Clinical audit as an educative tool for optometrists: an intervention study in age-related macular degeneration

Abstract

Purpose: Age-related macular degeneration (AMD) is a major cause of vision loss. This study investigated whether performing clinical audit and receiving analytical performance feedback altered documentation of the AMD care provided by optometrists.

Methods: Australian optometrists were recruited and completed a survey about their demographics and confidence in AMD care, and a three-month audit of their practice records using an AMD audit tool (termed the pre-audit evaluation). After receiving analytical feedback, participants identified areas for improvement and re-audited their practices after three months to analyse changes in performance (termed the post-audit evaluation). Paired t-tests and Wilcoxon signed-rank tests, as appropriate, were used to compare pre- and post-audit data.

Results: Twenty optometrists, most practising in Victoria, Australia, completed the study. Participants primarily worked in corporate practice and/or rural settings and had a range of optometric experience (2-40 years). At baseline, participants felt confident in their: knowledge of AMD risk factors (65%), advice to patients about these factors (55%) and management of earlier stages of AMD (55%). Each clinician completed (median [IQR]): 15 [IQR: 10-19] and 12 [IQR: 8-16] audits of unique patient records, pre- and post-audit, respectively. Post-audit, average record documentation (per optometrist) improved for asking about: AMD family history (94% to 100%, p = 0.03), smoking status (21% to 58%, p < 0.01), diet (11% to 29%, p < 0.01) and nutritional supplementation (20% to 51%, p < 0.01). For clinical examination, compliance with documenting pinhole visual acuity, performing an in-office Amsler grid (upon indication) and using optical coherence tomography improved post-audit (p < 0.05). Accuracy of severity documentation improved for earlier stages of AMD (p < 0.05). For earlier stages of AMD, documentation of counselling about modifiable risk factors significantly improved post-audit (p < 0.05). Aspects well-performed pre-audit that did not change included documenting: medical histories (100% at both time points, p = 0.06) and retinal imaging (77% at both time points, p = 0.97).

Conclusions: Self-audit with analytical feedback improved clinical record documentation of: AMD risk factors, clinical examination, AMD severity classification and management advice. These findings support a role for audit to improve optometric clinical care of AMD, as evidenced by improved documentation of the AMD care delivered.

Keywords: age-related macular degeneration; clinical audit; clinical record; optometry.