Managing the growing burden of glaucoma

The number of patients with glaucoma will rise dramatically in the future because of growth in both the size of the aged population and in demographic groups at high-risk for the disease. Ophthalmology, however, is not equipped to handle the increasing demand for services considering workforce projections and current models of care.

Chicago-The number of patients with glaucoma will rise dramatically in the future because of growth in both the size of the aged population and in demographic groups at high-risk for the disease.

Ophthalmology, however, is not equipped to handle the increasing demand for services considering workforce projections and current models of care.

Delivering the Robert N. Shaffer Lecture at AAO 2016, George A. Cioffi, MD, proposed potential solutions and offered some testable hypotheses aimed at addressing the problem of glaucoma population management.

“There are a lot of people thinking about ways to solve the question of how will we handle the increasing number of patients with glaucoma who will be coming our way, and I think there are some novel ways that can enhance practice efficiency,” said Dr. Cioffi, Edward S. Harkness Chairman and ophthalmologist-in-chief, Department of Ophthalmology, New York-Presbyterian Hospital/Columbia University Medical Center, New York. “However, those can only go so far, and we have to think about different models of care.”

An eye on enhanced efficiency

One way to increase practice efficiency is based on an alternate approach to using electronic medical records (EMRs).

Dr. Cioffi said he has started a mantra within his institution “to get the doctor out of the EMR.”

“EMRs bring a lot to the table, but we all hate being in the record because it takes so much time,” he said.

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In the system he discussed, physicians would access their patient list for the day on their smartphone.

For each patient encounter, they would be instantly taken to a recordable, HIPAA-compliant system that links them with a human transcriber who directly enters the visit information into the EMR.

“EMRs are not going to disappear, and so we have to figure out how to use them effectively,” Dr. Cioffi said.

Results from one study

He noted systems of this type have been developed and in one study was shown to reduce the amount of physician time spent with the EMR by about 64%.

Other approaches for meeting the need to handle the growing glaucoma population relate to the idea that medical care situations can be divided into sequential and iterative types that should be managed with different care systems. According to this concept, described in the 2009 book Designing Care by Richard Bohmer, patient needs and care delivery needs increase with increasing disease complexity.

In accordance with the sequential versus iterative care model, Dr. Cioffi discussed roles for risk-targeted screening, telemedicine, physician extenders, and a team care approach across the spectrum of the glaucoma disease course.

Speaking about risk-targeted screening, Dr. Cioffi cited a paper describing a model that simulated how SD-OCT imaging for glaucoma screening in African American communities would affect disease outcomes. The investigation showed this risk-targeted screening would be a cost-effective way to lessen glaucoma visual morbidity.

“This represents sequential, low physician touch care because most of the imaging can be read by machine learning capabilities. So, let’s get on with it,” Dr. Cioffi said.

He also discussed the use of telemedicine for lessening physician time spent in diagnosis and management, and he emphasized that telemedicine can be done asynchronously.

“Telemedicine does not have to be where a physician is talking to the patient directly because that does not save the physician much time,” Dr. Cioffi said. “Being able to look at the data in an asynchronous time period and only at the data that needs to be seen because it crosses a certain threshold would bring efficiencies and allow physicians to manage many more patients along the spectrum of disease.”

He also noted benefits of appropriately expanding use of physician extenders, which could even be applied to management of patients with more complex disease.

Dr. Cioffi reassured younger glaucoma subspecialists, however, that the solutions he was proposing will not eliminate the need for their expertise.

Rather it will allow them to spend more time managing patients with progressive pseudoexfoliation or primary open angle disease-the population of glaucoma patients that is really exploding and that needs the most attention.

Testable hypotheses

In concluding his lecture, Dr. Cioffi enumerated some testable hypotheses and he urged that they be investigated.

That traditional models of care will fail to meet the needs of the increasing glaucoma disease burden and that targeting high-risk groups with currently available imaging technology can be implemented for effective screening and will decrease the burden of severe disease were two of the hypotheses on his list.

In addition, Dr. Cioffi proposed that glaucoma care would be improved by implementing routine optic nerve imaging for everyone at age 40.

“Think of all the 80-year-olds we would not be dealing with as glaucoma suspects because they have a little bit of cupping,” Dr. Cioffi said. “We can take this idea to the government and say it is our preventive medicine strategy for ophthalmology.

“We have leaders within ophthalmology that can help us, so we can test these hypotheses for new diagnostic and therapeutic models,” he concluded.