What is best for our patients needs to be our guide with respect to managing patients with glaucoma. What should this model look like? Is it a collaborative model between Optometrists and Ophthalmologists or competitive? When should Optometrists check with Comprehensive Ophthalmologists or Glaucoma specialized ophthalmologists when caring for glaucoma patients? Should the model be different for rural vs urban centres and how are these defined? Should only Ophthalmologists provide initial glaucoma therapeutic recommendations or Optometrists as well? How do we know what is best for our patients - longterm progression outcomes? Cost analysis?
All of these issues have been debated in different forums in Canada, mostly within Optometry and Ophthalmology associations and colleges. The result is many differing opinions on how best to handle glaucoma care. The challenge now is to remember to keep care focused on the patient and not on turf wars as we begin Optometry/Ophthalmology discussions on how to achieve these goals.
Putting money where my mouth is, I am deeper into this process at the federal and provincial levels. I was involved in helping develop the recommendations from the Canadian Glaucoma Society as to how glaucoma sub-specialized ophthalmologists see this model of collaborative care. This is now in the hands of the Canadian Ophthalmological Society and they are in dialog with the Canadian Association of Optometrists. I have been appointed by the BC College of Physicians to the pharmacy advisory committee of the College of Optometrists of BC. I am hoping that discussions can prove helpful to our patients but worry about the risk of a no win situation for patients, optometrists, ophthalmologist and myself. I'll keep you posted with updates to this article but will not be able to post any confidential information.
What are your opinions on this subject? Please add your comments to share in this discussion.
(The following comments were copied from original submission dates and posted as a journal follow-up article in preparation for changing to DISQUS for future commenting on my blog.)
I think it's a great chance to discuss about patient care.
In the case of patients, I have found that wherever they may be, either in an urban or rural area, patients will have access problems. In an urban area, it might be that as a senior citizen, they cannot make 3 bus connections or wait for the municipal taxi bus service to pick and drop off reliably. In a rural setting, the office may not be near enough.Therefore, the distinguishing factor may not be urban vs rural.
Similarly, should an patient be seen if there is any chance there is glaucoma vs "advanced" glaucoma. Then we get into discourse what constitutes just a little bit of glaucoma and what is advanced glaucoma. Some might that optometrists shouldn't manage any one but glaucoma suspects, but that is a bit extreme. Optometrists may argue that they can manage any kind of glaucoma including field losses that account are greater than 50% of the visible field.
Somewhere in between should be the compromise. Its best for the patient. I believe that swaying too far on either end of the continuum will satisfy the least number of people and produce no measurable or incremental improvement on the patient's quality of health care.
Richard Hom OD
I am an optometrist practicing in "rural" BC. I see a whole lot of everything, including patients that have glaucoma. I utilize the same diagnostic testing as a general ophthalmologist in deciding if my patients have the disease.
I have a great relationship with the local ophthalmologist, but he is extremely busy and "glaucoma suspects" that I refer to him are often not seen for well over a year. That is the norm in rural BC - one or two years to get in.
I am fully capable of initiating glaucoma therapy, and would do so, if not limited by current regulations. I think it would benefit patients if I was permitted to initiate their treatment while they wait for the assessment of an ophthalmologist OR if I could simply initiate treatment and folloow the patients in accordance with the standards of care for glaucoma, and use my discrestion as to when and if they need to be seen by a glaucoma specialist.
Then I what I'm perceiving is that you might be in favor of a scheme that authorizes optometrists who possess sufficient data to initiate glaucoma treatment without prior pre-authorization by an ophthalmologist? And continue management unless the patient's condition changes (worsens)?
Richard Hom, OD, FAAO
You are perceiving correctly. I think that most optometrists currently in practice have the knowledge and ability to initiate glaucoma therapy, and are fully capable of independently managing their patients. Also, optometrists in BC that treat other conditions, such as anterior uveitis, would be better able to manage those few patients that are steroid responders, if they could prescribe glaucoma medications.
I have no problem involving ophthalmology in the management of glaucoma patients, but the current wait times to see an ophthalmologist in rural BC are, in my opinion, excessive, and I think patients would be better served if optometrists could at least initiate treatment, without consultation.
Please feel free to invite your colleagues in BC to also participate. I've only known Dr. Schertzer through an online discourse and you may know him better, but I original impression that he is supported of collaborative management of glaucoma between optometry and ophthalmology has been unchanged. My presence here should be some sign of this.
He is also looking for participation in a model now that might make collaboration much smoother than if collaboration was solely accomplished unilaterally.
What do you think?
Richard Hom, OD, FAAO
I certianly would agree that a collaborative approach to glaucoma management would be the ideal, and I would be more than happy to provide input/opinions if requested.
Thanks. Great. Couple of things. Ask your colleagues to post comments or questions.
Richard Hom, OD, FAAO
Dr Schertzer, et al
I think it is important to look at demographics and population trends as well. Because of the aging population in North America, we will soon have grossly insufficient numbers of Ophthalmologists. It would be a natural result for ODs to share some of the load of treating diseases like glaucoma. The healthcare community will really have no choice. In that light, I think it is best that Ophthalmology and Optometry work together. That means improved training for ODs, co-management of diseases like Glaucoma and the end to the turf wars of the past. It won't be long before we're all "up to our eyeballs in eyeballs".
Ron Hampel, OD
I have worked with many excellent optometrists and just as many bad ophthalmologists. But the fact remains that understanding disease from a surgical stand point makes you follow and treat it differently. In other fields of medicine, co-management is much easier typically because surgical indications are based on symptoms such as pain. In Glaucoma vision loss is often asymptomatic and painless and therefore early intervention can be difficult to determine by the non-surgeon. Collaborative guidelines would be helpful for glaucoma. Otherwise poor care can result.
C. Robert Bernardino, MD FACS
I find your comments interesting...I have co-managed many glaucoma patients over the years, and have had the privelage of learning from some excellent ophthalmologists. The logic that they seem to employ in the managment of their patients seems to be in line with the standard of care that optometrists also follow. I would be interested to hear what nuances of glaucoma care a surgeon would employ in the early stages of the disease, that an optometrist would be unaware of? Aside from IOP, the appearance of the optic nerve, fields, pachymetry, OCT or HRT comparisons to baseline, appearance of the angle, what other factors are considered? I think most ODs can determine if glaucoma is remaining unchanged or if the disease is progressing using the same tools as ophthalmologists.
If the signs of glaucoma worsen under the care of an optometrist, referal to a glaucoma specialist would be indicated. However, the benefit of utilizing the hundreds of well-trained optometrists in the province to the full-extent of their training would provide more expedient access to care.
Many, if not most glaucoma patients are already finding their way to the office of an ophthalmologist via their optometrist...the optometrist has already essentially diagnosed the disease. Does it make more sense for treatment to begin immediately with the optometrist, or be delayed 1-2 years while the patient waits for their appointment with an ophthalmologist?
As for misdiagnosis, I have seen patients who have been treated by ophthalmologists that clearly did not have glaucoma, and were subsequently pulled-off their medications by another ophthalmologist, and I have referred patients for glaucoma assessment and were determined not to have glaucoma, only to be reassessed and treated a year or two later, often by the same ophthalmologist.
Neither optometrists or ophthalmologists are going to starve anytime soon...time to end the turf war and start thinking about optimum patient care.
I concur that surgical management of glaucoma requires a surgical and medical background and experience in that modality.
Of all glaucomas, what do you feel is the proportion of them are more than 50% of visual field loss?
Richard Hom, OD, FAAO
This is truly a very informative and constructive discussion. We should definitely have more colleagues in both Optometry and Ophthalmology in this discussion. I regret to find this site so late.
I do want to make a comment to Dr. Proctor however, I 'm not sure if I can completely agree with you on the following quote: "I think that most optometrists currently in practice have the knowledge and ability to initiate glaucoma therapy". I personally think because Optometry do not have a set routine assessment for the registrants on a normal basis (every 3-5 yrs for ex.), the standard of OD's may vary by far. Furthermore, If you were to look into an average clinic in the lower mainland, you would most likely see exam rooms equipped with a standard lane + VF or Retinal camera at most. I do not believe that an average OD in Lower Mainland have the necessary equipments (OCT/GDX/HRT) to give proper diagnostic exams for glaucoma suspects.
I'm not too familiar with the rural BC clinics; however, we often think what will we say to the patient if we are to charge them individually for each extra testing. They often ask why SHOULD they pay optometrists for the testing when the same testings done by an ophthalmologist are free. With an average wait time of only around 1-2 months to see an ophthalmologist, is it really necessary for them to have the testing done in an optometric practice.
Dear Dr. firstname.lastname@example.org,
Thank you for your post.
Admittedly, not all optometrists may be equipped either by motivation or by equipment to address the question of glaucoma diagnosis and therapy. Ideally, though, this is a self selection whereby motivated optometrists will involve themselves either through technology and /or continuing education to manage glaucoma.
In summary, I don't believe that a few optometrists who may not be interested in glaucoma management should dictate how all of glaucoma will participate in glaucoma care.
Richard Hom, OD, FAAO
I think in communities where the wait time for glaucoma patients is truly only a month or two, then yes, referring those patients out would make good sense.
In my region, however, it can take up to 2 YEARS for a patient to finally get an appointment with an ophthalmologist. It's certianly not the fault of the over-burdened rural ophthalmologists, but simply the reality for many, if not most, rural areas. Additionally, suggesting that patients travel to the lower mainland to see a specialist is not a solution. Many of these patients are elderly, on a fixed income, and not comfortable with travel. Also, many First Nations patients, in my experience, simply refuse to travel to the LML.
Having the authority to prescribe glaucoma medications will also help optometrists more efficiently treat their uveitis patients, or others that require longer-term treatment with corticosteroids. I have had several steroid responders, that could not be taken-off their steroids, and required a glaucoma med for the duration of their treatment. Currently, I have to call the primary care physician, and have them call it in. It all works out in the end, but really, why can't I simply write the Rx myself??
Dear "Cat" and Dr Proctor,
Thanks for contributing to this discussion.
Cat, the guidelines stipulated by the therapeutics committee from the BC College of Optometry actually just specify that the optometrist has to have access to disc imaging and visual fields that are capable of documenting progression; the optometrist need not have these actual pieces of equipment as long as they can get the patients to someone who does have them. This can be a local ophthalmologist providing that service or a group of optometrists can create a centralized testing centre if they would like to care for patients with glaucoma.
Dr Proctor, these same guidelines do allow treatment of stable glaucoma patients with common types of glaucoma, but they do not permit treatment of patients with uveitic glaucoma without consulting with an ophthalmologist. Having a family doctor prescribe medications on your behalf is probably something that is not in the patients' best interests. That being said, there are certainly logistical issues when trying to practice in remote communities and in dealing with patients who are reluctant to or financially unable to travel a great distance. That being said, there are also government programs that pay for First Nations patients to get the care that they need including travelling to areas where there are ophthalmologists or glaucoma specialists such as myself who have virtually no waiting list for new consults.
The bottom line is that we need to be doing what would be in the best interests of our patients. Qualified eye care professionals need to work together to achieve these goals.
Robert M Schertzer, MD, MEd, FRCSC
Dear Drs Schertzer, Proctor and Hom,
Thank you for providing different perspectives regarding the purposed regulation. It definitely give me new insights regarding this issue. I guess I just never knew there is such a long waiting list to see an ophthalmologist in rural B.C. By all means, I totally agree with Dr. Schertzer that we need to come up with something that is in the best interest of patients.
When I did my optometry rotations in the US (East Coast), we often are assigned to clinics that are well equipped with latest technology with preceptors that are often up to date in the management of ocular diseases. These clinics are usually pretty big in size (5+ rooms, with advance Dx equipments, Optos, etc etc.); however, ever since I start practicing in LML, I have yet to see a clinic that is nearly as grand as those in U.S.
Pardon my rudeness for being blunt and materialistic Dr. Hom, but I believe part of the reason that some optometrists in Lower Mainland are not motivated to be up to date and acquire extra Dx equipments is because in a business sense, it is simply not a good investment. If you look into B.C Optometry Billing Schedule, there are approx. 4-5 fees schedule that we use (Major, Minor, Fields and IOP). By acquiring an OCT/HRT or even a Pachymeter, the rate of return is simply zero if you do not charge the patient (even ONH photo is not covered by MSP even if it's required). Furthermore, because Optometry clinics normally reside in "retail" areas, it is very expensive to lease the extra space.
Dr. Schertzer, I guess my question to you will be if you are an OD instead of an OMD in the lower mainland, would you go ahead and start purchasing OCT/HRT etc to monitor glc. suspects knowing that the patient will have to pay out of pocket? Say that you have a retinal camera and a visual field, but isn't it still better if you refer your patient to somewhere that has a HRT or an OCT?
As an optometrist, I am happy to see OD's in BC strive to increase the scope of practice to match closer to our colleagues in the U.S.; however, I'm a little concern with our healthcare system, is it the best for the patients.
Even as an ophthalmologist, the decision more than 5 years ago to buy an optic nerve imaging device (the HRT) was not an easy one from a return on investment perspective. In my case, since all I do is glaucoma, it is an investment that eventually does pay off. However, the government reimbursement was reduced last year for this from $64 to $54 and we can no longer do this on the same day as seeing the patient if we want to get paid because it got reclassified from being a diagnostic ancillary test to being an eye exam. So, if I see a patient on the same day, I cannot bill for an eye exam as well as this would be duplicate billing. Now the burden has shifted to the patient who must make three trips to the office instead of just one if they need a visual field, HRT and to see me (or pay the difference out of pocket for what I cannot otherwise bill; or be referred back each time and treat as a new consult every visit and generate a consult report in order to only need two office trips instead of three.) So, it optic nerve imaging is by no means a big money generator and adds a burden on the patients.
Now that SD-OCT has matured and is actually useful for progression which TD-OCT was never, I face this return on investment challenge again. Would a patient pay out of pocket for the SD-OCT as I would still keep doing HRTs since I have data going back to 1994 on many patients and cannot bill MSP for both HRT and SD-OCT? Or do I lose money on every patient I see?
Robert M Schertzer, MD, MEd, FRCSC
I don't want to treat glaucoma for financial gain. For an optometrist in BC it is not going to make me any money. I do, however, want the privelage of prescribing glaucoma medications to facilitate optimum patient care.
Dr. Schertzer, I understand that getting PCPs to prescribe medications for patients is not the ideal way to deal with some of the more complex patients, that would be better served by seeing an ophthalmologist, but when no ophthalmologist is available, and the patient is unable or unwilling to travel long distance, what is the option?
As for First Nations, even if transportation is arranged for them at no cost, there are still many who will not travel to the LML. I worked in Williams Lake for a few years, and saw it many times. It's certainly frustrating. One man had an open-globe injury from an incident with a horse, and refused to leave the region for treatment even though an ambulance was waiting to take him to Kamloops (only 3 hours away). He simply went home.
There are realities of rural practice for BOTH optometrists and ophthalmologists, that are difficult for urban ODs and MDs to understand.
Totally agree with you that there is really no ideal solution when a patient is unwilling to make the trip to the lower mainland or even to undergo recommended treatment locally. As for financial gain with ophthalmology, I wouldn't be a glaucoma specialist if that was my goal! I do however have to make sure I can at least cover my expenses...each new device makes this less possible.
Robert M Schertzer, MD, MEd, FRCSC