21st-century optometric care for the 21st-century pandemic
ILLUSTRATIONS BY BRUCE MORSER
Thirty years later, Roger Phelps, O.D., CDE, retired, still recalls, with a sardonic huff, the standard diabetes eye care lecture he’d heard time and time again.
“‘Don’t eat chocolate cake—but you’re going to go blind anyway,’” says the Ojai, California, practitioner. “It’s got to be better than that.” As an individual with type 1 diabetes, Dr. Phelps comes from a place of sincerity when addressing diabetes’ toll on America; he’s lost one brother to type 1 diabetes while another was diagnosed with diabetes at 40, as was his mother at 60. In seeking his own treatment, Dr. Phelps knows what works and uses that knowledge not only in his patient care, but also lecturing and contributing for organizations such as the American Diabetes Association (ADA) and American Association of Diabetes Educators.
At 70, Dr. Phelps prides himself on his “perfect” vision—a living, breathing testament to how conscientious self-care can make a difference in the lives of patients with diabetes. And that’s the point: More show, less tell. Why? Because there’s a disconnect between patients and their doctors’ orders, Dr. Phelps says. Plain and simple.
“You have to show some people that fundus picture, show them how their diabetes is causing this and that, and then ask them how we can help get them under better management,” Dr. Phelps says.
“Patients with diabetes listen to eye doctors when they’re being told they’re risking their vision, or if they make a change now, then they can prevent vision loss and other diabetes complications—it’s a big motivational thing, more so than just a nurse consulting in an office.”
That’s not to say well-meaning patient education and dialogue is less effective than a photograph; quite the contrary. But “more show, less tell” implies going one step beyond a canned conversation. It means taking meaningful action.
Today, 30.3 million Americans have diabetes while an additional 84.1 million are at such severe risk of developing the condition, they’re defined as having prediabetes. That’s more than a 275% increase in diabetes diagnoses since those chocolate cake lectures of the ’80s. Presently, almost 1 in 4 American health care dollars are spent on people with diabetes.
If ever there was a time for action, it’s now.
“Optometry needs to know proper diabetes management so when they detect type 2 diabetes or the fact that a patient has gone from one microaneurysm to moderate background, we can encourage action right then,” Dr. Phelps says. “We need to encourage the next step.”
Where optometry has been
Optometry’s medical contribution to the diabetes pandemic is one that closely mirrors the disease’s progression over the past 30 years. Each passing decade sees diabetes prevalence increase while optometry’s scope of practice and role do the same.
Traditionally, optometry has acted in a triage capacity, detecting the vascular changes associated with diabetes and transitioning that patient into more comprehensive or advanced care. Consider the influential 1987 study, “Detection of diabetic retinopathy by optometrists,” by Robert Kleinstein, O.D., Ph.D., and Jeffrey Roseman, M.D., Ph.D., et al., which showed that doctors of optometry correctly diagnosed the type and degree of diabetic retinopathy in fundus examinations, and at a higher rate than general ophthalmologists. Early on, evidence showed optometry’s utility—hyperglycemia, for instance, affects all microvascular beds in the body but is most efficiently observed in its earliest stages in the retina, making the eye a primary reference point for diabetes blood glucose diagnostic endpoints.
In other words, the eye is the veritable canary in the coal mine when it comes to diabetes detection, says Michael Duenas, O.D., AOA chief public health officer, and doctors of optometry are those primary providers ready and able to initiate that care. In three decades, optometry has come off the sidelines and asserted itself as a valued team player on the field, Dr. Duenas says. For example, he helped initiate the Centers for Disease Control and Prevention (CDC)/ National Diabetes Education Program (NDEP) Pharmacy, Podiatry, Optometry and Dentistry (PPOD) model of interconnected care early, championing the cost-effective, team-based approach.
“As in baseball and other team sports, it’s not just about who hits a home run or scores the goal, but more importantly, who gets on base and advances other team players,” Dr. Duenas says.
“The optometry mindset must grow, adapt, recognize and promote. For example, the more than 300,000 patients, who last year first learned of their type 2 diabetes diagnoses through their optometric eye exam, each constitute a base hit. Again and again, optometrists must adopt a mindset to more fully tally these and other hits, promote these hits through engagement in optometry translation research, and nurture and fertilize these hits through relentless state and federal advocacy to grow optometric diabetes care and prevention.”
But the status quo is changing. Technology progresses by leaps and bounds daily, and health care remains an industry rife with advances that can upturn routine patient care in the blink of an eye. More research is needed, but there soon may be tools to assist in patient diagnosis that also provide decision support for treatment.
A study published in Nature Medicine reported that the Google DeepMind artificial intelligence (AI) system could not only identify dozens of diseases with 94% accuracy by reviewing optical coherence tomography (OCT) scans, but also could indicate what portions of those scans it relied upon for the diagnoses. In other words, DeepMind explained its “thought process” for such conclusions. But that’s not all: In April, the U.S. Food and Drug Administration (FDA) approved AI software, called IDx-DR, which can detect diabetic retinopathy and prompt referral for further care.
Regarding technology, the future isn’t just over the horizon any longer. Therefore, it’s time optometry makes its shift toward the future, too.
“If one looks at the prevalence of diabetes in 1987, compared to the present, one will understand immediately that to meet the current and future public health challenge of the diabetes epidemic, optometry, as a licensed medical profession, must once again reposition itself, through expanded clinical services that may necessitate expansion in scope of practice, both horizontally and vertically,” says AOA President Samuel D. Pierce, O.D.
“At a time when the American Association of Medical Colleges projects a shortage of as many as 40,000 primary care physicians (PCPs) within the next decade, today represents an opportune time to activate the comprehensive, medical skills of our nation’s doctors of optometry by expanding their diagnostic and treatment role in diabetes care and its comorbidities, well beyond retinopathy detection.”
Where optometry is going
So what’s the next step? It’s expanding that continuum of care beyond detection and routine eye care, and into timely, critical interventions and management that help reinforce the patients’ diabetes care team. Presented at the 2018 National Academies of Practice Annual Meeting & Forum, April 13-14 in Atlanta, Georgia, a new study co-authored by Millicent Knight, O.D., and Dr. Duenas, et al., titled, “The Eyes Have It … The Collaborative Role of Doctors of Optometry in Improving Diabetes Health,” illustrated that optometry can positively affect diabetes outcomes through timely, thoughtful, clinical interventions and relationships.
Conducted collaboratively by the AOA, Johnson & Johnson Vision and Johnson & Johnson Diabetes, the study tracked nearly two dozen doctors of optometry and 95 traditionally noncompliant patients with diabetes (PWDs) over the course of six weeks, as doctors integrated diabetes management strategies into their intervening care. Doctors were trained and educated on the importance of self-monitoring of blood glucose (SMBG), then provided their suboptimally controlled PWDs with glucose monitoring systems and patient education on SMBG, as well as encouragement to reconnect with their PCP. After six weeks, patients were surveyed about the intervention, and their responses were insightful.
Not only were patients more engaged in SMBG after six weeks, but also the number of patients testing daily jumped 100% while almost 1 in 5 reported reconnecting with their PCP at the urging of their doctor of optometry. Moreover, patient satisfaction with the program was positive with 56% noting they would “definitely continue” daily SMBG.
“With the rampant increase in diabetes across America, any avenue for the pursuit of public health is worth exploring. Even a 5% reduction in costs would save the country almost $18 billion a year,” the study concluded. “This intervention by the [doctor of optometry] provided a unique opportunity to create shared value between themselves, the patient and their primary diabetes PCP.
“Blood glucose testing increased significantly and a proportion of sub-optimally controlled PWDs were reengaging with their diabetes care provider. The good news is that this helped PWDs prevent problems by aiding their blood glucose control and by working more efficiently and effectively with their diabetes health care team providers.”
So, how does this pilot research inform the diabetes debate? There are three distinct spheres of necessary expansion for optometry: (1) enhanced patient care beyond retinopathy detection, (2) assured diagnosis and treatment of previously undetected individuals, and (3) diagnosis and prescribed Diabetes Prevention Program treatment of individuals with prediabetes.
Therefore, authors argue, doctors of optometry may provide even greater value by incorporating point-of-care-testing (POCT) inoffice that can aid them in making an initial diagnosis and combine that clinical data with individual SMBG patient education.
Adds study co-author Dr. Knight: “It’s not just about treating patients and making sure they come back to monitor retinal progression, but remembering to look long-term at your all-inclusive role in their overall diabetes care.”
How optometry gets there
Optometry must be a more active participant in the patient’s wellbeing. This next level of care includes POCT for diabetes and sophisticated assessment of early vision function and structural abnormalities that precede the classical findings of diabetic retinopathy, and for which we now have science-based, diabetes-specific ocular nutritional products, says A. Paul Chous, O.D., CDE, AOA representative to NDEP and a past member of the AOA Guideline Development Group for Eye Care of the Patient with Diabetes Mellitus.
“Equally important, improving optometric diabetes care also includes educating and motivating patients to better manage their condition and potentially reverse it, as well as helping high-risk patients prevent both prediabetes and diabetes from occurring in the first place,” Dr. Chous says.
Additionally, it means using new technologies, such as OCT, lens glycation and macular pigment measurement, and fundus photography, to catalog diabetes’ scope and staying up to date on the latest pharmaceutical management options for both diabetes and diabetes-related ocular complications. It’s also about knowledgably navigating patients through the interdisciplinary diabetes care network.
It’s less a paradigm shift than it sounds—already doctors of optometry provide some or all of these points—but it’s the next logical progression that optometry must embrace. And doctors of optometry are well-suited to meet this growing need, Dr. Chous says.
That progression begins with POCT and segues into patient education. The United Kingdom Prospective Diabetes Study (UKPDS) found the rate of microvascular complications from diabetes fell 25% when comparing patients with a mean HbA1c (A1c) of 7.9% to those more tightly controlled at 7.0%. Additionally, among those who successfully controlled their A1c, the incidence of diabetes-related morbidities fell significantly for each 1% improvement in A1c.
“POCT has some merit for identifying previously undiagnosed cases of both diabetes and prediabetes/ insulin resistance/metabolic syndrome, as well as for risk stratification that helps me gauge my examination frequency for specific patients and informed referral to other specialists,” Dr. Chous says. “Many patients simply don’t know— or haven’t been given goals for— their level of metabolic control, and POCT helps cut through this. POCT glucose analysis also mitigates the risk of refractive surprise in poorly controlled patients.”
That said, Dr. Chous notes inoffice glucose testing may not detect diabetes in its earliest stages. Continuous glucose monitoring (CGM) will likely significantly increase predictive power above and beyond fasting, spot or mean blood sugar, Dr. Chous says. Here, horizon technologies in the form of wearable devices (smart contact lenses, watches, etc.) could help provide accurate, consistent data.
To begin POCT, doctors of optometry should consult their state scope of practice (see Eye Chart on page 18) and apply for a Clinical Laboratory Improvement Amendments (CLIA) “Certificate of Waiver” to perform blood testing and bill such tests. Simple to obtain, the CLIA waiver permits doctors of optometry to provide diagnostic tests, such as blood testing. The CLIA waiver also can open practices to certain other rapid-test and diagnostic instrumentation available only to laboratory practice settings, such as lipid and glucose measuring systems (e.g., blood sugar and A1c) that provide more accurate and immediate results.
Tina MacDonald, O.D., CDE, AOA Evidence-Based Optometry Committee member writing the guideline update for Eye Care of the Patient with Diabetes Mellitus, set for 2019, says POCT is a critical first step that influences the entire patient encounter.
“Not only can it help the optometrist make clinical decisions (e.g., when or how to treat or refer a patient according to blood glucose control), but immediate results can help interdisciplinary communication— not to mention that face-to-face communication with our patients—and collaboration,” Dr. MacDonald says. “Testing is an important part of patient education and reinforcement that can promote self-care behavior.”
Again, more show and less tell; A1c is a tangible measure that doctors can present to their patients and open a dialogue about their management. These A1c tests can be performed in the doctor's office, as a CLIA-waived test, or ordered every 3 to 6 months with a target of keeping the patient under 7%. Depending on the results, A1c is a conversation starter about doing a better job of self-management, the risks of suboptimal control or encouragement to continue doing SMBG. There is a “huge role” for diabetes education in the optometric practice, Dr. Chous says.
After Dr. MacDonald blazed a trail for optometry, persuading the National Certification Board of Diabetes Educators to allow doctors of optometry to obtain certified diabetes educator (CDE) certification, optometry can earn the comprehensive training in diabetes prevention and management, as well as prediabetes identification. This advanced certification allows the direct provision of diabetes education.
“Doctors of optometry don’t need to become CDEs to do a fabulous job educating patients, but becoming a CDE or collaborating with one might make sense depending on patient demographics,” Dr. Chous says.
Adds Dr. MacDonald: “Doctors of optometry have extensive knowledge already, but no one knows that until you show them. From a personal standpoint, I’ve found that many professionals don’t know that doctors of optometry know anything at all about diabetes.”
How optometry stays there
Optometry is countering those notions daily, however. The growth of inter-professional collaboration and diabetes prevalence have fundamentally increased the importance of doctors of optometry on the diabetes care team. For instance, the AOA worked collaboratively with NDEP to develop the PPOD Toolkit—a guide to communicating, referring and working with these disciplines— and help educate providers about optometry’s capabilities. So, too, the AOA was one of 20 professional organizations and federal agencies ascribing its support to NDEP’s updated Guiding Principles for the Care of People with or at Risk for Diabetes. The latter reinforces optometry’s role in frequent diabetes eye examinations, as well as the role doctors of optometry fill in educating about the importance of early, good glycemic control. It also reinforces a two-way communication with patients’ primary care providers and/or endocrinologists.
“We must actively seek out collaborative partnerships with PCPs and other members of the diabetes care team,” Dr. Chous says. “Send a copy of your eye findings and treatment recommendations not only to PCPs—help them meet their quality measures—but also to every other provider whom your patient sees. Make sure to communicate information about your specific technologies and skills related to diabetes care.”
Building that network is important for not only diabetes care, but also prediabetes identification and intervention. The AOA works to collaborate with dozens of diabetesrelated organizations as one of the co-founding organizations of the Diabetes Advocacy Alliance™ (DAA). According to Dr. Duenas, the AOA’s representative to DAA, “The DAA organizational membership list can serve as an important guide to the doctor of optometry in reaching out to other disciplines and DAA messaging in highlighting their individual role in diabetes care and prevention. DAA member organizations have products that are useful to doctors of optometry, including the American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Type 2 Diabetes Management Algorithm 2018.” (Learn more at aace.com/publications/algorithm.)
In the case of prediabetes, blood sugar is higher than normal but not quite high enough for a diabetes diagnosis. These patients are at increased risk for type 2 diabetes, cardiovascular disease or stroke yet may be completely unaware of their condition. As such, doctors of optometry who identify a patient with prediabetes should refer the patient to a National Diabetes Prevention Program and continue to follow the patient along with the patient’s PCP.
The key is early identification. By the time of a type 2 diabetes diagnosis, many patients have already lost as much as 40 to 50% of insulin-producing pancreatic beta cell function, the UKPDS found. That’s why optometric care—in coordination with all other members of the care team— can be so impactful to stemming diabetes. And, advances in optical imaging technology might make optometry even more critical.
Advanced glycation endproducts (AGEs) accumulate in the presence of uncontrolled glucose and diabetes over time and are involved in diabetic retinopathy and cardiovascular disease risk. Their accumulation in tissues can be analyzed by measuring the skin autofluorescence (SAF) or lens autofluorescence (LAF).
In 2013, the FDA approved a device for the detection of AGEs using LAF. Although the LAF device is not currently being marketed, the SAF device, AGE-Reader (DiagnOptics B.V., Groningen, The Netherlands) is currently available. Such technology could be employed to identify biomarkers indicative of enhanced diabetes and cardiovascular risk.
Although growth of AGE measurement is on the horizon, studies demonstrate a significant relationship between LAF and SAF. Additionally, studies show the prevalence of diabetic retinopathy increases with diabetes duration, arterial hypertension, renal parameters (serum creatinine and albumin excretion rates) and SAF.
While AGE may be on the horizon, its underlying promise is relevant now: Early identification and intervention in diabetes care is critical. Patients—whether diabetic or prediabetic—benefit from the collaboration of doctors of optometry and other members of their care team.
“Small-town doctors of optometry have the best opportunity to work with hospitals, clinics and other providers—everyone knows everyone,” says David Masihdas, O.D., AOA Evidence-Based Optometry Committee member who contributed to the 2014 edition of Eye Care of the Patient with Diabetes Mellitus and is now working on the newer edition. “They can say, ‘Look, let me help you take care of your patients with diabetes, let me help you meet your HEDIS (Healthcare Effectiveness Data and Information Set) scores,’ and it will be amazing, if you are persistent and diligent in developing those relationships, how that will help your patients and practice.”
That’s certainly the case for Dr. Phelps. He’s made a name for himself in Ojai for the comprehensive diabetes care he provides, and that’s garnered a level of respect from other physicians in town. He’s willing to practice the fullest scope permissible and work collaboratively with patients' PCPs or navigate them to the appropriate care. It’s about knowing your limits and demonstrating your expertise.
“It’s important that we as doctors of optometry make a commitment to understanding proper care of the patient with diabetes,” Dr. Phelps says. “I think it’s a good thing for optometry, and as patients see you demonstrate that care, those patients will come away with that assuredness that you’re doing what’s best for them.”
Optometry can make a difference. Now it’s time to show them.
Thanks to Johnson & Johnson Vision and Johnson & Johnson Diabetes for their collaboration on "The Eyes Have It: The Collaborative Role of Doctors of Optometry in Improving Diabetes Health"
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