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BMC Health Services Research

, 19:646 | Cite as

Systematic review of the appropriateness of eye care delivery in eye care practice

  • Kam Chun Ho
  • Fiona Stapleton
  • Louise Wiles
  • Peter Hibbert
  • Sally Alkhawajah
  • Andrew White
  • Isabelle JalbertEmail author
Open Access
Research article
Part of the following topical collections:
  1. Organization, structure and delivery of healthcare

Abstract

Background

Health care systems are continually being reformed, however care improvement and intervention effectiveness are often assumed, not measured. This paper aimed to review findings from published studies about the appropriateness of eye care delivery, using existing published evidence and/or experts’ practice and to describe the methods used to measure appropriateness of eye care.

Methods

A systematic search was conducted using Medline, Embase and CINAHL (2006 to September 2016). Studies reporting the processes of eye care delivery against existing published evidence and/or experts’ practice were selected. Data was extracted from published reports and the methodological quality using a modified critical appraisal tool. The primary outcomes were percentage of appropriateness of eye care delivery. This study was registered with PROSPERO, reference CRD42016049974.

Results

Fifty-seven studies were included. Most studies assessed glaucoma and diabetic retinopathy and the overall methodological quality for most studies was moderate. The ranges of appropriateness of care delivery were 2–100% for glaucoma, 0–100% for diabetic retinopathy and 0–100% for other miscellaneous conditions. Published studies assessed a single ocular condition, a sample from a single centre or a single domain of care, but no study has attempted to measure the overall appropriateness of eye care delivery.

Conclusions

These findings indicated a wide range of appropriateness of eye care delivery, for glaucoma and diabetic eye care. Future research would benefit from a comprehensive approach where appropriateness of eye care is measured across multiple conditions with a single methodology, to guide priorities within eye care delivery and monitor quality improvement initiatives.

Keywords

Glaucoma Delivery of health care Diabetic retinopathy Public health Evidence-based practice Process assessment (health care) 

Abbreviation

A&E

Accident and emergency

AAO

American Academy of Ophthalmology

CASP

Critical Appraisal Skills Programme

CINAHL

Cumulative Index to Nursing and Allied Health Literature

EGS

European Glaucoma Society

EPHPP

Effective Public Health Practice Project

JBI

Joanna Briggs Institute

N/A

Not applicable

NICE

National Institute for Health and Clinical Excellence

NIH

National Institutes of Health

NZ

New Zealand

PRISMA

Preferred Reporting Items for Systematic reviews and Meta-Analyses

UK

United Kingdom

USA

United States of America

Background

Globally, 285 million people of all ages suffer from visual impairment [1]. Long-term ocular conditions, including both ocular diseases (e.g. glaucoma, diabetic retinopathy, age-related macular degeneration and cataract) and uncorrected refractive errors are the major causes of visual impairment worldwide [2]. The prevalence of vision problems is strongly associated with ageing and this compromised visual function affects individuals’ ability to perform activities of daily living [3]. Common eye diseases can often be detected early and their visual impact minimised or they can be prevented by appropriate eye care services, including routine eye examinations [4, 5, 6]. Due to the growing demand for eye care in the context of resource scarcity, interest in measuring and improving the appropriateness of eye care delivery is growing [7, 8]. Appropriate care is defined as provision of evidence-based care that is relevant to the patient’s needs and based on established standards [9].

Translation of best available evidence into clinical practice is important, ensuring that both efficacy and cost-effectiveness of patient management is maintained [10]. Evidence-based guidelines aim to translate well conducted scientific trials into easy to apply recommendations. Such guidelines intend to guide practitioners and help them to improve their professional practice and optimize patient care [11]. Evidence-based guidelines are not always adhered to and/or fully implemented in the clinical setting. Adherence to guidelines can be quantitatively measured using quality indicators of appropriateness of care delivery. Quality Indicators can be defined as “measurable components of a standard or guideline, with explicit criteria for inclusion, exclusion, time frame, setting and compliance action” [12].

Evidence of suboptimal care being delivered exist, arising from several large studies assessing appropriateness of care across different health conditions. The RAND study conducted in 2000 in the United States evaluated performance on 439 quality indicators of appropriateness of care for 30 acute and chronic conditions as well as preventive care. The RAND study showed that American adults received recommended care only 55% (range 11–79%) of the time [13]. More recently, the CareTrack study in Australia showed similar results with 57% (range 13–90%) of Australian adults receiving appropriate care across 22 conditions [12]. Ocular conditions were not included in the CareTrack study [12]. Defining existing eye care practice patterns and current variation from best practices is an important component of a systemic approach to improving appropriateness of eye care [14, 15].

Purpose

This paper aimed to review findings from published studies about the appropriateness of eye care delivery, using existing published evidence and/or experts’ practice. A secondary aim was to describe and compare the variety of methods used to measure appropriateness of eye care.

Methods

Data sources and searches

A systematic search was conducted using Medline, Embase and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases to identify studies related to the appropriateness of eye care. The search strategy was reviewed and tested by an academic librarian and reviewed by content experts (IJ and FS). The literature review process followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) procedures [16] and the review protocol was published on PROSPERO (http://www.crd.york.ac.uk/prospero/, reference CRD42016049974). As eye conditions with higher prevalence and heavier burden on the health system, the emphasis was put on glaucoma, diabetic retinopathy, refractive error, cataract and macular degeneration [17]. The search incorporated the three elements:
  1. 1)

    Profession-specific terms: “Optometr*”, “Ophthalmolog*”, “General practitioner*”, “Orthopt*”, “Ophthalmic nurse*”, “Ophthalmic practitioner*”.

     
  2. 2)

    Subject headings: Exp”Quality of Health Care” in Medline, Exp”Health care quality” in Embase, MH”Health Services Research+” in CINAHL.

     
  3. 3)

    Condition-specific terms: Exp Glaucoma, Exp diabetic retinopathy, Exp refractive errors, Exp macular degeneration, Exp cataract.

     

An example of the full electronic search strategy for Medline database is illustrated in Additional file 1.

Study selection

Reference lists and citations were used to cross-check the results of our search. The reference details and abstracts of the 5596 articles retrieved from the literature search after duplicates removal were reviewed by one reviewer (KCH). Studies assessing the processes of eye care delivery against existing published evidence and experts’ practice (e.g. consultant ophthalmologists’ practice) were included. Studies assessing outcomes of care delivery such as patient satisfaction or those assessing structural aspects of care delivery such as workforce characteristics, infrastructure, regulations and policies were excluded from analysis in this review. The search was not restricted by type of study design, and no other limitations (e.g. population, intervention, comparison, length of follow-up) were set. The search was limited to English and 10 years to the search date (2006 to 16th September 2016). Studies conducted more than 10 years ago were excluded, on the basis that appropriateness of care was likely to change over time, and that older studies might not reflect recent changes in care delivery standards [18]. The references were narrowed to 65 articles after title and abstract screening following the application of exclusion criteria (Fig. 1). A further six articles were excluded after full text review with three that did not access process of care and three that did not measure against existing published evidence or experts’ practice.
Fig. 1

PRISMA flow diagram for appropriateness of eye care delivery

Data extraction and quality assessment

Each paper was reviewed and information was extracted based on the following characteristics:
  • Country

  • Condition(s) – the eye condition(s) for which the appropriateness of care was assessed

  • Professions – the health professions delivering the care of the assessed eye condition

  • Methods – the method used to assess the appropriateness of eye care delivered

  • Sample size

  • Response rate

  • Evidence sources – the reference standard used to assess the appropriateness of eye care delivered

  • Settings – classification based on whether study was conducted in hospital or independent practice

  • Number of sites – the number of sites that the study was conducted at

  • Timing – the timing and visit types assessed in the article (e.g. at diagnosis, follow-up, etc)

  • Percentage of encounters with appropriate eye care – the number of quality indicators met over the total number of relevant quality indicators

Taking into consideration the diversity of study types (e.g. descriptive, interventional and observational studies, record reviews, and surveys), two reviewers (KCH and SA) independently assessed the quality of each article using a validated critical appraisal tool [19]. The applied tool was modified by adding questions from other validated critical appraisal tools including Critical Appraisal Skills Programme (CASP) diagnostic checklist [20], National Institutes of Health (NIH) Quality Assessment Tool For Observational Cohort And Cross-Sectional Studies [21], Joanna Briggs Institute (JBI) Critical Appraisal Checklist For Studies Reporting Prevalence Data [22], Effective Public Health Practice Project (EPHPP) Quality assessment tool for quantitative studies [23].

The modified quality assessment tool included 17 individual criterions with questions from validated critical appraisal tools [20, 21, 22, 23] (Additional file 2) and grouped in the seven categories listed below:
  • Quality of reporting (adequate description of the context [19], clearly stated aims [19, 20, 21], eligibility [21], methods and findings [20])

  • Selection bias (representative of the selected individuals [22, 23], response rate at least 50% [21], and sample size justification [21])

  • Study design (presence of randomisation [23], presence of control group [19, 23])

  • Blinding (blinding of outcome assessors to the intervention or exposure status of participants [20, 21, 23], blinding of participants to research question [23], and blinding of decision making between participants and experts [20])

  • Data collection tools (reliability of the data collection tool [22, 23] and valid reference used to assess the appropriateness of care [20])

  • Analysis (sufficient rigorous data analysis [19, 22, 23])

  • Limitations (key potential confounders are identified and accounted for [21, 22, 23])

The number of criteria used varied depending on the study design of the publication being reviewed. An overall rating was allocated for each paper as a percentage based on the number of criteria met over the number of relevant criteria for the corresponding study design. If less than 60% criteria relevant to the study design was met, this item was scored as Weak in the quality assessment tool. It was scored moderate if 60–79% of criteria were met and strong if 80–100% of criteria were met. A third reviewer (IJ) resolved any disagreements and consensus was reached through discussion. All articles were included, and the results of critical appraisal are provided in Additional file 3.

Data synthesis and analysis

Due to the anticipated heterogeneity of included studies, no plans were made to pool the results statistically, therefore a meta-analysis was not undertaken. For each study, the range of percentage of appropriate care (summary data from published reports, but not individual patient-level data) and the number of quality indicators were separated according to the nature of the quality indicators into the following six domains of care: ‘history taking’, ‘physical examination’, ‘management’, ‘recall period’, ‘referral’ and ‘patient education’. On occasion, data provided in the papers had to be reclassified to fit these proposed domains of care. Data were also reanalysed as required so that the results could be presented in terms of appropriateness to prescribed care and not the reverse (i.e. percentage with inappropriate care).

Results

Of 6472 citations, 57 articles met the inclusion (see Fig. 1). The characteristics of these studies are presented in Table 1. The majority of the studies were from the United Kingdom (UK) (n = 25) and the United States of America (USA) (n = 15), with Australia (n = 5), Australia and New Zealand (NZ) (n = 2) and other countries accounting for the remainder. Among the 57 papers, two-thirds examined eye care delivery for glaucoma (n = 28) and diabetic retinopathy (n = 11). The majority of papers assessed the care delivered by optometrists (n = 22) and ophthalmologists (n = 19), with another seven studies including both professions. Half of the studies were rated moderate (60–79% of quality criteria met) for the methodological quality (n = 29), another one-third were rated strong (80–100% of quality criteria met) (n = 19) and the remainder were rated weak (< 60% of quality criteria met) (n = 9). For all conditions but diabetic retinopathy, a similar pattern of distribution of methodological quality (i.e. mostly moderate) was observed. However, for diabetic retinopathy most of the studies (73%) were rated strong in methodological quality.
Table 1

Study Characteristics (n = 57). USA = United States of America, UK=United Kingdom, NZ = New Zealand, A&E = accident and emergency

Country

Evidence sources

Year

Professions

Outcomes

Methods

Overall qualitya

Author (reference)

nb

Glaucoma

 UK

Clinical practice guidelines [24, 25]

2013

Ophthalmologist

Current practice pattern

Record review

Strong

Fung et al. [26]

101

 UK

Clinical practice guidelines [25]

2012

Ophthalmologist & optometrist

Guidelines adherence

Record review

Weak

Chawla et al. [27]

200

 UK

Clinical practice guidelines [25, 28]

2012

Optometrist

Guidelines adherence

Record review

Moderate

Khan et al. [29]

114

 UK

Clinical practice guidelines [30]

2012

Optometrist

Validation of self-reported practice

Interview with practitioner and unannounced standardised patient

Moderate

Theodossiades et al. [31]

34

 UK

Clinical practice guidelines [25]

2011

Ophthalmologist

Current practice pattern

Practitioner Survey

Moderate

Stead et al. [32]

626 (69%)

 UK

Clinical practice guidelines [33, 34]

2009

Optometrist

Quality of referral letter

Record review

Moderate

Scully et al. [35]

121

 UK

Experts’ opinions

2012

Optometrist

Diagnostic accuracy

Clinical agreement with expert

Moderate

Marks et al. [36]

145

 UK

Experts’ opinions

2011

Optometrist

Diagnostic accuracy

Record review

Moderate

Ho and Vernon [37]

140

 UK

Experts’ opinions

2011

Optometrist

Quality of referral

Record review

Moderate

Shah and Murdoch [38]

110

 UK

Experts’ opinions

2010

Optometrist

Feasibility of shared care

Record review

Strong

Syam et al. [39]

1184

 UK

Experts’ opinions

2010

Optometrist

Quality of referral

Record review

Weak

Lockwood et al. [40]

441

 UK

Experts’ opinions

2007

Ophthalmologist & optometrist

Diagnostic accuracy

Clinical agreement with expert

Strong

Azuara-Blanco et al. [41]

100

 UK

Experts’ opinions

2006

Optometrist

Quality of referral

Record review

Weak

Patel et al. [42]

376

 UK

Experts’ opinions

2006

Optometrist & associate specialists

Diagnostic accuracy

Clinical agreement with expert

Moderate

Banes et al. [43]

350

 USA

Clinical practice guidelines [24, 44]

2016

Ophthalmologist

Current practice pattern

Record review

Moderate

Solano-Moncada et al. [45]

250

 USA

Clinical practice guidelines [44]

2016

Ophthalmologist & optometrist

Current practice pattern

Claims data

Strong

Elam et al. [46]

56,675

 USA

Clinical practice guidelines [47]

2015

Ophthalmologist

Diagnostic accuracy

Record review

Moderate

Zebardast et al. [48]

212

 USA

Clinical practice guidelines [49] & experts’ opinions

2013

Ophthalmologist

Guidelines adherence

Record review

Strong

Ong et al. [50]

103

 USA

Clinical practice guidelines [44]

2012

Ophthalmologist & optometrist

Current practice pattern

Claims data

Moderate

Swamy et al. [51]

143,374

 USA

Clinical practice guidelines [49]

2007

Ophthalmologist

Guidelines adherence

Claims data, record review, practitioner survey and patient survey

Moderate

Quigley et al. [52]

300

 USA

Clinical practice guidelines [53]

2006

Ophthalmologist

Current practice pattern

Claims data

Strong

Coleman et al. [54]

4427

 Australia & NZ

Clinical practice guidelines [55]

2015

Optometrist

Current practice pattern

Practitioner Survey with case vignette

Moderate

Zangerl et al. [56]

818 (18%)

 Australia & NZ

Clinical practice guidelines [47, 57, 58]

2008

Ophthalmologist

Current practice pattern

Practitioner Survey

Strong

Liu [59]

627 (78%)

 Scotland

Clinical practice guidelines [25, 60]

2015

Optometrist

Quality of referral

Record review

Strong

El-Assal et al. [61]

1622

 Scotland

Clinical practice guidelines [60]

2009

Optometrist

Quality of referral

Record review

Moderate

Ang et al. [62]

303

 Canada

Clinical practice guidelines [63]

2014

Ophthalmologist & optometrist

Quality of referral letter

Record review

Moderate

Cheng et al. [64]

200

 Germany

Clinical practice guidelines [57]

2008

Ophthalmologist

Guidelines adherence

Practitioner Survey

Moderate

Vorwerk et al. [65]

335 (12%)

 Singapore

Clinical practice guidelines [66]

2008

Ophthalmologist

Current practice pattern

Practitioner Survey

Strong

Ang et al. [67]

126 (80%)

Diabetic retinopathy

 Australia

Clinical practice guidelines [68]

2011

Optometrist

Current practice pattern

Practitioner Survey

Weak

Slater and Chakman [69]

985 (26%)

 Australia

Clinical practice guidelines [70]

2011

Optometrist

Current practice pattern

Practitioner Survey with case vignette

Strong

Ting et al. [71]

568 (57%)

 Australia

Clinical practice guidelines [70]

2010

Ophthalmologist

Guidelines adherence

Practitioner Survey with case vignette

Strong

Yuen et al. [72]

480 (63%)

 NZ

Clinical practice guidelines [73]

2012

Optometrist

Guidelines adherence

Record review

Strong

Hutchins et al. [74]

157

 USA

Clinical practice guidelines [75]

2012

Ophthalmologist & optometrist

Current practice pattern

Patient survey

Strong

Chou et al. [76]

29,495

 USA

Clinical practice guidelines [77]

2010

Ophthalmologist

Guidelines adherence

Record review

Strong

Tseng et al. [78]

70

 Hong Kong

Clinical practice guidelines [79]

2016

General practitioner

Guidelines adherence

Practitioner Survey

Strong

Wong et al. [80]

414 (13%)

 Bahrain

Clinical practice guidelines [81]

2014

General practitioner

Guidelines adherence

Record review

Strong

Al-Ubaidi et al. [82]

200

 Switzerland

Clinical practice guidelines [83]

2013

General practitioner

Guidelines adherence

Record review

Moderate

Burgmann et al. [84]

275

 UK

Clinical practice guidelines [85]

2011

General practitioner

Guidelines adherence

Record review

Strong

Mc Hugh et al. [86]

3010

 Brazil

Clinical practice guidelines [87]

2007

General practitioner

Current practice pattern

Practitioner Survey

Weak

Preti et al. [88]

168 (34%)

Age-related macular degeneration

 Italy

Multiple clinical trials [89, 90, 91, 92]

2016

Ophthalmologist

Guidelines adherence

Interview with patient

Moderate

Parodi et al. [93]

283

 Turkey

Multiple clinical trials [89, 90, 94]

2015

Ophthalmologist

Current practice pattern

Practitioner Survey

Moderate

Muhammed et al. [95]

249 (21%)

 UK

Multiple clinical trials [89, 96, 97, 98, 99]

2013

Ophthalmologist & optometrist

Current practice pattern

Practitioner Survey with case vignette

Weak

Lawrenson and Evans [100]

1468 (15%)

 USA

Multiple clinical trials [89, 101, 102]

2008

Ophthalmologist

Current practice pattern

Patient survey

Moderate

Charkoudian et al. [103]

332 (99%)

Cataract

 UK

Clinical practice guidelines [104]

2011

Ophthalmologist

Current practice pattern

Practitioner Survey

Weak

Gomaa and Liu [105]

158 (53%)

 UK

Clinical practice guidelines [106]

2009

Optometrist & general practitioner

Quality of referral letter

Record review

Strong

Park et al. [107]

124

 UK

Clinical practice guidelines [108]

2006

Optometrist

Quality of referral letter

Record review

Moderate

Lash et al. [109]

351

 USA

Clinical practice guidelines [110]

2009

Resident ophthalmologist

Guidelines adherence

Record review

Strong

Niemiec et al. [111]

129

Preventative eye care

 UK

Clinical practice guidelines [112, 113, 114] & experts’ opinions

2009

Optometrist

Current practice pattern

Unannounced Standardised patient

Moderate

Shah et al. [115]

100

 UK

Clinical practice guidelines [114, 116, 117] & experts’ opinions

2009

Optometrist

Current practice pattern

Unannounced Standardised patient

Moderate

Shah et al. [118]

102

 UK

Clinical practice guidelines [114, 117, 119] & experts’ opinions

2008

Optometrist

Current practice pattern

Unannounced Standardised patient

Moderate

Shah et al. [120]

100

 Australia

Multiple clinical trials’ results [89, 90, 121, 122, 123, 124, 125, 126, 127, 128]

2015

Optometrist

Current practice pattern

Practitioner Survey

Moderate

Downie and Keller [129]

283 (6.7%)

Dry eye

 Australia

Clinical practice guidelines [130, 131]

2013

Optometrist

Guidelines adherence

Practitioner Survey

Moderate

Downie et al. [132]

144 (22%)

 USA

Clinical practice guidelines [133]

2010

Ophthalmologist

Guidelines adherence

Record review

Weak

Lin et al. [134]

178

All ocular conditions at A&E

 UK

Experts’ opinions

2007

Optometrist

Diagnostic accuracy

Clinical agreement with expert

Moderate

Hau et al. [135]

150

Amblyopia

 USA

Multiple clinical trials [136, 137]

2013

Ophthalmologist

Guidelines adherence

Record review

Moderate

Jin et al. [138]

123

Esotropia

 USA

Clinical practice guidelines [139]

2010

Ophthalmologist

Guidelines adherence

Record review

Weak

Gupta et al. [140]

200

Non-infectious uveitis

 USA

Clinical practice guidelines [141]

2011

Ophthalmologist & rheumatologist

Current practice pattern

Record review and practitioner survey

Moderate

Nguyen et al. [142]

580

aIf less than 60% criteria in the quality assessment tool were met, quality was scored as weak; it was scored moderate if 60–79% were met and strong if 80–100% were met. bResponse rate reported in bracket where applicable

Record review (26 of 57 studies) and practitioner survey with or without case vignettes (15 of 57 studies) were the most commonly used methods, with one study using a combination of both methods and one study using both methods with claims data and patient survey. When eye care appropriateness was measured using record review, assessments were most frequently conducted at a single site (n = 19) and in these cases, studies were conducted in a hospital setting (Fig. 2). Use of a single site reduces logistical challenges, but the results may not be generalisable to other environments with a different location, business models and case-mix. For example, the record review conducted in the Department of Veterans Affairs, which caters to a population that is predominantly male, may not be generalised to clinic settings and patient populations outside the Veterans Affairs system [50].
Fig. 2

Review Site Characteristics (n = 29). The number on each bar indicates the number of included studies (a) assessed within the corresponding settings, (b) conducted at single or multiple sites. When eye care appropriateness was measured using record review, assessments were most frequently conducted at a single site (n = 19) and in these cases, studies were conducted in a hospital setting. Use of a single site reduces logistical challenges, but the results may not be generalisable to other environments with a different location, practice types and case-mix

Appropriateness of eye care was generally measured as compliance against scientific evidence or consensus with clinical experts in the field with around two-thirds of the articles having measured eye care appropriateness against recommendations from clinical practice guidelines (n = 38) and 16% having used experts’ opinions (n = 9).

A small number of studies measured eye care appropriateness against expert care rather than against clinical practice guidelines, where the same patients are examined twice, once by the practitioners and once by experts [36, 135, 143].

Eye care appropriateness results are summarized in Table 2. It is important to note at the outset that the timing (e.g. once during a period, at the diagnosis visit, etc.), type of visits (e.g. first visit, follow-up visit, etc.), the health professions and settings assessed, and the method used to collect the data (e.g. record review) vary between studies (see Table 2) and may confound the appropriateness of eye care results.
Table 2

Appropriateness of eye care by domain of care. Numbers are percentage of encounters with appropriate care (number of quality indicators). If more than one quality indicator was assessed, the percentage of encounters with appropriate care is presented as a range of percentage. NZ = New Zealand, A&E = accident and emergency, N/A = not applicable as no specific timing was measured

Country

Year

Health Practitioner

Timing

Domain of care

Author (reference)

History taking

Physical examination

Management

Recall period

Referral

Patient education

Glaucoma

 UK

2013

Ophthalmologist

All visits (at least up to 17.5 years)

 

0,87% (1)a

    

Fung et al. [26]

 UK

2012

Optometrist

First visit

 

74–100% (6)

96% (1)

   

Chawla et al. [27]

First follow-up visit

88% (1)

94–100% (3)

 

92% (2)

  

Ophthalmologist

First visit

 

10–100% (6)

100% (1)

   

First follow-up visit

24% (1)

8–100% (3)

 

66–86% (2)

  

 UK

2012

Optometrist

Referral letter for glaucoma diagnosis

    

70% (1)b

4–99% (6)c

 

Khan et al. [29]

 UK

2012

Optometrist

Results of interview

77% (1)

19–98% (4)

    

Theodossiades et al. [31]

First visit of standardised patient

41% (1)

3–100% (4)

    

 UK

2011

Ophthalmologist

N/A

  

23% (1)

   

Stead et al. [32]

 UK

2009

Optometrist

Referral letter for glaucoma diagnosis

    

27–100% (14)c

 

Scully et al. [35]

 UK

2012

Optometrist

First full visit

 

91–98% (1)

97% (1)

 

87% (1)2

 

Marks et al. [36]

 UK

2011

Optometrist

All follow-up visits

 

96% (1)

99% (1)

93% (1)

  

Ho and Vernon [37]

 UK

2011

Optometrist

Referral letter for glaucoma diagnosis

    

25% (1)b

 

Shah and Murdoch [38]

 UK

2010

Optometrist

All visits

  

93% (1)

86% (1)

  

Syam et al. [39]

 UK

2010

Optometrist

Referral letter for glaucoma diagnosis

    

37% (1)b

72–99% (3)c

 

Lockwood et al. [40]

 UK

2007

Optometrist

First visit

  

85% (1)

   

Azuara-Blanco et al. [41]

Ophthalmologist

First visit

  

83% (1)

   

 UK

2006

Optometrist

Referral letter for glaucoma diagnosis

    

45% (1)b

 

Patel et al. [42]

 UK

2006

Optometrist

All follow-up visit

 

62–98% (5)

72–97% (5)

79% (1)

  

Banes et al. [43]

Associate specialists

All follow-up visit

 

54–100% (5)

71–99% (5)

73% (1)

  

 USA

2016

Ophthalmologist

All follow-up visits

  

68% (1)

   

Solano-Moncada et al. [45]

 USA

2016

Ophthalmologist & optometrist

All visits within 2 years after glaucoma diagnosis

 

27–74% (2)

    

Elam et al. [46]

 USA

2015

Resident ophthalmologist

Third (or more) follow-up visit

88% (1)

62–100% (5)

74% (1)

   

Zebardast et al. [48]

Faculty ophthalmologist

Third (or more) follow-up visit

100% (1)

87–100% (5)

100% (1)

   

 USA

2013

Resident ophthalmologist

First follow-up visit

49–97% (5)

93–100% (4)

82–100% (6)

96–97% (2)

16% (1)

5% (1)

Ong et al. [50]

 USA

2012

Ophthalmologist & optometrist

All visits within 3 years after glaucoma or glaucoma suspect diagnosis

 

12–34% (2)

    

Swamy et al. [51]

 USA

2007

Ophthalmologist

First claim for a prostaglandin prescription

 

50–90% (5)

19% (1)

100% (1)

 

38% (1)

Quigley et al. [52]

 USA

2006

Ophthalmologist

All visits within 5 years before surgery for glaucoma

 

49% (1)

    

Coleman et al. [54]

 Australia & NZ

2015

Optometrist (Australia)

N/A

99% (1)

25–100% (10)

    

Zangerl et al. [56]

Optometrist (NZ)

N/A

100% (1)

27–100% (10)

    

 Australia & NZ

2008

Ophthalmologist

N/A

 

13–96% (4)

    

Liu [59]

 Scotland

2015

Optometrist

Referral letter for glaucoma diagnosis BEFORE guidelines published

    

62% (1)b

33–85% (3)c

 

El-Assal et al. [61]

Referral letter for glaucoma diagnosis AFTER guidelines published

    

76% (1)b

76–81% (3)c

 

 Scotland

2009

Optometrist

Referral letter for glaucoma progression BEFORE guidelines published

    

18% (1)b

2–94% (7)c

 

Ang et al. [62]

Referral letter for glaucoma progression AFTER guidelines published

    

32% (1)b

24–93% (7)c

 

 Canada

2014

Ophthalmologist

Referral letter for glaucoma diagnosis

    

10–100% (16)c

 

Cheng et al. [64]

Optometrist

Referral letter for glaucoma diagnosis

    

7–100% (16)c

 

 Germany

2008

Ophthalmologist

N/A

  

96% (1)

   

Vorwerk et al. [65]

 Singapore

2008

Ophthalmologist

N/A

 

75–93% (2)

    

Ang et al. [67]

Diabetic retinopathy

 Australia

2011

Optometrist

N/A

    

83–99% (2)b

 

Slater and Chakman [69]

 Australia

2011

Optometrist

N/A

43–96% (6)

23–89% (2)

 

6–98% (12)d

  

Ting et al. [71]

 Australia

2010

Ophthalmologist

N/A

41–55% (4)

49–90% (2)

56–94% (2)

38–71% (10)d

  

Yuen et al. [72]

 NZ

2012

Optometrist

Fundus screening visit

    

60% (1)b

 

Hutchins et al. [74]

 USA

2012

Ophthalmologist & optometrist

N/A

 

71% (1)

    

Chou et al. [76]

 USA

2010

Resident ophthalmologist

First ever diabetic retinopathy examination

41–57% (5)

0–100% (7)

70–79% (2)

69–70% (2)

 

0–27% (3)

Tseng et al. [78]

 Hong Kong

2016

General practitioner

N/A

 

33% (1)

 

27% (1)

  

Wong et al. [80]

 Bahrain

2014

General practitioner at general practitioner clinic

All follow-up visits within previous 12 months

 

0% (1)e

    

Al-Ubaidi et al. [82]

General practitioner at diabetes care clinic

All follow-up visits within previous 12 months

 

87% (1)e

    

 Switzerland

2013

General practitioner

First hospitalisation

 

31% (1)e

    

Burgmann et al. [84]

 UK

2011

General practitioner

Second diabetic visit

 

71% (1)e

    

Mc Hugh et al. [86]

 Brazil

2007

General practitioner

N/A

 

34–87% (2)e

    

Preti et al. [88]

Age-related Macular Degeneration

 Italy

2016

Ophthalmologist

N/A

  

44% (1)

   

Parodi et al. [93]

 Turkey

2015

Ophthalmologist

N/A

  

23% (1)

   

Muhammed et al. [95]

 UK

2013

Ophthalmologist & optometrist

N/A

21–32% (2)

 

28–70% (5)

  

49% (1)

Lawrenson and Evans [100]

 USA

2008

Ophthalmologist

N/A

  

76% (1)

   

Charkoudian et al. [103]

Cataract

 UK

2011

Ophthalmologist

N/A

  

51–99% (3)

   

Gomaa and Liu [105]

 UK

2009

Optometrist

Referral letter for cataract surgery

    

0–100% (10)c

 

Park et al. [107]

General practitioner

Referral letter for cataract surgery

    

0–100% (10)c

 

 UK

2006

Optometrist

Referral letter for cataract surgery

    

48% (1)c

 

Lash et al. [109]

 USA

2009

Resident ophthalmologist

Preoperative care visits for first cataract surgery

73–100% (4)

59–100% (9)

0–100% (9)

   

Niemiec et al. [111]

All postoperative follow-up visits for first cataract surgery

14–78% (6)

77–100% (7)

98% (1)

98% (1)

43% (1)b

98% (1)

Preventative eye care

 UK

2009

Optometrist

First visit

95% (1)

0–100% (5)

    

Shah et al. [115]

 UK

2009

Optometrist

First visit

26–87% (8)

24–99% (10)

29% (1)

   

Shah et al. [118]

 UK

2008

Optometrist

First visit

1–100% (14)

59–100% (8)

14–80% (6)

   

Shah et al. [120]

 Australia

2015

Optometrist

N/A

47–55% (2)

 

62–80% (2)

   

Downie and Keller [129]

Dry eye

 Australia

2013

Optometrist

N/A

 

4–93% (3)

    

Downie et al. [132]

 USA

2010

Ophthalmologist

Initial diagnosis visit BEFORE guidelines revised

6–99% (12)

6–100% (12)

5–90% (5)

 

48% (1)b

47–89% (3)

Lin et al. [134]

Initial diagnosis visit AFTER guidelines revised

6–100% (16)

6–100% (13)

0–100% (7)

 

33% (1)b

33–89% (4)

All ocular conditions at A&E

 UK

2007

Optometrist

First visit

    

91% (1)

 

Hau et al. [135]

Amblyopia

 USA

2013

Ophthalmologist

Initial visit

  

12–24% (2)

   

Jin et al. [138]

Esotropia

 USA

2010

Ophthalmologist

Initial esotropia evaluation

64% (4)f

99.6% (6)f

94% (4)f

  

94% (2)f

Gupta et al. [140]

 

70% (4)g

90% (6)g

94% (4)g

  

94% (4)g

Non-infectious uveitis

 USA

2011

Ophthalmologist & rheumatologist

All visits since initial diagnosis

  

12–23% (2)

   

Nguyen et al. [142]

aFung et al. [26] reported 0 and 87% compliance for frequency of visual fields examination against two sets of glaucoma guidelines, the European Glaucoma Society (EGS) [24] and the United Kingdom’s National Institute for Health and Clinical Excellence (NICE) guidelines [25], respectively. bPercentage of appropriateness of referral to relevant health practitioners. cPercentage of appropriate content of the referral letters. d‘’Recall period’ and ‘referral’ were assessed by the same set of case vignettes [71, 72]. ePercentage of diabetic patients who visited general practitioners and were arranged a diabetic retinopathy screening by ophthalmologists. fMean appropriate care measured against guidelines published by American Academy of Ophthalmology (AAO) in 2002. Appropriate care was defined as documentation of 50% or more of the specific parameters listed for each quality indicator. gMean appropriate care measured against guidelines published by NICE in 2007. Appropriate care was defined as documentation of 50% or more of the specific parameters listed for each quality indicator

Twenty-eight studies reporting on eye care appropriateness in glaucoma screening, glaucoma suspects and/or glaucoma patients were included. In more than half of the studies (15 of 28), the appropriateness of glaucoma care was measured via a review of hospital records. Appropriate ‘management’ and ‘recall period’ for glaucoma were reported most of the time, whereas ‘physical examination’ and ‘referral’ for glaucoma were not delivered as appropriately at times (Fig. 3a and b). Overall, the appropriateness of glaucoma care ranged widely from 2 to 100%. The appropriateness of glaucoma care assessed using clinical agreement with experts was the only method where appropriate care was delivered consistently at least 50% of the time. Although studies investigated the appropriateness of glaucoma delivered by optometrists and ophthalmologists, no obvious differences between professions were noted.
Fig. 3

Appropriateness of eye care for glaucoma (a, b) and diabetic retinopathy (c, d) for various domains of care by profession (a, c) and methods (b, d). All quality indicators from the included studies were pooled together. Each data point represented the percentage of compliance against a quality indicator. a Overall, the appropriateness of glaucoma care ranged widely from 2 to 100%. The appropriateness of glaucoma delivered by optometrists and ophthalmologists appeared similar. b When appropriateness of glaucoma care was assessed using clinical agreement with experts, care was delivered appropriately at least 50% of the time. The appropriateness of glaucoma care assessed using other methods ranged more widely. c, d The appropriateness of diabetic eye care ranged widely from 0 to 100%. The wide range and the relatively small number of studies measuring appropriateness of diabetic eye care limited our ability to detect obvious patterns in individual domains for diabetes care

Eleven studies have reported on appropriateness of eye care delivery in diabetic patients. Overall, diabetes eye care compliance also ranged widely from 0 to 100%. That wide range and the relatively small number of studies available makes it challenging to detect obvious patterns in individual domains for diabetes care (Fig. 3c and d). For example, only a single study with three quality indicators sampled the appropriateness of ‘patient education’ in diabetes eye care at a single site and reported a below 50% appropriateness of ‘patient education’ overall.

Appropriateness of eye care delivery has been measured for cataract, age-related macular degeneration, preventative eye care and five other ocular conditions in 18 separate articles (Table 2). Eye care appropriateness also ranged widely in those studies, for example from 0 to 100% for dry eye care [134] and for the referral of cataract surgery [107].

Very few studies examined or reported on factors that can modulate appropriateness of eye care delivery. Modifiable factors that have been shown to impact appropriateness of eye care delivery include data entry system (i.e. electronic or paper records) [134], health insurance coverage [76], higher eye care provider density [76], awareness of clinical practice guidelines availability [142], procedural confidence and therapeutic endorsement of optometrists [56] and specialty training conducted in a supportive environment [43]. Non-modifiable factors that may impact appropriateness of eye care include the severity of patients’ eye condition [71], patient’s age and ethnicity [54], and practitioner’s age [72, 129], gender [129] and years of experience [88]. These factors must therefore be measured and controlled for in any future studies assessing the appropriateness of eye care delivery.

Discussion

This systematic literature review summarises studies reporting the process of eye care delivery in many different countries using existing published evidence and/or experts’ practice to measure appropriateness of eye care. The appropriateness of eye care delivered was found to vary widely for the most commonly reported conditions (glaucoma and diabetic eye care) from 0 to 100%. Appropriate ‘management’ and ‘recall period’ for glaucoma were observed. Record review was most commonly used to assess the appropriateness of eye care delivery; this may be explained by the ease of administration and low cost associated with this method, especially when conducted at a single site.

The methodological quality was rated as moderate on average across all methods. Different quality assessment tools were used for to appraise studies with different study design, where some criteria were the same between tools. With consideration of the variety of the study designs and the total numbers of included studies, it was considered beneficial to use a modified quality assessment tool with all questions sourced from existing validated critical appraisal tools (Additional file 2). The quality of the included studies should not be different when different tools are used, when the studies are assessed against the same questions from the existing validated critical appraisal tools.

Comparison of the overall appropriateness of eye care versus the appropriateness for individual domains of eye care between studies presented some challenges for the following reasons:
  1. 1)

    Differences in the number of quality indicators used. Seven quality indicators were used in the Zebardast et al. [48] study, but 19 quality indicators were used by Ong et al. [50] Although both studies assessed appropriateness of eye care against the same glaucoma guidelines, the overall result cannot be easily compared, unless this is done by comparing appropriateness of care of individual quality indicators used by both studies.

     
  2. 2)

    Differences in eligibility criteria and time frame of quality indicators. Quigley et al. [52] assessed whether practitioners have performed gonioscopy at least once within the previous 6 years for all patients with open-angle glaucoma and found that appropriate care was delivery only 50% of the time. Conversely, Ong et al. [50] reported 90% appropriate care for performing gonioscopy on indication. A possible conclusion may be that practitioners in the latter study performed much better than in the former. However, careful observation of the study population characteristics reveals that this appropriateness of care results simply reflects how often practitioners perform gonioscopy in open angle glaucoma in the first instance and use of gonioscopy in cases with a suspicious angle in the latter study.

     
  3. 3)

    Differences in time interval. Chawla et al. [27] assessed both planned and actual review interval for glaucoma against the guidelines whereas Ong et al. [50] only assessed if the planned follow-up complied with guidelines.

     
  4. 4)

    Different aspects of the quality indicator are assessed. Appropriateness of ‘referral’ can be considered in terms of the appropriateness of the referral criteria, the timing of the referral or in terms of the appropriateness and contents of referral letters. Appropriateness of referral often describes whether patients were referred to the correct people or facilities. Appropriateness and contents of referral letters typically considers if the referral letters contained the required information, according to guidelines or specialist’s opinions. However, the percentage of appropriate care of these two aspects may not directly be comparable. Appropriateness of referral pathway or criteria is not necessarily equivalent to an appropriate referral letter and vice versa. For example, Ang et al. [62] reported that the appropriateness of referral letters from optometrists referring for glaucoma progression was 32% whereas the appropriateness and contents of their referral letters exhibited 24–93% compliance against the seven quality indicators used.

     
  5. 5)

    Differences in quality indicator weighing. Most studies weighed all quality indicators evenly, but some assigned different weightings for different quality indicators. Quigley et al. [52] assigned weighting (0, 1, 2 or 3) according to the imputed importance of individual items. Gupta et al. [140] defined appropriate care as the practitioners documenting 50% or more of the sub-indicators listed for each element. For example, once 2 or more of the 4 sub-indicators (frequency of deviation, date of onset, and presence of diplopia or squint) of ocular signs and symptoms were documented, this quality indicator was counted as compliant.

     

The findings of this systematic review are limited by the lack of a standardised method to measure and report the appropriateness of eye care delivery. The extent to which eye care appropriateness may have been under or overestimated may be significantly influenced by the choice of method used to assess care delivery in these studies. Two-thirds of the included articles measured compliance against recommendations from clinical practice guidelines, which are likely to have been developed using similar evidence sources. In this review, this is likely to have manifested as reporting the appropriateness of eye care according to a somewhat narrow evidence base. However, clinical practice guidelines are primarily developed for and made available to clinicians for the purposes of guiding evidence-based care, which lends credibility to their use as a compliance tool. In addition, studies conducted in one country might not reflect the appropriateness of eye care received in a different country where the health care and education systems, values and expectations could be significantly different [144]. Given that and the diversity of countries where eye care appropriateness has been measured, the generalisability of the various reported findings to other countries is uncertain.

Conclusion

Studies reporting the appropriateness of eye care delivery in Australia and other developed mainly English-speaking countries, indicated a wide range of appropriateness of care delivery, for glaucoma and diabetic eye care. Existing eye-related studies have assessed a single condition, a sample from a single centre or a single domain of care even as specific as only one examination technique such as gonioscopy. Consequently, none of the studies identified in the literature review attempted to measure the overall appropriateness of care provided in eye care. One important purpose of measuring appropriateness of care is to help policy makers to allocate limited health resources. Future research would benefit from a more comprehensive approach where appropriateness of eye care delivery is measured across multiple conditions with a single methodology to guide priorities within eye care delivery and monitor quality improvement initiatives.

Notes

Acknowledgements

We thank UNSW Library, Academic Services Team for their contribution on reviewing the search strategy and conducting the test run.

Authors’ contributions

KCH contributed to search, study design, study selection, data extraction, quality assessment, data analysis, and writing the report. FS contributed to search, study design, quality assessment, data analysis, and critical review. LW contributed to study design and critical review. PH contributed to study design and critical review. SA contributed to quality assessment. AW contributed to study design and critical review. IJ contributed to search, study design, quality assessment, data analysis, and critical review. All authors read and approved the final manuscript.

Funding

This work was supported by a UNSW Sydney Tuition Fee Scholarship [to KCH]; the Saudi Arabian Ministry of Higher Education [to SA]; a UNSW Sydney Faculty of Science June Griffith Fellowship [to IJ]; and a UNSW Sydney Faculty of Science Research Program Grant. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Supplementary material

12913_2019_4493_MOESM1_ESM.docx (15 kb)
Additional file 1: Full electronic search strategy for Medline. (DOCX 15 kb)
12913_2019_4493_MOESM2_ESM.docx (22 kb)
Additional file 2: Quality assessment tool. (DOCX 22 kb)
12913_2019_4493_MOESM3_ESM.docx (52 kb)
Additional file 3: Results of quality appraisal of included studies. (DOCX 52 kb)

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Authors and Affiliations

  1. 1.School of Optometry and Vision ScienceUNSW SydneySydneyAustralia
  2. 2.Eye Health, Injury DivisionThe George Institute for Global HealthSydneyAustralia
  3. 3.Faculty of Medicine and Health SciencesAustralian Institute of Health Innovation, Macquarie UniversitySydneyAustralia
  4. 4.Centre for Population Health Research, School of Health SciencesUniversity of South AustraliaAdelaideAustralia
  5. 5.Optometry and Vision Science DepartmentKing Saud UniversityRiyadhSaudi Arabia
  6. 6.Save Sight Institute, University of Sydney, Westmead HospitalSydneyAustralia
  7. 7.Centre for Vision ResearchWestmead Institute for Medical Research, University of Sydney, Westmead HospitalSydneyAustralia

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