Introduction to Q.REC

About

This toolkit & protocol was developed by Anthea Burnett PhD and Ling Lee PhD, with major contributions by Myra McGuiness PhD, Beatrice Varga, Yadira Perez Hazel and Suit May Ho PhD and in collaboration with The University of New South Wales

This work was funded by The Fred Hollows Foundation with support from the Australia Government through the Australian NGO Cooperation Program (ANCP).

Background

Uncorrected refractive errors are the leading global cause of vision impairment, with 161 million people living with distance vision and an additional 510 million people living with near vision impairment. [1]
The WHO World Report on Vision states that integrated people-centred eye care, and a commitment to Universal Health Coverage, is the model of choice for quality and affordable eye care services, and that quality eye care services need to be provided according to population needs.[2]
The Lancet Global Commission on Global Eye Health argues that universal health coverage is not universal without affordable, high quality, equitable eye care.[3]
In 2021, the United National General Assembly adopted a resolution committing the international community to provide eye health for the 1.1 billion people living with vision impairment by 2030.[4] Effective refractive error care (eREC) is one of two global targets endorsed by Member States at the 74th WHA to measure progress towards achieving UHC.
To be able to monitor progress towards universal health coverage and the quality of eye care services, a broader set of measurement indicators are required to monitor progress and drive change. Indicators should provide insights to shape change and stimulate action, track outcome progress and the quality of an intervention.[3]
Initial estimates suggest a need for substantial improvements in both quantity and quality of refractive error services, particularly for near vision impairment.[5]

What is a Q.REC study?

A Quality of Refractive Error Care (Q.REC) study is a real-world assessment of the quality of available spectacles. A Q.REC study identifies the proportion of prescribed and dispensed spectacles that are optimal for individuals’ refractive error needs and examines attributes of the optical service that are associated with spectacle quality, so that specific and targeted responses can be identified.

In brief, a Q.REC study uses:

Simulated patients: Simulated patients, or Unannounced Standardised Patients (USPs) — the gold standard for evaluating quality in clinical practice[6] — are ‘actors’ who are trained to act covertly as patients in a standardised fashion, while observing clinical techniques and services provided. USPs have been used extensively in low- and middle-income countries, often in evaluating family planning, pharmaceutical dispensing patterns, and clinical prescribing patterns.[7] Studies employing USPs have also previously been conducted to evaluate refractive error outcomes.[8],[9] The distinct advantage of this method is that observation bias is minimised, as care providers are likely to modify their behaviours.
Optimal spectacle definitions: Spectacles and written prescriptions are categorised as optimal or sub-optimal according to the tolerance indicators [10]. This allows assessment of the quality of various components of the spectacles, and comparison with the written prescription and the baseline refraction for each USP. Visual acuity and vision comfort as also assessed at distance and near.

What a Q.REC study will provide:

The proportion of people that are prescribed and dispensed spectacles appropriate for their refractive error needs
Adherence to national refraction guidelines or best practice
Specific opportunities for quality improvement which can then be translated into policy changes or quality improvement initiatives
Ability to monitor ongoing delivery of quality refractive error care services, within the context of integrated people-centred eye care.

Intended audiences:

The intended audiences for these findings are eye health managers, Ministry of Health personnel, NGO’s and other service providers responsible for providing quality refractive care, Research personnel, and those responsible for analysing trends and associations between quality and other epidemiological factors, and those interested in cross-country/regional analysis and comparison.

Advantages of a Q.REC Study

Methodological Benefits:

Minimises observation bias as providers maintain natural behaviour
Provides standardized patient experiences across different settings
Enables direct comparison between services and regions
Captures both technical and interpersonal aspects of care
Evaluates real-world service delivery
Assesses actual patient experience
Identifies gaps between standards and practice
Measures both clinical and communication quality

Practical Advantages:

More cost-effective than traditional audits
Generates data on routine care delivery
Reveals systemic issues in service provision
Provides evidence for targeted improvements

Implementation Benefits:

Can be conducted in both urban and rural settings
Adaptable to different healthcare contexts
Allows for repeat assessments over time
Supports both research and quality improvement goals

Disadvantages of a Q.REC Study

This protocol is unlikely to provide specific information for each facility as only a few USPs visit each service.
As all USPs will be adults, the findings might not be applicable to the quality of children’s refractive error care.
There is a possibility that USPs might be detected, and if so, the data should be excluded. If there is a significant proportion of visits where the USP were detect (i.e. > 5% of visits), and the USP continues to complete the visits and data are included, then there could be an overestimation on the Q.REC.
USPs might also inadvertently mislead optical service staff to either perform better or poorer than usual behaviour. To reduce these potential biases, well-delivered USP training is essential.

Summary

A Q.REC study is designed to identify the proportion of people that are prescribed and dispensed spectacles appropriate for their refractive error needs.
It can identify adherence to national guidelines or best practice and identify specific opportunities for quality improvement which can then be translated into policy changes or quality improvement initiatives.
Q.REC studies can also be used to monitor ongoing delivery of quality refractive error care services, within the context of integrated people-centred eye care.
If a Q.REC study is executed well, the distinct advantage of employing USPs is that observation bias is minimised, as refractive error services are likely to modify their behaviours if they feel that they are being observed or assessed.

Q.REC Publications

Key publications related to the Q.REC methodology and implementation:

References

Adelson J, Bourne RRA, Briant PS, et al. Causes of blindness and vision impairment in 2020 and trends over 30 years : evaluating the prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight. Lancet Global Health Published Online First: 2020. doi:doi.org/10.1016/ S2214-109X(20)30489-7
World Health Organization (WHO). World report on vision. Geneva: 2019.
Burton MJ, Ramke J, Marques AP, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health 2021;9:e489–551. doi:10.1016/S2214-109X(20)30488-5
United Nations General Assembly. Vision for Everyone: accelerating action to achieve the Sustainable Development Goals. 2021.https://undocs.org/en/A/RES/75/310 (accessed 3 Sep 2021).
Bourne RRA, Cicinelli MV, Sedighi T, et al. Effective refractive error coverage in adults aged 50 years and older: estimates from population-based surveys in 61 countries. Lancet Glob Health Published Online First: October 2022. doi:10.1016/S2214-109X(22)00433-8
Rethans J-J, Gorter S, Bokken L, et al. Unannounced standardised patients in real practice: a systematic literature review. Med Educ 2007;41:537–49. doi:10.1111/j.1365-2929.2006.02689.x
Wiseman V, Lagarde M, Kovacs R, et al. Using unannounced standardised patients to obtain data on quality of care in low-income and middle-income countries: Key challenges and opportunities. BMJ Glob Health 2019;4:1–3. doi:10.1136/bmjgh-2019-001908
Shah R, Ctori I, Edgar DF, et al. Use of standardised patients in optometry training. Clin Exp Optom Published Online First: 2021. doi:10.1080/08164622.2021.1896332
Nie J, Zhang L, Gao J, et al. Using incognito standardised patients to evaluate quality of eye care in China. British Journal of Ophthalmology 2020. doi:10.1136/bjophthalmol-2019-315103
Lee L, Burnett AM, D’Esposito F, et al. Indicators for Assessing the Quality of Refractive Care. Optometry and Vision Science 2021;98:24–31. doi:10.1097/OPX.0000000000001629

Q.REC Toolkit