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Health care reform increases ODs’ role in diabetes care
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In a perfect world, all health care providers involved in the care of patients with diabetes would take an active role in disease management, patient education, advice and counseling, along with communicating electronically for easier accessibility, Scott A. Edmonds, OD, FAAO, told Primary Care Optometry News.
“Optometrists would integrate diabetic care with eye care visits for diabetic patients with co-existing eye problems,” he said. “It would be much easier to have the optometrist manage diabetes than have the primary care physician (PCP) manage glaucoma or other chronic eye problems.”
In this medical utopia, “all providers, including optometrists, would be better reimbursed for counseling patients about prevention and for diabetes education once the diagnosis is established,” A. Paul Chous, OD, MA, FAAO, said in an interview with PCON. “Eye care providers would receive timely reports from PCPs about current laboratory findings, patient metabolic targets and treatment plans so we could assist with reinforcement of complementary messages.”
Edmonds sees such changes to health care as extremely positive.
“Health care reform has set the stage for a broader scope for optometry,” he said. “Optometry, however, must step up and embrace this opportunity.”
Growing responsibility
It is a widely held belief that health care reform will allow millions of new patients to access the health care system. Many of these patients who were previously uninsured did not receive medical care for years.
“These patients will end up in our offices, and a significant number will have diagnosed or undiagnosed diabetes,” Donald J. Siegel, OD, told PCON. “It is our responsibility to carefully assess the retinal status of those who know they have diabetes and to encourage a full physical examination for those newly insured who have not accessed the health care system for many years.”
“We, as optometrists, are in the perfect position to effect change for the at-risk population, as patients start with us when they are young, and those with refractive error see us every year,” Edmonds added.
Effects of health care reform
The Affordable Care Act requires an electronic health record that collects data and facilitates communication between ODs and primary care providers, Edmonds continued.
“We are a critical part of element 10 (child eye exams), and most of us know that, but we are also an important factor in element 9 (prevention, wellness and care for chronic health problems), and very few know that,” he said. “ODs, their patients, PCPs and health plans do not know how to operationalize that.”
“Pay-for-performance means that we have to demonstrate we are adhering to standards of care and it underscores, I am convinced, the importance of helping patients help themselves through prevention of catastrophic vision loss and associated complications,” Chous said.
“The Affordable Care Act is set up to give the patient the ability to make informed decisions regarding coverage, health care and treatment options,” Tina R. MacDonald, OD, CDE, FAAO, said in an interview. “This may translate into more patients, but especially initially, more headaches with reporting and payments.”
The current health care system is not as well integrated as it needs to be, she said, and contains many barriers to proper communication.
Only time will tell, however, how health care reform will change the landscape of diabetes care for optometry and if it will improve outcomes. MacDonald believes the changes may cause problems with the current infrastructure, but better patient management may also result.
Major cause of death
The World Health Organization estimates that in 2012, 1.5 million deaths were directly caused by diabetes. They group projects that diabetes will be the seventh leading cause of death in 2030. According to the Centers for Disease Control and Prevention, about 29 million people in the U.S. have diabetes.
Among a sample of 1,074 U.S. adults involved in the Diabetes Eye Health Survey (conducted by Everyday Health Inc. on behalf of Regeneron Pharmaceuticals), only 44% said they were knowledgeable about eye diseases that could result in vision loss.
Currently, diabetic retinopathy accounts for about 12% of new cases of blindness each year, according to the Evidence-Based Clinical Practice Guideline: Eye Care of the Patient with Diabetes Mellitus, from the American Optometric Association.
Need for education
According to Chous, the average patient without diabetes knows very little about the disease, and “most patients with diabetes know the disease can cause blindness, but little else. Most don’t know that optometrists are part of the diabetes care team and that we are specifically trained to diagnose and manage diabetic eye disease.”
Most patients are unaware of the role of optometrists in diabetes education and referrals to other diabetes care team members, he added.
Image: Siegel DJ
Optometrists need a more active role in diabetic care and should ask patients their A1C, recent fasting blood sugar and how often they test their sugar level, Edmonds said. He recommended encouraging them to always know these numbers.
“The patient should be advised to locate the numbers and get them back to the OD as soon as possible,” he said. “The doctor needs to impress upon the patient that the day-to-day control of their blood sugar is critical to maintaining vision. Many fear blindness more than death.”
“I cannot tell you how many times I’ve been told, ‘Oh, I didn’t think an optometrist would know anything about diabetes,’” MacDonald said. “And this doesn’t come just from patients, but health care professionals as well. I became a Certified Diabetes Educator, in part, because I thought it would be ‘the path of least resistance’ in communicating with my patients’ health care team and that I wouldn’t be ignored because I was an OD, not an MD.”
“We have a powerful tool in diabetic eye care that primary care providers rarely use,” Siegel said. “We can show them their retina on a monitor in the exam room and help them see the damage their diabetes is doing.”
Changes to practice
Chous stressed the need for education, communication and new technologies.
“Optometrists can improve early diagnosis by being fundamentally aware of diagnostic criteria for diabetes and prediabetes, by encouraging suspected patients to receive more than a fasting blood glucose test for timely diagnosis, by performing in-office blood glucose measurement and through the use of new technologies that assess long-term glucose status,” he said.
“I am a big fan of talking to my patients about lifestyle, including a low glycemic index, high-fiber diet, avoidance of high fructose corn syrup, good sleep habits, minimization of melatonin-suppressing blue light exposure at night and daily physical activity,” Chous continued. “The American diet is, on the whole, conducive to disease. ODs and all other health care professionals need to be conversant in nutrition, should give specific dietary advice and should counsel patients about avoidance of environmental risk.”
Chous encouraged optometrists to know the results of the Diabetes Prevention Program (DPP) and convey its key message to every patient through direct counseling and handouts, whether patients have the disease or not.
The landmark trial concluded that lifestyle changes, including 30 minutes of walking 5 days per week, can effectively delay diabetes, for the short- and long-term, in American adults with prediabetes who are at highest risk of developing type 2 diabetes, he said.
“The OD should have their staff measure vital signs at each visit as part of a routine work-up,” Edmonds added. “This is a new concept for many ODs. The doctor should then review the vitals and counsel any patients that are overweight or obese about increased health risk, including increased risk for developing type 2 diabetes.”
In many states, optometrists can do a finger stick to check blood sugar, order an A1C blood test or refer the patient at risk to their PCP for a diabetes work-up, Edmonds continued.
Most often, patients develop diabetic retinopathy, macular edema, refractive fluctuation, dry eye disease and premature cataracts. Hypertensive retinopathy, retinal vascular occlusion, ocular hypertension and glaucoma and both motor and sensory cranial neuropathies may also occur, according to Chous.
Eye muscle weakness may present as eye strain, or reading problems may be another indicator, added Edmonds.
On a positive note, Chous sees a change in diabetes management coming in the future.
“Progress will occur through individual optometrists doing a great job with diabetes patients; by state, regional and national media efforts to inform patients about optometric care of diabetes; and perhaps via a standardized diabetes certification program for optometrists,” he said.
Education for ODs
Edmonds recommends optometrists take education courses on the chronic disease issues that overtax the health system, with the big three being diabetes, hypertension and hyperlipidemia.
“All of these problems have a negative impact on our patients’ vision throughout life,” he said. “They lead to low vision and blindness and can be prevented or well managed to avoid vision problems when identified early, diagnosed early and managed aggressively.”
Chous recommended www.diabetesincontrol.com, a free resource for health care professionals. He said that in only 10 minutes one can stay up-to-date on the latest breaking news in diabetes care and research.
Because the OD’s role in element 9 of health care reform is not well understood, Edmonds recommends that optometrists pursue education and legislation and provide care that elicits acceptance from the patients of optometrists as diabetes care providers.
“We did this for glaucoma in my career, and I expect we will do this again for diabetes in the career of my two sons in optometry,” he said.
Specific challenges
As for the future, communication is a key component of diabetic care advancement, or failure.
Siegel said that health care providers have the responsibility to reinforce each other’s message: to control diet and encourage weight loss and regular exercise to give the patient the best chance of avoiding or delaying loss of eye function.
Chous sees time management as a challenge to diabetes management within health care reform.
“The estimates are that providers trying to deliver optimal diabetes care would need to be reimbursed about 20% more just to break even,” he said. “This represents a real challenge to providers and health systems alike, and I fear that prevention will increasingly be supplanted by crisis management. This also represents an opportunity to deliver premium services to patients able to pay out of pocket for that care, not an optimal outcome for a democratic society that values equal opportunity. Prevention is far less costly than treatment and better for society at large.”
“We have a shortage of resources in America to meet the need for basic primary health care services,” Edmonds said. “Optometrists, with a reasonable continuing education and certification process, could go a long way to meet that need. We are broadly distributed across the U.S., have medical privileges in all states, have excess capacity in our offices and have a health care mission in the primary care space.”
“In a perfect world, diabetic care would be 100% prevention,” Siegel said. “It would start in childhood with education about healthy eating as well as healthy food provided in the schools, and through physical education classes that are expanded, not minimized or canceled due to budgetary decisions. Any changes to the health care system that increase patient access and encourage both screenings and prevention will save costs and lives.” – by Abigail Sutton
Click here to view the sidebar: OCT assists ODs in diabetes care.
- References:
- American Optometric Association. Evidence-based Clinical Practice Guideline: Eye Care of the Patient with Diabetes Mellitus. http://www.aoa.org/optometrists/tools-and-resources/evidence-based-optometry/evidence-based-clinical-practice-guidlines/cpg-3--eye-care-of-the-patient-with-diabetes-mellitus?sso=y. Approved February 7, 2014. Accessed November 20, 2015.
- National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes Prevention Program. http://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp/Pages/default.aspx. Updated September 9, 2013. Accessed November 20, 2015.
- World Health Organization. Diabetes. http://www.who.int/mediacentre/factsheets/fs312/en/. Updated January 15, 2015. Accessed November 20, 2015.
- For more information:
- A. Paul Chous, OD, MA, FAAO, specializes in diabetes eye care and education at his private practice in Tacoma, Wash. He is the primary investigator for the Diabetes Visual Function Supplement Study and vice president of the Ocular Nutrition Society. He can be reached at: dr_chous@diabeticeyes.com
- Scott A. Edmonds, OD, FAAO, is the chief medical officer of MARCH Vision Care, the co-director of the Low Vision/Contact Lens Service at Wills Eye Hospital in Philadelphia and a member of the Primary Care Optometry News Editorial Board. He can be reached at: scott@edmondsgroup.com.
- Tina R. MacDonald, OD, CDE, FAAO, is director of diabetic optometric services and coordinator of the residency program at the Center for the Partially Sighted in Culver City, Calif. She can be reached at: tmacdonald@low-vision.org.
- Donald J. Siegel, OD, practices in Sun City West, Ariz. He can be reached at: scweyecare@gmail.com.
Disclosures: Chous has been a consultant to Bausch + Lomb, Freedom Meditech, LifeMed Media, Regeneron, VSP and ZeaVision. Edmonds is a consultant for Freedom Meditec, March Vision and OcuHub. MacDonald reports no relevant financial disclosures. Siegel is a consultant for CenterVue.