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TPA privileges, amplifications help ODs provide patients with complete care
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The 1990s were a time of therapeutic change for optometrists across the country. Many states saw approval of therapeutic pharmaceutical agent (TPA) legislation or amplification of current laws. While the first TPA legislation was enacted in West Virginia in 1976, ODs in several states received their privileges only within the last few years and, more frequently, many have seen amplifications that include orals, glaucoma medications and, in one case, lasers.
Primary Care Optometry News interviewed representatives from several states who most recently acquired TPA privileges or achieved amplifications to their laws. Massachusetts was the last state in the union to acquire TPA privileges on July 31, 1997, and Washington, D.C., finally received privileges April 22, 1998.
Mass. ODs prescribe for allergy, infections
John Mooney, OD, president of the Massachusetts Society of Optometrists Inc., said that ODs in the state most often prescribe topical medications for common ophthalmic conditions such as allergic or bacterial infections. He said that he sees such eye conditions in his office on a relatively frequent basis.
“I would say it’s nearly every day,” said Dr. Mooney. “Sometimes, you’ll get a run of 3 or 4 patients in a day.” One benefit of being able to prescribe for a trauma to the eye, for instance, is that patients need not spend unnecessary hours in an emergency room, he added.
“It takes a little traffic away from the emergency room, which is nice,” Dr. Mooney said. “It could save the patient 2 or 3 hours there, and it’s a little more comforting to see somebody who knows your eye history, too.”
Massachusetts is filing a bill this month for amplification for both glaucoma and orals, said Dr. Mooney. “There are 45 states now that have glaucoma capabilities, so we’re hoping to be the 46th instead of the 50th,” he laughed.
Approximately 80% of the practitioners in the state who have received their certification since the law’s passage are utilizing their privileges, Dr. Mooney said.
Broad scope in D.C.
ODs in Washington, D.C., however, have a greater scope of practice – their TPA law boasts all privileges except for injections and surgery, said association vice-president Stephen L. Glasser, OD, FAAO. Dr. Glasser said that prescribing privileges have allowed him greater freedom when treating his patients, and the impact goes beyond the financial aspect. “It was incredibly frustrating when patients would have something as simple as seasonal allergies affecting their eyes and I was unable to give them anything but over-the-counter medications that had minimal results,” he said. “The ability to prescribe also eliminated confusion on the patient’s part concerning who they should see when they were having some sort of ocular problem.
“I would explain that we could render every type of eye care, but we do not do surgery,” he continued. “So we’ve tried to educate our patients, both in-office as well as by newsletters and mailings, to allow them to understand that we now have this ability to provide complete care, and they now seek us first before going anywhere else.”
Dr. Glasser said Washington, D.C., is unique because ophthalmologists outnumber optometrists by a 3-to-2 margin. “So the fact that we have this ability also allows us to raise our own prestige, not only among our patients, but among other professionals as well,” he said. “Rather than referring patients with ocular problems to the general ophthalmologist or general practitioner or even to an emergency room, other types of doctors will send the patients directly to us.”
Dr. Glasser said that the “vast majority” of cases requiring prescriptions are contact lens related or, particularly, allergy related. Topical medications head the list of commonly prescribed drugs in Washington. Since passage of the law is so recent, he expects the number of ODs utilizing these privileges to increase.
“There’s still a bit of the fear factor among practitioners because we are getting our feet wet,” he said. “I think as time goes on, treatment of more complex patients – whether they be internal eye infections or ongoing glaucoma treatment – will become much more prominent as the practitioners feel more comfortable dealing with them. I’m very comfortable with topicals and I feel comfortable with orals as needed, but with more complex infections such as central corneal ulcers, I usually refer them out. I think with time that will occur less and less.”
Orals amplification in Kansas, Arizona
The Kansas legislation was amplified to include oral medications in June of 1999. Gary L. Beaver, OD, president of the Kansas Optometric Association, said that like many other practitioners, the orals he most often prescribes are oral antibiotics, antivirals, allergy medications or analgesics. He also encounters quite a few workman’s compensation and injury-related cases, he said.
“We deal with all types of conditions, whether it’s more extensive ocular preseptal cellulitis, or something less involved such as severe internal hordeolum,” he said. “I see a few patients with viral conditions, such as herpes zoster.”
Dr. Beaver said that his practice can write several prescriptions for oral medications in a few days and then go the same period of time without writing any. But he feels the frequency will increase. “The more patients know you are a complete primary care outlet, the more they’ll seek your care,” he said.
In Arizona, the orals amplification law was passed July 30, 1999, but optometrists there have not yet had the opportunity to prescribe those medications.
Upon completing the rules writing process, practitioners there took a 12-hour course followed by a test the next weekend, said Marc R. Bloomenstein, OD, FAAO, immediate past president of the Arizona Optometric Association.
The state’s orals amplification includes oral antibiotics classified as tetracycline and its derivatives, penicillin and its derivatives, erythromycin, azithromycin and clarithromycin, except to those younger than 6 years. Antihistamines, such as cetirizine, loratadine and fexofenadine, may be prescribed for no more than 7 days for a patient, after such time the optometrist must consult with a primary care physician about a referral.
Nonsteroidal anti-inflammatory drugs may be prescribed under certain conditions, and Schedule III controlled substances may be prescribed, dispensed and administered by a practitioner who is a certified licensee.
Nebraska gets glaucoma privileges
The Nebraska TPA law was amplified to include glaucoma on Feb. 24, 1999. Joseph L. Shetler, OD, president of the Nebraska Optometric Association, said their newly amplified privileges have boosted comanagement cases in his two-partner practice since there is no resident ophthalmologist. “It certainly has helped us comanage cases where we need to modify the medications of patients who were previously managed by the ophthalmologist,” he said. “Then, of course, we are successfully managing new cases ourselves.”
Dr. Shetler said that he typically prescribes Timoptic (timolol maleate, Merck) as first-line therapy for glaucoma, but is using Xalatan (latanoprost, Pharmacia & Upjohn) more frequently, as well as Alphagan (brimonidine, Allergan). “We are limiting our use of pilocarpine to those who have used it well in the past because of some of the side effects to the small pupil,” he said.
He said he has seen an increase in the number of patients as part of his glaucoma practice since the amplification, and expects his glaucoma prescribing to increase with time. “The thing about glaucoma patients is that they are your patients for life,” he said. “So as you add them to your practice, you begin to see them more frequently. Even though you may not change the medication for quite awhile if it’s maintaining good control, you’ll see that patient much more frequently than those coming for more routine care.”
The addition of glaucoma may aid optometrists in gaining access in other areas as well, he noted. “I think it’s also a benefit to practitioners who are applying for hospital privileges,” Dr. Shetler said. “It’s just another avenue of care they can provide.”
For Your Information:
- John Mooney, OD, president of the Massachusetts Society of Optometrists, Inc., may be reached at Leominster Optometric Assoc., 292 North Main St., Willingminster, MA 05413; (978) 537-5546; fax: (978) 537-9998.
- Stephen L. Glasser, OD, FAAO, vice-president of the Optometric Society of the District of Columbia, may be reached at 1050 17th St., Suite 200, Washington, DC 20036; (202) 223-3530; fax: (202) 223-9748.
- Gary L. Beaver, OD, president of the Kansas Optometric Association, may be reached at 300 West Laurel, PO Box 47, Independence, KS 67301; (316) 331-2112; fax: (316) 331-2147.
- Marc R. Bloomenstein, OD, FAAO, immediate past president of the Arizona Optometric Association, may be reached at 4800 N. 22nd St., Phoenix, AZ 85016; (602) 955-1000; fax: (602) 508-4700; e-mail: marc@bdpec.com.
- Joseph L. Shetler, OD, president of the Nebraska Optometric Association, may be reached at Gordon Vision Center, 106 North Main, Gordon, NE 69343; (308) 282-0820; fax: (308) 282-0833. None of these doctors has a direct financial interest in the products mentioned in this article, and none is a paid consultant for any companies mentioned.