s headaches, giving the percentage of practitioners who asked each question. 1 Table 4.6 A table showing the percentage of optometrists visited who 84 asked questions relating to the exact nature of the patient’s symptoms of flashing lights. Table 4.7 Outcomes that emerged from the question: “Did the 85 practitioner ask you to seek a medical opinion regarding the headaches?” Table 4.8 Table showing further advice provided by the optometrists 86 regarding the nature of the patient’s headache diagnosis, giving the percentage of practitioners who provided each piece of advice. Table 4.9 The percentages of optometrists working in independent 90 practices, small multiples and large multiple practices that carried out tests recommended by the expert panel in case scenario 1. Table 5.1 An overview of the second standardised patient’s symptoms, 103 and answers to questions asked during the eye examination. Table 5.2 Primary and secondary research objectives relating to 108 scenario 2. Table 5.3 Responses to the question “Am I at a greater risk of any 111 particular conditions”? Table 5.4 The percentages of optometrists working in independent 115 practices, small multiples and large multiple practices that carried out tests recommended by the expert panel in case scenario 2. Table 6.1 An overview of the third standardised patient’s symptoms, and 127-8 answers to questions asked during the eye examination. Table 6.2 Primary and secondary research objectives relating to 133 scenario 3. Table 6.3 Questions appropriate to identifying the nature of the patient’s 135 presenting symptom of flashing lights, giving the percentage of optometrists who asked each question. Table 6.4 Outcomes that emerged from the question: “What proportion 138 of optometrists would have referred this patient to the Hospital Eye Service (HES) and with what urgency?” Table 6.5 Table showing percentages of optometrists working in 142 independents, small multiples and large multiples who carried out the tests suggested by the expert panel in case scenario 3 Table 7.1 A summary of previous studies of reproducibility of refractive 156 error assessments. Table 7.2 The mean refractive findings (benchmark) for the three 161 standardised patients obtained from eye examinations carried out at the Institute of Optometry. The standardised patients’ visual acuities are also presented. 2 Table 7.3 Descriptive statistics of the spectacle prescriptions (expressed 162 as equivalent spheres) obtained for the standardised patients. Table 7.4 Percentage agreement for refractive error between different 163 practitioners. Table 7.5 The 95% limits of agreement for the spherical equivalent, C0 164 and C45 components for prescriptions obtained by the three standardised patients. Table 8.1 2x2 tables comparing the gold standard (SP) findings to the 185 information gathered from record abstraction for three different patient scenarios.
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