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

A literature review revealed a lack of systematic research investigating standards of clinical practice within optometry. Three main approaches have been used to evaluate the content of clinical consultations: abstraction of clinical records, clinical vignettes and unannounced standardised patients. The aim of this thesis was to obtain an objective insight into the content of optometric eye examinations using these three approaches. In the first scenario, the SP presented for a private eye examination as a 20 year-old myope, complaining of recent onset headaches. The presence of headache was detected in 98% of cases. 22% asked at least four of the eight questions appropriate for primary care headache investigation and 69% of practitioners asked the patient to seek a medical opinion regarding the headaches. The second SP presented as a 44 year-old patient of African racial origin for a private eye examination having experienced recent difficulty with her near vision. 95% of optometrists visited carried out optic disc assessment and tonometry and 35% of optometrists carried out all of these tests. 6% advised the SP of the increased POAG risk in those of African racial descent. The third SP presented for a private eye examination as a 59 year-old patient, with recent onset flashing lights in one eye in the dark. The presence of photopsia was proactively detected in 87% of cases. 35% asked four of the seven questions appropriate for identifying the nature of the flashing lights. 66% recommended dilated fundoscopy to be carried out by either themselves or by another eyecare practitioner. 29% of optometrists asked the patient to seek a second opinion regarding the photopsia. SP encounters are an effective way of measuring clinical care within optometry. Substantial differences exist between different practitioners in the duration and depth of their clinical investigations. This is not surprising, since practitioners are individuals with different levels of experience and therefore variations in approach are inevitable. This highlights the fact that not all eye examinations are the same. The findings of optometric consultations for record abstraction mirror the findings in other healthcare disciplines: clinical records are an imperfect representation of the content of a clinical consultation. Clinical records are subject to a recording bias leading to both under- and over-estimation of the care provided due to the presence of false negatives and false positives. It was proven that clinical vignettes can be easily administered and are a cost-effective way of assessing levels of clinical care and can therefore be used in a great variety of settings. Different methods of measuring clinical care capture different elements of clinical practice and are prone to different biases. A three-way comparison of standardised patient, clinical record cards and computerised vignettes showed that clinical records are an imperfect representation of the content of an optometric clinical consultation as they tend to under-estimate actual care provided, while vignette scores tend to over-estimate clinical performance