The Ever Shifting Line in the Sand

There’s a tug of war being contested between the Optometry Board of Australia (OBA) and the Optometrist Association Australia (OAA) versus Royal Australian and New Zealand College of Ophthalmologists (RANZCO) over glaucoma management. It’s creating frictions and threatens to break down relationships between the professions that have been established over years. And it gives rise to a bigger question for the future. How can eye health professionals work together more effectively to meet the needs of an ageing population?

Managing the eye care needs of the Australian community is a challenge – and it’s one that will continue to grow as we live into our 80s and 90s. It’s most likely that with increasing age, we’ll be inflicted with not one, but two or more eye diseases, accompanied by other conditions that affect the heart, brain, lungs and so on.

Depressing isn’t it? The thought of moving from one specialist’s waiting room to another, so that all of our ailments can be monitored and managed.

When collaboration works it can be very powerful, I’ve seen it work very well to the patients’ and community’s benefit…

In the case of ophthalmologists monitoring eye conditions like macular degeneration or glaucoma, the picture of having a waiting room full of the elderly – day after day – who simply need their condition(s) checked once a month to monitor treatment and disease progression, can hardly be exciting.

And spare a thought for the carers, often unpaid, whose lives will be disrupted as they transport and accompany their loved ones about town to specialist visits that often entail several hours spent in each waiting room.

There has to be a better way.

Relieving the Burden

Many optometrists we spoke to said yes, there is. While all of them paid tribute to the expertise, the commitment and the achievements of ophthalmologists, they were also all quite certain of their own capacity to work more closely with ophthalmologists to relieve patients and carers of the burden of sitting in waiting rooms.

Optometrist Dr. Jim Kokkinakis says there is no reason why optometrists can’t take on some of the load. “As the population ages ophthalmologists are going to need more help.

“Ophthalmologists treating AMD are already overwhelmed and so they’re talking about training their nurses to inject. That’s fine, nurses are quite used to giving injections, but training to inject an eye has a very emotional component to it. In other areas health practitioners are talking about training nurses to deal with diabetes and cholesterol. Yet no one can get their heads around educating optometrists to take on more of a role in managing eye disease.

“I believe it’s because an optometrist’s education process is off what they perceive as the medical path – as opposed to nurses who are trained under the medical path. But our training is medical at the end of
the day,” said Dr. Kokkinakis.

Referring to the debate raging between the OBA, OAA and RANZCO regarding management of glaucoma, Dr. Kokkinakis said experienced optometrists already have the skills.

“Treating glaucoma isn’t rocket science – time moves on and I think experienced optometrists have the training – not to do surgery but to manage garden variety glaucoma and refer on when more complex management is required. We can manage a significant number of cases.

“After all, the hardest thing to do is the diagnosis – and we already have that responsibility, otherwise we wouldn’t be able to make a referral.”

He suggested a three-month course focussed on glaucoma, on top of the years training in therapeutics would equip young optometrists to manage the disease.

Optometrist Micheal Knipe from Total Eyecare in Tasmania believes improved detection rates may drive a shift in the scope of optometric practice.

“The Australian Medical Health Research Council has estimated that a significant number of people with glaucoma are undiagnosed. The incidence of macular degeneration and diabetes is also rising in the community. The increased incidence and improved detection could mean too many people needing care from too few practitioners,” he said.

More Regulatory Change Needed

Andrew Harris, Chairman of the National Board of the OAA agrees that the combination of an ageing population and increased detection rates will drive change. “One would suspect that to cope with this, there would have to be changes in the workforce – either in the numbers of ophthalmologists or the way work is apportioned – so that people with these eye conditions can be looked after,” said Mr. Harris. “The skills of the eye health workforce should be available and need to be used efficiently and intelligently.”

Either way, he said, the health community must work together for the sake of the patient. “No-one in the eye care community should consider a patient to be ‘their patient’. It’s about working together to ensure the patient – that is a person with an eye condition – gets the appropriate treatment and care,” said Mr. Harris.

“So it’s about the optometrist using the appropriate health resources available – communicating with the general practitioner for example about whether there are any medicine contraindications, and with the pharmacist to ensure the patient is procuring the prescribed medications and compliant, if that is of concern. And it’s beholden on the optometrist to refer the patient to an ophthalmologist when appropriate.”

It’s a line the OAA has been pushing with fervour in recent months as the debate over glaucoma management has raged: effective collaboration and communication between the many practitioners that make up the eye care network, including optometrists, ophthalmologists, pharmacists and GPs and the wider eye health sector, is in the best interests of patients.

“Entry-level optometric training already provides the platform for optometrists in Australia to provide a wide scope of eye health and vision care services. There is some overlap in the services provided by optometrists and ophthalmologists, but in most cases the roles of the two professions are complementary, with optometrists providing primary eye care, and ophthalmologists providing secondary and tertiary care,” said Genevieve Quilty, CEO of the OAA.

“There are many models of interaction between optometrists and ophthalmologists. The Association is keen that the regulatory structures governing optometry practice recognise there needs to be flexibility to allow for these different models of care to develop and grow in the best interest of patient care.

Looking to the UK

The United Kingdom’s shared care arrangements between ophthalmologists and optometrists have been upheld as models that work exceptionally well. Dr. Brad Bowling, a UK trained ophthalmologist and co-author of the Kanski textbooks moved to Australia in 2011. He was responsible for innovating a shared care scheme for glaucoma patients in the United Kingdom some three or four years ago and said it worked well.

“The scheme covered a large area – two health care districts – and it encompassed the lower risk patients – people with ocular hypertension (pre-glaucoma) and glaucoma suspects. The patients would be given a management plan by the ophthalmologist and discharged to the optometrist in the community who then took sole clinical responsibility for the patient.”

He said this scheme replaced an earlier one, which saw optometrists in the community looking after patients who had been discharged from hospital care with “stable or so-called stable” glaucoma.

“Although the audit on that was reasonable, there were a few patients whose glaucoma progressed substantially in the community, which is why we downgraded the scheme. So in my view the initial scheme didn’t work well because a few patients with established glaucoma did slip through the net,” said Dr. Bowling. “Even with the later scheme, some ophthalmologists were still reluctant to assign patients’ care to other professionals.”

He said another model used extensively in the United Kingdom had optometrists spending one session a week in hospital in a glaucoma clinic. “They worked in a hospital clinic under direct supervision of a consulting ophthalmologist so therefore they had the volume of patients to cultivate their expertise and they had immediate access to advice and feedback. This model worked extremely well and some of those optometrists would then take their expertise out into the community,” said Dr. Bowling.

“There are various models in operation in the UK but despite the fact that these are presented as being popular they are still relatively small scale – there are no very large scale co-management schemes.”

Dr. Bowling acknowledges that the UK eye care system is very different from Australia’s primarily privately run eye care industry.

“In the United Kingdom most health care is provided by an overburdened public sector via the National Health Service (NHS). That presents a key difference because it brings into play financial factors, which drive the government to find alternatives.”

The Right Circumstances

Dr. Simon Chen from Vision Eye Institute has witnessed eye care co-management in play at the Oxford Eye Hospital in the United Kingdom, at Auckland City Hospital in New Zealand and in private practice at Vision Eye Institute here in Australia. He believes that under the right circumstances, there are many potential benefits for patients, optometrists, ophthalmologists, and the healthcare system.

“Some of the advantages include reduced waiting times and convenience for the patient, increased job satisfaction and professional development for the optometrist, and freeing up time to perform surgery and attend to complex cases for the ophthalmologist, as well as more efficient utilisation of limited resources for the healthcare system,” said Dr. Chen.

“Although there are local examples of successful co-management arrangements, they are relatively few. Before co-management can become more widely accepted in Australia, there are numerous barriers, which need to be overcome. These include political, educational, risk management, and financial issues amongst others.”

Additionally, he said “unresolved concerns remain regarding inter-professional trust between optometry and ophthalmology, the level of training and competence of optometrists to co-manage eye disease, medico-legal liability in the event of adverse outcomes in co-managed patients and the remuneration of professionals participating in co-management”.

Even then, he said, “co-management only makes sense for ophthalmologists if they are working at full capacity, for example in the public hospital system or a very busy private practice. Ophthalmologists that have excess capacity available will see no real benefit in co-management. Likewise an optometrist in a very busy practice may have no time or desire to co-manage,” said Dr. Chen.

Ms. Quilty said the public hospital system, in particular, would benefit from involvement by optometrists.

“In the Association’s view, one area where optometrists have potential to make a significant contribution to eye care in Australia is by supporting eye health in public hospitals. The Association views this as natural evolution in the delivery of efficient eye health care that is needed as a result of our ageing population and an increased prevalence of chronic eye disease. Waiting lists for ophthalmic surgery are extremely long and diverting patients from inpatient clinics to optometry as well as utilisation of optometrists in public hospitals is a rational use of limited health care resources, allowing ophthalmology to focus on and provide the urgent eye health care the community needs,” said Ms. Quilty.

Glaucoma Debate Regrettable

The debate about glaucoma management continues to be battled within the eye care profession and has the potential to damage long term relationships between ophthalmologists and optometrists.

Therapeutically endorsed optometrist Dr. Alan Burrow says this is regrettable.

“I fully support the changes to the OBA guidelines in relation to glaucoma management as they provide greater flexibility. However, I regret the resulting conflict, which has arisen between optometry and ophthalmology, particularly as I am indebted to many ophthalmologists for their assistance in improving my diagnostic and therapeutic skills.”

Dr. Burrow believes “an erroneous impression might have been created that optometrists were intending to undermine ophthalmology in glaucoma management”.

“The guideline’s restrictions ensure that only a limited number of experienced therapeutically endorsed optometrists are likely to treat selected patients, often from their own patient base. A significant number will still co-manage or onward refer to ophthalmologists.”

He said optometrists share the concerns raised by ophthalmologists of misdiagnosis as a result of masquerading pathologies. “However, these conditions presented in daily practice, frequently with no clinical signs of glaucoma.”

He acknowledged that “reports of some optometrists, particularly new graduates, being expected to perform full examinations in a very limited time and frequently without dilation is concerning because of the increased risk in overlooking subtle diagnostic signs”.

“While the aim is a ‘gold standard’ system, this needs to be viewed against the backdrop of the status quo,” said Dr. Burrow. “Even though I practice in a regional centre with five ophthalmologists, I still regularly see patients whose GPs prescribed glaucoma medication without the necessary equipment. This situation is likely to be even more common in rural areas with no ophthalmologist.”

He said across the country – whether in regional or metropolitan areas –collaboration is the key. “The maximum reduction in glaucoma related visual loss could be achieved if optometry, ophthalmology and Glaucoma Australia cooperated to reduce the estimated 50 per cent of undiagnosed cases.

“Furthermore, the widespread use of ready-made ‘spectacles’ often results in users significantly postponing vision examinations. As glaucoma is symptom-free in the early stages, the delay in diagnosis will inevitably lead to unnecessary loss of sight. These individuals should be encouraged to have regular eye examinations,” said Dr. Burrow.

How Much Interest Is There?

What has become clear, from talking to both optometrists and ophthalmologists, is that in reality, there aren’t too many optoms who are interested in extending their scope of practice any further than they’ve already taken it.

“I believe only about 20 per cent of optometrists really want to do more than what they’re doing at the moment,” said Jim Kokkinakis. “But that 20 per cent, are most likely very capable of taking more of a role in managing eye disease.”

But Dr. Chen expects this to change over time. “My impression from speaking with a range of optometrists is that a large proportion have no desire to co-manage eye disease and are happy with the traditional optometric roles of optical correction, retail optometry, primary eye care, disease detection and referral to ophthalmologists for management.

“However, this may be changing, with the younger generation of therapeutically trained optometrists that are coming through the system. These new graduates often expect to take on a more active role in ocular disease management. The increasingly widespread availability of high tech assessment devices such as retinal cameras, corneal topographers and optical coherence tomography scanners is another factor, which is leading some optometrists to take a greater interest in disease management,” said Dr. Chen.

So What Will It Take?

“In my opinion,” said Dr. Chen, “the key requirements for effective co-management include a desire by both optometrists and ophthalmologists to collaborate, mutual professional respect and trust, adequate clinical training, a commitment to on-going communication, patient consent, a stable disease condition and clear
referral guidelines.

“Having hosted numerous optometrists during clinical placements for their therapeutic training, I have been struck by the wide variation in the level of confidence, clinical knowledge, competence and experience in disease diagnosis and management between different optometrists. Some demonstrate excellent diagnostic and clinical skills, whilst others have a more limited knowledge base and less clinical experience.

“For co-management to become more widely supported by ophthalmologists, they need to have confidence that the optometrists they collaborate with will have a consistently high level of clinical competence.

“This can only be obtained through extensive hands-on clinical training with adequate assessment processes to ensure a consistent level of professional competence in disease management. This training would ideally include extensive exposure to a wide range of patients with common and rarer eye conditions of varying levels of severity, instruction in the application and interpretation of modern diagnostic tests and training in the pros and cons of various therapeutic drugs and management strategies,” he said.

Financial Implications

Optometrist Jim Papas from eyeclarity said the potential to co-manage patient eye care is also dependent on an improved financial model for optometrists.

“Medicare fees will need to be uncapped before optometrists can begin to take on more of a role in eye disease management. This will be an important progression for optometry – services need to be self-funding… one would hope that there will be a change in the fee structure with the upcoming election,” said Mr. Papas.

“The Association is doing all it can to get this to happen, and they’re doing a great job of that – this is a more concerted effort than we’ve ever seen before and I think they should be commended for that,” he said.

Genevieve Quilty, CEO of the OAA said the current Medicare cap impacts the viability of providing the full scope of optometry services and it’s something she would like to see changed.

“Optometrists, unlike any other health professional in Medicare, are unable to charge above the scheduled fee for Medicare services. Following years of inadequate indexation of the MBS, this means optometrists are now able to charge well less than they used to as a result of inadequate remuneration, in real terms, for the same consultation item,” she said, adding that the system isn’t sustainable.

“The Association is seeking a simple amendment to bring billing arrangements for optometrists in line with all other health professionals under Medicare. We don’t see the current Medicare ‘fee cap’ as impacting on the scope of practice for optometry in itself, rather on the viability of providing the full scope of optometry services covered by Medicare – current arrangements make it difficult for optometrists with particularly high caseloads of patients that require more costly levels of care, which are less likely to be linked to other sources of practice income.

She said any further expansion to the scope of an optometrist’s services will be dependent on precise circumstances.

“The scope of practise for optometry is regulated by the OBA, rather than Medicare and optometrists are able to charge a private fee for services that are not included in the Medicare schedule. There are also established systems to seek amendments to existing MBS items, or to seek additional items, if this is seen as required, and this would occur by changing best practice optometry or the profession’s scope of practise.”

Micheal Knipe believes the eye care community could explore ways to effectively manage this developing situation. “There’s such an investment by the community in training optometrists and ophthalmologists that it would be sensible to work together to improve the access and services to manage eye care for the benefit of the people we see,” he said.

“Collaboration that results in the use of each others’ strengths is in the community interest and the best use of scarce resources. The potential is there for a superior outcome – whether that’s in a hospital setting, a shared or a separate facility will depend on the personalities you’re talking about – but either way, there is the potential to produce the maximum benefit possible. When collaboration works it can be very powerful, I’ve seen it work very well to the patients’ and community’s benefit,” said Mr. Knipe.