Is there scope for expanding the optometrist’s scope of practice in Singapore? – A survey of optometrists, opticians in Singapore

Contact Lens and Anterior Eye 42 (2019) 258–264

Contents lists available at ScienceDirect

Contact Lens and Anterior Eye journal homepage: www.elsevier.com/locate/clae

Is there scope for expanding the optometrist’s scope of practice in Singapore? – A survey of optometrists, opticians in Singapore

T

Pradeep Paul Georgea,f,g, , Olivia Chng Shih Yunb, Kalin Siowc, Nakul Saxenaa, Bee Hoon Henga, Josip Card, Craig Lockwoode ⁎

a

Health Services & Outcomes Research (HSOR), National Healthcare Group, Singapore Optometry Service, Tan Tock Seng Hospital, Singapore c Optometry Service, Singapore National Eye Centre, Singapore d Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore e Implementation Science, The University of Adelaide, Adelaide, Australia f Faculty of Public Health and Epidemiology, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore g Faculty of Health Sciences, University of Adelaide, Australia b

ARTICLE INFO

ABSTRACT

Keywords: Extended scope practice Optometrists Opticians Primary eye care Survey Singapore

Purpose: In Singapore, optometrists’ roles are limited compared to their counterparts elsewhere. The purpose of the survey is to investigate optometrists’ current roles, views on extended roles, self-reported primary eye care knowledge, needs for continuing professional education (CPE) and views on suitable modes for CPE. Methods: Members of the Optometrist and Optician Board (OOB) were invited via email to take part in an anonymous online survey. The survey questions covered the following areas: current scope of practice, self-rated primary eye care knowledge, confidence in screening, co-managing minor eye conditions, CPE and referral behavior. Results: A total of 230 optometrists completed the survey (response rate 30%). Their current roles were limited to diagnostic refraction (92%), colour vision assessment (65%), contact lens fitting and dispensing (62%) amongst others. The average self-rated score for primary eye care knowledge was 8.2 ± 1.4; score range 1-10 (1Very poor, 10-Excellent). Self-rated confidence scores for screening for cataract, diabetic retinopathy, chronic glaucoma and age-related macular degeneration were 2.7 ± 1.5, 3.7 ± 1.9, 4.0 ± 1.9 and 3.8 ± 1.8, respectively. 71% of the optometrists felt that they should undertake regular CPE to improve their primary eye care knowledge. Blended learning (eLearning and traditional face-to-face lectures) (46.1%) was the most preferred mode for CPE delivery. Conclusion: Optometrists in Singapore represent a skilled underutilized primary eye care provider. Though their self-reported primary eye care knowledge is high, their confidence in screening and co-managing chronic eye conditions is low. Enabling them for extended primary eye care role would require further training. Significance: Singapore ageing population has led to greater eye care demands. Task-shifting from ophthalmologists to optometrists has been proposed in the literature to handle this growing care demands. At this juncture, this study provides evidence based answers to issues revolving around optometrists’ readiness for a role expansion in Singapore.

1. Introduction Optometrist’s role in eye-care delivery has evolved worldwide. In the last two decades, technological advancements in spectacle lens and contact lens technologies, low-vision services and refractive services, have given the profession a platform to deliver a broader scope of primary eye care to the community [1]. Primary eye care is defined as

⁎

the provision of appropriate, accessible, and affordable care that meets patients’ eye care needs in a comprehensive and competent manner. It provides the patient with the first contact for eye care as well as a lifetime of continuing care [2]. In view of these developments, the World Council of Optometry (WCO) developed a Global CompetencyBased Model of Scope of Practice in Optometry to reconcile the variations in the scope of optometric practice internationally [3]. The model

Corresponding author at: National Healthcare Group, 3 Fusionopolis Link, #03-08 Nexusone-north, 138543, Singapore. E-mail address: [email protected] (P.P. George).

https://doi.org/10.1016/j.clae.2019.02.008 Received 20 March 2018; Received in revised form 19 February 2019; Accepted 19 February 2019 1367-0484/ © 2019 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Contact Lens and Anterior Eye 42 (2019) 258–264

P.P. George, et al.

includes optical technology services (dispensing of lenses and frames), visual function services (examination and measurement of vision defects), ocular diagnostic services (examination and evaluation of the eye to manage diseases) and ocular therapeutic services (using pharmaceutical agents to manage conditions) [4].

take on this active primary eye care role in Singapore. The purpose of this study is to assess current scope, primary eye care knowledge, views on extended role in primary eye care, preference for continuing professional education (CPE) and referral behavior of optometrists in Singapore.

1.1. Optometrists’ roles globally and in Singapore

2. Methods

Optometrists’ scope of practice worldwide ranges from provision of optical technological and visual function services in Japan, to provision of optical technological, visual function and ocular diagnostic services in Malaysia, Indonesia and Hong Kong [5] and provision of ocular therapeutic services in New Zealand [3]. In Singapore, according to the “Optometrists and Opticians Act”, optician’s main task is to refract the eyes, prescribe and dispense spectacles. The optometrist on the other hand, can perform the task of an optician while performing an extended role in providing primary eye care to the public [6]. Opticians usually hold a certificate in basic opticianry practice, or diploma in opticianry or advance certificate of performance in ophthalmic dispensing or advance certificate of performance in ophthalmic dispensing and refraction. While, opticians usually hold a diploma, or degree or master’s degree in optometry [7]. Optometrists provide a range of primary eye care services in government polyclinics and private clinics. The services include refraction, prescription of optical appliances and detection of ocular abnormalities through binocular vision tests, ophthalmoscopy or fundoscopy, retinoscopy, slit-lamp examination, tonometry and visual field testing [8,9]. They are trained to detect common eye conditions such as cataracts, dry eyes, strabismus in children and more sightthreatening eye diseases such as glaucoma, diabetic retinopathy and age-related macular degeneration to enable early intervention. In hospitals, optometrists conduct various eye examinations and work closely with ophthalmologists in co-managing various eye diseases and refer patients to ophthalmologist for further treatment. On the other hand, opticians often work together with optometrists, and some may perform refraction, interpreting prescriptions of medical practitioners and optometrists; supplying, preparing and dispensing optical lenses (except contact lenses), and performing fitting and adjustment of optical appliances. However, the scope of practice of an optometrist and optician in Singapore depends on the level of training, experience and competence [8,9].

An anonymized online survey was conducted among opticians and optometrists registered with Optometrists and Opticians Board (OOB) using a self-administered questionnaire. The OOB is the regulating authority for optometrists and opticians in Singapore. Optometry practice in Singapore requires mandatory registration with OOB [19]. An advisory group of five members which included: academic optometrists, practicing optometrists/opticians working in private practices and members of the OOB developed the draft survey questionnaire. The questionnaire was pilot tested to establish its face validity. Refinements were made to the questionnaire based on the feedback received during the pilot study. The questionnaire was organized into eight sections, with a total of 36 questions (Appendix). Questions within each section required Yes/No responses or the use of Likert scales for those questions relating to barriers and preferences. The survey was designed to be completed within 25 min. It was estimated that the minimum of 278 optometrists need to be surveyed from the sample of 700 optometrists with full registration, assuming a margin of error of ± 5% and α error of 5% level. The finalised survey was distributed by email via Survey Monkey to all Singapore-based optometrists/opticians registered with the OOB membership database along with a cover letter and participant information sheet informing them about the purpose of the survey and requesting their consent for the survey. Participation in the study was voluntary and informed consent was explicit when a participant attempted the questionnaire. The initial mailing took place on July 2016. Seven reminder mailings were sent, the first after ten days and the last after 90 days to maximise the response rate. Ethics approval for this research was granted by the National Healthcare Group's domain specific review board (2015/00549) and University of Adelaide Human Research Ethics Committee Office (HREC) (H-2015-237). The research was carried out in accordance with the tenets of the Declaration of Helsinki. Optometrists’ primary eye care knowledge and confidence in screening and co-managing simple eye conditions with guidance from ophthalmologist were assessed on a scale of one to ten, one referring to very poor knowledge and ten referring to excellent knowledge. Primary eye care (PEC) was defined as identification, treatment or referral of individuals with treatable causes of blindness and the diagnosis and treatment of common eye conditions [20,21]. And knowledge of PEC was defined as primary eye care knowledge. Optometrists were asked about how much they would be willing to pay ($SGD; 1 SGD = 0.74 USD, as of July 1, 2016) for a 24-hour short course on primary eye care given that it was a) not recognised as professional development course b) has been subsidized 50% by their employer c) was a recognised professional development course d) was recognized as prior learning (of appropriately 5–10%) course leading to a university postgraduate qualification. The survey responses were exported into PASW statistics 18 for data analysis. Interval data generated using Likert scales were described using mean and standard deviation (SD). Frequencies were presented as % valid (n absolute/n valid), as the number of valid values differed from item to item. Proportions were compared using the Chi-square test to determine associations between optometrists’ responses and categorical variables, including age-groups, gender, mode of practice, credentials, awareness of CPE and preferred mode of CPE. Where appropriate, continuous variables were presented as mean ± standard deviation (SD) and were statistically compared using the T-test/Median test. Where appropriate, association between the various factors was

1.2. Optometrists’ role in primary eye care Singapore, like many countries, is experiencing a rapidly ageing society [10,11]. It’s estimated that 28% of its population would be 65 years or older by 2030 [12]. This is likely to result in a considerable increase in the prevalence of important sight-threatening conditions commonly affecting the elderly, such as cataract, age-related macular degeneration (AMD) and diabetic retinopathy (DR). A systems dynamic model has predicted doubling of patients with diabetic retinopathy, glaucoma and epiretinal membrane in Singapore by 2040 [13]. Additionally, Singapore has one of the highest prevalence of myopia in the world [14]. The current primary eye care model is costly as ophthalmologists are made to assess minor eye conditions when this can be performed by trained optometrists [15]. Consequently ophthalmologist in specialist outpatient clinics (SOCs) is seeing overwhelming numbers of non-urgent cases such as stable dry eye; early stage cataract, annual eye screening for diabetic retinopathy patients where such patients can be more efficiently co-managed by trained optometrist. This phenomenon is due to the lack of primary eye care in the community, which could be better managed by optometrists acting as gate keepers for primary eye care in the community [16,17]. To cope with the greater eye care demands of the future, taskshifting from ophthalmologists to mid-level ophthalmic professionals such as optometrists has been suggested in the literature [18]. However, not much is known about how equipped the optometrists are to 259

Contact Lens and Anterior Eye 42 (2019) 258–264

P.P. George, et al.

analysed using logistic regression adjusting for age, gender, type of practice, credentials, the number of patients seen per year, self-rated primary eye care knowledge and awareness of CPE. P value of < 0.05 was deemed statistically significant.

13.0, 95% CI: 2.3–73.7) and private hospitals/clinics (OR: 3.8, 95% CI: 1.2–12.0) were more likely to perform diagnostic refraction compared to their counterparts working at academic/research setups, Table 3. Optometrists working at academic/ research centers (OR: 2.7, 95%CI: 1.4–5.0) and in private clinics/hospitals (OR: 4.6, 95% CI: 1.8–11.7) were more likely to perform topography/pachymetry compared to their counterparts working in private clinics/ hospitals. Determinants of an extended role of the optometrists in Singapore included their credentials, place of practice, current roles in practice, confidence in screening for glaucoma and their awareness of available CPE courses in primary eye care, Table 3.

3. Results 3.1. Sample characteristics Of the total of 787 surveys emailed to optometrists and opticians, 237 completed the online survey (response rate of 30%), the sample size achieved was lower than the estimated ideal sample size (sampling error: 4.9%). The response rate was higher among optometrists from government (sample: 28% vs population: 12%) and academic/research set-ups (sample: 12% vs population: 4%) and lower among optometrists from the private sector (sample: 60% vs population: 81%). Ninety-seven percent of the respondents were optometrists, hence for brevity and generalizability, this study analyzed and presented data from optometrists (n = 230) only in this manuscript. The respondents included 65 (28%) males and 165 (72%) females. Majority of the respondents were Chinese (95%), 50% had a diploma, 34% had a bachelor's degree, 13% had a master’s degree and 1% had a doctorate degree in optometry. Average years in practice for optometrists were 12 ± 7.4 years (Table 1). 61% of the optometrists were working in private practice in clinics/hospitals as single or partner owners, 28% worked in Government restructured hospital and 11% in academic/ research set-ups.

3.3. Optometrists referral behavior (Q30–34) Most of the optometrists (n = 155, 67.4%) refer patients to general practitioners (GPs) or ophthalmologists in SOCs for treatment. Referral rates varied significantly by optometrists’ practice, 47.4% in private chain stores/clinics/hospitals (n = 109), 11.7% in government restructured hospitals (n = 27) and 8.3% in academic/research setups (n = 19), (chi-square, p < 0.0001). On an average, optometrists referred 3 ± 3 patients per month to GPs and 10 ± 26 patients per month to ophthalmologists at SOCs. These patients were referred for conditions such as cataract (62%), diabetic retinopathy (55.3%), chronic glaucoma (48.1%), acute glaucoma (39.2%) and age-related macular degeneration (56.1%). Of those patients referred to GPs and SOCs, feedback on their course of treatment was received by optometrists only for about 42.6% of the patients (n = 66). Of these, 17.3% received feedback by e-mail, 10.9% received feedback through letters, 4.2% received feedback verbally through patients, 3.8% each received feedback through phone, SMS, and 3.4% received direct feedback from doctors (face-to-face). Optometrists aged ≤ 30 years (OR: 6.8, 95% CI: 1.2–38.2) were more likely to refer patients to GPs or ophthalmologists compared to optometrists aged 50–59 years. Optometrists working in government restructured hospitals (OR: 5.6, 95% CI: 2.7–11.6) were more likely to refer patient to GPs or ophthalmologists compared to those working in private setups. Similarly, optometrists with higher self-reported primary eye care knowledge scores (OR: 0.77, 95% CI: 0.61–0.98) were less likely to refer patients to GPs or ophthalmologists.

3.2. Current scope of practice and extended role Optometrist current roles in Singapore are shown in Fig. 3, (Q11). Most optometrists (n = 171, 83%) felt that there is scope for them to play extended roles in areas such as screening for eye diseases and comanaging simple eye conditions along with ophthalmologists in hospitals and primary eye care setups, (Q12). However, currently eye screening is done by fewer than 3% of the optometrists in Singapore. Optometrists working in government restructured hospitals (OR: Table 1 Characteristics of survey respondents. Variables

Categories

N = 230 (%)

Age group

≤ 30 yrs. 30 – 39 yrs. 40 – 49 yrs. 50 – 59 yrs. ≥ 60 yrs. Male Female Diploma Bachelor’s degree Master degree PhD Other Singapore Polytechnic University of Manchester Pennsylvania College of Optometry Cardiff University University of Melbourne Others*

74 (32) 121 (53) 10 (4) 17 (7) 8 (4) 65 (28) 165 (72) 116 (50) 79 (34) 30 (13) 3 (1) 2 (1) 132 (57) 35 (15) 31 (14)

Gender Credentials

Institution of highest qualification in optometry

Years in practice (Mean ± SD) No of patients seen in the practice in a month (Mean ± SD)

3.4. Self-rated primary eye care knowledge and confidence in screening and co-managing The results showed that average self-rated primary eye care knowledge as 8.2 ± 1.4, Table 2, (Q13). 47.4% of the respondents (n = 109) had a knowledge score of 8 or more. Fig. 1 shows the selfreported knowledge score by optometrists’ credentials. Optometrists’ confidence in screening (confidence score of 8 or more) was 79.3% for cataract, 51.1% for DR, 42.2% for chronic glaucoma and 42.3% for AMD. Similarly, their confidence in co-managing (confidence score of 8 or more) was 76.4% for cataract, 62% for DR, 58.2% for DR and 58.6% for AMD, (Q14 and 15) Optometrist’s confidence in screening and co-managing common eye conditions such as cataract, diabetic retinopathy, chronic glaucoma and age-related macular degeneration was generally low, average scores ranged from 2.6 to 4.0, Table 2. Multivariate analysis showed that the self-rated primary eye care knowledge increased with optometrists’ credentials. Optometrists with bachelors, masters and doctorate degrees were more likely to report higher knowledge scores, Table 4.

8 (4) 4 (2) 19 (8) 12 ± 7 177 ± 182

* others included association of British Dispensing Opticians, Ngnn Ann polytechnic, University of Bradford, Hong Kong Polytechnic University, Aston university, Auckland university, Glasgow Caledonian University, National University of Malaysia, Queensland University of Technology, SIM (Singapore Institute of Management), Unspecified, University of Wales, UNSW and not specified by two respondents.

3.5. Continuing professional education for optometrists Seventy-one percent of the optometrists (n = 164) felt that they should undertake regular continuing professional education to improve their primary eye care knowledge, (Q16). However, only 31.1% and 260

Contact Lens and Anterior Eye 42 (2019) 258–264

P.P. George, et al.

Table 2 Self-rated knowledge and confidence in co-managing eye conditions by optometrists' credentials. Variables

Overall

Credentials (Mean ± SD)

n = 230

Diploma

ǁ

Self-rated primary eye care knowledge score 8.2 (1.4) 7.8 ± 1.6 Confidence in screening for eye conditions Cataract 2.7 (1.5) 3.2 ± 1.7 Diabetic retinopathy 3.7 (1.9) 4.4 ± 2.0 Chronic Glaucoma 4.0 (1.9) 4.6 ± 2.1 Age related macular degeneration 3.8 (1.8) 4.4 ± 2.0 Confidence in co-managing eye conditions in primary eye care set up with guidance from ophthalmologist Cataract 2.6 (1.7) 3.1 ± 1.8 Diabetic retinopathy 3.3 (1.8) 3.9 ± 1.9 Chronic Glaucoma 3.5 (1.8) 3.9 ± 1.9 Age related macular degeneration 3.4 (1.8) 3.9 ± 1.9 ǁ ǂ

p-valueǂ

Bachelors

Masters

Doctorate

8.5 ± 1.1

9.0 ± 0.7

9.0 ± 0.0

0.0001

2.2 3.1 3.6 3.3

± ± ± ±

1.0 1.5 1.6 1.4

1.9 2.7 3.2 3.0

± ± ± ±

0.9 1.4 1.4 1.4

1.7 2.7 2.7 2.7

± ± ± ±

1.2 0.6 0.6 0.6

0.0001 0.0001 0.0040 0.0001

2.3 3.0 3.2 3.1

± ± ± ±

1.5 1.5 1.7 1.6

1.8 2.2 2.4 2.4

± ± ± ±

0.8 1.1 1.1 1.2

2.3 2.3 2.3 2.3

± ± ± ±

1.2 1.2 1.2 1.2

0.0001 0.0001 0.0060 0.0020

scale range 1–10. (1=very poor; 10=excellent). Median test.

23.7% of these had any previous training (other than CPE) in eye screening (n = 51) and co-managing minor eye conditions (n = 39) respectively (Q17a). Similarly, only 27.4% of the optometrists (n = 63) were aware of CPE courses on primary eye care for conditions such as cataract, glaucoma, age-related macular degeneration and diabetic retinopathy in Singapore, (Q21). 28.3% (n = 65) of the optometrists/ opticians reported taking more than 40 h of CPE in the past year, (Q22).

eLearning and blended learning, (Q25), they chose better efficiency as the foremost enabler (mean rank ± SD: 1.3 ± 0.5) for blended learning followed by lower cost (1.7 ± 0.7) and flexibility in training (1.9 ± 0.8). Similarly, the enablers for eLearning were flexibility (1.2 ± 0.6) and cost (1.8 ± 1.0). Barriers to eLearning, blended learning are presented in Fig. 2. Lack of access to instructor/expert was identified as the most important barrier. Optometrists from government restructured hospitals were more likely to select didactic lectures as their preferred delivery mode for CPE compared to their counterparts working in private chain stores/clinics/hospitals (OR: 2.4, 95% CI: 1.1–5.2). Optometrists who felt they had an extended role in hospital, primary eye care set-ups were more likely to prefer blended learning course as the delivery mode for CPE compared to those who were not sure of their extended role (OR:2.7, 95% CI: 1.3–5.6). Male optometrists

3.5.1. Preferred mode for CPE The blended learning course defined as use of both eLearning and face-to-face learning was the most preferred mode of delivery for CPE (n = 106, 46.1%), followed by online eLearning course (n = 69, 30%), didactic lectures (n = 50, 21.7%) and conferences (n = 5, 2.2%), (Q24). Optometrists were asked to rank the enablers, barriers for Table 3 Predictors of optometrist’s current job scope and their views of an extended scope. Variable

Category

Odds ratio

95% Confidence interval Upper

Scope for extended role

1

Current scope2, diagnostic refraction 2

Current scope , spectacle dispensing

Current scope2, contact lens fitting and dispensing 2

Current scope , low vision management Current scope2, visual field analysis Current scope2, ocular photography 2

Current scope ,Fundus examination Current scope2, Topography/Pachymetry

Optometrists in government set-ups Optometrists in Private set-ups Current roles in practice, Diagnostic refraction (Yes) Current roles in practice, Contact lens fitting (Yes) Current roles in practice, Ocular photography (Yes) Confidence in screening for Chronic glaucoma Awareness of CPE courses (No) Optometrists in Academic/ Research set-ups Optometrists in government set-ups Optometrists in Private set-ups Female Optometrists (Reference: Male) Optometrists in government set-ups Optometrists in Private set-ups Optometrists in Academic/ Research set-ups Optometrists in government set-ups Optometrists in Private set-ups Optometrists in Academic/ Research set-ups Male optometrists (Reference: Female) Optometrists in government set-ups Optometrists in Academic/ Research set-ups Diploma Bachelor’s degree Master’s degree Diploma Master’s degree Optometrists in Private set-ups Optometrists in government set-ups Optometrists in Academic/ Research set-ups

1.0 6.0 17.4 0.2 0.3 0.5 5.3 1.0 13.0 3.8 2.9 1.0 56.7 13.3 1.0 43.8 7.0 2.8 1.0 4.3 1.0 2.4 3.9 1.0 3.9 1.0 2.7 4.6

Reference 1.4 2.2 0.0 0.1 0.2 1.7 Reference 2.3 1.2 1.1 Reference 18.0 3.5 Reference 17.1 2.3 1.1 Reference 1.6 Reference 1.3 1.7 Reference 1.6 Reference 1.4 1.8

Lower 24.8 139.9 0.8 1.0 1.0 17.0 73.7 12.0 7.5 178.8 50.0 112.5 21.7 7.1 11.8 4.4 9.1 9.2 5.0 11.7

1 adjusted for age, gender, credentials, place of practice, current roles in practice, self-reported primary eye care knowledge, confidence in screening and comanaging eye conditions and awareness of CPE in primary eye care. 2 Adjusted for age, gender, credentials, place of practice, ǂConfidence score 1–10 (1=Not confident at all, 10=Very confident).

261

Contact Lens and Anterior Eye 42 (2019) 258–264

P.P. George, et al.

Fig. 1. Optometrists primary eye care knowledge by gender and credentials.

were more likely to prefer online eLearning course (OR: 2.3, 95% CI: 1.1–2.1) as the delivery mode for CPE compared to females. Optometrists with bachelor’s degree were more likely to prefer online eLearning course as the delivery mode for CPE compared to optometrists with master’s degree. (OR: 3.8, 95% CI: 1.1–13.1). Optometrists who were not sure about their extended role in hospital, primary eye care set-ups were more likely to prefer online eLearning course as the delivery mode for CPE compared to those who felt that they had an extended role (OR: 2.5, 95% CI: 1.1–5.3).

Table 4 Significant positive predictors of optometrist’s self-rated primary care knowledge, confidence in screening and co-managing chronic eye conditions. Category

Self-rated primary eye care Diploma Bachelors Masters Doctorate Low vision management Colour vision assessment Confidence in screening for Doctorate Diploma Confidence in screening for Females (Males: Reference) Current practice: Spectacle dispensing – Yes (No-Reference) Confidence in screening for degeneration ≤ 30 yrs. Old 50 – 59 yrs. Old Doctorate Diploma Current practice: Spectacle dispensing (Yes)

exp(Coefficient)

knowledge 1.00 2.17 2.43 5.57 2.39 1.96 cataract 1.00 5.55 Diabetic retinopathy 1.81 2.40

95% Confidence interval Upper

Lower

Reference 1.44 1.42 1.13 1.38 1.26

3.25 4.16 27.48 4.13 3.05

Reference 1.03

30.10

1.05 1.19

3.12 4.82

3.5.2. Priority topics for CPE (Q28) Respondents were asked to rank the priority topics for CPE in order of their importance. Glaucoma (mean rank ± SD:1.8 ± 0.9) was identified as the most important topic, followed by diabetic retinopathy (mean rank ± SD: 1.7 ± 0.8) and age-related macular degeneration (mean rank ± SD: 2.0 ± 0.9). Some other priority topics mentioned were anterior eye conditions, binocular vision, cataract, contact lens complications, corneal conditions, central retinal artery occlusion flashes and floaters, diagnostic tools for assessment of the common eye conditions, hypertensive retinopathy, strabismus, low vision, ocular inflammation, orthokeratology, ophthalmic imaging, latest development in management options for common eye conditions, myopic degeneration, neuro-ophthalmology, ocular pharmacology, orthoptics, paediatric eye problems, keratoconus, systemic diseases and eye, geriatric eye conditions, paediatric optometry, retinal holes, retinal pathologies, retinal detachment, therapeutic contact lenses, vascular occlusive disease and vitreo-retinal conditions.

Age-related macular 1.00 3.53 1.00 7.43 2.14

Reference 1.32 Reference 1.01 1.07

9.42 54.92 4.29

Adjusted for age, gender, credentials, place of practice, current roles in practice and awareness of CPE in primary eye care.

Fig. 2. Barriers for online eLearning, blended learning by mean rank order. 262

Contact Lens and Anterior Eye 42 (2019) 258–264

P.P. George, et al.

Fig. 3. Optometrists, Opticians current roles in practice (n = 234**). *Other roles include electro diagnostics, LASIK surgery assistance, OCT, Angiographies (FFA/ICG), Hess test, Research, Pre-OP counseling, Slit lamp photography, Fundus photo reading, Lens edging, Orthoptics, Post-OP review, Retinal Detachment, Central Serous Retinopathy and Epiretinal Membrane. **mutually exclusive categories, does not add up to the total. 3 persons skipped this question.

3.5.3. Willingness to pay for CPE (Q29) Optometrists were willing to pay USD 17.0 ± 32.5 (median: $7.4) for the unrecognised professional developmental course, USD 80.4 ± 481.7 ($7.4) for 50% subsidized course by their employer, USD 115.1 ± 967.1 ($7.4) for an accredited professional development course and USD 247.1 ± 1168.4 ($7.4) for course leading to a postgraduate degree. ($SGD; 1 SGD = 0.74 USD, as of July 1, 2016)

4.2. Referral, communication with medical practitioners Two in three optometrists in Singapore referred patient to general practitioners or ophthalmologists. The referral rates varied significantly by practice and ranged from 71.4 to 81.8%, the referral rates were higher than studies elsewhere [24,25]. The differences between referral rates in this study and elsewhere could be due to factors such as optometrist’s competency, clinical practice guidelines, healthcare access issues and local legislations.

4. Discussion The role of the optometrist in Singapore has traditionally been detection and correction of refractive error and referral of eye diseases. In recent years, optometrists have started to play an active role in the provision of eye care in Singapore. Given these developments, it was timely to survey the profession to determine current clinical practice and readiness to take on an extended primary eye care role to address the growing ocular morbidity in Singapore.

4.3. Knowledge, co-management of ocular disease

4.1. Optometrist’s roles in Singapore

4.4. Continuing professional education

The study found that majority of the optometrists’ felt that there is a scope for them to play extended roles in areas. Their current roles were dependent on the place of practice, their primary eye care knowledge and awareness of CPE. Optometrists working in academic/research setups reported extended roles such as visual field analysis and topography/pachymetry whilst optometrists working in government restructured hospitals, private hospital were restricted to diagnostic refraction, color vision assessment, contact lens fitting and dispensing. Three in four optometrists felt that there is scope for them to play extended role in the hospital and primary care-setups. Interestingly, optometrists who endorsed an extended role in this sample reported a higher degree of primary eye care knowledge, however their confidence in screening and co-managing conditions was low. Elsewhere in polyclinics, general practitioners (GPs) refer patients to optometrists for tele-ophthalmology services, for co-managing the patient along with the ophthalmologist based at the hospital [15,22]. In hospitals, optometrists conduct eye examinations and co-manage eye diseases with ophthalmologists [9]. A study conducted at a primary care setting in Singapore showed that an optometrist supported tele-ophthalmology system was successful in detecting the causes of chronic blurred vision accurately [23]. This study shows, optometrists positive views on an extended primary eye care role, however there could be several barriers to its successful implementation, most notably remuneration, time and costs involved in training. The current survey did not explore these barriers and further work is needed.

Almost a third of the optometrists indicated that they undertook 40 or more hours of CPE in the previous year. This is consistent with the fact that at the time of the survey, OOB requires minimum 50 CPE credits per qualifying period of two years (October- following year September) for optometrists [28]. This is in line with CPE guidelines in other countries such as UK, France and Germany which require appropriate number of training hours to keep their knowledge up-to-date. Blended learning and eLearning were the most preferred modes for delivery of CPE for optometrists in Singapore. Coincidentally many studies worldwide have shown that blended learning and online eLearning can enhance learning and improve satisfaction of learners [29,30].

Overall, optometrists self-rated primary eye care knowledge was high, however their confidence in screening and co-managing chronic eye conditions such as cataract, diabetic retinopathy, chronic glaucoma and age-related macular degeneration was low when compared to optometrists elsewhere [26,27].

4.5. Limitations The study had a few limitations. Firstly, the survey response rate was low (30%), even after seven email reminders, this could affect the generalizability of the findings. Response percentage was higher among optometrists from government (sample: 28% vs population: 12%) and academic research institutes (sample: 12% vs population: 4%). Secondly, the outcomes reported in the survey were self-reported and consequently prone to response/selection bias toward conscientious optometrists or those with an interest in role expansion. The self-reported primary eye care knowledge, confidence in co-managing chronic eye conditions, may be under/overestimate owing to legislative, 263

Contact Lens and Anterior Eye 42 (2019) 258–264

P.P. George, et al.

professional reasons. Despite the limitations, this survey provides valuable insights into optometrist’s scope of practice, views on extended primary care role, their primary eye care knowledge, preference for CPE modes and referral behavior in Singapore. This would facilitate training programs for preparing the optometrist for an extended primary care role.

[3]

[4]

4.6. Implications

[5]

Singapore’s reliance on specialists for managing ocular problems is reinforced by historical trends and public perceptions, many patients who seek SOC care may not need it. Patients in the early stages of the disease may only need a regular eye examination to monitor further progression. These patients requiring relatively simple interventions can be efficiently performed by optometrists [18]. Similarly, many other patients with chronic eye disorders have repeated follow-up visits to the specialist. As long as these patients remain either stable or fully treated, they would require infrequent monitoring. These patients could also be better managed by the optometrist through established clinical pathways [18]. Such an effort will reduce waiting time and workload at the hospital SOC clinics and would free up ophthalmologists’ time to manage complex cases. The findings from the survey show that majority of the optometrists in Singapore provide optical technology services (category 1) and visual function services (category 2) of the WCOs global model, similar to optometrists in Israel [3]. Expanding their services to ocular diagnostic services (category 3) and ocular therapeutic services through task-shifting would require substantial CPE, on-the-job and formal training and legislative support. Future studies should be aimed at objectively assessing optometrist’s knowledge and compare diagnostic accuracy/agreement with ophthalmologist for detection of common ocular conditions seen in primary eye care set-ups.

[6] [7]

[8]

[9] [10] [11] [12]

[13] [14] [15]

5. Conclusion

[16]

This is the first survey of optometrists in Singapore to assess their scope of practice, knowledge, confidence in screening and co-managing minor eye conditions, their views on CPE and referral. Optometrists in Singapore represent a skilled underutilized resource. Though their selfreported primary eye care knowledge is high, their confidence in screening and co-managing chronic eye conditions is low. Enabling them for expanded primary eye care role would require further training, especially to improve their confidence in screening and comanaging patients. Blended learning, eLearning is their preferred choice for CPE.

[17] [18] [19] [20] [21] [22]

Conflict of interest

[23]

None Acknowledgement

[24]

This research was a part of PPG’s doctoral work and he gratefully acknowledges the funding received towards his PhD from the National Healthcare Group, Singapore.

[25]

Appendix A. Supplementary data

[27]

[26]

[28]

Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.clae.2019.02.008. References

[29] [30]

[1] A. Harris, The boundaries of optometric practice, Clin Exp Optom 97 (2) (2014) 97–98. [2] Definition of Primary Eye Care 2014 AAO Hoskins Center for Quality Eye Care, American Academy of Ophthalmology, 2014 [cited 2018 02/08/2018]. Available

264

from: https://www.aao.org/clinical-statement/definition-of-primary-eye-care– policy-statement. M.A. Padilla, A.F. di Stefano, A snapshot of optometry around the world: optometric scope of practice is literally all over the map. Take a look at what optometrists are doing in other countries–and how it’s changing, Opt J Rev Optom 146 (6) (2009) 55–58. D. Thomas, L. Weegen, A. Walendzik, J. Wasem, R. Jahn, Comparative analysis of delivery of primary eye care in three European countries, Ibes Diskussionsbeitrag 189 (2011). M.Y. Vanessa Thai, Optometry in Asia [English], [cited 2019. Available from: Old Post Publishin, Cadyville, NY, 2010https://www.slideshare.net/hmirzaeee/section5-optometry-in-asia-by-thai-and-yap. Act OaO, Optometrists and opticians act - Singapore statutes online, Singapore2018 [cited 2018 Oct 4, 2018]. Available from: (2018) https://sso.agc.gov.sg/Act/ OOA2007. Health Professionals S, List of approved optometry and opticianry qualifications, 2018 [cited 2018 Oct 4, 2018]. Available from: MOH, Singapore, Singapore, 2018www.healthprofessionals.gov.sg/oob/registration-as-an-optometrist-andoptician/list-of-approved-optometry-and-opticianry-qualifications. Acts or activities constituting optometry OaCLP. Acts or activities constituting optometry, opticianary and contact Lens practice, OOB: MOH, Singapore, 2015 [Oct 4, 2018]. Available from: http://www.healthprofessionals.gov.sg/content/hprof/ oob/en/leftnav/becoming_professionals/information_for_ optometristsopticiansandcontactlenspractitioners.html. Hospital TTS, The role of optometry in Singapore - Tan Tock Seng Hospital Singapore, [cited 2017 May 15, 2017]. Available from: (2017) https://www.ttsh. com.sg/changing-role-of-optometrist-in-Singapore/. W.K. Wen, Futures of ageing in Singapore, J Futures Stud. 17 (3) (2013) 81–102. S. Swee-Hock, The population of Singapore, Institute of Southeast Asian Studies, 2012. TODAY online, Eldelry to make up almost half of S’pore population by 2050, TodayOnline; 2018 [cited 2018 Oct 5, 2018]. Available from: United Nations, Singapore, 2018https://www.todayonline.com/singapore/elderly-make-almosthalf-spore-population-2050-united-nations. J.P. Ansah, D. De Korne, S. Bayer, C. Pan, T. Jayabaskar, D.B. Matchar, et al., Future requirements for and supply of ophthalmologists for an aging population in Singapore, Hum Resour Health 13 (1) (2015) 86. A.P. Awodele, Prevalence, incidence and progression of myopia in Singaporean adolescents, Duke University, 2016. H.V. Nguyen, G.S. Tan, R.J. Tapp, S. Mital, D.S. Ting, H.T. Wong, et al., Cost-effectiveness of a national telemedicine diabetic retinopathy screening program in Singapore, Ophthalmology 123 (12) (2016) 2571–2580, https://doi.org/10.1016/j. ophtha.2016.08.021 PubMed PMID: 27726962 Epub 2016/10/12. W. Lien, Waiting times for new appointments at specialist outpatient clinics (SOC) in restructured hospitals: ophthalmology, MOH Information Paper (2007), p. 23. B. Sibbald, R. McDonald, M. Roland, Shifting care from hospitals to the community: a review of the evidence on quality and efficiency, J Health Serv Res Policy 12 (2) (2007) 110–117. V. Drury, Korne Dd, R. Gopalan, J. Thiyagarajan, A six-step approach to curriculum development for mid-level ophthalmic professionals in Singapore, Int J Oph Pract. 6 (1) (2015) 36–42. Health professionals S, Optometrists & opticians board (OOB) Singapore, [Oct 4, 2018]. Available from: MOH, Singapore, 2018www.healthprofessionals.gov.sg. Ophthalmology AAo, Definition of primary eye care - 2014 [English], [cited 2018 Jan 18, 2018]. Available from: (2014) https://www.aao.org/clinical-statement/ definition-of-primary-eye-care–policy-statement. C. Gilbert, The importance of primary eye care, International Centre for Eye Health, 1998. H.T.J. Choon, T.P.E. Wei, S. Sanjay, H.T. Tock, A pilot trial of tele-ophthalmology for diagnosis of chronic blurred vision, J Telemed Telecare 19 (2) (2013) 65–69, https://doi.org/10.1177/1357633x13476233 PubMed PMID: 23520212. H.T. Johnson Choon, T.P. Eugenie Wei, S. Sanjay, H.T. Tock, A pilot trial of teleophthalmology for diagnosis of chronic blurred vision, J Telemed Telecare 19 (2) (2013) 65–69. V. Sundling, P. Gulbrandsen, R. Bragadottir, L.S. Bakketeig, J. Jervell, J. Straand, Optometric practice in Norway: a cross‐sectional nationwide study, Acta Ophthalmol 85 (6) (2007) 671–676. E. Konstantakopoulou, D. Edgar, R. Harper, H. Baker, M. Sutton, S. Janikoun, et al., Evaluation of a minor eye conditions scheme delivered by community optometrists, BMJ Open 6 (8) (2016) e011832. P.M. Kiely, S. Cappuccio, E. McIntyre, Optometry Australia scope of practice survey, Clin Exp Optom 2017 (2015). A. Ly, L. Nivison-Smith, B. Zangerl, N. Assaad, et al., Self‐reported optometric practise patterns in age‐related macular degeneration, Clin Exp Optom (2017). Board OaO, Guide to CPE programme for fully registered optometrists and opticians 2016, May 22, 2017 [cited 2017 May 22, 2017] (2016) Available from: http:// www.healthprofessionals.gov.sg/content/dam/hprof/oob/docs/ ContinuingProfessionalEducation/Guide%20to%20Enhance%20CPE %20Framework%20for%20Practitioners%20(2016)1.pdf. D. Goodwin, L.V. Hua, J.R. Hayes, Blended learning in optometric clinical procedures instruction, Optom Educ 39 (2) (2014). M.L. Acosta, A. Sisley, J. Ross, I. Brailsford, A. Bhargava, R. Jacobs, et al., Student acceptance of e-learning methods in the laboratory class in optometry, PLoS One 13 (12) (2018) e0209004.