NBEO study shows refractive error, systemic conditions as most common diagnoses

A study commissioned by the National Board of Examiners in Optometry (NBEO) has found that refractive error diagnosis and ocular disease management are integral parts of today’s optometric practice. The NBEO will use the results as a foundation to restructure the board exams.

The study, “Profiling the Contemporary General Clinical Practice of Doctors of Optometry,” sought to glean information about the “typical” day in general optometric practice to update relevant content for the NBEO exam.

“The global theme of this study was important, not just for the national board, but also for the profession,” said Linda Casser, OD, FAAO, a 7-year member of the NBEO Board of Directors, in an interview. “The study helps us define where we are and will help us look to the future.”

According to Steven H. Eyler, OD, NBEO president, the NBEO’s primary mission is to develop, administer and score examinations as they relate to the entry-level competency of the optometrist. “Philosophically, the national board has been a forward-thinking organization. We have always embraced new technologies and new testing techniques,” he told Primary Care Optometry News. “The scope of optometric practice has broadened during the past 30 years, and schools and colleges have continued to train and educate their students to develop the corresponding competencies.”

Dr. Casser, associate dean for academic programs at Pacific College University College of Optometry and a Primary Care Optometry News Editorial Board member, added, “We certainly want to make sure we’re responsive to the profession and that we’re testing elements that are germane to the profession,” she said. “The real driving element here is anticipated change in the content outline of the exam.”

Study design

Dr. Casser said the NBEO issued a request for proposals for the study. “After considering several, we selected Mort Soroka, PhD, from the State University of New York,” she said. “He designed the study utilizing excellent scientific methodology.”

The study culled data from 11,012 patient encounters in rural, urban and suburban environments. “It was conducted with a high level of statistical accuracy to be representative of the entire profession,” she said.

The study was designed to reflect “2 days in the life of optometrists,” Dr. Casser said. Researchers gathered data from 480 practitioners who chronicled their patients over a 2-day period.

A diverse population of optometrists was included in the study, added Dr. Eyler. “It was representative of profession-wide practitioner demographics, geographic distribution, practice setting (for example, hospital-based, VA, private practice and commercial) and scope,” he said. “It did not focus on isolated segments.”

Findings: optometry is primary care profession

Dr. Soroka said a comprehensive review of the data collected during the study provides insights into the most common diagnostic and therapeutic procedures performed, medications prescribed and referrals made in general optometric practices in the United States.

Refractive error was the most prevalent diagnostic category, reflective of the ocular problems found in the general population, Dr. Soroka said. “Although optometry has its roots as a refractive profession, its scope of practice has expanded during the past several decades. The high number of refractive diagnoses was predictable,” he told Primary Care Optometry News. “Somewhat less predictable but logical is that systemic conditions were the second largest diagnostic category.”

He said that given the undeniable link between eye care and systemic conditions, this outcome supports optometry’s role as a primary care profession.

“This information comes from the case history and reveals that optometrists are encountering these conditions in their patients and investigating ocular sequelae,” he said. “Recent years have seen an increase in the number of hours devoted to systemic disease in optometric curricula, and this finding suggests that this knowledge is being put to good use in the field.”

According to Dr. Soroka, the two most common diagnostic categories after refractive error and systemic diseases were conditions of the crystalline lens and of the cornea. “In fact, 20% of all eye examinations in those between the ages of 60 and 64 were ocular disease-related visits,” he said. “Among patients 65 and older, more than 30% of all visits were for ocular disease-related reasons. The treatment of ocular disease by optometrists was found to be extensive.”

Dr. Soroka said the study found that 20% of patients received a prescribed medication and 5% of patients in the study were treated for glaucoma. “Optometry today is a broad, multifaceted primary health care profession,” he said. “Therefore, it must provide within its educational training a strong base for the diagnosis and treatment of ocular disease on a primary care level, including triage and referral as appropriate for secondary and tertiary eye care.”

Areas for expansion

Dr. Soroka said while some aspects of his findings were expected, others were not. “For example, it was surprising that relatively few children younger than 10 years were seen in optometric offices,” he said. “The potential for expanding care to meet the needs of younger children should be considered.”

Vision training and low vision services also were not seen with the frequency that might have been expected, Dr. Soroka said. “Vision training was seldom performed in general practices, and few low vision services were rendered,” he said. “As a primary care provider, one would think that more of these services should be provided.”

Dr. Soroka emphasized, however, that more specialized optometric practices were not represented in the study.

“This study was limited to providers who classified themselves as general practitioners; optometrists who stated that they specialized in any area were excluded,” he said. “Therefore, diagnostic procedures or treatment services rarely reported in the study, such as low vision or vision therapy, should be interpreted with this in mind.”

Inter- and intraprofessional referrals

Also studied was the occurrence of referrals, both to other optometrists and physicians. “Although this study specifically targeted optometrists in non-specialty settings, referrals to other optometrists (for low vision or vision therapy, for example) were exceedingly rare,” he said. “Patients were referred to other practitioners when necessary, although interestingly enough, not to other optometrists.”

Dr. Soroka said, based on these findings, he recommends that the optometric curriculum reinforce intraprofessional referrals. “No one practitioner can or should be expected to manage every patient who comes through his or her door,” he said. “So already knowing how to deal with these patients by referring them to, or comanaging them, with another practitioner who may be in the same profession is both appropriate and desirable.”

He said although 12% of all patients were referred to an ophthalmologist for further care, other types of referrals were infrequent. “Referrals to a primary care physician, lab or imaging or to a surgeon for refractive surgery accounted for only 8% of all referrals,” he said. “Overall, referrals for refractive surgery represented fewer than 1% of all patients seen.”

The “typical” optometrist: a changing role

Dr. Soroka said that the “typical” optometrist that emerged from the study data is significantly different from the optometrist of the past. “Optometrists are no longer providing routine eye examinations,” he said. “Ocular disease treatment is an integral part of the optometrist’s practice, and patients seeking medical treatment for ocular diseases are coming in for optometric care.

“Prescribing topical ocular medications, both legend and over-the-counter,” Dr. Soroka continued, “was the primary treatment option offered by optometrists to their patients in this study.”

He said the passage of topical ocular therapeutic laws in all 50 states may have had an impact on this tendency. “Since topical ocular therapeutic laws have been passed in all 50 states, optometrists are indeed utilizing their prescribing privileges in managing many conditions that can be treated on a primary care level,” he said.

The most common medications prescribed were for glaucoma, Dr. Soroka said, with antibiotics, anti-inflammatory and anti-allergy drops making up the remainder, in descending frequency.

“Next in frequency in the treatment categories came prescribing and/or fitting spectacles, followed by fitting or dispensing contact lenses,” he said.

Members of the health care team

Dr. Soroka said today’s optometrist is no longer defined as a solo practitioner rendering routine eye care. “Optometrists are found in many settings and practice modes,” he said.

According to the study, more than 11% of all providers practiced with an ophthalmologist, while almost 10% practiced within an educational institution, Public Health Service, the Veterans Administration or an HMO.

“Today’s optometrist is more integrated within the health delivery system than in the past,” he said. “As a member of the health care team, the responsibilities and expectations of the optometrist have increased tremendously.”

Condition-based content outline

Jack Terry, OD, PhD, executive director of the NBEO, said the current national board exam consists of three parts. Part I, Basic Science, includes 435 multiple-choice items. Basic Science “assesses a candidate’s fundamental knowledge and understanding of the scientific principles upon which optometric practice is based.”

Part II, Clinical Science, also consists of 435 multiple-choice items. Clinical Science “assesses a candidate’s application of the knowledge of Basic Science to the prevention, diagnosis, treatment and management of clinical conditions that relate to optometric practice.” The emphasis in this exam is on the candidate’s ability to apply knowledge.

Part III, Patient Care, evaluates the candidate’s ability to examine an actual patient, to assess clinical data and to make patient care decisions. These abilities are assessed via the hands-on Clinical Skills exam and the case-based Patient Assessment and Management (PAM) exam.

Dr. Terry said the anticipated new NBEO exam content outline will be developed from the study and will emphasize clinical conditions. “We view these outlines to be conditions-based. We believe they will permeate all three parts of the exam,” he said. “Consider diabetes mellitus as an example. Diabetes might be a major reference point on the new content outline, and in each of the three parts, different issues related to diabetes will be tested.”

He said Part I would, for example, test on the pathophysiology of diabetes. In Part II, candidates would be tested on the clinical presentation of diabetes, including diagnosis, treatment and follow-up, and in Part III, the test would assess the techniques that candidates use to examine a patient with diabetes.

“The need to establish an integrated conditions-based content outline as the basis for the restructured examinations is what necessitated the Domain of Conditions Study,” Dr. Terry said.

Impact of the study

Dr. Eyler said the next step for the NBEO is to determine how Dr. Soroka’s data will be used for the exam restructuring. He added that the results of this study could have larger implications for the future of the profession.

“This is the best study that has been done in the past 10 or 12 years on what optometrists are doing and what kinds of patients they are treating,” he said. “It’s more encompassing than looking at the prescribing of glasses or contact lenses. It includes data on the frequency of writing glaucoma prescriptions and techniques such as foreign body removal.”

Dr. Eyler said that the new examination format will be introduced in 2009. “Between now and 2009, we certainly have to prepare the students, the schools and colleges and the profession for this change,” he said.

He said the new examination format will include a combination of current Parts I and II into a more clinically relevant exam. “The new Part II will be an expanded version of the current PAM examination, which is a section of Part III, and the new Part III will be an expanded clinical skills examination,” he said. “For example, this exam may include injections and more advanced techniques.”

Dr. Terry said that the profession has expanded. “We have held onto our traditional roots, yet it is clear that the profession is comfortable and proficient in providing broader patient care services related to both ocular and systemic diseases,” he said. “This is a win-win for the patients that our profession serves.”

For Your Information:

• Linda Casser, OD, FAAO, is a member of the NBEO Board of Directors, associate dean for academic programs at Pacific University College of Optometry and a member of the Primary Care Optometry News Editorial Board. In January, Dr. Casser will join the NBEO staff as director of clinical examinations. She can be reached at 2043 College Way, Forest Grove, OR 97116; (503) 352-2766; e-mail: casserl@pacificu.edu.
• Steven H. Eyler, OD, is president of the National Board of Examiners in Optometry. He can be reached at 6604-East W.T. Harris, Charlotte, NC 28215; (704) 536-6042; e-mail: seylerod@ix.netcom.com.
• Mort Soroka, PhD, is director of the Center for Vision Care Policy at the State University of New York. He can be reached at 33 West 42nd St., New York, NY 10036; (212) 938-4174; e-mail: msoroka@sunyopt.edu.
• Jack Terry, OD, PhD, is executive director of the NBEO. He can be reached at 200 South College St., Suite 1920, Charlotte, NC 28202; (704) 332-9565; e-mail: terry@optometry.org.