Levels of state and trait anxiety in patients referred to ophthalmology by primary care clinicians: a cross sectional study

What are the experiences of teleophthalmology in optometric referral pathways? A qualitative interview study with patients and clinicians

OBJECTIVE

Implementing teleophthalmology into the optometric referral pathway may ease the current pressures on hospital eye services caused by over-referrals from some optometrists. This study aimed to understand the practical implications of implementing teleophthalmology by analysing lived experiences and perceptions of teleophthalmology in the optometric referral pathway for suspected retinal conditions.

DESIGN

Qualitative in-depth interview study SETTING: Fourteen primary care optometry practices and four secondary care hospital eye services from four NHS Foundation Trusts across the UK.

PARTICIPANTS

We interviewed 41 participants: patients (17), optometrists (18), and ophthalmologists (6) who were involved in the HERMES study. Through thematic analysis, we collated and present their experiences of implementing teleophthalmology.

RESULTS

All participants interviewed were positive towards teleophthalmology as it could enable efficiencies in the referral pathway and improve feedback and communication between patients and healthcare professionals. Concerns included setup costs for optometrists and anxieties from patients about not seeing an ophthalmologist face to face. However, reducing unnecessary visits and increasing the availability of resources and capacity were seen as significant benefits.

CONCLUSIONS

Overall, we report positive experiences of implementing teleophthalmology into the optometric referral pathway for suspected retinal conditions. Successful implementation will require appropriate investment to set up and integrate new technology and remunerate services, and continued evaluation to ensure timely feedback to patients and between healthcare professionals is received.

TRIAL REGISTRATION NUMBER

ISRCTN18106677.

Improving equity, efficiency and adherence to referral in Pakistan's eye health programmes: Pre- and post-pandemic onset

Background

Over one billion people worldwide live with avoidable blindness or vision impairment. Eye Health Programmes tackle this by providing screening, primary eye care, refractive correction, and referral to hospital eye services. One point where patients can be lost in the treatment journey is adherence to hospital referral.

Context

Peek Vision's software solutions have been used in Pakistan with the goal of increasing eye health programme coverage and effectiveness. This involved collaboration between health system stakeholders, international partners, local community leaders, social organizers and “Lady Health Workers”.

Results

From the beginning of the programmes in November 2018, to the end of December 2021, 393,759 people have been screened, 26% of whom (n = 101,236) needed refractive services or secondary eye care, and so were referred onwards to the triage centers or hospital services. Except for a short period affected heavily by COVID-19 pandemic, the programmes reached an increasing number of people over time: screening coverage improved from 774 people per month to over 28,300 people per month. Gathering and discussing data regularly with stakeholders and implementers has enabled continuous improvement to service delivery. The quality of screening and adherence to hospital visits, gender balance differences and waiting time to hospital visits were also improved. Overall attendance to hospital appointments improved in 2020 compared to 2019 from 45% (95% CI: 42–48%) to 78% (95% CI: 76–80%) in women, and from 48% (95% CI: 45–52%) to 70% (95% CI: 68–73%) in men. These patients also accessed treatment more quickly: 30-day hospital referral adherence improved from 12% in 2019 to 66% in 2020. This approach helped to utilize refractive services more efficiently, reducing false positive referrals to triage from 10.6 to 5.9%. Hospital-based services were also utilized more efficiently, as primary eye care services and refractive services were mainly delivered at the primary healthcare level.

Discussion

Despite various challenges, we demonstrate how data-driven decisions can lead to health programme systems changes, including patient counseling and appointment reminders, which can effectively improve adherence to referral, allowing programmes to better meet their community's needs.

A prospective study on effectiveness of elevated intraocular pressure as a criterion for glaucoma referrals by optometric practitioners in Sweden

PURPOSE

To evaluate the outcome of referrals for suspected glaucoma based on elevated intraocular pressure (IOP) made by optometric practitioners in Sweden.

METHODS

This prospective study included 95 individuals referred to the Skåne University Hospital Malmö, Sweden, during 2019, by optometric practitioners, based on elevated IOP. Positive outcome was defined as a diagnosis of glaucoma, or a diagnosis of suspected glaucoma. Referral accuracy was analysed. Positive predictive values (PPV) of different hypothetical IOP and age thresholds were calculated.

RESULTS

In 34% (95% CI: 24-43%) of the referrals, no eye disease was found. Intraocular pressure (IOP) was the only referral criterion in 77% (73/95). The PPV was 35% (95% CI: 25-45%) for all referrals, 27% (95% CI: 16-38%) for IOP-only referrals and 59% (95% CI: 36-82%) for referrals including additional findings. In IOP-only referrals, no definite diagnosis of glaucoma was made in any patients <45 years of age. Applying a theoretical age limit of ≥45 years with a hypothetical IOP limit of ≥25 mmHg in patients 45-69 years and of ≥22 mmHg in patients ≥70 years increased the PPV to 42% (95% CI: 27-57%). IOP-only referrals would have been reduced by 27% without missing any glaucoma cases.

CONCLUSION

The overall predictive value of the referrals was poor. Glaucoma resources would have been used more effectively by increasing the required age for IOP-only referrals to ≥45 years in combination with different IOP thresholds for certain age groups.

Detectability and Bias Indices of Pneumatic Corneal Stimuli Using Signal Detection Theory

Purpose

To evaluate the feasibility of using signal detection theory (SDT) in estimating criterion and detectability indices for corneal pneumatic stimuli and test corneal psychophysical data against linking hypotheses from nonprimate physiology using Bayesian analysis.

Methods

Corneal pneumatic stimuli were delivered using the Waterloo Belmonte esthesiometer. Corneal thresholds were estimated in 30 asymptomatic participants and 1.5× threshold stimuli were used as signals (with 0.4 probability). There were 100-trial mechanical and cold stimulus experiments and 50-trial chemical experiments. Trials were demarcated auditorily and "yes" or "no" recorded after each trial. Cold stimulus experiments were conducted with 0.6 signal probability. Criterion (c), likelihood ratio (lnβ), and d' were calculated from the yes-no responses.

Results

Average d' was 0.59 ± 0.1, 1.65 ± 0.37, and 1.14 ± 0.3 units for cold, mechanical, and chemical stimuli, respectively. Bayes factors obtained using Bayesian analysis of variance mildly favored (BF10 = 1.55) differences between d's of the stimulus types, with no support for differences in criteria between stimulus types. Multiple comparisons of d' supported linking hypotheses based on nociception and nerve conductance theories.

Conclusions

Our experiments are the first to demonstrate the feasibility of estimating SDT indices and test different hypotheses. The conservative strategy (reporting "no" more often) chosen by participants was anticipated due to relatively large proportion of catch trials.

Translational Relevance

SDT when using pneumatic esthesiometry is vital to evaluate bias in responses of participants. Considering the varied forms of inherent noise in the corneal sensory system, SDT is critical to understand the sensory and decisional characteristics.

A needs assessment for a minor eye condition service within Leeds, Bradford and Airedale, UK

Background

There are a number of limitations to the present primary eye care system in the UK. Patients with minor eye conditions typically either have to present to their local hospital or GP, or face a charge when visiting eye care professionals (optometrists). Some areas of the UK have commissioned enhanced community services to alleviate this problem; however, many areas have not. The present study is a needs assessment of three areas (Leeds, Airedale and Bradford) without a Minor Eye Conditions Service (MECS), with the aim of determining whether such a service is clinically or economically viable.

Method

A pro forma was developed for optometrists and practice staff to complete when a patient presented whose reason for attending was due to symptoms indicative of a problem that could not be optically corrected. This form captured the reason for visit, whether the patient was seen, the consultation funding, the outcome and where the patient would have presented to if the optometrists could not have seen them. Optometrists were invited to participate via Local Optical Committees. Results were submitted via a Google form or a Microsoft Excel document and were analysed in Microsoft Excel.

Results

Seventy-five percent of patients were managed in optometric practice. Nine and 16% of patients required subsequent referral to their General Practitioner or hospital ophthalmology department, respectively. Should they not have been seen, 34% of patients would have presented to accident and emergency departments and 59% to their general practitioner. 53% of patients paid privately for the optometrist appointment, 28% of patients received a free examination either through use of General Ophthalmic Service sight tests (9%) or optometrist good will (19%) and 19% of patients did not receive a consultation and were redirected to other providers (e.g. pharmacy, accident and emergency or General Practitioner). 88% of patients were satisfied with the level of service. Cost-analyses revealed a theoretical cost saving of £3198 to the NHS across our sample for the study period, indicating cost effectiveness.

Conclusions

This assessment demonstrates that a minor eye condition service in the local areas would be economically and clinically viable and well received by patients.

Measuring Anxiety in Patients With Early-Stage Parkinson's Disease: Rasch Analysis of the State-Trait Anxiety Inventory

The State-Trait Anxiety Inventory (STAI), composed of two 20-item subscales (STAI-state and STAI-trait), has been increasingly used to assess anxiety symptoms in patients with Parkinson's disease (PD). However, the clinimetric attributes of the STAI under the statistical framework of the item-response theory (IRT) have not been fully elucidated within this population to date. We performed an IRT-based Rasch analysis of the STAI outcomes of patients with de novo PD from the Parkinson's Progression Markers Initiative database. The unidimensionality, Rasch model fit, scale targeting, separation reliability, differential item functioning, and response category utility of the STAI were statistically evaluated. A total of 326 (209 males, 117 females) patients without cognitive dysfunction were enrolled in our study. The original versions of the STAI-state and STAI-trait had acceptable separation reliability but lacked appropriate response category functioning, exhibited scale off-targeting, and several items demonstrated poor fit to the Rasch model. The response categories were reduced from four to three, and the rescored three-point TASI-trait demonstrated a marked improvement in clinimetric properties without a significant impact on unidimensionality and separation reliability. The rescored three-point version of the STAI-state required the additional removal of four misfitting items in order to improve the Rasch model fit. To our knowledge, this is the first study to assess the measurement properties based on the IRT of the STAI in patients with PD. Our Rasch analysis identified the components requiring possible amendments in order to improve the clinimetric attributes of the STAI.

An Automated Grading System for Detection of Vision-Threatening Referable Diabetic Retinopathy on the Basis of Color Fundus Photographs

OBJECTIVE

The goal of this study was to describe the development and validation of an artificial intelligence-based, deep learning algorithm (DLA) for the detection of referable diabetic retinopathy (DR).

RESEARCH DESIGN AND METHODS

A DLA using a convolutional neural network was developed for automated detection of vision-threatening referable DR (preproliferative DR or worse, diabetic macular edema, or both). The DLA was tested by using a set of 106,244 nonstereoscopic retinal images. A panel of ophthalmologists graded DR severity in retinal photographs included in the development and internal validation data sets (n = 71,043); a reference standard grading was assigned once three graders achieved consistent grading outcomes. For external validation, we tested our DLA using 35,201 images of 14,520 eyes (904 eyes with any DR; 401 eyes with vision-threatening referable DR) from population-based cohorts of Malays, Caucasian Australians, and Indigenous Australians.

RESULTS

Among the 71,043 retinal images in the training and validation data sets, 12,329 showed vision-threatening referable DR. In the internal validation data set, the area under the curve (AUC), sensitivity, and specificity of the DLA for vision-threatening referable DR were 0.989, 97.0%, and 91.4%, respectively. Testing against the independent, multiethnic data set achieved an AUC, sensitivity, and specificity of 0.955, 92.5%, and 98.5%, respectively. Among false-positive cases, 85.6% were due to a misclassification of mild or moderate DR. Undetected intraretinal microvascular abnormalities accounted for 77.3% of all false-negative cases.

CONCLUSIONS

This artificial intelligence-based DLA can be used with high accuracy in the detection of vision-threatening referable DR in retinal images. This technology offers potential to increase the efficiency and accessibility of DR screening programs.

Expanding the traditional role of optometry: Current practice patterns and attitudes to enhanced glaucoma services in Ireland

PURPOSE

To investigate current diagnostic equipment availability and usage for glaucoma case-finding within community optometric practice, and to explore optometrists' attitudes towards an enhanced scope of clinical practice.

METHODS

An anonymous survey was developed, validated, and distributed to all optometrists in Ireland.

RESULTS

199 optometrists (27% of registrants) responded to the survey. 87% had access to the traditional triad of tests necessary to conduct adequate glaucoma case finding. Standard automated perimetry was the most commonly absent (13%) of the three essential screening tests. 64% of respondents indicated that monocular direct ophthalmoscopy was their first choice technique for fundus examination. 47% of respondents had access to contact applanation tonometry, though just 14% used it as first choice during routine eye examinations. Among the 73 participants with access to both contact and non-contact tonometry (NCT), 80.8%, used NCT preferentially. The significant majority (98%) indicated an interest in enhanced glaucoma services with 57% agreeing that postgraduate training was an essential prerequisite to any increase in scope of practice.

CONCLUSION

Irish optometrists are well equipped with the traditional tests used in glaucoma detection. However, implementation of enhanced referral schemes or glaucoma monitoring or management services would require equipment upgrades and associated training in at least half of the surveyed practices. There is strong interest in furthering optometric professional development and expanding the traditional role boundaries of optometrists, incorporating further education as an essential prerequisite to an enhanced scope of practice.

The relationship between unwarranted variation in optometric referrals and time since qualification

PURPOSE

To investigate variation in optometric referral decision-making and the influence of experience and continuing education and training (CET).

METHODS

To gain insight into unwarranted variation in referral activity in the United Kingdom (UK): (1) triage data were audited to investigate source of referral, provisional diagnosis, and outcome; (2) an online system was developed to present two sets of 10 vignettes, designed to avoid prompting answers. Participating optometrists completed 10 pre-CET vignettes, recording their tests and management decisions. The main group of participants chose whatever CET they wished over a 6-month period and then completed another 10 post-CET vignettes. A second group of newly-qualified optometrists completed the vignettes before and after a CET course intervention, followed by a third group of pre-registered optometrists with an intervention of 6-months experience of their pre-registration year.

RESULTS

The audit identified 1951 optometric referrals and 158 optometrists (211 referrals were from general medical practitioners), with 122 of the 158 optometrists making fewer than ten referrals. Two newly-qualified optometrists generated 12.5% of the total referrals in the audit (N = 2162). Many suspect glaucoma referrals were based on a single suspect measurement resulting in a high discharge rate after community review, as did referrals for certain fundus-related appearances for which no treatment was indicated. The intervention of gaining CET points appeared to have no significant impact (p = 0.37) on referral decision-making, although this part of the study was underpowered. Self-selection bias was confirmed in the main group. When the main group and newly-qualified practitioners were compared, the number of referrals was negatively associated with time since qualification (p = 0.005). When all 20 referral decisions were compared, all optometrists referring more than 10 vignette patients came from a group of newly-qualified practitioners up to 2 years post-qualification. Pre-registered optometrists generally referred more appropriately than newly-qualified. Upon qualification, there was a significant increase in the number of sight tests undertaken per day (p = <0.0005).

CONCLUSIONS

Gaining CET points alone is unlikely to significantly improve referral decision-making. Mentoring and targeted CET for the newly-qualified up to 2 years post-qualification should be considered. Ophthalmology replies to the referring newly-qualified optometrist are vital for moderating future referrals and developing clinical confidence.

Factors influencing accuracy of referral and the likelihood of false positive referral by optometrists in Bradford, United Kingdom

AIMS

Levels of false positive referral to ophthalmology departments can be high. This study aimed to evaluate commonality between false positive referrals in order to find the factors which may influence referral accuracy.

METHODS

In 2007/08, a sample of 431 new Ophthalmology referrals from the catchment area of Bradford Royal Infirmary were retrospectively analysed.

RESULTS

The proportion of false positive referrals generated by optometrists decreases with experience at a rate of 6.2% per year since registration (p<0.0001). Community services which involved further investigation done by the optometrist before directly referring to the hospital were 2.7 times less likely to refer false positively than other referral formats (p=0.007). Male optometrists were about half as likely to generate a false positive referral than females (OR=0.51, p=0.008) and as multiple/corporate practices in the Bradford area employ less experienced and more female staff, independent practices generate about half the number of false positive referrals (OR=0.52, p=0.005).

CONCLUSIONS

Clinician experience has the greatest effect on referral accuracy although there is also a significant effect of gender with women tending to refer more false positives. This may be due to a different approach to patient care and possibly a greater sensitivity to litigation. The improved accuracy of community services (which often refer directly after further investigation) supports further growth of these schemes.

Initial Development and Factor Structure of the Educator Test Stress Inventory

With the proliferation of test-based accountability policies, educators and students alike are under pressure to improve test performance. However, little is known regarding the stress experienced by educators in response to these policies. The purpose of this article is to describe the initial development and validation of a new measure of stress associated with high-stakes testing. Psychometric properties were examined within a sample of 8,084 educators in a southeastern state in the United States. An exploratory and confirmatory factor analysis of the Educator Test Stress Inventory supported a bifactor model of teacher test stress, with one general factor of Total Teacher Stress and two narrow factors of Sources of Stress and Manifestations of Stress. This study is an important first step in establishing a reliable and valid measure of teacher stress and better understanding the impact of high-stakes testing and educational accountability policies. Implications for the assessment and intervention of teacher stress are discussed.