Task shifting in primary eye care: how sensitive and specific are common signs and symptoms to predict conditions requiring referral to specialist eye personnel?

Abstract

BackgroundThe inclusion of primary eye care (PEC) in the scope of services provided by general primary health care (PHC) workers is a ‘task shifting’ strategy to help increase access to eye care in Africa. PEC training, in theory, teaches PHC workers to recognize specific symptoms and signs and to treat or refer according to these. We tested the sensitivity of these symptoms and signs at identifying significant eye pathology.MethodsSpecialized eye care personnel in three African countries evaluated specific symptoms and signs, using a torch alone, in patients who presented to eye clinics. Following this, they conducted a more thorough examination necessary to make a definite diagnosis and manage the patient. The sensitivities and specificities of the symptoms and signs for identifying eyes with conditions requiring referral or threatening sight were calculated.ResultsSensitivities of individual symptoms and signs to detect sight threatening pathology ranged from 6.0% to 55.1%; specificities ranged from 8.6 to 98.9. Using a combination of symptoms or signs increased the sensitivity to 80.8 but specificity was 53.2.ConclusionsIn this study, the sensitivity and specificity of commonly used symptoms and signs were too low to be useful in guiding PHC workers to accurately identify and refer patients with eye complaints. This raises the question of whether this task shifting strategy is likely to contribute to reducing visual loss or to providing an acceptable quality service.

Strengthening primary eye care in South Africa: An assessment of services and prospective evaluation of a health systems support package

“…The potential for training to improve clinical skills of PHC workers may be limited due to the low numbers of ophthalmic patients who present at PHC compared to patients with other conditions, making it difficult to gain sufficient experience for the retention of knowledge and skills [ 37 ]. The findings of this study add to the body of evidence which questions whether primary eye care can indeed provide an acceptable quality of service or meet the needs of target populations [ 44 , 45 ]. As previously suggested, primary eye care might therefore be better suited to eye health education and referral of patients using well-defined guidelines as opposed to providing diagnostic and clinical management services [ 43 , 46 ].…”

Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used?

“…More recently, research has highlighted the inadequate skills of general primary care workers in recognizing and managing important eye conditions [ 43 – 45 ]. Considering the complexity and variety of conditions that can lead to vision loss, the paucity of tested curricula and treatment algorithms for this level, and the low numbers of patients with eye problems compared to other conditions demanding time from primary health care workers, it is unrealistic to expect much eye care to be delivered at the primary care level [ 46 ]. Instead, eye services at this level could more usefully focus on eye health education messages, health promotion, identification of abnormal eyes (without necessarily reaching a diagnosis), and clear referral guidelines.…”

Improving Ghana’s mental healthcare through task-shifting- psychiatrists and health policy directors perceptions about government’s commitment and the role of community mental health workers

“…The latter requirement, that there be reliable indicators, is critical in any scheme to shift tasks from highly competent specialist medical personnel with in-depth knowledge to generalist health workers with limited specialist knowledge, experience, and equipment, while avoiding an unacceptable decrease in quality of care. The development of successful algorithms and training for primary health care workers is based on likelihoods that specific, easily identifiable signs (indicators) reflect certain pathophysiologic processes [ 39 ]. For example in mental health, several validated instruments exist to guide clinicians with diagnosis and these could be incorporated into an assessment kit for the CMHWs to guide them in categorising mental health conditions.…”

“…If such indicators cannot be identified then it may not be reasonable to expect “task shifting” to be successful. Useful indicators need to be simple to use and should have high sensitivity and specificity [ 39 ]. The lack of consensus among all our study participants regarding the existence of clear treatment protocols need to be examined more closely and addressed at the policy level.…”