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TPA laws are in place, but most ODs are not yet putting the drugs to use

Issue: January 1997

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--- Paula R. Newsome, OD

CHARLOTTE, N.C. — Paula R. Newsome, OD, writes an average of seven prescriptions a week and finds it hard to believe that many of her colleagues are still hesitant to put pen to prescription pad.

"I've never been unable to prescribe," said Newsome, in private practice here. "I don't know what life would be like without that ability. I used to think a lot of optometrists were writing prescriptions, but when I lecture and listen to their questions, I know many of them are not. That shocks me."

Although Newsome enjoys some of the country's oldest therapeutic pharmaceutical agent (TPA) privileges — in 1977 North Carolina was the second state to approve TPA legislation — almost half of the profession acquired TPA legislation only a few years ago.

In all, 17 states have received therapeutic privileges for optometrists since 1993. The total number of licensed optometrists in these states is approximately 16,500, according to data from state optometric licensing boards compiled by the International Associaton of Board of Examiners in Optometry. There are approximately 34,000 optometrists in the United States.

These privileges also vary from one state to another; for example, 11 states have TPA privileges but do not allow optometrists to treat glaucoma.

Although optometry appears to have completed the last lap in the race to use therapeutics — waiting only for Massachusetts and Washington, D.C., to pass TPA laws — the percentage of ophthalmic prescriptions written by ODs last year was less than 5%, according to various prescription tracking services.

It has been estimated that the bulk of ophthalmic prescriptions — 60% — are written by ophthalmologists, and the remaining prescriptions are written by pediatricians, internists, allergists, immunologists, general practitioners and doctors in hospital settings.

Rob Houdek, OD, director of optometric services for Ciba Vision Ophthalmics, Duluth, Ga., believes optometrists will become a major part of ophthalmic prescription writing, but not as quickly as some first thought.

"We anticipated that the growth would be more rapid than it has been," Houdek said. "The volume of optometrists is large, but if you back a third of that out to represent those who just recently got their TPA laws, that affects the numbers."

Houdek also credits this slow growth to the cautious nature of the profession. "We are glad to have our privileges, but we're going to be very judicious about utilizing those privileges," he said. "This is a maturation process for the profession."

Confidence comes with experience

The most common prescription Newsome writes is for Livostin (levocabastine HCl, Ciba Vision), followed by Xalatan (latanoprost, Pharmacia & Upjohn) and Acular (ketorolac tromethamine, Allergan). She explains that her confidence in writing prescriptions for newer drugs came with time and experience.

"Two years ago I wrote the most prescriptions for Blephamide (sulfaceta mide-prednisolone acetate, Allergan), but now I try newer medications because I want to see what the efficacy is and how they work for patients," Newsome said. "As soon as I've read as much as I can about a new drug and feel comfortable with what I've read, I will prescribe it."

In addition to prescribing glaucoma medication, Newsome treats a lot of red eyes, anterior uveitis and nonspecific conjunctivitis. She takes her experience and message on the road when she lectures, encouraging optometrists to prescribe.

"There are financial and personal rewards to prescribing," Newsome said. "I tell optometrists they should prescribe for four reasons:

1. They're losing revenue if they don't;
2. They could potentially lose a patient to another doctor;
3. They're not fully using the skills they have; and
4. They've got to be more willing to change and take on the challenge of using everything in their armamentarium."

Newsome advises her colleagues to meet with one another to clear the first hurdle in prescription writing. "Meet with a prescribing colleague and talk about the drugs until you feel comfortable. If you want that OD there while you are examining the patient, call them and ask them to come over," she said. "Once you prescribe one or two times, you're fine."

Houdek is concerned that if optometrists do not take advantage of TPA privileges the profession could dampen recent legislative gains. "If we don't use the privileges, we could weaken our role as primary eye care providers and possibly lose patients to the general practitioner," he said. "If we don't keep eye care decisions in the eye care community, it's a loss for the profession and for patients."

Ease into prescribing slowly

--- Jimmy D. Bartlett, OD

Jimmy D. Bartlett, OD, professor of optometry at the University of Alabama at Birmingham, said there are several ways optometrists can ease into prescribing. They could, for example, start with "something that can't go terribly wrong, such as staphylococcal blepharitis," he said. "That's more of an annoyance to patients than a serious health issue."

Allergic diseases are straightforward, too, Bartlett said, and a good place for optometrists to begin is treating self-limiting conditions with known therapies. "Get over that hurdle," he said, "and then move on to red eye patients with bacterial conjunctivitis where the cornea is clear. Then you keep going up the ladder one step at a time."

Bartlett compares optometry's foray into therapeutics with its journey into diagnostics in the mid-1970s. "With diagnostics 20 years ago, the big fear was that you were going to cause angle closure or cardiovascular accidents," he said. "We saw that doesn't happen, and now the majority of optometrists use diagnostic agents and dilate pupils and feel comfortable. We'll have to go through the same steps for therapeutics."

Education keeps pace

In addition to optometrists themselves keeping pace with therapeutic changes, schools of optometry have been able to stay ahead of the curve, said Bartlett, often with the help of professional organizations such as the American Optometric Association (AOA).

Nearly 25 years ago, Bartlett said, the AOA decided that optometry's path should be primary eye care although many of the educators did not know exactly what that meant. "We thought we'd start using the term 'primary eye care' to carve out what optometry ought to be in this perceived new arena of health care delivery in the 1970s, 1980s and beyond," he said. "Both political optometry and academic optometry bought into the idea that our niche is primary eye care, and not just the disease aspect."

When West Virginia broke the TPA barrier in 1976 and health maintenance organizations began shifting health care from private payers to third-party payers, optometric education again shifted. "We began to see that optometrists were truly going to have to be primary eye care providers and provide therapeutic care independent of ophthalmology or medicine," Bartlett said.

In the early 1980s many schools strengthened their biomedical science courses, adding toxicology and physical diagnosis. "Residents coming out now have a better appreciation for the eye as a component of the entire body," Bartlett said, "and about working with other physicians and comanaging patients for a variety of diseases."

Today's graduates also have more practical hands-on and clinical experience than their predecessors, said Bartlett, especially in prescription writing. "Students feel very comfortable writing prescriptions when they finish their 4 years," he said. "Doctors who do residencies write them every day."

TPA approval timeline*

* Optometrists do not have TPA privileges in Massachusetts or Washington, D.C.

For Your Information:

• Paula R. Newsome, OD, is in practice at Apogee Vision Care, 1812 Lyndhurst Ave., Charlotte, NC 28203; (704) 375-3935.
• Jimmy D. Bartlett, OD, is a professor of optometry and pharmacology at the University of Alabama School of Medicine, 1716 University Blvd., Birmingham, AL 35294-0010; (205) 934-5161.
• The International Association of Board of Examiners in Optometry is located at 4340 East West Hwy., Suite 401, Bethesda, MD 20814; (301) 718-6506.