Are evidence-based guidelines being followed for the monitoring of ocular toxicity of hydroxychloroquine? A nationwide survey of practice amongst consultant rheumatologists and implications for clinical governance

Objective. To determine whether consultant rheumatologists monitor the ocular toxicity of hydroxychloroquine according to standards set by national guidelines. Method. An observational cross-sectional questionnaire study of all consultant rheumatologists in the UK was undertaken. The main outcome measure was the proportion of rheumatologists who practise in compliance with nationally set standards. Results. A wide variation in practice was found. Nearly half the respondents did not assess either baseline visual symptoms or visual acuity, and 3% undertook infrequent visual monitoring at intervals of longer than 1 yr. At least a quarter of rheumatologists within the survey routinely referred patients to ophthalmology, either for baseline visual screening or for regular visual monitoring. Such use of ophthalmology services was outside the recommendations of the guidelines and would suggest that these referrals were unnecessary. No differences in monitoring practices were ascertained between respondents from district general and teaching hospitals. Conclusion. The present study shows that nationally set guidelines for the monitoring of ocular toxicity of hydroxychloroquine are not consistently followed by rheumatologists with regard to baseline assessment, referral to ophthalmology and frequency of monitoring. Clinical guidelines aim to reduce variations in practice and to promote uniform and consistent best practice. The present study demonstrates a lack of conformity to national guidelines in respect of the monitoring of ocular toxicity of hydroxychloroquine. Clinical governance provides a framework for assuring quality in health care. The implications of this study for clinical governance would include understanding why barriers to the use of guidelines might occur and how they might be overcome, risk management, accounting for the reasonableness of a decision for positive divergence and audit.