City Research Online

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

Parkins, D. J., Benwell, M. J., Edgar, D. F ORCID: 0000-0001-9004-264X & Evans, B. J. W. (2018). The relationship between unwarranted variation in optometric referrals and time since qualification. Ophthalmic And Physiological Optics, 38(5), pp. 550-561. doi: 10.1111/opo.12580


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.

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).

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 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
Text - Accepted Version
Download (315kB) | Preview



Downloads per month over past year

View more statistics

Actions (login required)

Admin Login Admin Login