Sight saver, life changer: part of a day's work for an eye care practitioner: course code: C-15475 O/D/CL.
The role of an eye care practitioner is rewarded by the piece of mind that comes from knowing we are helping to prevent blindness and visual disability amongst those who seek our expertise. Many ECPs are fortunate enough to be able to contribute to 'sight saving' on a greater level, for example, by working overseas as part of charity projects or working in secondary or tertiary care hospital optometry clinics to name but a few. And, for the vast majority of primary ECPs, the opportunity to 'save' a patient's sight (for example, by appropriately dealing with a medical or emergency condition) is one of the most rewarding and fulfilling aspects of the role. However, for the vast majority of practitioners, opportunities to 'save sight' are a relatively infrequent occurrence when considering the proportion of patients who make use of primary eye care services on an annual basis. In relative terms therefore, correcting refractive error with the aid of spectacles or contact lenses contributes significantly more to what the vast majority of practitioners do within their professional environment.
If correcting peoples vision is, to the largest extent, 'what we do' as ECPs, is it possible to quantify the impact of our work and if so, how? How much fulfilment should we be able to take from this and are there ways to help patients benefit from and value our ability to manage refractive error? To answer these questions it is worth looking at the measures typically used to quantify patient 'satisfaction' and/or 'quality of life' (QoL).
Measuring 'satisfaction' and quality of life
Traditionally, the measurement and correction of refractive error has been characterised by clinical measures such as visual acuity (VA) or contrast sensitivity (CS). Whilst these measures provide vital information regarding a patient's vision, they provide little indication of the impact we are making on the person as a whole. To obtain a more complete sense of what a patient feels, it is more appropriate to assess their satisfaction with their vision and/or their QoL.
There is no single method of refractive correction that is appropriate or appealing to all patients. However, some patients and practitioners may restrict their correction options based on such factors as previous experience, current knowledge/understanding of a given correction method, and ease of provision. However, understanding the relative impact of different methods of refractive correction on QoL is beneficial for ECPs for several reasons:
* Allows practitioners to more positively influence their contribution to a patient's QoL
* Enables practitioners to communicate more effectively and quantify their patients relative QoL gain (1)
* Allows practitioners to more consistently fulfil their patients expectations
* Enables practitioners to identify which patients stand to gain the most from a given method of refractive correction (2)
* Allows practitioners to deliver 'bespoke' eye care
* Contributes to patient compliance and loyalty. (3)
What is 'quality of life'?
In health terms, QoL encompasses
the physical, functional, social and emotional well-being of an individual. QoL is an important metric used routinely in many areas of healthcare and especially in oncology and chronic illness where QoL information is used as a prognostic indicator and aids decision-making. Information about QoL provides vital detail about a particular course of action or decision, which is based on more than clinical opinion alone. There are over 150,000 published papers that investigate QoL with 1,700 relating to vision. As highlighted by Lesley Fallowfield, Professor of Psychology, Brighton and Sussex Medical School, "the challenge remains to encourage more clinicians to use them [QoL information] outside of a clinical trial setting." (4)
QoL related to methods of refractive correction
The QoL contribution made by different forms of refractive correction has received growing attention since methods to measure vision specific-QoL (VS-QoL) were first described about ten years ago. Since then researchers have developed more robust methods and the standard approach is through the use of questionnaires (or 'instruments'). (5,6) Several instruments have shown promise in accurately measuring VS-QoL with respect to the different methods of refractive correction, including spectacles, hard and soft contact lenses and refractive surgery (7,8) and also within specific groups, for example paediatric contact lens wearers (9) and contact lens wearers with abnormal ocular conditions such as keratoconus. (10) VS-QoL instruments include the Refractive Status and Vision Profile (RSVP), (11) National Eye Institute Visual Function Questionnaire (NEI-VFQ), (12) the Quality of Life Impact of Refractive Correction (QIRC) (8) and the Paediatric Refractive Error Profile (PREP). (9) Typically, respondents are required to answer each question in the form of a subjective rating, for example on a scale between 1 and 5. This allows the patient greater scope to express their preferences and opinions; closed questions (ie, 'yes' or 'no' type questions) are purposely avoided. By applying an analysis algorithm such as Rasch Analysis, investigators are then able to generate a VS-QoL 'score', which relates to a measure of that specific method of refractive correction.
Several investigators have compared VS-QoL scores between different methods of refractive correction. (8,9) Using the QIRC instrument, Pesudovs et al. (8) compared the VS-QoL scores for spectacle wearers, contact lenses wearers, and individuals who had undergone refractive surgery. Their findings indicate significantly better QoL outcomes for individuals who had undergone refractive surgery (Mean score of 50.2[+ or -]6.3 logits) than those who wore contact lenses (Mean score of 46.7[+ or -]5.5 logits), who in turn were significantly higher than spectacle wearers (Mean score of 44.1[+ or -]5.9 logits); scores were especially higher in those people with high refractive error. The authors suggest that the enhanced QoL that comes through 'spectacle freedom/reduced dependence on spectacles' occurs due to factors including less difficulty with driving in glare conditions, being able to use non-prescription sunglasses, greater convenience during exercise, and being more confident in their appearance. (8) Spectacle wearers only achieved a higher QoL score than both contact lens wearers and refractive surgery patients in one area, that being 'concern for medical complications'. (8) Interestingly the authors point out that a small proportion of individuals who had undergone refractive surgery (6.7%) exhibited significantly reduced QoL outcomes, as a result of post-operative complications. (8) In a separate study, Rah et al. (9) utilised the PREP instrument to assess the benefits to wearing spectacles versus wearing contact lenses amongst children under the age of 12 years. (9) During the three-year investigation, the study group observed a significantly greater improvement in mean QoL score in children who wore contact lenses (increase of 14.2[+ or -]18.1 units) compared to children wearing spectacles only (increase of 2.1[+ or -]14.6 units) (P<0.001). (9) This almost seven-fold difference is reported to be due to better subjective preference towards contact lenses or reduced dependence on spectacles, most notably in the appreciation of their own appearance when carrying our recreational activities. (9)
Can practitioners enhance their patient's quality of life?
It would appear from the studies described previously that ECPs, knowingly or otherwise, do play an important role in contributing to their patients' QoL. It stands to reason that patients who experience particularly low QoL using their current method of refractive correction may be more likely to consider an alternative form if such a recommendation was made. This logic has also been expressed previously. (8) Thus the likelihood that a patient will accept an optical practitioner's recommendation for a given method of refractive correction will be increased if the practitioner can effectively translate and communicate the benefits of their recommendation in specific QoL terms. For the vast majority of ECPs in the UK, the stalwart methods for refractive correction involve the provision of spectacles and contact lenses (other less frequently encountered methods include orthokeratology and refractive surgery). Thus it is important for ECPs to appreciate the relative contribution to a patient's QoL made when providing (or recommending) any given method of refractive correction.
Figure 1 Examples of good and bad questions for lifestyle questionnaires Example of a good question for a lifestyle questionnaire: * On a scale of 1 to 10, how desirable do you find being able to see clearly without spectacles? Example of a bad question for a lifestyle questionnaire: * If recommended by your optometrist, would you try contact lenses? YES / NO
Can optical practitioners measure QoL in practice?
Whilst the aforementioned VS-QoL instruments are valid and robust tools in research, their application to primary eye care is limited by several factors. Firstly, these instruments are relatively long and require what may be deemed as an 'excessive' amount of time to complete. (4) Secondly, the analysis of the data is potentially time consuming and complicated. (4) This is not to say that QoL questionnaires are a bad idea in primary eye care. In fact, it is quite the opposite and for ECPs who desire a better understanding of their patients' visual requirements, patient participation in the information gathering, evaluation and decision making process is vital. This is echoed in other areas of healthcare, where the benefits of patient participation in these processes have been quantified in terms of improved satisfaction with management recommendations, a positive commitment to management recommendations and better overall outcomes. (13,14)
A type of QoL instrument which is perhaps more suited to primary eye care is found in the form of an appropriately constructed lifestyle questionnaire of which there are many different versions commonly adopted by practitioners. It is especially useful if the chosen lifestyle questionnaire employs questions where the answers are given on a subjective grading scale eg, 1-10, as employed by the aforementioned VS-QoL instruments. Questionnaires that are based on subjective rating scales rather than binary measures (eg, 'yes'/'no') (Figure 1) can better differentiate those attributes of a refractive correction or lifestyle situation that are deemed 'good/acceptable' from those that may be deemed problematic. The lifestyle questionnaire also serves as a useful benchmark for ECPs seeking to highlight the relative gain obtained from a new method of refractive correction/management eg, when a patient experiences contact lenses for the first time.
What can ECPs do to enhance QoL and satisfaction for patients?
Patients are exposed to a wealth of information about different methods of refractive correction, from a range of sources including the media, advertising, word of mouth, and the Internet. Factors that will influence a patient's choice of refractive correction include first and/or second-hand experience, relevance to lifestyle, limitations of current refractive correction, affordability, fashion, and cosmetics. Irrespective of a patient's prior knowledge, understanding, or interest in a particular method of refractive correction, ECPs play an important role in providing patients with information and opportunities, which in the broadest terms, contribute to QoL. Indeed, it has been shown that whilst non-surgical refractive corrections provide 'good/very good health and safety', refractive surgery (LASIK) was stated as the preferred method of refractive correction under hypothetical conditions where all methods of refractive correction had equal health and safety, visual clarity, doctor recommendation and cost. (2) This highlights the understandable desire amongst ametropes to have 'normal vision'.
The way in which refractive correction methods and their associated QoL benefits are communicated/recommended to patients has a large influence on whether or not the recommendation is (a) acted upon, and (b) understood. If information provided to patients is difficult to comprehend it may fail to achieve the desired change in knowledge or behaviour. (15) If the information is understood by the patient but the practitioner fails to explain the relevance of the information to the patient, then the same outcome may occur.
Shared decision making, between patient and practitioner, appeals to a patient's 'need' for information regarding their health and wellbeing (16) and is commonplace in the medical profession. Whilst shared decision making is the gold standard approach, patients also seek to place the responsibility for decision making with the practitioner. (17) These findings emphasise the need for optical practitioners to provide clear, unambiguous information about the refractive correction options available to a patient and also to provide clear avocation for the most appropriate or relevant option/s. In combination with the desire to 'know' and 'understand', patients also have a desire to feel 'known' and 'understood'. Making recommendations that are relevant to information gathered throughout the consultation process helps patients to feel that their 'needs' have been acknowledged and acted upon. The choice of language used by an ECP is extremely important in demonstrating this to patients.
As an example, it may seem appropriate to ask patients who are suitable for contact lenses the question "have you ever considered contact lenses?" or "would you like to try contact lenses?" There are several limitations to these (or similar) questions: (a) they do not demonstrate the practitioner's understanding of a patients specific visual requirements (b) they portray no sense of shared decision making, and (c) they provide no information regarding what contact lens wear involves. Thus the specific language used whilst communicating a recommendation is very important. A possible alternative recommendation may be: "There are several simple ways to correct your vision which could provide you with advantages over spectacles, especially whilst ... [eg, playing golf]. On a scale of 1 to 10 how desirable is being able to see clearly without your spectacles?"
The same 'principle' can be applied to any recommendation made by an optical practitioner to a patient. The decision whether or not to accept the recommendation still remains with the patient; the support of the practitioner towards a particular option is strengthened and the patient gains an understanding of the ECP's raison d'etre for presenting the opportunity.
Conclusion and implications
It is important for optical practitioners to understand the contribution of different methods of refractive correction to an individual's QoL. In order to measure the significance/impact of the contribution, Optical practitioners must employ a reliable method of measuring QoL both within a single visit (cross-sectional) and between visits (longitudinal). Whilst robust VS-QoL instruments have been developed for use in research, appropriately constructed lifestyle questionnaires may provide ECPs with a useful surrogate measurement of QoL in a primary eye care setting. Attitudes towards refractive corrections appear to change with time (2) and are influenced by a range of factors. Therefore, ECPs need to be aware of how to best communicate the benefits and risks of refractive corrections to patients, in order to facilitate the correct selection and to maximise satisfaction and QoL.
About the author
Dr Cameron Hudson is the professional services manager for CIBAVision, UK
See http://www.optometry.co.uk/clinical/index. Click on the article title and then download "references"
Dr Cameron Hudson BSc (Hons) PhD MCOptom
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|Title Annotation:||CET: CONTINUING EDUCATION & TRAINING|
|Date:||Jan 28, 2011|
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