The Glaucoma Specialist’s Extended Care Network

A patient-centered model for the future.

By Sayoko E. Moroi, MD, PhD; Paula Anne Newman-Casey, MD, MS; Sarah Dougherty Wood, OD, MS; and Cheryl Khanna, MD

The Patient Protection and Affordable Care Act,1,2 an aging US population,3 the projected shortage of ophthalmologists,4 Accountable Care Organizations,5 and greater accountability are all affecting the delivery of eye care. Other influential changes beyond the scope of this article are meaningful-use incentives,6 electronic health records,7 and alterations in the health insurance market.8,9 Together, these forces pose many challenges, expose gaps in the traditional patient care model, and raise the question of how to meet the needs of patients and providers.

This article characterizes the gap between the aging population’s need for eye care and the ability of traditional models to provide that care based on current workforce projections. One potential solution is a shift to a team-based model of care. This article does not discuss referral patterns of glaucoma patients from vision care providers not a part of the care team.

THE GAP BETWEEN THE AGING POPULATION AND WORKFORCE PROJECTIONS

Three factors will affect how glaucoma care is provided in the future. The first is an increase in the number of patients with the disease.3 The number of Americans older than 75 years of age will more than double between 2010 and 2050.10 The prevalence of glaucoma is projected to increase from 1.86% among those older than 40 to 10.3% among those older than 65.12,13

The second factor is the increased access to health care brought about by the Affordable Care Act.1,2 It is estimated that, of the 49 million previously uninsured people, 11 million have become insured and will have access to specialty care. This shift means that the newly insured beneficiaries will have improved access to specialty care, which will increase the number of patients diagnosed with glaucoma who require care.

The third factor is the projected change in the eye care workforce.14,15 According to the Association of American Medical College’s Center for Workforce Studies, there are 18,317 active ophthalmologists.4 Nearly half (47.5%) of US ophthalmologists are over the age of 55 and will likely retire by 2020.4 Younger ophthalmologists increasingly choose an abbreviated work week compared to those who are retiring.16 Because the number of ophthalmology training slots has not changed significantly during the past decade, the number of ophthalmologists is not expected to rise in the near future.14 Meanwhile, according to the US Bureau of Labor Statistics, the number of employed optometrists was 33,100 in 2012 and is projected to increase by 24% to 41,200 in 2022.17

TEAM-BASED GLAUCOMA CARE MODELS

New vision care team models for managing chronic eye diseases such as glaucoma are required to meet the needs of patients and providers. The authors believe that implementing an extended glaucoma care model within an institution or community necessitates a multidisciplinary approach such as partnering with optometrists.18-20 The glaucoma team concept was introduced in 1990 by The Optical Audit Committee in Great Britain.21 This approach has been adopted in Australia,22 Canada,23 and more recently, the United States.19,20

Figure. The Mayo Clinic Care Model for glaucoma patients provides a standardized approach to glaucoma assessment, treatment, and defining disease progression to ensure consistent, high-quality care. The team consists of a steady group of optometrists and ophthalmologists who share the care of a glaucoma patient. The glaucoma fellowship-trained ophthalmologist establishes the diagnosis and treatment plan. Patients with stable disease are seen by the ophthalmologist at least every 2 years. (Abbreviation: Dx, diagnosis.)

A five-member team was initiated in 2007 at the Mayo Clinic (Figure). Two glaucoma fellowship-trained ophthalmologists, one comprehensive ophthalmologist, and two optometrists function within an organized system with checks and balances among providers. This model has eight components:

(1) standardized glaucoma testing

(2) shared electronic medical records

(3) a treatment plan defined by consultation with the glaucoma specialist

(4) a standardized treatment algorithm

(5) a standardized definition of glaucomatous progression

(6) optometrists observing patients with stable disease

(7) a mandatory consultation with the specialist every 2 years for patients with stable disease

(8) timely access to the specialist for patients with unstable glaucoma

In Dr. Khanna’s experience, this approach improves patients’ access to the glaucoma service and prioritizes glaucoma specialty care for those with unstable or advanced disease. The Mayo glaucoma team members demonstrated higher adherence to the American Academy of Ophthalmology’s guidelines than single-provider care by optometrists or comprehensive ophthalmologists.24 A cost-effectiveness study is in progress to investigate the potential cost benefit of the Mayo Clinic team model.

FUTURE CONSIDERATIONS

Preventing glaucoma-related blindness demands quality care for a growing number of patients. A vision care team of glaucoma specialists and optometrists is one possible solution to meeting this challenge. This model could be enhanced by engaging other providers (eg, primary care physicians, pharmacists, ophthalmic support staff ) to meet the unique needs of each patient. This team approach coordinates patients’ care and improves their access to glaucoma specialists. Potential limitations include poor communication among team members, inconsistent use of the algorithm, and fragmented care. The model will evolve as data are generated to analyze cost-effectiveness and patients’ outcomes. n

1. Beland D, Rocco P, Waddan A. Polarized stakeholders and institutional vulnerabilities: the enduring politics of the Patient Protection and Affordable Care Act. Clin Ther. 2015;37(4):720-726.

2. Glied SA, Miller EA. Economics and health reform: academic research and public policy [published online ahead of print April 8, 2015]. Med Care Res Rev. pii:1077558715579866.

3. Chou CF, Cotch MF, Vitale S, et al. Age-related eye diseases and visual impairment among U.S. adults. Am J Prev Med. 2013;45(1):29-35.

4. Center for Workforce Studies. Physician Specialty Data Book 2014. Association of American Medical Colleges. http://bit.ly/1KHt5t9. Accessed July 6, 2015.

5. Nyweide DJ, Lee W, Cuerdon TT, et al. Association of Pioneer Accountable Care Organizations vs traditional Medicare fee for service with spending, utilization, and patient experience. JAMA. 2015;313(21):2152-2161.

6. Neuner J, Fedders M, Caravella M, et al. Meaningful use and the patient portal: patient enrollment, use, and satisfaction with patient portals at a later-adopting center. Am J Med Qual. 2015;30(2):105-113.

7. Kim YA, Jang SY, Ahn M, et al. SMART Careplan System for Continuum of Care. Healthc Inform Res. 2015;21(1):56-60.

8. Centers for Medicare & Medicaid Services, HHS. Patient Protection and Affordable Care Act; HHS notice of benefit and payment parameters for 2016. Final rule. Fed Regist. 2015;80(39):10749-10877.

9. McCue MJ, Hall MA. What’s behind health insurance rate increases? An examination of what insurers reported to the federal government in 2013-2014. Issue Brief (Commonw Fund). 2015;3:1-5.

10. 2014 national population projections. United States Census Bureau. http://1.usa.gov/1KSoEvM. Accessed July 9, 2015.

11. Friedman DS, Wolfs RC, O’Colmain BJ, et al. Prevalence of open-angle glaucoma among adults in the United States. Arch Ophthalmol. 2004;122(4):532-538.

12. Klein R, Klein BE. The prevalence of age-related eye diseases and visual impairment in aging: current estimates. Invest Ophthalmol Vis Sci. 2013;54(14):ORSF5-ORSF13.

13. Ryskulova A, Turczyn K, Makuc DM, et al. Self-reported age-related eye diseases and visual impairment in the United States: results of the 2002 national health interview survey. Am J Public Health. 2008;98(3):454-461.

14. Lee PP, Hoskins HD Jr, Parke DW 3rd. Access to care: eye care provider workforce considerations in 2020. Arch Ophthalmol. 2007;125(3):406-410.

15. Mets MB, Rich WL 3rd, Lee P, et al. The ophthalmic practice of the future. Arch Ophthalmol. 2012;130(9):1195-1198.

16. Mets MB, Brown A, Doan AP, et al. The ophthalmologist of the future. Arch Ophthalmol. 2012;130(9):1190-1194.

17. Bureau of Labor Statistics. Occupational Outlook Handbook. Optometrists. United States Department of Labor. http://www.bls.gov/ooh/healthcare/optometrists.htm. Published January 8, 2014. Accessed July 6, 2015.

18. Pikey KP. Creating an optometric referral network for your practice. Glaucoma Today. January/February 2012;10(1):43-44.

19. Fingeret M. The optometrist’s role in glaucoma care. Glaucoma Today. May/June 2014;12(3):30,41.

20. Khatana AK. Does the integrated MD-OD model represent the future? Glaucoma Today. May/June 2014;12(3):32-33.

21. Morley AM, Murdoch I. The future of glaucoma clinics. Br J Ophthalmol. 2006;90(5):640-645.

22. O’Connor PM, Harper CA, Brunton CL, et al. Shared care for chronic eye diseases: perspectives of ophthalmologists, optometrists and patients. Med J Aust. 2012;196(10):646-650.

23. Canadian Glaucoma Society Committee on Interprofessional Collaboration in Glaucoma C. Model of interprofessional collaboration in the care of glaucoma patients and glaucoma suspects. Can J Ophthalmol. 2011;46(6 suppl):S1-21.

24. Winkler N, Damento G, Hodge D, et al. Analysis of a novel physician-led team-based care model for the treatment of glaucoma. Poster presented at: American Glaucoma Society 25th Annual Meeting; February 28, 2015; Coronado Island, CA.

Cheryl Khanna, MD
• Assistant professor in the Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
• (507) 284-2787; khanna.cheryl@mayo.edu

Sayoko E. Moroi, MD, PhD
• Professor, Glaucoma Service chief, and glaucoma fellowship director for the Department of Ophthalmology and Visual Sciences, University of Michigan, in Ann Arbor
• (734) 763-3732; smoroi@med.umich.edu

Paula Anne Newman-Casey, MD, MS
• Assistant professor in the Department of Ophthalmology and Visual Sciences, University of Michigan, in Ann Arbor
• (734) 936-9503; panewman@med.umich.edu

Sarah Dougherty Wood, OD, MS
• Clinical instructor in the Department of Ophthalmology and Visual Sciences, University of Michigan, in Ann Arbor
• (734) 615-2479; skwood@med.umich.edu