Referrals from community optometrists in England and their replies: A mixed methods study.

PURPOSE: Community optometrists, through routine eye examinations, identify patients with disease or ocular abnormalities requiring referral to the Hospital Eye Service. In many cases no reply to the referral letter is received, resulting in some patients being re-referred unnecessarily, potentially increasing the number of other patients who lose sight whilst on hospital waiting lists. This study investigated, qualitatively and quantitatively, factors influencing optometric referrals and replies. METHODS: The three-phase, sequential mixed methods study started with a literature review and qualitative phase, interviewing stakeholders to identify issues for exploration in subsequent phases. The second, quantitative phase, undertook documentary analysis of 349 patient referral records from three optometric practice modalities (domiciliary, independently owned, and corporate chain) in England. A final qualitative phase obtained views from stakeholders to explore unexplained findings from the first two phases. RESULTS: Phase 1 identified communication, financial, professional and technological issues for further exploration. In Phase 2, the referral rate was 22.2% for domiciliary provider, 2.1% for independent practice and 2.5% for the corporate chain, with the variation most likely explained by patient age and associated ophthalmic disease, illness and disability. The referral reply rate was 5.7% for domiciliary provider, 25.0% for independent practice and 4.9% for the corporate chain. The community optometrist remained unaware of the outcome of their referral in 72.8% of cases. Qualitative analyses indicate the main factors influencing referral reply rates are technology, the General Medical Practitioner, community optometrists' utility to and utility of the National Health Service and patient mobilisation. CONCLUSIONS: The low referral reply rate creates a break in the feedback loop required to raise the standard of referrals and avoid unnecessary re-referral. Of the factors identified that influence referral reply rates, technology is key in view of the increasing use of online referral platforms. Feedback to the referring optometrist should be embedded in such systems.

Design and use of vignettes to investigate referral decision-making by optometrists

Purpose: This study describes the design and application of a range of online clinical vignettes for measuring the impact of Continuing Education and Training (CET) and identifying unwarranted variation in optometric decision-making concerning referrals to secondary care.MethodsTwenty computerised vignettes were developed to assess clinical and referral management decisions taken in primary care optometry. The online system was specifically designed to present vignettes (ten pre-CET and ten post-CET) that avoided prompting correct answers. The main study group was qualified optometrists (N = 31) who chose any CET options available to United Kingdom optometrists over six months. Participants submitted a record of the CET undertaken, which was compared with an anonymised General Optical Council (GOC) reference sample. The vignettes were also completed by newly-qualified (N = 18) and pre-registration (N = 11) groups.ResultsCET had no significant correlation (p = 0.37) with improvement in optometric clinical decision-making and referral practice (qualified group). Selection bias affected this group who had more CET points (p = 0.008) and peer discussion points (p = 0.003) than the GOC reference sample. Results were indicative due to small sample sizes. Newly-qualified practitioners were significantly more likely to refer than the qualified group (p = 0.004). Number of referrals decreased with time since qualification (p = 0.006). (AU)

Design and use of vignettes to investigate referral decision-making by optometrists.

PURPOSE: This study describes the design and application of a range of online clinical vignettes for measuring the impact of Continuing Education and Training (CET) and identifying unwarranted variation in optometric decision-making concerning referrals to secondary care. METHODS: Twenty computerised vignettes were developed to assess clinical and referral management decisions taken in primary care optometry. The online system was specifically designed to present vignettes (ten pre-CET and ten post-CET) that avoided prompting correct answers. The main study group was qualified optometrists (N = 31) who chose any CET options available to United Kingdom optometrists over six months. Participants submitted a record of the CET undertaken, which was compared with an anonymised General Optical Council (GOC) reference sample. The vignettes were also completed by newly-qualified (N = 18) and pre-registration (N = 11) groups. RESULTS: CET had no significant correlation (p = 0.37) with improvement in optometric clinical decision-making and referral practice (qualified group). Selection bias affected this group who had more CET points (p = 0.008) and peer discussion points (p = 0.003) than the GOC reference sample. Results were indicative due to small sample sizes. Newly-qualified practitioners were significantly more likely to refer than the qualified group (p = 0.004). Number of referrals decreased with time since qualification (p = 0.006). CONCLUSION: Computerised vignettes are a useful tool for comparing referral decisions between groups. Recruiting clinicians for time-consuming vignette studies is challenging. Strategies to reduce unwarranted variation in optometry, including support for newly-qualified optometrists, require further investigation.

An evaluation of MRI lumbar spine scans within a community-based diagnostic setting.

BACKGROUND: With an ongoing move towards more management of patients within the community setting, demand for magnetic resonance imaging (MRI) is increasing and commonly used in lower back conditions. There is well recorded overuse of MRI in this scenario which goes against evidence-based practice and adds to rising healthcare costs. METHODS: The study was a retrospective review of lumbar spine MRI scans performed within a community-based setting over an 18-month period. The review took a randomised purposive sample of patients (n = 450); looking at adherence to, and relevance of, guidelines in managing lower back conditions. Data extracted provided information on demographics and prevalence of clinical presentation and report observations. RESULTS: There is variation in practice and utlisation of MRI with this patient group which warrants further exploration. Results support inappropriate use, lacking adherence to guidelines and pathways, leading to unnecessary imaging. 46% of referrals were considered clinically justified with 38% of report findings considered abnormal and of clinical relevance. Chi-square and binomial logistic regression were used to assess the significance and relationship of any factors on referral justification and report outcome. No difference was found between type of referrer, with patient age and leg symptoms being significant factors. CONCLUSION: The study highlights the opportunity to integrate better referral criteria to improve referral quality, its suitability and the relevance of final reports. In the current climate this would help manage appropriate use of imaging resources during the post COVID-19 pandemic recovery phase, as well as support recommendations regarding diagnostic reform and a move towards more community-based diagnostics.

Randomised controlled trial of corneal vs. scleral rigid gas permeable contact lenses for keratoconus and other ectatic corneal disorders.

PURPOSE: To compare the comfort and visual performance of corneal rigid gas permeable contact lenses (CoL) and scleral rigid gas permeable contact lenses (SL) in participants with corneal ectasia, successfully wearing "habitual" CoL. METHODS: In a randomised controlled trial (RCT) with a 2 × 2 crossover, 34 participants were recruited and randomised into two groups. Group 1 (sequence AB), were fitted in period 1, with new CoL and after a 4-week washout period, in which habitual CoL were worn, were fitted with and crossed-over to SL, period 2. Group 2 (sequence BA), were first fitted with SL in period 1 and after a washout period of 4 weeks, crossed-over to new CoL, period 2. The median lengths in weeks of Periods 1 and 2 were: 17.5 (IQR 12.4) and 14.5 (IQR 6.2) respectively. The outcome measures for visual performance were best corrected visual acuity and the contrast sensitivity function. Vision related quality of life (Qol) was assessed using the National Eye Institute Visual Function Questioannaire-25 and reported subjective perception of vision (SPV) and reported subjective perception of comfort (SPC) scores, recorded on a scale from 1-10. The final outcome measure was the selection of the preferred lens type at the completion of the RCT. RESULTS: For the 30 who completed the trial, significantly higher SPC scores were found for SL compared to CoL (p = 0.002). Significantly higher SPC scores for CoL were found in participants who selected CoL as their preferred lens for future use, compared to those who selected SL (p = 0.009). All other outcomes exhibited no significant difference between the experimental lenses. There was no significant difference (p=0.86) in the proportion preferring CoL (53%) and SL (47%). CONCLUSION: Significantly better comfort was reported for SL compared with CoL. Significantly higher comfort in CoL was found in those who preferred CoL, than those who preferred SL. Successful CoL wearers whose SPC in CoL is <7 are likely to achieve better comfort with SL. On average, successful CoL wearers found SL more comfortable and there are unlikely to be any significant visual or visual Qol advantage or disadvantage in refitting successful CoL wearers with keratoconus and other corneal ectasia disorders, with SL and vice versa.

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.

Sunglass Filter Transmission and Its Operational Effect in Solar Protection for Civilian Pilots.

INTRODUCTION: The ocular effects of excess solar radiation exposure are well documented. Recent evidence suggests that ocular ultraviolet radiation (UVR) exposure to professional pilots may fall outside international guideline limits unless eye protection is used. Nonprescription sunglasses should be manufactured to meet either international or national standards. The mean increase in UVR and blue light hazards at altitude has been quantified and the aim of this research was to assess the effectiveness of typical pilot sunglasses in reducing UVR and blue light hazard exposure in flight. METHOD: A series of sunglass filter transmittance measurements were taken from personal sunglasses (N = 20) used by pilots together with a series of new sunglasses (N = 18). RESULTS: All nonprescription sunglasses measured conformed to international standards for UVR transmittance and offered sufficient UVR protection for pilots. There was no difference between right and left lenses or between new and used sunglasses. All sunglasses offered sufficient attenuation to counter the mean increase in blue light exposure that pilots experience at altitude, although used sunglasses with scratched lenses were marginally less effective. One pair of prescription sunglasses offered insufficient UVR attenuation for some flights, but would have met requirements of international and national standards for UV-A transmittance. This was likely due to insufficient UVR blocking properties of the lens material. CONCLUSIONS: Lenses manufactured to minimally comply with standards for UVR transmittance could result in excess UVR exposure to a pilot based on in-flight irradiance data; an additional requirement of less than 10% transmittance at 380 nm is recommended.

Occupational Ocular UV Exposure in Civilian Aircrew.

INTRODUCTION: Ultraviolet radiation (UVR) increases with altitude; however, there are a number of other factors which may influence ocular exposure during flight. The aim of this study was to assess ocular UVR exposure of pilots in airline and off-shore helicopter operations on different aircraft types and to compare with exposure in a typical office environment. METHOD: In-flight data were captured on equipment including a CCD array spectroradiometer on five return sector European airline flights and one transatlantic flight from London Gatwick in addition to four helicopter flights from Aberdeen Dyce airport. Further data were collected in an office environment from three workstations during summer and winter months. RESULTS: A wide variation in ocular UVA dose was found during flights. The main factor influencing exposure was the UVR transmission of the windshield, which fell into two distinct profile types. In an aircraft with good UVA blocking properties, ocular exposure was found to be equivalent to office exposure and did not exceed international guideline limits regardless of external conditions or flight time. Most aircraft assessed had poor UVA blocking windshields which resulted in an ocular exposure to the unprotected eye in excess of international guideline limits (up to between 4.5 to 6.5 times greater during one flight). No significant UVB dose was found. DISCUSSION: Pilots should be warned of the potential high UVA exposure during flight and advised on the use of sunglasses. A windshield labeling system would allow the pilot to tailor their eye protection practices to that particular aircraft.

Solar Eye Protection Practices of Civilian Aircrew.

INTRODUCTION: There is good evidence that long term exposure to ultraviolet (UV) radiation increases the risk of cataracts. The 'blue light hazard' is considered a risk factor for retinal changes similar to those seen in macular degeneration. Previous studies ascertaining the prevalence of radiation related ocular disease in pilot cohorts have not considered use of solar eye protection. The aim of this study was to explore pilot use of sunglasses and other solar eye protection habits and to gain insight into the difficulties encountered managing sunlight on the flight deck. Additionally, the prevalence of radiation related ocular pathology in the study group was calculated. METHODS: A web based questionnaire was developed and administered to a large population of current UK professional pilots. RESULTS: There were 2917 respondents who completed the questionnaire, demonstrating a wide range of sunglass use during flight. A number of barriers to sunglass use were identified, the most prevalent being the requirement for corrective lenses to be used. Pilots most commonly increase sunglass use due to ocular health concerns. A high level of dissatisfaction with standard aircraft sun protection systems was reported. Long haul airline pilots were the highest users of nonstandard sunlight blocking strategies. No correlation between reported pathology and flying experience was found. DISCUSSION: The use of sunglasses during flight is complex; however, a number of practical recommendations can be made to increase the success for those pilots who wish to use sunglasses more. Aircraft manufacturers should consider how greater control of cockpit sunlight levels can be achieved.

Knowledge, attitudes, beliefs, behaviour and breast cancer screening practices in Ghana, West Africa.

BACKGROUND: Late presentation has been observed as the hallmark of breast cancer in Ghanaian women where over 60% of patients report with either stage 3 or 4 of the disease. This cross-sectional study aimed at exploring breast cancer related knowledge and practices in order to develop an appropriate socio-economic and cultural specific model to improve breast cancer care in Ghana. METHODS: The study which was conducted in Accra and Sunyani in Ghana used both quantitative and qualitative methods and employed the theory of planned behavior as a communication and educational model. Information was collected from 474 women using questionnaires. In addition semi-structured interviews were conducted on 10 breast cancer patients; 10 breast clinic attendants; 3 Oncology Consultants and 2 herbalists. RESULTS: Generally, the respondents displayed knowledge deficit about the disease. However, higher levels of education was associated with better appreciation of the disease (rs = 0.316, N = 465, p < 0.001). The respondents' attitudes include fear of the disease which was linked to death in most cases; denial and guilt; as well as supernatural attributes. The self-reported breast cancer screening rate (BSE 32%, CBE 12% and mammogram 2%) was poor, however, higher educational of the respondents was very significant for breast cancer screening practices. CONCLUSION: The study found that routine mammography screening is not feasible in Ghana at the moment which therefore requires a different approach.

Knowledge; Attitudes; Beliefs; Behaviour and Breast Cancer Screening Practices in Ghana; West Africa

Background: Late presentation has been observed as the hallmark of breast cancer in Ghanaian women where over 60 of patients report with either stage 3 or 4 of the disease. This cross-sectional study aimed at exploring breast cancer related knowledge and practices in order to develop an appropriate socio-economic and cultural specific model to improve breast cancer care in Ghana. Methods: The study which was conducted in Accra and Sunyani in Ghana used both quantitative and qualitative methods and employed the theory of planned behavior as a communication and educational model. Information was collected from 474 women using questionnaires. In addition semi-structured interviews were conducted on 10 breast cancer patients; 10 breast clinic attendants; 3 Oncology Consultants and 2 herbalists. Results: Generally; the respondents displayed knowledge deficit about the disease. However; higher levels of education was associated with better appreciation of the disease (rs =0.316; N= 465; p 0.001). The respondents' attitudes include fear of the disease which was linked to death in most cases; denial and guilt; as well as supernatural attributes. The self-reported breast cancer screening rate (BSE 32; CBE 12 and mammogram 2) was poor; however; higher educational of the respondents was very significant for breast cancer screening practices. Conclusion: The study found that routine mammography screening is not feasible in Ghana at the moment which therefore requires a different approach

Civilian pilot exposure to ultraviolet and blue light and pilot use of sunglasses.

Population and animal studies indicate that long-term exposure to short-wavelength visible light and ultraviolet (UV) radiation causes increased risk of certain ocular pathologies such as cataracts and maculopathy. The potential risk to flight crew is unknown. The UK Civil Aviation Authority (CAA) has issued guidance to pilots regarding sunglass selection; however, it is not known if this guidance is appropriate given pilots' unique occupational environment. A search and appraisal of the relevant literature was conducted which showed that within the airline pilot population, there is limited evidence of a higher prevalence of cataracts. There are no data of other known UV-related ocular pathology. There is some evidence of higher prevalence of skin melanomas. Studies measuring cockpit UV radiation levels are limited and leave unanswered questions regarding airline pilot exposure. Data from optical transmission of cockpit windshields demonstrates the UV blocking properties at sea level. No studies have addressed the occupational use of sunglasses in airline pilots. Although it is likely that an aircraft windshield effectively blocks UV-B, the intensity of UV-A and short wavelength blue light present within the cockpit at altitude is unknown. Pilots may be exposed to solar radiation for periods of many hours during flight where UV radiation is known to be significantly greater. Aircraft windshields should have a standard for optical transmission, particularly of short-wavelength radiation. Clear, untinted prescription glasses will offer some degree of UV protection; however, sunglasses will offer superior protection. Any sunglasses used should conform to a national standard.