Investigating target refraction advice provided to cataract surgery patients by UK optometrists and ophthalmologists.

PURPOSE: To determine whether UK optometrists and ophthalmologists provide target refraction advice to patients prior to cataract surgery, and when this should first be discussed. METHODS: Optometrists and ophthalmologists were asked to complete a survey of two clinical vignettes (both older patients with cataract; a pre-operative myope who routinely read without glasses and a patient using a monovision approach), plus multiple choice and short answer questions either using hard copy or online. RESULTS: Responses were obtained from 437 optometrists and 50 ophthalmologists. Optometrists who reported they would provide target refraction advice were more experienced (median 22 years) than those who would leave this to the Hospital Eye Service (median 10 years). The former group reported it was in the patients' best interest to make an informed decision as they had seen many myopic patients who read uncorrected pre-operatively, and were unhappy that they could no longer do so after surgery. Inexperienced optometrists reported that they did not want to overstep their authority and left the decision to the ophthalmologist. The ophthalmologists estimated their percentage of emmetropic target refractions over the last year to have been 90%. CONCLUSION: Currently, some long-term myopes become dissatisfied after cataract surgery due to an emmetropic target refraction that leaves them unable to read without glasses as they did prior to surgery. Although experienced optometrists are aware of this and attempt to discuss this issue with patients, less experienced optometrists tend not to. This suggests that target refraction needs greater exposure in university training and continuing professional development. To provide patients with the knowledge to make informed decisions regarding their surgery, we suggest an agreed protocol within funded direct referral schemes of initial target refraction discussions by optometrists to introduce the idea of refractive outcomes and outline options, with further discussion with the ophthalmologist to clarify understanding.

What are patients' beliefs about, and experiences of, adaptation to glasses and how does this affect their wearing habits?

PURPOSE: It is well known that some patients experience difficulties adapting to new glasses. However, little is known about what patients themselves understand of the adaptation process, and how this influences their attitudes and the decisions they make when adapting to a new pair of glasses. Nor is it understood whether these factors affect their wearing habits. METHODS: We conducted four focus groups. Participants were 22 glasses wearers (mean ± SD age 43 ± 14 years, range 21-71 years) who reported they: (1) wore spectacle correction for distance vision (single vision, bifocal or progressive lenses); (2) had struggled to get used to a new pair of glasses and (3) sometimes chose not to wear their distance correction. Focus groups were audio recorded, transcribed verbatim and analysed thematically. RESULTS: We identified three themes. Trust is about how participants' trust in their optometrist and themselves influences the likelihood of them adapting successfully to new glasses. Conflict describes how the advice patients have received about adapting to glasses can conflict with what they have experienced and how this conflict influences their expectations. Part of Me explores how participants' experiences and feelings about their glasses are important to adaptation and this includes physical, visual, emotional and behavioural aspects. CONCLUSIONS: The traditional optometric perspective of adaptation to glasses is much narrower than that held by patients, and significantly underestimates the physical, behavioural and emotional adaptation that patients must go through in order to feel fully comfortable wearing their glasses. Patients should receive significantly more information about adaptation, including symptoms that may be experienced and why these happen, practical tips to aid adaptation, and when and how to raise concerns. Patients should also receive information about the day-to-day effects of blur adaptation to avoid them not wearing their glasses, including for vision-critical tasks such as driving.

The mental health and wellbeing survey of Australian optometrists.

PURPOSE: To investigate the prevalence of mental health conditions and burnout among practising optometrists in Australia. METHODS: A cross-sectional survey of registered practising Australian optometrists was undertaken over a three-week period from mid-November 2019. The survey comprised three well-established mental health scales (Kessler Psychological Distress Scale [K10], Depression Anxiety Stress Scales [DASS-21] and Maslach Burnout Inventory [MBI]) and an open-ended question inviting comments. RESULTS: Five hundred and five respondents completed the K10, representing 8.8% of registered optometrists in Australia; 466 completed all three scales. Prevalence of moderate to severe psychological distress (K10 ≥ 25) was 30.7% (95% CI 26.7%-34.7%), with similar findings for depression and anxiety (DASS-21). Prevalence of high burnout, as indicated by MBI-GS exhaustion was 56.1% (95% CI 51.7%-60.4%), cynicism 57.1% (95% CI 52.7%-61.5%) and professional efficacy 23.1% (95% CI 19.4%-26.8%). Optometrists aged ≤ 30 years were 3.5 times more likely to report moderate to severe psychological distress compared to optometrists aged >30 years (OR = 3.54, P < 0.001, 95% CI 2.38-5.25). The most frequently mentioned work-related issues concerned retail pressures, workload and career dissatisfaction. CONCLUSIONS: The rates of mental health conditions and burnout reported by practising Australian optometrists were high compared with the general population and other health professionals. Younger age and burnout were significant risk factors for psychological distress. Interventions are required to address these issues, particularly for younger optometrists, and could include workplace modifications and building resilience to improve personal mental wellbeing and ensure patient safety.

Co-creating social licence for sharing health and care data.

BACKGROUND: Optimising the use of patient data has the potential to produce a transformational change in healthcare planning, treatment, condition prevention and understanding disease progression. Establishing how people's trust could be secured and a social licence to share data could be achieved is of paramount importance. METHODS: The study took place across Yorkshire and the Humber, in the North of the England, using a sequential mixed methods approach comprising focus groups, surveys and co-design groups. Twelve focus groups explored people's response to how their health and social care data is, could, and should be used. A survey examined who should be able to see health and care records, acceptable uses of anonymous health and care records, and trust in different organisations. Case study cards addressed willingness for data to be used for different purposes. Co-creation workshops produced a set of guidelines for how data should be used. RESULTS: Focus group participants (n = 80) supported sharing health and care data for direct care and were surprised that this is not already happening. They discussed concerns about the currency and accuracy of their records and possible stigma associated with certain diagnoses, such as mental health conditions. They were less supportive of social care access to their records. They discussed three main concerns about their data being used for research or service planning: being identified; security limitations; and the potential rationing of care on the basis of information in their record such as their lifestyle choices. Survey respondents (n = 1031) agreed that their GP (98 %) and hospital doctors and nurses (93 %) should be able to see their health and care records. There was more limited support for pharmacists (37 %), care staff (36 %), social workers (24 %) and researchers (24 %). Respondents thought their health and social care records should be used to help plan services (88 %), to help people stay healthy (67 %), to help find cures for diseases (67 %), for research for the public good (58 %), but only 16 % for commercial research. Co-creation groups developed a set of principles for a social licence for data sharing based around good governance, effective processes, the type of organisation, and the ability to opt in and out. CONCLUSION: People support their data being shared for a range of purposes and co-designed a set of principles that would secure their trust and consent to data sharing.

Experiences following cataract surgery - patient perspectives.

PURPOSE: Most patients report being highly satisfied with the outcome of cataract surgery but there are variable reports regarding the impact of cataract surgery on some real-world activities, such as fall rates. We hypothesised that adaptations to changed refractive correction and visual function may cause difficulties in undertaking everyday activities for some patients and used a series of focus groups to explore this issue. METHOD: Qualitative methods were used to explore patients' experiences of their vision following cataract surgery, including adaptation to vision changes and their post-surgical spectacle prescription. Twenty-six participants took part in five focus groups (Mean age = 68.2 ± 11.4 years), and the data were analysed using thematic analysis. RESULTS: We identified three themes. 'Changes to Vision' explores participants' adaptation following cataract surgery. While several had problems with tasks relying on binocular vision, few found them bothersome and they resolved following second eye surgery. Participants described a trial and error approach to solving these problems rather than applying solutions suggested by their eyecare professionals. 'Prescription Restrictions' describes the long-term vision problems that pre-surgery myopic patients experienced as a consequence of becoming emmetropic following surgery and thus needing spectacles for reading and other close work activities, which they did not need before surgery. Very few reported that they had the information or time to make a decision regarding their post-operative correction. 'Information Needs' describes participant's responses to the post-surgical information they were given, and the unmet information need regarding when they can drive following surgery. CONCLUSION: The findings highlight the need for clinicians to provide information on adaptation effects, assist patients to select the refractive outcome that best suits their lifestyle, and provide clear advice about when patients can start driving again. Patients need to be provided with better guidance from clinicians and prescribing guidelines for clinicians would be beneficial, particularly for the period between first- and second-eye surgery.

Making it work for me: beliefs about making a personal health record relevant and useable.

BACKGROUND: A Personal Health Record (PHR) is an electronic record that individuals use to manage and share their health information, e.g. data from their medical records and data collected by apps. However, engagement with their record can be low if people do not find it beneficial to their health, wellbeing or interactions with health and other services. We have explored the beliefs potential users have about a PHR, how it could be made personally relevant, and barriers to its use. METHODS: A qualitative design comprising eight focus groups, each with 6-8 participants. Groups included adults with long-term health conditions, young people, physically active adults, data experts, and members of the voluntary sector. Each group lasted 60-90 min, was audio recorded and transcribed verbatim. We analysed the data using thematic analysis to address the question "What are people's beliefs about making a Personal Health Record have relevance and impact?" RESULTS: We found four themes. Making it work for me is about how to encourage individuals to actively engage with their PHR. I control my information is about individuals deciding what to share and who to share it with. My concerns is about individuals' concerns about information security and if and how their information will be acted upon. Potential impact shows the potential benefits of a PHR such as increasing self-efficacy, uptake of health-protective behaviours, and professionals taking a more holistic approach to providing care and facilitating behaviour change. CONCLUSIONS: Our research shows the functionality that a PHR requires in order for people to engage with it. Interactive functions and integration with lifestyle and health apps are particularly important. A PHR could increase the effectiveness of behaviour change apps by specifying evidence-based behaviour change techniques that apps should incorporate. A PHR has the potential to increase health-protective behaviours and facilitate a more person-driven health and social care system. It could support patients to take responsibility for self-managing their health and treatment regimens, as well as helping patients to play a more active role when care transfers across boundaries of responsibility.

Participants' preference for type of leaflet used to feed back the results of a randomised trial: a survey.

BACKGROUND: Hundreds of thousands of volunteers take part in medical research, but many will never hear from researchers about what the study revealed. There is a growing demand for the results of randomised trials to be fed back to research participants both for ethical research practice and for ensuring their co-operation in a trial. This study aims to determine participants' preferences for type of leaflet (short versus long) used to summarise the findings of a randomised trial; and to test whether certain characteristics explained participants' preferences. METHODS: 553 participants in a randomised trial about General Practitioners' access to Magnetic Resonance Imaging for patients presenting with suspected internal derangement of the knee were asked in the final follow-up questionnaire whether they would like to be fed back the results of the trial. Participants who agreed to this were included in a postal questionnaire survey asking about their preference, if any, between a short and a long leaflet and what it was about the leaflet that they preferred. Multinomial logistic regression was used to test whether certain demographics of responding participants along with treatment group explained whether a participant had a preference for type of leaflet or no preference. RESULTS: Of the participants who returned the final follow-up questionnaire, 416 (88%) agreed to receive the results of the trial. Subsequently 132 (32%) participants responded to the survey. Most participants preferred the longer leaflet (55%) and the main reasons for this were the use of technical information (94%) and diagrams (89%). There was weak evidence to suggest that gender might explain whether participants have a preference for type of leaflet or not (P = 0.084). CONCLUSIONS: Trial participants want to receive feed back about the results and appear to prefer a longer leaflet. Males and females might require information to be communicated to them differently and should be the focus of further research. TRIAL REGISTRATION: The trial is registered with http://www.isrctn.org/ and ID is ISRCTN76616358.

Using postal randomization to replace telephone randomization had no significant effect on recruitment of patients.

OBJECTIVE: To test the effect of postal randomization on recruitment of patients into a randomized trial in primary care. STUDY DESIGN AND SETTING: General practices used a telephone service to randomize patients in our trial. Delays in the start of recruitment at some sites led us to modify the randomization procedure. When new practices took part patients completed and posted baseline materials to the Trial Secretary in York who performed the randomization and informed those concerned of the allocation. RESULTS: Of the 647 practices who were invited to take part, 130 (45%) of 288 agreed to participate using telephone randomization and 155 (43%) of 359 using the postal method. These practices recruited 553 patients from November 2002 to October 2004 across 11 sites in the United Kingdom. The postal method reduced the number of patients recruited by a factor of 0.86 (95% confidence interval=0.62-1.20), or 14%. The number of general practitioners working in a practice significantly increased patient recruitment by a factor of 1.12 (1.05-1.20), whereas practice distance from hospital significantly decreased recruitment by a factor of 0.98 (0.97-0.99). CONCLUSION: Postal randomization had no significant effect on recruitment of patients into our trial.

Health promotion at NHS breast cancer screening clinics in the UK

Suboptimal diets, sedentary lifestyles, overweight and obesity expose two-thirds of women in England aged over 50 to a heightened risk of lifestyle-related morbidities. The UK's NHS Breast Cancer Screening Programme now reaches 75 per cent of all women aged 53-64 but provides only mammography screening. This cross-sectional survey of 413 women attending two NHS breast screening clinics in North Yorkshire found that the majority of women were interested in having diet and exercise advice at screening clinics and anticipated a neutral or positive effect on their future screening appointments. Interest was highest among older, less educated and overweight women suggesting that this may be a particularly effective medium for reaching higher risk subgroups. Women showed most interest in problem-solving advice, which provided short-term, life-enhancing benefits such as looking and feeling better, having more energy, losing weight and reducing menopausal symptoms, as well as potentially reducing their disease risk. Most appeared to find doing sufficient exercise more problematic than eating healthily and this might be exacerbated by low awareness of exercise guidelines. Given a choice, preferences were to access advice in leaflets or one to one from an expert; however, many younger, professional women were also interested in computer access. Findings indicate the need first for flexible, multi-level access, combining some broad-based information dissemination with pathways to more personalized support and secondly for the relevant consumer benefits associated with better diet and exercise to be promoted as well as longer-term disease prevention. Overall, this study indicates that the UK's NHS Breast Cancer Screening Programme may be uniquely placed to provide health-enhancing advice as well as mammography screening to the majority of women in England, throughout the course of their mid-life. (AU)

Improving response rates using a monetary incentive for patient completion of questionnaires: an observational study.

BACKGROUND: Poor response rates to postal questionnaires can introduce bias and reduce the statistical power of a study. To improve response rates in our trial in primary care we tested the effect of introducing an unconditional direct payment of 5 pounds for the completion of postal questionnaires. METHODS: We recruited patients in general practice with knee problems from sites across the United Kingdom. An evidence-based strategy was used to follow-up patients at twelve months with postal questionnaires. This included an unconditional direct payment of 5 pounds to patients for the completion and return of questionnaires. The first 105 patients did not receive the 5 pounds incentive, but the subsequent 442 patients did. We used logistic regression to analyse the effect of introducing a monetary incentive to increase the response to postal questionnaires. RESULTS: The response rate following reminders for the historical controls was 78.1% (82 of 105) compared with 88.0% (389 of 442) for those patients who received the 5 pounds payment (diff = 9.9%, 95% CI 2.3% to 19.1%). Direct payments significantly increased the odds of response (adjusted odds ratio = 2.2, 95% CI 1.2 to 4.0, P = 0.009) with only 12 of 442 patients declining the payment. The incentive did not save costs to the trial--the extra cost per additional respondent was almost 50 pounds. CONCLUSION: The direct payment of 5 pounds significantly increased the completion of postal questionnaires at negligible increase in cost for an adequately powered study.

Health promotion at NHS breast cancer screening clinics in the UK.

Suboptimal diets, sedentary lifestyles, overweight and obesity expose two-thirds of women in England aged over 50 to a heightened risk of lifestyle-related morbidities. The UK's NHS Breast Cancer Screening Programme now reaches 75% of all women aged 53-64 but provides only mammography screening. This cross-sectional survey of 413 women attending two NHS breast screening clinics in North Yorkshire found that the majority of women were interested in having diet and exercise advice at screening clinics and anticipated a neutral or positive effect on their future screening appointments. Interest was highest among older, less educated and overweight women suggesting that this may be a particularly effective medium for reaching higher risk subgroups. Women showed most interest in problem-solving advice, which provided short-term, life-enhancing benefits such as looking and feeling better, having more energy, losing weight and reducing menopausal symptoms, as well as potentially reducing their disease risk. Most appeared to find doing sufficient exercise more problematic than eating healthily and this might be exacerbated by low awareness of exercise guidelines. Given a choice, preferences were to access advice in leaflets or one to one from an expert; however, many younger, professional women were also interested in computer access. Findings indicate the need first for flexible, multi-level access, combining some broad-based information dissemination with pathways to more personalized support and secondly for the relevant 'consumer benefits' associated with better diet and exercise to be promoted as well as longer-term disease prevention. Overall, this study indicates that the UK's NHS Breast Cancer Screening Programme may be uniquely placed to provide health-enhancing advice as well as mammography screening to the majority of women in England, throughout the course of their mid-life.

The DAMASK trial protocol: a pragmatic randomised trial to evaluate whether GPs should have direct access to MRI for patients with suspected internal derangement of the knee.

BACKGROUND: Though new technologies like Magnetic Resonance Imaging (MRI) may be accurate, they often diffuse into practice before thorough assessment of their value in diagnosis and management, and of their effects on patient outcome and costs. MRI of the knee is a common investigation despite concern that it is not always appropriate. There is wide variation in general practitioners (GPs) access to, and use of MRI, and in the associated costs. The objective of this study was to resolve uncertainty whether GPs should refer patients with suspected internal derangement of the knee for MRI or to an orthopaedic specialist in secondary care. METHODS/DESIGN: The design consisted of a pragmatic multi-centre randomised trial with two parallel groups and concomitant economic evaluation. Patients presenting in general practice with suspected internal derangement of the knee and for whom their GP was considering referral to an orthopaedic specialist in secondary care were eligible for inclusion. Within practices, GPs or practice nurses randomised eligible and consenting participants to the local radiology department for an MRI examination, or for consultation with an orthopaedic specialist. To ensure that the waiting time from GP consultation to orthopaedic appointment was similar for both trial arms, GPs made a provisional referral to orthopaedics when requesting the MRI examination. Thus we evaluated the more appropriate sequence of events independent of variations in waiting times. Follow up of participants was by postal questionnaires at six, twelve and 24 months after randomisation. This was to ensure that the evaluation covered all events up to and including arthroscopy. DISCUSSION: The DAMASK trial should make a major contribution to the development of evidence-based partnerships between primary and secondary care professionals and inform the debate when MRI should enter the diagnostic pathway.

Visual illusions? Beliefs and behaviours of presbyope clients in optometric practice.

Many clients in optometry practice have reported that they do not receive sufficient information from practitioners to make informed purchasing decisions for corrective spectacles. The aim of this study was to identify participants' attitudes and beliefs towards visiting an optician and purchasing spectacles, to compare clients' and practitioners' perceptions of purchasing decisions, and to examine clients' preferences for information and decision making. One hundred and fifty-eight presbyopes completed a questionnaire to examine attitudes and behaviours regarding visiting an optician. Thirty-four practitioners completed a questionnaire examining the purchasing recommendations they make to clients, and their perceptions of clients' purchasing decisions and information needs. Participants reported positive attitudes towards visiting an optician but required more information about their eyesight and about purchasing options. A discrepancy was found between client and practitioner perceptions of purchasing decisions and of involvement in the decision making process. Practitioners overestimated the importance of price to clients and underestimated the importance of their own recommendations on purchasing decisions. The findings of this study could be used to guide practitioners in their provision of information to clients.

Four different types of client attitudes towards purchasing spectacles in optometric practice.

BACKGROUND: Unmet expectations are a major cause of client dissatisfaction, yet very little is known about the expectations and health values that clients in optometry practice hold about having an eye examination and purchasing spectacles. This study identified different attitudes and behaviours held by presbyope clients in optometric practices. METHOD: A total of 158 presbyope clients, recruited from 14 practices, completed a questionnaire which was developed from the theory of planned behaviour. The questionnaire examined attitudes towards spectacles and visiting the optician, motivation to visit the optician, perceptions of barriers to attending the opticians, information requirements, and preferences for shared decision-making. Responses were analysed using principal components analysis. RESULTS AND CONCLUSIONS: Four factors were identified, which were labelled style, vision, avoiding and seeking. Style is concerned with the importance of appearing fashionable or stylish, and desiring approval from others. Vision relates to clients' attitudes towards obtaining clear vision and to maintaining healthy eyesight. Avoiding describes the perceived difficulties associated with visiting the optician and purchasing new spectacles. Seeking corresponds to the desire for information on the technical details of lenses. Practitioners could use these characteristics to tailor information to meet the needs and address the expectations of individual clients. This may make the information provided more personally relevant, and could enhance client satisfaction.

Information within optometric practice: comprehension, preferences and implications.

The partnership approach to health care, in which patients take an active role in decision making, can potentially improve patient satisfaction and adherence to clinician recommendations. However, the process can be impeded by insufficient or poor-quality information provision. This study explored participants' understanding of, and requirements for, optometric information. Information leaflets were obtained from 12 optometry practices and four internet-based resources. Sixty-four patients/ clients participated in focus groups that explored: (1) their understanding of diagrams of visual function, (2) perceptions of good information, (3) information requirements and (4) perceptions of the effects of improved information. A theory-led thematic analysis identified three major themes within each of the four categories. The use of jargon and the inappropriate layout of diagrams and text impeded comprehension of the leaflets. High-quality information was defined as being written concisely with simple explanations and clear diagrams. There was also a preference for information to be relevant and applicable to the patient's own eye care needs. In addition, participants expressed a desire for both written and verbal information regarding eye examination procedures and interpretation of prescriptions. Advice regarding eye care was also requested. To facilitate a partnership approach and improve patient satisfaction, patients should be provided with jargon-free concisely written and clearly presented information. In addition to general information, patients would also benefit from personalised information regarding test results and eyecare regimes.