EYE CARE RECONSIDERED

As a prominent researcher in the fields of optics, aberrations in refractive corrections and early ocular disease detection, Raymond A Applegate OD, PhD used to present regularly at American Academy of Ophthalmology meetings. Then one year he was not invited. In part responding to optometry groups pushing state laws permitting them to practise refractive surgery, the American Academy of Ophthalmology had banned optometrists from attending educational activities at its meetings.

Relations between ophthalmology and optometry had been cool since before he entered the field in the 1970s, said Dr Applegate, who served the eye care profession for 14 years as a professor of ophthalmology at the University of Texas Health Science Center San Antonio and is currently professor and Borish Chair of Optometry at the University of Houston. But in his mind, the ban on the open exchange of information strikes at the core interests of both professions, and is bad for patient care.

“The mark of most successful healthcare professions is the open exchange of information. The American Academy of Ophthalmology action put a stake in that. We should always, regardless of the letters after our name, exchange information for the benefit of patients and the public,” says Dr Applegate, who has served on the editorial boards of several optics, ophthalmology and optometry journals, and presents regularly at ESCRS meetings.

The American Academy of Ophthalmology hasn’t yet reversed the ban. But late last year, the society took two steps toward thawing relations with optometry.

In his opening remarks at the 2013 American Academy of Ophthalmology annual meeting, the then academy president, Paul A Sternberg Jr MD, called for better integration of optometrists and other health professionals into the eye care team. As the baby boom generation ages into retirement – and many prolific ophthalmologists among them exit practice – demand for services will greatly exceed the supply of ophthalmologists, he noted. Meeting growing patient needs, not to mention rising service and outcomes expectations, will require not just a truce, but a new collaborative relationship with optometry.

“We need to build an ophthalmologistled care team, but one that relies on optometrists to help in screening, primary diagnosis and care management of our patients with eye disease. It is a more efficient model. It addresses our emerging supply side problems, and maybe it can help us reallocate the resources that both professions have expended fighting a seemingly endless scope of practice battle,” Dr Sternberg said.

Educational initiative

Three weeks later, the American Academy of Ophthalmology announced formal dialogue with the American Academy of Optometry. “What prompted this was not an event but a growing realisation that even though many ophthalmologists and optometrists have good, patient-focused relationships on an individual basis, the two professions have negligible interface on the educational front. In a team-based care delivery world, it makes sense that we open an ongoing dialogue in the interest of our patients,” American Academy of Ophthalmology chief executive officer David W Parke II MD told EuroTimes.

 “When the American Academy of Ophthalmology reached out to us, we thought it was an excellent opportunity to move forward our education for our patients and improve patient care,” said Bernard J Dolan OD, MS, president of the American Academy of Optometry. The initiative was taken by decision of the two organisations’ boards. The next step is to get feedback from members, and appoint a joint taskforce to focus on the details – possibly joint symposia, educational programmes and standards of care and care guidelines for team-based practice. “The first thing we needed to do was build the bridge. Now we get down to the nitty gritty,” Dr Parke said. The organisations anticipate these programmes will be developed over the next 12 to 18 months.

The American Academy of Ophthalmology’s move follows development by the American Society of Cataract and Refractive Surgeons (ASCRS) of the Integrated Ophthalmic- Managed Eyecare Delivery Model (IOMED). It debuted at the ASCRS meeting in April 2013 with a slate of educational programming for optometrists employed by ophthalmologists or organisations that integrate optometric and ophthalmologic practice. According to an ASCRS survey, 34 per cent of US ophthalmologists employ optometrists and 38 per cent anticipate doing so in the future. Dr Applegate notes that many more optometric practices are hiring ophthalmologists as well to meet patient needs. More than 130 ODs registered for the first programme. Integrated eye care creates a system in which ophthalmologists and optometrists work together synergistically so that total care of a patient is coordinated.

“Integrated eye care makes sense, given the state of affairs we are presently in,” said Stephen S Lane, MD, chairman of the ASCRS Committee of Integrated Eyecare. “We have an increasing number of patients and a diminishing number of eye care providers to take care of them. We need a system available so patients receive good care and are seen efficiently and cost effectively. ASCRS has taken a leadership role in developing and nurturing an educational process directed at optometrists and ophthalmologists to promote this practice model.” These moves toward accepting and making fuller use of trained optometrists don’t end friction between the professions. But it does create a framework for working together in the interest of optimal patient care, Dr Parke said. “Realistically, there is no chance any two organisations will agree on everything. The key is to identify likely areas for productive engagement.”

The American Academy of Optometry steers away from politics, Dr Dolan said. “We are an educational organisation. We were approached on patient-focused education and research, and we are very interested in the opportunity,” Dr Dolan said. Other optometry organisations are responsible for advocacy, he pointed out. For Dr Applegate, the legislative fights have never really reflected the view of most practitioners. “Unfortunately in political/economic decision-making, the people who buck the hardest often ignore advances in education, training and research and ever changing societal needs in their decision making while the people who actually deliver care are often left on sidelines.”

Dr Applegate notes that as knowledge and training advances, practice scope inevitably expands for all healthy professions. He hopes for a more productive relationship to come between optometry and ophthalmology that better respects the fact that education, research and training evolve to meet unmet needs and consequently practice patterns, skill sets and associated reimbursements change.

Raymond A Applegate: rapplegate@uh.edu Linda Apeles: lapeles@aao.org Cindy Sebrell: csebrell@ascrs.org