City Research Online

Abstract

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 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 ten vignettes, designed to avoid prompting answers. Participating optometrists completed ten pre-CET vignettes, recording their tests and management decisions. The main group of participants chose whatever CET they wished over a six-month period and then completed another ten 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 six-months experience of their pre-registration year.

Results:
The audit identified 1951 optometric referrals and 158 optometrists (211 referrals were from GP practices), 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 twenty referral decisions were compared, all optometrists referring more than ten vignette patients came from a group of newly-qualified practitioners up to two 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 two years post-qualification should be considered. Ophthalmology replies to the referring newly-qualified optometrist are vital for moderating future referrals and developing clinical confidence.

Publication Type:	Article
Additional Information:	This is the peer reviewed version of the following article: Parkins, D. J., Benwell, M. J., Edgar, D. F and Evans, B. J. W. (2018). The relationship between unwarranted variation in optometric referrals and time since qualification, which has been published in final form at https://doi.org/10.1111/opo.12580. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.
Publisher Keywords:	variation, decision-making, referral, optometry
Subjects:	R Medicine > RE Ophthalmology
Departments:	School of Health & Psychological Sciences > Optometry & Visual Sciences
SWORD Depositor:	Symplectic Administrator

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