Mar 26, 2021 • 12 minutes read

How to start working with evidence-based optometry in your daily busy practice

Jon V. B. Gjelle

Introduction

With
Jon V.B. Gjelle

In this Expert Conversation, we talk to the highly skilled optometrist and researcher, Jon Gjelle, who explains to us what evidence-based optometry is all about, and how you, as a clinician, can implement it into your daily busy practice.

Jon Gjelle has also written a handbook on this subject, which provides a detailed guide on all the tools you need to know to practice evidence-based optometry. You can read the handbook here.

Read Jon's bio

Welcome, Jon! Today, we’re going to talk about a crucial subject for all clinicians and eye care professionals out there. Together, we'll dive into evidence-based optometry, where you will provide some tips for our readers on how they can use it in their daily busy practice.

So, let's start with the basics. What is evidence-based practice?

Jon V.B. Gjelle

A standard definition is that evidence-based practice aims to incorporate the acquired knowledge from science and research in clinical decision-making to improve patient outcomes.

In other words, we need to have a system to ensure that what we learn from research is also implemented in practice. Working evidence-based means that we follow a framework to ensure we base our recommendations and management strategies on the latest and most sound knowledge and research out there.

Why is evidence-based practice important in optometry? It sounds very medical?

Jon V.B. Gjelle

That’s an excellent question because most people probably think that all optometrists do are refractions or dispensing glasses and contact lenses, which probably won’t change drastically over time. But ever since optometry became a recognised field within healthcare, we’ve seen a shift in optometrists doing more detection of diseases, referrals and co-management. All of which has become essential elements of how we work today, and even more so in the future.

And as an optometrist, you might think that evidence-based practice is only about treatment, but it goes way beyond that. It covers everything from; How to best communicate with your patients? How often do you need to see a patient with dry AMD to catch an eventual conversion to wet so they can be referred? How do you best treat myopia to avoid unnecessary progression? And what is the best treatment regime for convergence insufficiency or other binocular conditions?

With evidence-based practice, we get a framework that enables us to find answers to all the questions, which we see in our clinical practice. And yes, those answers will also change over time. For instance, I have a textbook here beside me, which I love, about anterior eye disease. It has an excellent management guide and everything. But if you look at the preface, you’ll see that it’s from 2011. So, it’s ten years old at this point. And it could be that most of it is still what we’re doing today, but it’s not necessarily best practice today. And that’s where evidence-based practice comes into the picture and gives us a framework that actually enables us to find answers to new clinical questions or procedures that might turn up in our practices.

With evidence-based practice, we get a framework that enables us to find answers to all the questions, which we see in our clinical practice.

It almost sounds obvious that we should work like this, aren’t we already?

Jon V.B. Gjelle

Optometrists are generally quite eager to learn new things. You’ll see that when you visit the Clinical Conference or other conferences. Optoms love learning! But evidence-based practice is just not that well integrated into our ways of working.

It’s important to remember that evidence-based means that we’re looking at a larger body of evidence with little bias – or put differently, with a small probability of incorrect results. If we were only looking at one research article or study, it could be that it was right in one context, but not in another necessarily. And that’s why we aim for evidence that comes from systematic reviews.

There are lots of research articles that touch upon this. An interesting one is this survey from 2020 by James Wolffsohn and colleagues. They looked at myopia management attitudes among eye care practitioners. And although many practitioners are concerned about myopia progression, the most used correction method was not a method they thought would slow down progression.

They even found that 20 % reported using undercorrection to treat myopia, while the systematic review from 2020 by Walline and colleagues tells us that undercorrection, at best, does nothing but accelerate the progression of myopia.

And this clearly shows how just over a couple of years, the latest evidence might advise us to treat some conditions slightly different from what we’ve always been doing as clinicians.

How do we go about finding good clinical evidence to guide practice?

Jon V.B. Gjelle

Before you start searching for systematic reviews, there are a few steps you need to take. The first step is to check if any national guidelines apply to your clinical case – those might be governed by your authorities or your National Optometry Association. An important thing to keep in mind here is that they might not all be evidence-based. Some could also be consensus-based, but you’ll typically be judged by the guidelines that apply to your country legislation if anything should go wrong.

As a second step, it might be worth your while to look at the evidence-based practice guidelines of some other countries, like the American Optometric Association. They have some excellent evidence-based guidelines that grade evidence and tell you how strong the recommendation is for each specific treatment.

But, of course, keep in mind that those guidelines are written for another jurisdiction and might not apply entirely to your country or clinical case.

As a third step, it can also be beneficial to look at clinical decision tools – like UpToDate or BMJ Best Practice. They give you evidence-based information on specific topics in a condensed and user-friendly format. On top of that, they tell you how recent the evidence is – meaning when the article was last updated and reviewed. That way, you can feel more confident taking guidance from it.

However, access to those tools costs money. Some countries have access through their National Health Library, so I would advise you to check with them first. Or if you’re connected to a university hospital, they also typically have access to something like that as well.

Finally, if you can’t find what you need there or want to dig deeper, you have to search in bibliographical research databases like PubMed/MEDLINE and Embase. And for that, you need to set up a focused search question to define what you’re looking for precisely. My handbook on evidence-based optometry will guide you on setting up focused search questions using the so-called PICO model. The handbook also covers how you can appraise systematic reviews to ensure they are qualified to base your clinical decisions on.

And just to highlight how important it is to sit down and formulate a focused research question, you will come across lots of studies if you search on, for example, myopia and myopia progression. A good way to narrow down your search is to be mindful about the age, so think about; How old is your patient? How old are the patients in those studies you’re reading? It will help if you make sure that the reviews you find are comparable or adaptable to the group you’re examining. And a focused search question lets you do exactly that.

How can you find time to practice evidence-based in a busy clinic?

Jon V.B. Gjelle

Yes, that’s the million-dollar question and always the most challenging part of it all – simply finding time to do it. But before I let you in on some of my tips, I just want to stress how important it is to find time for evidence-based research.

Let’s say you were going to your GP or physician, and they weren’t up to date about the latest treatment for your disease. My best guess would be that you would feel very disappointed with your GP and probably not return if you found out about that.

And that would also be the outcome for you if you don’t deliver on the latest research and recommendations to your clinic’s patients. Working more and more with evidence-based optometry will benefit not only your patients’ safety but also satisfaction. There’s no doubt about that. You might even see an increase in the number of patients visiting your clinic once word gets out that you’re delivering on high-quality recommendations.

But if you’re struggling on busy days, I would suggest checking up on what kind of diseases and problems you’ve encountered during your day. Then on quieter days, try to find time to backlog those and look into: What was the problem? What was the management solution I discussed? What was the treatment I gave?

After that, set up focused search questions and look for evidence to check if your prescribed treatment or management was the best solution or if you could have done something else. When the patient visits your clinic the second time around, or if you get a similar patient in, you can adapt your recommendations to what you learned through your research.

Working more and more with evidence-based optometry will benefit not only your patients’ safety but also satisfaction.

Doing evidence-based research will also pay out in the conversation you have with your patients. If you mention the evidence-level of your recommendations, it’s much easier for them to understand or appreciate the research and time you put into managing their problem. Especially for dry-eye disease where you might have patients using eye bags – those cases take 5-10 minutes per day for each patient, and that is a significant amount of their time. So, taking the time to show that your recommendations are up to date is an important part of ensuring their adherence to the management.

If you continue to backlog your patient diseases and management solutions over time, you will continuously improve and be more evidence-based in what you do in your practice.

In addition to that, I suggest having access to clinical decision tools because they are pretty condensed, so it’s easy to check up. They are quick to use, and that’s why they fit so well into a busy clinical setting. If you have 1 minute here or 30 seconds there, you can actually get some answers for what you’re looking for.

If you continue to backlog your patient diseases and management solutions over time, you will continuously improve and be more evidence-based in what you do in your practice.

Are there any common traps people can fall into when searching for clinical evidence?

Jon V.B. Gjelle

Absolutely. There’s one big issue with evidence-based research, and that’s systematic reviews. We prefer to base our decisions on systematic reviews, but there’s only so many in optometry as a field. We don’t have a vast amount of them, simply because our field is relatively small. So, how do you decide what’s the right thing to do, if you don’t have a systematic review to base your decision on?

Well, if you can’t access a specific systematic review on your focused search question, I would say you should start by looking at the lower levels of the pyramid of evidence. And hopefully, if you’re lucky, you will be able to find some randomized control trials that cover your question. And yes, it’s time-consuming to analyse those control trials as well, but here you can use the Centre for Evidence-based Medicine, which has free tools available to use for that.

However, what’s really important to think about is that even though one control trial shows something, it’s not necessarily true for all patients in that group because you are dealing with a slightly lower level of evidence, so you need to a bit more careful in terms of how you go about the treatment and management based on that evidence.

If you’re unsure about applying or evaluating the systematic reviews or randomized control trials, I would advise you to consult with your colleagues in the clinic. It’s also great to consult with researchers or colleagues you know from your university or even your old teachers because they are typically more inclined to think in the lines of systematic reviews.

And then I think sparking conversations between researchers and clinicians is so important for the optometry field to move forward as a profession, so we need to think more about discussions and collaborations with our peers on these kinds of topics and with researchers or allied health professionals. For instance, if you are approaching an ophthalmologist with a focused search question or sharing your thoughts on a systematic review you’ve found, then the ophthalmologist will be more likely to acknowledge you as a like-minded healthcare professional who cares about patient outcomes.

When you start to talk to other people, such as researchers or ophthalmologists, new ideas spark. Because as an optometrist, you’ve seen something in practice which the researchers might haven’t thought about before, and then suddenly you have a new trial starting, and then they add that to the knowledge-base. And the bigger the knowledge-base gets, the easier it becomes to do systematic reviews, and that’s when we all get better at what we do in our practices.

I think sparking conversations between researchers and clinicians is so important for the optometry field to move forward as a profession.

What makes you an expert on this subject?

Jon V.B. Gjelle

Well, that’s a very relevant question now that we’re talking evidence! I’ve spent many years involved in research, which has taught me that the truth is not constant. It has also given me a bunch of experience in finding and evaluating research and systematic reviews. Knowing how time-consuming it is, I’m also involved with the clinical guidelines committee in the Norwegian Association of Optometry to ensure clinicians get easy access to best-practice cases that provide better patient safety.

What inspires you?

Jon V.B. Gjelle

I know this is probably the worst answer to give in 2020-2021, but specifically for the optometry profession, I think one of the most important things we can do is meet and discuss with other professionals – both from the clinic, academia, and research. Discuss the issues you experience in your clinic and talk to researchers who know the subject more in-depth. Academia and clinicians should also seize any opportunity to cooperate in research, so enough knowledge is available to assemble systematic reviews.

But, of course, we can’t participate in gatherings and conferences all-year-round. So, one of my favourite sources to browse on the web is the Centre for Evidence-Based Medicine from the University of Oxford. It’s good if you want to dig deeper than my handbook and learn more about evidence-based practice – specifically, how to find and appraise articles.

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