Identifying decisions in optometry: A validation study of the decision identification and classification taxonomy for use in medicine (DICTUM) in optometric consultations

Identifying decisions in optometry: A validation study of the decision identi fi cation and classi fi cation taxonomy for use in medicine

(DICTUM) in optometric consultations

Vibeke Sundling

*, Hege Anita Stene

, Hilde Eide

, Eirik Hugaas Ofstad

aNationalCentreforOptics,VisionandEyeCare,DepartmentofOptometry,RadiographyandLightingDesign,FacultyofHealthandSocialSciences, UniversityofSouth-EasternNorway,Kongsberg,Norway

bScienceCenterHealthandTechnology,FacultyofHealthandSocialSciences,UniversityofUniversityofSouth-EasternNorway,Drammen,Norway

cDepartmentofMedicine,NordlandHospitalTrust,Bodø,Norway

dDepartmentofCommunityMedicine,UiTtheArcticUniversityofNorway,Tromsø,Norway

ARTICLE INFO

Articlehistory:

Received21June2018

Receivedinrevisedform15February2019 Accepted16February2019

Keywords:

Communication Clinicaldecisions Medicine Optometry DICTUM

ABSTRACT

Objective:TheaimofthisstudywastoassessthevalidityandreliabilityoftheDecisionIdentificationand ClassificationTaxonomyforUseinMedicine(DICTUM)appliedtooptometry,tocomparedecisionsin medicalandoptometricconsultations,andtodescribedecisionsinoptometry.

Methods:Thestudyhadacross-sectionaldesign.DatawascollectedfromJanuarytoAugust2016.Forty video-recordedpatient-optometristconsultationswereanalysed.Clinicaldecisionswerecategorised accordingtoDICTUMbytwoindependentcoders.

Results:Theframeworkwasapplied withoutmodification.Theinter-raterreliabilitywas moderate, Cohen’skappa0.57.Themeandurationoftheconsultationswas41(9)minutes.Inall,891clinical decisionswereidentified,mean22(13)perconsultation.Typesofdecisionsweresignificantlydifferent betweenoptometricandmedicalconsultations(chi-square,p<0.001).Morefrequently,optometrists conveyedinterpretedtestresults(27.6%vs16.7%)andgaveadvice(23.6%vs8%),whiledoctorsdefined theproblem(30.4%vs24.6%)anddecidedontreatment(17.8%vs13.4%).

Conclusion:DICTUMisapplicabletooptometryencountersandmayprovidevaluableinsighttodifferent healthcaresettings.

Practiceimplications:Descriptivestudiesofdecisionsinpatient-providerconsultationsisafirststepfor normativeandprescriptiveexplorationofdecision-makingprocessesinhealthcare.

©2019TheAuthors.PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.Introduction 1.1.Clinicalreasoning

Clinicaldecision-makingincludesobservation,patienthistory, physicalexamination,andproblemsolvingtounderstandofthe relationship between clinical findings and to confirm/rule out clinicalhypotheses[1].Clinicalexpertsusebothformal/scientific andinformal/experientialknowledgeinproblem-solving.Experi- entialknowledgelaysgroundforpatternrecognition,whilelisting uppossible differential diagnoses drawsonboth scientific and experientialknowledge[1,2].Patternrecognitioncanbeeffective andefficientforsimpleandfrequentlyencounteredproblems,but

for rare and complexproblems, a wide range of scientific and experientialknowledgeisrequired.

1.2.Person-centredcareandshareddecision-making

Evidence-based medicine defines what should influence managementdecisions,butweknowlittleaboutwhatinfluence practitionersmanagement decisions[2].Theessenceofperson- centredhealthcareisthatpatientsshouldbe“treatedaspersons” in the “context of their social world, listened to, informed, respectedandinvolvedintheircare–andtheirwisheshonored” [3,4].Hence,goodcommunicationskillsandabilitytorelateare essential [3,5,6]. Person-centred communication should ensure attentiontothewholeperson,includingsharinginformationand decisions, deliveringcompassionate and empoweringcare, and beingperceptivetopatientneeds[7].Thepatient’sviewiscentral fordecisionsbothinperson-centredcareandclinicaljudgment[8].

Whenthereismorethanoneequallyrelevantmanagementoption

*Correspondingauthorat:Postboks235,3603Kongsberg,Norway.

E-mailaddress:[email protected](V.Sundling).

https://doi.org/10.1016/j.pec.2019.02.018

0738-3991/©2019TheAuthors.PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

ContentslistsavailableatScienceDirect

Patient Education and Counseling

j o u r n al h o m e p a g e : w w w . el s e v i e r . c o m / l o c a t e / p a t ed u c o u

or when the patient has preferences concerning the different options,patientsshouldbeinvitedinashareddecision-making process[9,10].Arecentstudyhasdescribedhowoptometristsdo clinicalreasoning[11],butwedonotknowwhatdecisionsthey make,how theymake andconvey thedecisions,and howthey involvepatientsindecisions.Stiggelboutetal.havedefinedfour stepsforshareddecision-makingtotakeplace.Thehealthcare providermustinformthepatientthatadecisionhastobemade andthatthepatient'sopinionisimportant.Theoptionsandtheir advantagesand disadvantagesmust beexplained.The patient's preferencesmustbetakenintoaccount.Finally,thepatient’swish tomakethedecisionmustbeclarifiedbeforethedecisionismade andmanagementisdiscussed[12].Inclinicalencounters,decision talkoftenstartswithadiagnosticstatementbytheclinician,which istheresultofadecision-makingprocessinvolvinginformation revealed through history taking, clinical examination and test interpretations. The clinician rarely includes the patientin the clinical reasoning, and infrequently in the decisions about treatment and management planning. Therefore, research on clinicaldecision-makingshouldincludebothdescriptive,norma- tive,andprescriptivefunctions;thatisexplorehowdecisionsare made(descriptive),definebestpractice(normative),anddevelop andimplementtoolsfordecisionsmaking(prescriptive).Identify- ingclinicallyrelevantdecisionsisakeytoexplorethesetopics.

1.3.Thedecisionidentificationandclassificationtaxonomyforusein medicine

To explore shared-decision making and how decisions are made,clinically relevant decisionsmust first beidentified.The Decision Identification and Classification Taxonomy for Use in Medicine(DICTUM)hasbeendevelopedtoidentifyandcategorise allclinicallyrelevantdecisionscommunicatedinmedicalencoun- ters [13]. DICTUM differs from other decision frameworks by havingadescriptiveapproach,whereasevidence-basedmedicine, shareddecision-making,and informeddecision-making allhave normative approaches with prescriptive intentions [14–17].

DICTUMdefinesaclinicallyrelevantdecisionas“averbalstatement committingtoaparticularcourseofclinicallyrelevantactionand/or statementconcerningthepatient’shealththatcarriesmeaningand weightbecauseitissaidbyamedicalexpert”.Insuch,thedefinition is more comprehensive than Braddock’s definition ‘a verbal statementcommittingtoaparticularcourseofaction’[14].

DICTUMwasdevelopedbasedontheSOAP-notestructurefor theclinicalconsultations(subjective(S),objective(O),assessment (A)andplan(P))[18],andincludesallclinicallyrelevantdecisions relatedtopatienthistory,physicalexamination,clinicalreasoning, andpatientmanagement.DICTUMcomprisesallclinicallyrelevant decisionsthatinfluencethecourseofaction-includingdiagnostic, treatmentandmanagementdecisions.Thenaturalflowoftheeye examinationalsofollowstheSOAP-structure,andincludespatient history(S),clinicalexamination(O),clinicalreasoning/diagnosis (A),andpatientmanagement(P).

1.4.Decisionsinoptometry

Poorvisionhasanimpactondailylivingactivitiessuchasdriving, reading,andmobility,as well as general healthandquality oflife[19– 22].Therefore,visioncareisessential.InNorway,optometristsare thelargestprofessioninvisioncare,andtheymakedecisionsrelated tobothvisionand ocularhealth[23–25].However,thescopeof practiceforoptometristsvariesworldwide[26].Theliteratureon clinical decision-making in optometryis sparse [27–32]. To our knowledge,therearenostudiesdescribingthelandscapeofclinical decisionsinoptometry,orhowoptometristsinvolvetheirpatientsin treatmentandmanagementdecisions.

1.5.Aimofthestudy

In this paper, we assess the validity and reliability of the DICUTM framework applied to optometry, compare decisions madeinmedicalandoptometricconsultations,anddescribethe natureofclinicallyrelevantdecisionsmadebyoptometrists.

2.Methods

2.1.Studydesign,sampleanddatacollection

Wechoseacross-sectional,exploratoryanddescriptivedesign becausedecision-makinginoptometryhaspreviouslyneverbeen observed and described in a precise, detailed, and exhaustive approach.Inouropinion,anunexploredphenomenonshouldbe precisely captured and explored before it can be assessed normative and/or prescriptive. The study was part of the COMHOMEstudy,a studyonperson-centredcommunication in thecareofolderpeople.[33]Inhomecareandradiography,we definedolderpeopleasbeing65yearsand older.Inoptometry, olderpeoplewasdefinedasbeing45yearsandolderasage-related visionchangesstartsandtheriskofeyediseaseincreasesafterthis age.ThetargetpopulationswereNorwegianoptometristsworking in a retail setting and theirencountering patients. The sample populations includedoptometrists practicing inthe counties of Buskerud,VestfoldandTelemarkandencounteringpatientsof45 yearsorolder.DatawascollectedfromJanuarytoAugust2016.All optometricpractices(n=17)ofanationalmembers-ownedoptical retailchain(AllianceOptikk)inBuskerud,VestfoldandTelemark were invited to takepart in thestudy. The optometrists were recruitedfromseven(41%)volunteeringpractices.Alloptometrists workinginthepracticeswereinvitedtotakepartinthestudy, 11of 13(85%)consentedtoparticipate.Patients45yearsorolderwere recruitedconsecutivelyduringonetothreepre-selectedworkdays for each optometrist aiming to recruit five patients for each optometrists. Allpatientsgaveinformed consenttoparticipate.

Datawascollectedusingvideo-recordings.Theprincipleinvesti- gator (VS) informed the patients, obtained the consent, and managed the video recording. In total, 40 video-recorded consultationswereavailableforanalysis,including11optometrists and 40 patients. The number of patient-consultations for each optometristrangedfromonetofive.Thepatientsmeanagewas66 (10)years,rangingfrom46to91years,20werefemaleand20 male. The study followed the ethical principles for medical researchinvolvinghumansubjects[34].Anapplicationdescribing theprojectwassubmittedtotheRegionalcommitteesforMedical andHealthResearchEthicsinNorway(REK),whichconcludedthat the project didnot fallunder the legislation of theNorwegian HealthResearchActandthereforedidnotrequireapprovalfrom REK. The Norwegian Centre for Research Data approved the statutory dataprivacyrequirements ofthestudy(#36017). The participantscouldrequestaccesstotheirdata,andhavetheirvideo andotherdatadeletediftheychosetowithdrawfromthestudy.

2.2.Datacodingandvalidation

The DICTUM framework consists of ten mutually exclusive categories [13], Table 1. The first three categoriesrelate tothe subjective, objective and assessment phases of the medical consultation, identifying decisions related to clinical evidence and medical problem solving. The remaining seven categories relate to the planning phase of the medical consultation, representing clinically relevant decisions about treatment and management.

A team of three researchers was formed to analyse the optometricconsultations.Theteamconsistedoftwooptometrists;

Table1

TheDecisionIdentificationandClassificationTaxonomyforUseinMedicine*andexamplesofstatementsconveyingdecisionsinoptometricconsultations.

Category name

Categorydescription Subcategory Statement

1 Gathering additional information

Decisiontoobtaininformationfromothersourcethan patientinterview,physicalexamination,andpatient chart

Orderingtest Consultingcolleague Seekingexternal information

“IthinkIwilltakeascanaswell,tohavealook,togetanideaofthe cause”

“So,Iwouldlikeinstalladropineachwhichwillmakeyourpupilsa bitlarger”

“So,wewillcheckyourperipheralvisionlater”

“So,Ithinkweshouldtakeofaphotoofyourretinaaswell”

“Iamabitunsure.ThatiswhyIwillaskmycolleagueaswell"

“Thenwewillcall,andgettheexactpower.”

2 Evaluating testresult

Simple,normativeassessmentsofclinicalfindingsand tests

Positive Negative Ambiguous

“Thisiswhatwecall100%visualacuity.Sothisseemsverygood”

“Theintraocularpressureisgoodinboththerightandlefteye”

“Thenervefiberlayerthicknesslooksnormal”

“Ithinktheylookatbitdry,youreyes

“Yourintraocularpressureisatbithigherthanlastvisit“

3 Defining problem

Complex,interpretativeassessmentsthatdefineswhat theproblemisandreflectsamedicallyinformed conclusion

Diagnosticconclusion Evaluationofstateof health

Aetiologicalinference Prognosticjudgment

“Therearenosignsofglaucomaorcataract.Withoptimalcorrection, yourvisualacuityisverygood.Yournearvisionisalsoverygood.”

“Youaremorelong-sightedthanlasttime”

“Youneedsomepowerbothatdistanceandnear.”

“thereisnodoubtthatyourvisualfunctionofyourrighteyeis poorerthanyouleft”

“Icanseethatyoureyesshowsignsofhavingbeenoutinsunand wind”

“Intheareaofdetailvisioninyourlefteyethereisasocalled cellophanemembrane.Thatcausesyourvisiontobeslightlypoorer inthateye”

“Itisyourtearfilm,whichisnotstable”

“ItisbecauseofUV-exposuretotheeyes”

“Itisdifficulttopredicthowthiswilldevelop.Itmightgofast,andit cangoveryslow."

“Youwillalwaysexperiencethatthevisualacuityinyourighteyeis strange,butwecannotalleviatethat.Soitisimportanttohave realisticexpectations”

"..butIthinkthiswillnotchangetomuchinthefuture”

4 Drug-related Decisiontostart,refrainfrom,stop,alterormaintaina drugregimen

Start Stop Alter Maintain Refrain

“Wetalkedabouteyedrops,Ithinkyoushouldtrytouseeyedrops.”

“Youareabitred,youreyeslookirritated.Trysomeartificialtears”

5 Therapeutic procedure -related

Decisiontointerveneuponamedicalproblem,plan, perform,orrefrainfromtherapeuticproceduresofa medicalnature

Start Stop Alter Maintain Refrain

"Youuseyourglassesalot,somultifocalswouldbeverygood."

“Ithinkweshouldkeepthesamepower”

“Fordistancethereislittletogainbyapairofspectacles”

“Ithinkitisabittooearlytoconsiderreferralforcataractsurgery,so Ithinkweshouldwait”

“Todoanythingsurgicalismorecomplicated,soIdonotthickthey areinterestedaslongasyourvisualacuityisgoodandyourvision hasnotdeteriorated

” 6 Legallyand

financially related

Medicaldecisionconcerningthepatient,whichisbased uponorrestrictedbyalegalregulation

Fitnesstodrive*

Workplaceoptical aids*

Opticalaidscovered bytheNational InsuranceAct*

"Youfulfilthecriteriafordriving."

“Thismeansthatyouhavetowearspectaclesfordriving”

”Theemployermaycontributetocostof....”

“WewillsendanapplicationtoNAVforreimbursementofthecostof youfilterglasses”

. 7 Contact-

related

Decisionregardingadmittanceordischargefrom hospital,schedulingofcontrolandreferraltootherpart ofthehealthcaresystem

Routineexamination Monitoring Referraltoother healthcareprovider

"Irecommendthatwesendyouanewappointmentin2yearsto examineyourocularhealth.”

“Ithinkweshouldrepeatthemeasurementofyourintraocular pressureinacoupleofweeks”

“Itisnotveryclearinthere,soIwouldliketoreferyouforan assessment.”

8 Adviceand precaution

Decisiontogivethepatientadviceorprecaution,thereby transferringresponsibilityforactionfromproviderto patient

Adviceon:

Spectacles*

Contactlenses*

Ocularprotection*

Furtherexamination/

followup*

Visualergonomics*

Lensdesignand coating*

Purchaseofoptical correction*

Managementof ocularproblems/

disease*

Precaution

“Multifocalspectacles,anall-roundsolution,isprobablyfirst priority”

“Youexerciseabit,thereisanoptiontousecontactlenses”

“ItisimportanttoprotectyoureyesfromUV-radiation”

“Theolderyouget,thehighertheriskofdevelopingoculardisease,so itisrecommendedtohaveregulareyeexams”

“Thisstainsyouneck.Trytobegoodatusingthis.Lookdown”

"Weshouldmakeagoodmultifocal,withapolarizedpairofglasses”

“Theriskisthatifsomethinggoeswrongwiththeframeandyou haveboughtnewlenses,youwillbestuckiftheframecannotbe replaced.”

“Oftenthemaincauseoftearingisdryeyes»

“Itisimportantthatyouletusknowifyouexperiencesomethingin theothereye”

“Itisimportantthatyouletusknowifthishappensagain.”

9 Treatment goal

Decisiontosetdefinedgoalfortreatmentandthereby beingmorespecificthangivingadvice

Quantitative Qualitative

anassociateprofessor inoptometry(VS)and amasters’ degree student in optometry (HAS), and a medical doctor; the main developerofDICTUM(EHO).Thetwooptometristsanalysedthe video material. They independently identified, transcribed, and reflected on observed statements that potentially conveyed clinically relevant decisions. Informed by their professional backgroundandclinicalexperience, theyhad fullknowledgeof the language terms used by optometristand patients, and the actionsobservedduringtheconsultations.

Theteam(VS,HASandEHO)hadgeneraldiscussionsaboutthe threshold for defining an observed statement or action as a clinically relevant decision, applying the same definition as in medicine:“averbalstatementcommittingtoaparticularcourseof clinicallyrelevantactionand/orstatementconcerningthepatient’s healththatcarriesmeaningandweightbecauseitissaidbyamedical expert”[13].Allstatementswererequiredtohavesomeelementof optometricormedicallyrelevantcontentlike“Youneedglasses”, andarelationtothepatient’sactualsituationdistinctfromgeneral optometricinformation,“Ithinkyouruncorrectedrefractiveerror iscausingyoureyestrain”asopposedto“Uncorrectedrefractive errormaycauseeyestrain”.

After statements or actions were identified as clinically relevantdecisions,theywerecategorizedaccording toDICTUM [13]. The coders and the developer of DICTUM continuously discussed the application of categories. Finally, inter-rater reliability was assessed. Coding consensus was developed in stepsusingsetsoftwoorthreevideos.Thisprocesswasrepeated for15videosintotal,andthecodebookwasadjustedafterteam discussion (VS, HAS, EHO). This process, including consensus discussion, controlled for the influence of the optometrists’ clinicalexperienceandreducedtheriskofcoderbias.Thisleadto astricterandnarrowerdefinitionofdrug-relatedandtherapeutic procedure-related decisions (category 4 and 5), so that only directive or imperative statements were defined as drug- or therapeuticprocedure-relateddecisions.Decisionsondrugsand therapeutic procedures expressed as recommendations were defined as advice (category 8). Further, optometry specific descriptions(subcategories)wereincludedfordecisionsrelated toevaluatingtestresults,adviceandprecaution(category2and 8)toscopepractice,Table1.

Whentheoptometristorderedadditionalauxiliarydiagnostic tests,discussedthepatientwithacolleague,orrequestedexternal information, this was coded as decisions to gather additional information.Normativeassessmentofclinicaltestswascodedas evaluationoftestresults,whereascomplexassessmentsproviding a diagnostic conclusion, an evaluation of state of health, an etiological inference,or a prognostic judgment were coded as definingthepatient’sproblem.Statementsprovidinginformation toandinvolving thepatientindecisions aboutmanagementof visualand ocular problems werecoded as decisions related to drugs,therapeuticprocedures,legalandinsuranceissues,follow- up, advice and precaution, treatment goals or deferment, respectively. Providing advice and precautions transfer the responsibilityforactionfromtheoptometristtothepatient.The adaptedconsensusversionofthetaxonomywas deemedfitfor reliabilitytesting.Wecodedfoursetsof fivevideostoestablish

consensusbetweenthetwocoders,thenafinalsetoffivevideos (178decisions)werecodedtoassessagreementbetweenraters andinter-raterreliability.Further,weaskednineclinicalexperts (optometrists) to review the relevance of the ten DICTUM categoriesonascalefrom1to4,where1wasnotrelevantand 4wasveryrelevant,toassesscontentvalidity.

2.3.Dataanalysis

The dataanalysiswas designed toassess thevalidityof the DICTUM framework, and to provide univariate and bivariate statisticalanalysisofclinicallyrelevantdecisionscommunicatedin patient-optometrist encounters. All 40 video recordings were includedintheevaluationofthetaxonomy’svaliditytooptometry, inthedescriptionofdecisionsmadebyoptometrists,inanalysisof correlationswiththenumberofdecisionsperencounterandthe difference between optometric and medical decisions. Content validityusingaveragingcalculationmethodforscale-levelcontent validityindex(S-CVI/Ave)[35].Inter-raterreliabilitywasassessed withCohen’skappa[36].Cohen’skappaissuitableforinter-rater reliabilityassessment ina fully-crosseddesignwithtwocoders assessing a nominal variable, Krippendorf’s alpha is more appropriate with more than two coders [37]. To determine an inter-raterreliabilityof0.5with80%powerand5%precisionfora 1010contingencytablewherethecategoriesarenotassumedto beproportionateassumingfairagreement(0.3)requiresasample sizeofminimum116[38].Distributionofdecisionswereanalysed infrequencyandsummationtables,correlationbetweennumber ofdecisionsanddurationoftheconsultationusingPearson’sR,and group differences betweenoptometryand medicine using Chi- square/FisherExacttestusingChi-square/FisherExacttest.

3.Results

3.1.Decisionsinoptometricencounters

Inourmaterial,wefounddecisionscomprisedbynineofthe ten DICTUM-categories. First, the optometrists made clinical decisions about obtaining more information, test results and clinical problem providing the patient with information about thesedecisions.Second,theoptometristsmadeclinicaldecisions about treatment and management providing the patientswith informationandopportunitytobeinvolveinthedecisions.These decisionswererelatedtodryeyetreatment,refractiveerror,ocular disease, referral toophthalmologist, fitnesstodrive, workplace visionaids,lowvisionaids,follow-upandfurtherexaminations, andtreatmentoptionsforopticalcorrection,oculardisease,optical protection andvisualergonomics.Table 1 showsthecharacter- istics of optometrists’ decisions distributed across DICTUM- categorieswithexamplesofstatementsandFig.1showsdecisions accordingtoSOAP-structure.ThecontentvalidityforDICTUMin optometry was excellent[35], S-CVI/Ave was 0.94. The simple agreementbetweencoderswas71%,andtheinter-raterreliability wasmoderate[36],Cohen’skappawas0.57.Theaveragetimeto codeandtranscribedecisionsverbatimwas2–2.5timesthelength oftheconsultation.

Table1(Continued) Category name

Categorydescription Subcategory Statement

10 Deferment Decisiontoactivelydelaydecisionorarejectionto decideuponproblempresentedbyapatient

Transfer responsibilityWait andsee

Changesubject

"IdeallyIshouldhavetakenascanoftheretinatoassessthecauseof thepoorvisioninherlefteye,butweknowthatthisistakencareby theophthalmologist”

*Addedtoscopethenatureofoptometricconsultations.

Thematerialincluded891clinicaldecisions.Theaverage(sd) durationoftheconsultationwas41(9)minutes,rangingfrom19 to60.Theaverage(sd)numberofdecisionsperconsultationwere 22 (13), rangingfromfive to63. Fig.2 showsthe numberof decisions per consultation for each optometrist, there was no correlationbetweennumberof decisionsandeach optometrist.

Thenumberofdecisionsperconsultationwascorrelatedwiththe duration of the consultation, r=0.48, p=0.002. The number of decisionsinoptometricconsultationswithrespecttodurationof consultation was similar tothe number of decision in medical consultations,mean22decisions/41min(0.54perminute)versus 13decisions/22min(0.59perminute)[39].

3.2.Comparisonofdecisionsinoptometricandmedicalencounters

In all, 30% of decisions were related to the subjective and objective phase of the consultation, and 25% and 45% the assessment and planning phase, respectively. Fig. 3 shows the distribution of decisions in optometric consultationscompared with the distribution of decisions found in hospital medical consultations [39]. The distribution of types of decisions were significantlydifferentbetweenoptometricandmedicalconsulta- tions(chi-square,p<0.001).Optometristscommunicatedahigher proportion of decisions related to theclinical assessment than doctors did (52.2 versus 47%) and more frequently conveyed interpretedtestresults(27.6%versus16.7%),whereasdoctorsmore frequentlydefined theproblem(30.4%versus24.6%).Moreover, the proportion of drug- and therapeutic-procedure related decisions and follow-up decisions were lower in optometric practicethaninthehospitalsetting(18.1%versus27.8%),whereas the proportion of clinical decisions provided as advice or precautionwasmuchhigherinoptometricconsultationsthanin medicalconsultations(23.6%versus8%).

3.3.ContentandfunctionoftheDICTUMcategoriesinoptometry

Decisions to do additional diagnostic tests included dilated fundus examination, digital retinal photography, visual field screening, dry eye assessment, and assessment of workplace visual ergonomics. Decisions defining the patients’ problem includeddiagnosisofrefractiveerror,visualproblemandocular disease,evaluationofvisualfunctionandocularhealth,identifi- cation of the cause of visual problem and ocular disease, and assessmentoftheseverityandprognosisofthevisualproblemand oculardisease.Managementdecisionswererelatedtotreatment andmanagementofvisionandocularproblems,includingtopical Fig.1.ClinicallyrelevantdecisionsdefinedbyDICTUMwithrespecttothenatural

flowoftheoptometricconsultation(SOAP-structure).

Fig.2.Numberofclinicallyrelevantdecisionsperconsultationforeachoftheoptometrists.

oculardrugs,opticalcorrection,visualergonomics,referrals,plans for follow-up and advice and precautions on treatment and management.

In17(42.5%)oftheconsultationstheoptometristsdecidedto gather additional information. In all consultations, they either expresseddecisionsabouttestresults(95%),definedtheproblem (95%)ordidboth(90%).Explicit decisionsabouttreatment was madein36(90%)oftheencounters.Decisionsonfollow-upand referral werefoundin 27 (67.5%) ofencounters, describing the courseofmanagementofvisionandocularhealth,andimplicitly indicatedthestateofvisionandocularhealthintermsofneedfor routineexaminationormonitoring,furthermedicalexamination, vision rehabilitation and pedagogical support. Further, the optometrist gave recommendations about management and precautionaryadviceonhowpatientsshouldactincaseofvisual symptomsorocularproblemsin39(97.5%)oftheencounters.The mainintentionoftheadvicewastoinvolvethepatientindecisions andtopromotegoodvisionandocularhealth.Nodecisionsabout treatmentgoals were made and deferments of decisions were found in five (12.5%) encounters. In these encounters the optometrists transferred the responsibility for the decision to thegeneralpractitionerortheophthalmologist.

4.Discussionandconclusion 4.1.Discussion

Toourknowledge,thisisthefirststudythatidentifyandclassify allclinicallyrelevantdecisionscommunicatedinpatient-optome- trist consultations. DICTUM is a novel method for assessing clinicallyrelevantdecisions[13],andpriortothisstudy,DICTUM hasonlybeenappliedtomedicalconsultations[39].Optometrists make and communicate a large number of clinically relevant decisions per encounter. The ratio of decisions per minute in optometricencounters,wassimilartotheratiofoundinhospital medicalencounters[39].Thiscouldindicatethatmoredecisions weremadebecausemoretestswerebeingdone.However,itcould alsoreflectthatthemoretimepeoplespendinthesameroom,the moretheytalkandthemoredecisionswillbemade.Our study

showsthatDICTUMhasvaliditybeyondthemedicalconsultation.

Thecontentvaliditywasexcellent,anddecisionswereidentified for nine of the ten mutually exclusive categories. The tenth category would likely be identified in a larger sample of consultations(n197),astheprevalenceofthetenthcategory (treatmentgoal)isrelativelow(15.1%)formedicalconsultations [39].Therewasnoneedforadditionalcategoriestoaccountfor decisionsmadebytheoptometrists,althoughweaddedoptometry specificdescriptionstoaidcoding.WethereforeproposeDICTUM asapotentialtooltobroadentheunderstandingofdecisionsmade and communicatedacrossthespectrum ofhealthcareconsulta- tions.

Thenumberandtypesofdecisionsinoptometricconsultations differed from medical consultations [39]. Optometrists in our study communicated more decisions per consultation than hospitaldoctorsdid;this couldberelatedtobothtothelength andcontentoftheconsultationastheratioofdecisionsperminute wassimilar.Theaveragedurationoftheoptometricconsultations wasnearlytwotimesthedurationofmedicalconsultations.The numberofdecisionsinoptometricconsultationswerealmosttwo times higher than inthe hospital encountersfromthe original study.Further,optometristsmorefrequentlyprovidedstatements abouttestresultsandadvicethanhospitaldoctorsdid[39].This mayreflectdifferentprofessionalcommunicationstyles,aswellas the scopeof practice.The optometrists are likely toundertake moretestsduringaneyeexaminationthanmedicaldoctorsdoin duringahospitalencounter.Moreover,optometristcouldattempt to engagepatientsin decisions abouttreatment, moreso than hospitaldoctorsdid.However,howoptometristengagepatientsin decisions was outside the scopeof this studyand needstobe further explored. Overall, optometrists communicated a higher proportion of decisions related tothe clinicalassessment than doctors,whichmayreflectclinicalcontext,theexpectedroleofthe healthcareprovider,aswellasthepurposeanddurationofthe consultation.Optometristsexpressedtestresults,whereasdoctors defined the problem. This may be explained by the fact that optometrists mainly examine healthy people who need a prescriptionforrefractiveerrororpresbyopia[23]anddecisions related to refractive error and presbyopia may not be Fig.3.Distribution(%)ofdecisionscategories*inoptometryconsultationscomparedwithhospitalmedicalconsultations**.

*1;Gatheringadditionalinformation,2;Evaluatingtestresult,3;Definingproblem,4;Drug-related,5;Therapeuticprocedure–related,6;Legallyandfinanciallyrelated,7;

Contact-related,8;Adviceandprecaution,9;Treatmentgoal,10;Deferment.**[39].

communicated as a diagnostic conclusion. On the other hand, peopleexaminedinhospitalsusuallyhaveamedicalproblem,and decisionsrelated to assessment commonlyregard the patient’s stateofhealth,provisionofa diagnosticconclusion,aetiological inferenceoraprognosticjudgment[13].Moreover,theproportion ofdrug-andtherapeutic-procedurerelateddecisionsandfollow- updecisionswerelowerinoptometricpracticethaninthehospital setting,whereastheproportionofclinicaldecisionsprovidedas adviceorprecautionwashigherinoptometricconsultationsthan inmedical consultations. Oneexplanationcouldbe thestricter definitionofthesecategoriesinourstudy.However,thismayalso reflect the different nature of clinical practices. Optometrists provideservicesin a retailsetting, and thenatureofcustomer servicescouldinclinetheoptometristtoprovidedecisionsabout thetreatment,suchasspectacles,contactlenses,eyedropsand followup,asoptionsandbythattransferringtheresponsibilityfor the decision to the patient, thereby laying grounds for shared decision-making.Theliteratureissparse,however,studieshave shown that optometrists can facilitate clinical management decisions [29,30,32] and this could be further improved by training, mentoring, and feed-back on clinical management decisions [25,27–29]. The optometrists in our study did not communicate anystatements classified as treatment goaldeci- sions.Thiscategory wasalsotheleastfrequent categoryinthe medical consultations. In general, the lack of communication concerningtreatmentgoalsinoptometricconsultations,together withthelowfrequenciesinmedicalconsultations,aresomewhat surprising,as treatment goals can bea tool to supportpatient empowermentandcompliance.However,inoptometrytreatment is mainly optical corrections, as a cure to the patients’ visual problem,thisrarelyrequireexplicitstatementsontreatmentgoals.

Moreover,implicitstatementsonhowandwhentousetheoptical correctionwasnotdefinedandcodedastreatmentgoalsinthis study, but as advice and precautions. In the hospital medical encounters,itisthepatientistheretohavetheirmedicalproblem cured,anddecisionsontreatmentgoalscouldbemorelikelyfound in the patient-general practitioner consultation. However, the current data is limited. The low frequency of treatment goal decisionsinhospitalmedicalencounters-andtheabsenceofgoal- orientedstatementsinouroptometrymaterial-couldalsoreflect thatNorwegianhealth careprovidershavea verylowfocus on goal-orientedcarecomparedtohealthcareprovidersincountries liketheUS.

4.1.1.Limitationsandstrengths

Thenumberofconsultationsinthisstudywaslimited,andmay notberepresentativeofNorwegianoptometricpracticeingeneral.

However,thesampleprovidedabroadrangeofoptometristswith regardstoeducationalbackgroundandworkexperience,andthe sampleof decisionswas well above thesample sizeneeded to assessinter-rater reliability. Simple agreement reflects thatthe majorityofdecisionswereidentifiedbybothcoders.Moreover,the inter-raterreliabilityestimatedinourstudyandtheoriginalstudy [33] is acceptable. The immediate applicability of DICTUM to clinicaldecisionsinoptometricconsultationsprovidesvalidityof DICTUM as a framework to other health care settings than medicine. Further, our study has showed that DICTUM has potentialtoprovideinsighttoclinicaldecisionsindifferenthealth caresettings.Increasedawarenessabouthowdecisionsaremade, conveyed,andwhoshouldmakethemisessentialtoimprovethe qualityofclinicaldialogandinturnthequalityofhealthcare.Two equallygood treatment options advocates for shared decision- making,inorderforthistohappen,theclinicianneedstobeaware thatadecision needstobemadeand takeappropriatestepsto teamwiththepatient,beforepresentingtheprosandconsofthe different options and collaboratively involve the patient in

deliberationand decision-making [10]. By identifying decisions intheobjective,subjectiveandassessmentphasethehealthcare provider’s clinical judgement and foundation for treatment decisions can be identified and explored. Whereas decisions identifiedintheplanningphasecanbeusedasastartingpointto describeandassessthestepsofshared-decisionmaking[10,12].

4.2.Conclusion

DICTUM is applicable to optometry encounters and may providevaluableinsighttodifferenthealthcaresettings.Descrip- tivestudiesofdecisionsinpatient-providerconsultationsisafirst step for normative and prescriptive exploration of decision- makingprocessesinhealthcare.

4.3.Practiceimplications

The findings from this study could influence research on decision-makinginhealthcare,aswellastheoptometryeducation andclinicalpracticeofoptometristsandeye carequalityinthe future.

Roleoffundingandconflictofinterest

TheresearchwasfundedbyTheResearchCouncilofNorway (Projectnumber:226537).

The ResearchCouncil ofNorway had noinvolvementthein studydesign;inthecollection,analysisandinterpretationofdata;

inthewritingofthereport;andinthedecisiontosubmitthepaper forpublication.

Competinginterests

Theauthorsdeclarethattheyhavenocompetinginterests.

Acknowledgement

Wethanktheoptometristsandtheirpatientsfortakingpartin thestudy.

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