Systematic review of the appropriateness of eye care delivery in eye care practice

Developing realistic benchmarks for glaucoma care delivery

CLINICAL RELEVANCE

Realistic benchmarks can serve as comparators for optometrists wishing to engage in clinical practice audits of their glaucoma care.

BACKGROUND

The iCareTrack study established the appropriateness of glaucoma care delivery through clinical record audits of Australian optometry practices. Benchmarks required for monitoring and improving glaucoma care delivery do not exist. This study developed realistic benchmarks for glaucoma care and then benchmarked the performance of practices from the iCareTrack study to establish aspects of care that warrant attention from quality improvement initiatives.

METHODS

Benchmarks were developed from the pre-existing iCareTrack dataset using the Achievable Benchmarks of Care (ABC) method. The iCareTrack study had audited the appropriateness of glaucoma care delivery against 37 clinical indicators for 420 randomly sampled glaucoma patient records from 42 Australian optometry practices. The four-step ABC method calculates benchmarks based on the top 10% of best-performing practices adjusted for low patient encounter numbers. iCareTrack results were compared to the benchmarks to explore the distribution of practices that were at, above or below benchmark.

RESULTS

Benchmarks were developed for 34 of 37 iCareTrack indicators. For 26 (of 34) indicators, the benchmarks were at or above 90% appropriateness. The benchmarks for 14 (of 34) iCareTrack indicators were met by more than 80% of eligible practices, indicating excellent performance. Some aspects of glaucoma care such as peripheral anterior angle assessment, applanation tonometry, and visual field assessment appeared to be delivered sub-optimally by optometrists when compared to the benchmarks.

CONCLUSION

This study established benchmarks for glaucoma care delivery in optometry practices that reflect realistic and top achievable performance. The large number of indicators with benchmarks above 90% confirmed that glaucoma care can and should be delivered by optometrists at very high levels of appropriateness. Benchmarking identified pockets of sub-optimal performance that can now be targeted by quality improvement initiatives.

Clinical indicators for diabetic eyecare delivered by optometrists in Australia: a Delphi study

CLINICAL RELEVANCE

Valid and updated clinical indicators can serve as important tools in assessing and improving eyecare delivery.

BACKGROUND

Indicators for diabetic eyecare in Australia were previously developed from guidelines published before 2013 and then used to assess the appropriateness of care delivery through a nationwide patient record card audit (the iCareTrack study). To reflect emerging evidence and contemporary practice, this study aimed to update clinical indicators for optometric care for people with type 2 diabetes in Australia.

METHODS

Forty-five candidate indicators, including existing iCareTrack and new indicators derived from nine high-quality evidence-based guidelines, were generated. A two-round modified Delphi process where expert panel members rated the impact, acceptability, and feasibility of the indicators on a 9-point scale and voted for inclusion or exclusion of the candidate indicators was used. Consensus on inclusion was reached when the median scores for impact, acceptability, and feasibility were ≥7 and >75% of experts voted for inclusion.

RESULTS

Thirty-two clinical indicators with high acceptability, impact and feasibility ratings (all median scores: 9) were developed. The final indicators were related to history taking (n = 12), physical examination (n = 8), recall period (n = 5), referral (n = 5), and patient education/communication (n = 2). Most (14 of 15) iCareTrack indicators were retained either in the original format or with modifications. New indicators included documenting the type of diabetes, serum lipid level, pregnancy, systemic medications, nephropathy, Indigenous status, general practitioner details, pupil examination, intraocular pressure, optical coherence tomography, diabetic retinopathy grading, recall period for high-risk diabetic patients without retinopathy, referral of high-risk proliferative retinopathy, communication with the general practitioner, and patient education.

CONCLUSION

A set of 32 updated diabetic eyecare clinical indicators was developed based on contemporary evidence and expert consensus. These updated indicators inform the development of programs to assess and enhance the eyecare delivery for people with diabetes in Australia.

Awareness of Common Eye Diseases and Their Risk Factors-A Nationwide Cross-Sectional Survey among Adults in Poland

Public knowledge and awareness of eye diseases may influence individuals' behaviors toward the use of eye care services and prevention methods. The objective of this study was to assess the awareness of common eye diseases and their risk factors among adults in Poland as well as to identify factors associated with knowledge of eye diseases. This nationwide cross-sectional web-based survey was carried out in December 2022 on a representative sample of 1076 adults in Poland. Most of the respondents had heard of cataracts (83.6%), glaucoma (80.7%), conjunctivitis (74.3%), and hordeolum (73.8%). Awareness of dry eye syndrome was declared by 50% of respondents, and 40% were aware of retinal detachment. Among the respondents, 32.3% had heard of AMD, and 16.4% had heard of diabetic retinopathy. A lack of awareness of glaucoma was declared by 38.1% of respondents, and 54.3% declared a lack of awareness of risk factors for AMD. Gender, age, and the presence of chronic diseases were the most important factors (p < 0.05) associated with awareness of common eye diseases and risk factors for glaucoma and AMD. This study demonstrated a low level of awareness of common eye diseases among adults in Poland. Personalized communication on eye diseases is needed.

Level of appropriate primary diabetic eyecare delivered and achievable in optometry practices in Australia

CLINICAL RELEVANCE

Current levels of appropriateness for primary diabetic eyecare delivered by Australian optometrists are presented along with realistic targets (benchmarks) for quality improvement. The demonstrated methods can be used in practice evaluation and benchmarking of other clinical practice areas and settings.

BACKGROUND

To examine the appropriateness of diabetic eye-care delivery and establish achievable benchmarks of care (ABCs) for optometry practices in Australia.

METHOD

In a retrospective audit, clinical records of patients with type-II diabetes obtained from a randomly selected nationally representative sample of optometry practices were assessed against evidence-based clinical indicators. Appropriate care is defined as care delivered in compliance with the indicators. The ABC for each indicator was calculated as the average performance for the top 10% of optometry practices after Bayesian adjustment to account for a low number of eligible records.

RESULTS

The audit of 420 randomly selected patient records from 42 practices against 12 clinical indicators showed an overall appropriateness of 69% (95% confidence interval (CI) 66%, 73%) for overall diabetic eye care. While a high level of appropriateness was identified for recall period (93%, 95% CI 85%, 100%) and referral (100%, 95% CI 38%, 100%), larger gaps existed in history taking (46%, 95% CI 44%, 52%), dilated fundus examination (80%, 95% CI 76%, 84%) and iris examination (0%, 95% CI 0%, 56%). The ABCs for 8 of 12 indicators were 100%, and the remaining three indicators had ABCs above 80%. An ABC for the iris examination indicator could not be calculated owing to the low number of eligible patient record cards.

CONCLUSIONS

This study demonstrated a systematic process of practice evaluation and benchmarking in optometry practices. The diabetic eye care delivered by Australian optometrists was largely appropriate; however, improvement opportunities exist for history taking and physical examination. The ABCs demonstrate that excellence in primary diabetic eye care is attainable and will serve as an important tool in future initiatives to reduce the identified evidence-to-practice gaps.

The appropriateness of and barriers to glaucoma care delivery by Australian optometrists

CLINICAL RELEVANCE

Establishing the level of appropriateness and barriers to glaucoma care delivery by Australian optometrists are important first steps in developing tailored interventions aimed at improving glaucoma care delivery.

BACKGROUND

To determine the appropriateness of and barriers to glaucoma care by optometrists.

METHODS

A mixed method study was conducted. Phase I was a retrospective cross-sectional medical record audit that assessed glaucoma care appropriateness against 37 clinical indicators from a nationally representative sample of 42 optometry practices. In Phase II, focus groups and interviews involving 31 optometrists explored audit findings to identify barriers to appropriate glaucoma care. Barriers were analysed by deductive and inductive qualitative analysis. Saliency analysis was used to identify key domains that influence glaucoma care.

RESULTS

Appropriate glaucoma care was delivered for 63% (95% CI 61%, 64%) of the 420 patient encounters audited. Appropriate care was delivered above 80% for most (57%) indicators, while 14 (38%) indicators were delivered below 60% appropriateness. Good compliance to appropriate care was noted for key indicators of intraocular pressure measurement (90%, 95% CI 87%, 93%) and optic nerve head/retinal nerve fibre layer imaging (78%, 95% CI 74%, 82%). Important barriers identified were beliefs about expected outcomes, lack of perceived relevancy, time constraints, poor organisational culture, knowledge gaps, focusing on some aspects of glaucoma care to the detriment of others, the complexity of glaucoma care, information recall, and social norms.

CONCLUSION

Glaucoma care was appropriate in most patient encounters, with opportunity to improve some aspects of history taking and physical examinations. Barriers to glaucoma care were diverse, existing at both the practitioner and organisational levels. These findings provide direction for the development of a tailored improvement intervention.

Feasibility of Implementing Recommendations to Reduce Fall Risk in Older People: A Delphi Study

SIGNIFICANCE

This study provides guidance for the implementation of recommendations for falls prevention in optometry practice, through synthesis with the optometrists' viewpoint as a major stakeholder. Educators and clinicians can adopt the revised recommendations and associated implementation strategies in this research for successful integration into optometric practice.

PURPOSE

Recommendations for optometrists to help prevent falls in older patients were published in 2019 by Optometry Australia. This study used the Delphi technique to gain perspectives on the feasibility of implementing the recommendations in optometric practice.

METHODS

A Delphi consensus process consisted of two rounds of anonymous questionnaires administered between October 2019 and February 2020. A panel of 12 optometrists scored and commented on the importance and feasibility of 28 recommendations based on a published evidence synthesis by Optometry Australia and a pilot Delphi round. Panelists were invited if they had at least 5-year experience in optometry practice and were involved in post-cataract surgery refractive management regularly in the past 12 months.

RESULTS

Twenty-four recommendations reached consensus after the Delphi process. Recommendations that reached consensus but had low uptake in the panelists' practices were history taking about risk of falls and provision of advice to patients to seek professional home modification. Four recommendations did not reach consensus because they were perceived to be too prescriptive and less feasible to execute in real-world settings. To improve the compliance of patients to recommendations to reduce the risk of falls, panelists recommended involving patients in decision making and practice staff should be involved in falls prevention messaging.

CONCLUSIONS

The Delphi panel supported the feasibility of most of the recommendations in optometric practice and provided suggestions to improve their implementation. Further research is needed to evaluate the implementation and benefits of these recommendations, designed to make optometric practice more effective in preventing patient falls.

Results of a Glaucoma Shared Care Model Using the Enhanced Glaucoma Staging System and Disc Damage Likelihood Scale with a Novel Scoring Scheme in New Zealand

Purpose

To report the results of a scheme sharing follow-up glaucoma consultations between community optometrists and secondary care in a hospital ophthalmic clinic.

Patients and Methods

Optometrists measured intraocular pressure (IOP) with Goldmann Tonometry, graded the optic disc with the Disc Damage Likelihood Score (DDLS) and graded visual field tests with the enhanced Glaucoma Staging Score (eGSS). A scoring system from these tests was applied, and patients were either seen routinely 6 months later within the scheme or returned non-routinely to secondary care. Appointments within the scheme were 6-monthly with the pattern of three community optometrist visits then one hospital clinic visit.

Results

Community optometrists conducted 529 appointments for 285 patients. A total of 114 patients were seen after non-routine return to secondary care, with 61 true positives (53.5%) and 53 false positives (46.5%). Forty-one patients (14.4%) developed glaucoma progression, and 18 patients (6.3%) developed new non-glaucomatous ophthalmic diseases. Fifty-two patients were seen at 2 years after the routine return to secondary care, and three had glaucoma progression, with scheme specificity of 94.2%. The overall false-positive returns to secondary care from eGSS alone was 7.4%, and from the DDLS was 0.01%.

Conclusion

The DDLS and eGSS performed well for this population and would be recommended for use in shared care schemes, and the scoring scheme fulfilled its clinical and clerical purposes. Secondary care appointments are recommended in shared care schemes to manage the expected comorbidities and glaucoma progression, and prevent sight loss from false negatives.