|Optometrists and their legislative advocates can expect to see these findings used against them in their ongoing scope expansion efforts. Currently, 10 states allow optometrists to perform YAG capsulotomies and other laser procedures. Click image to enlarge.
A leading argument to add certain laser procedures to optometrists’ scope of practice—including laser peripheral iridotomy (LPI), selective laser trabeculoplasty (SLT) and capsulotomy—is to increase access to care, especially for older individuals who face a higher risk and prevalence of eye disease. A research team consisting of ophthalmologists and statisticians but no optometrists published a new study in JAMA Ophthalmology that found no association between an expanded practice scope and increased access to laser procedures, as measured by reduced drive times to practices offering such services, among the Medicare population of five states with optometric laser laws: Oklahoma, Kentucky, Louisiana, Arkansas and Missouri.1 Importantly, patient access was solely measured by estimated travel time and 30-minute proximity to an optometrist or ophthalmologist.
The team reviewed a total of 1,564,307 Medicare Part B claims from 2016 through 2020 for patients who underwent LPI, SLT or YAG capsulotomy by an OD or ophthalmologist in the five states noted above. The primary outcome measure was the percentage of each state’s Medicare population within a 30-minute travel time of an optometrist or ophthalmologist based on US census block group population and estimated travel time from the patient to the clinic.
According to the study authors, the following conclusions were made from the data:1
- Optometrists performing laser eye surgery cover a geographic area similar to that covered by ophthalmologists.
- Less than 5% of the population had only optometrists (no ophthalmologists) within a 30-minute drive in every state except for Oklahoma for YAG and SLT.
- Patients had a longer travel time to receive all laser procedures from optometrists than ophthalmologists in Kentucky (for YAG, the difference was 49 minutes vs. 23 minutes, respectively).
- Optometrist-performed YAG also had a longer drive time than ophthalmologist-performed procedures in Oklahoma and Arkansas, but not in Louisiana.
The researchers pointed out that these statistics would change if patients were to see the healthcare professional closest to them. For example, for YAG procedures performed in Kentucky, they noted in their paper that, “Patients who initially chose an ophthalmologist had a median travel time of 23 minutes, which could have been reduced by five to 10 minutes if they selected the closest optometrist (median, 13 minutes) or ophthalmologist (median, 18 minutes).”1 On the other hand, they reported that “patients who chose to see an optometrist traveled significantly more with a median estimated travel time of 49 minutes. Choosing the nearest optometrist (median: 14 minutes) or ophthalmologist (median: 15 minutes) would have saved nearly 35 minutes of travel time.”1
At the conclusion of their study, the researchers bring attention to some limitations. “The study data are limited to geographical analysis and cannot address whether the quality of care was improved with this expanded access, whether ease or speed of appointments was improved, the impact of physician availability or if costs decreased without compromising quality,” they wrote.1 Additionally, racial, ethnic or cultural factors were not taken into account in the analysis.
Expanding on these cautionary statements, several ODs authored a recent commentary on the study, also published in JAMA Ophthalmology, highlighting the numerous factors other than geographic location that define patient accessibility.2 “Distance and drive time are concerns for patients who have limited access to care, especially patients from low-resource communities,” they wrote. “However, beyond accessibility, the theory of access framework from Penchansky and Thomas includes affordability, acceptability, availability and adequacy and has now been expanded to include awareness and patient-level factors. Understanding how each dimension impacts access will be critical to reduce eye health disparities.”2
The commentary goes on to describe each facet of patient accessibility, beginning with affordability, which the authors note focuses on the direct eyecare costs to the patient. In addition to the patient’s ability to pay all out-of-pocket costs, this also includes lost productivity due to missed work, as well as transportation and lodging costs, they noted.
Acceptability describes patient expectations. “Patients may find that a service is unacceptable due to a poor physician-patient relationship, lack of adequate communication with the eyecare clinician or minimal patient education from the eyecare clinician about eye diagnoses and treatment,” the commentary authors explained.2
The next measure of patient access is availability, which involves the supply and demand of patient needs vs. available eyecare services. For example, in areas with an older population, there may be more demand for care of eye diseases such as glaucoma. Complementing this, the factor of adequacy refers to the capacity of optometry and ophthalmology practices to properly care for patients and facilitate services.
The final factor, awareness, focuses on the information and communication about available eyecare services. The commentary authors provide the example of clinicians who begin offering a mobile eye clinic. In this case, they note that everyone involved must know whom the service is for, what it does, when it will be available (dates and times), how and where to use the service and, lastly, its purpose. Additional patient-level factors of accessibility include situations that can prevent an individual from accessing care (i.e., missed appointments due to illness or caregiver difficulties).
The commentary authors argue that “multidimensional approaches are needed to understand where access to eyecare services is lacking,” and that “research can grow beyond geographical access.”2 They offer suggestions for a follow-up study to assess each factor affecting the association between optometrist- and ophthalmologist-performed laser procedures and patient access. For example, they note that adequacy could be measured by poverty indices and the percentage of non-native English speakers, and neighborhood-level factors such as fuel cost and median income could help measure affordability.
Overall, while allowing ODs to perform laser procedures wasn’t shown to improve patient access based on geographic data alone, it would be beneficial to examine the various dimensions of accessibility in future studies.
1. Shaffer J, Rajesh A, Stewart MW, et al. Evaluating access to laser eye surgery by driving times using Medicare data and geographical mapping. JAMA Ophthalmol. July 20, 2023. [Epub ahead of print].
2. Hicks PM, Asare AO, Woodward MA. Beyond accessibility in exploring access to eye care to achieve vision health equity. JAMA Ophthalmol. July 20, 2023. [Epub ahead of print].