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Vision Care
Section Newsletter
Winter 2007

Message from the Chair

Happy New Year!

 

The Vision Care Section is fortunate to have an enthusiastic core of members who are willing to lend a hand, and a number of exciting and noteworthy projects are in the works for 2007.

 

Here are the highlights for the coming year:

 

  • A working group on aging and health care is being spearheaded by Dr. Bill Monaco.  The group will be examining the challenges to delivering health care to the elderly, in particular those who are in nursing homes and other facilities.
  • A proposed policy statement on the effects of smoking on eye health is being prepared by the Resolutions Committee (chaired by Dr. Mort Soroka, VCS chair-elect).  Thanks again to Dr. Paul Berman for his fine work on the sports eye protection resolution, sponsored by VCS and approved by the Governing Council at the APHA Annual Meeting in November.
  • “Fact sheets” are being developed by VCS to aid APHA staff in responding to topical inquiries.  Dr. Elizabeth Hoppe has volunteered to get the ball rolling.
  • New Web site and communications system to launched soon by APHA.  The new system, called “e-communities,” ought to enhance communication with members.  To that end, be on the lookout for periodic communications from me as a supplement to the Section newsletter to keep everyone apprised of news items as they develop.  You’ll be receiving information from APHA when they are finally able to get it launched (after several postponements so far).

 

If any member is interested in helping with a particular project, or have questions, concerns or ideas, please contact me at ghomvcs@gmail.com.  I’d be very interested in hearing from you.

 

Take care!

Visual impairment and Access to Eye Care for Adults 50 years of Age and Over

Most of the information and data in this summary article appear in the Dec.15, 2006 issue of the CDC’s Morbidity and Mortality Weekly Report, Visual Impairment and Eye Care Among Older Adults - Five States, 2005.  This MMWR is reported by Xinzhi Zhang, MD, PhD; L.S. Geiss, MS; Michael R. Duenas, OD; and Jinan Saaddine, MD, of the CDC; Robert Indian, MS, of the Ohio Dept of Health, and myself.  

 

Blindness and visual impairment are associated with a shorter life expectancy and a lower quality of life.  Estimated state-specific prevalence of visual impairment and eye diseases has been unknown.  In 2005, five states utilized the new optional module called, “Visual Impairment and Access to Eye Care” in their Behavioral Risk Factor Surveillance System telephone surveys.  The collected data were analyzed to estimate the self-reported prevalence of visual impairment, eye diseases, and access to eye care at the state level among people 50 years of age and older. 

 

The Behavioral Risk Factor Surveillance System survey, known as the BRFSS, is the largest telephone-based health surveillance system in the world.  Annually conducted by state health departments, it is a cross-sectional survey with required CDC core questions and a few optional modules of questions.  Because the length of the survey must not require more than about 20 to 25 minutes of telephone time, there is much competition for the limited space for optional questions to any state survey.

 

By its name, the survey gains information about health risk behaviors of those interviewed.  Questions to determine levels of preventive practices and health care utilization are also asked.  The BRFSS is unlike other national health monitoring systems in that it allows the collection of state-specific data.  The Visual Impairment and Access to Eye Care optional vision module was used for the first time in 2005 by five states; Iowa, Louisiana, Ohio, Tennessee and Texas.  Only those respondents 50 years of age or older were asked the vision module questions.  There were a total of 13,931 responses from those 50 years of age and older.  

 

Estimates of visual impairment and other factors surveyed are intended to reveal state-specific prevalence for each condition, not intended to compare states in terms of factors not specifically addressed by the survey.  That is, while the numbers between states may vary, and one may speculate as to why they vary, it is not possible to explain the reasons for variation by the data – only to note that variation exists.  Speculation about variation can raise questions to be answered by further research. 

 

The prevalence of visual impairment varied from about 14 percent in Iowa to about 20 percent in Ohio, being higher in the older age groups and greater among females than among males. 

Non-Hispanic whites had a lower prevalence of visual impairment than did non-Hispanic blacks or Hispanics.  The reported prevalence of visual impairment declined as the income level of the respondents increased.  Reported visual impairment also declined with respondents’ increasing years of education. 

 

Cataracts were reported by all states as more prevalent than the other eye diseases.  Glaucoma was reported as the second most prevalent by these states.  Both macular degeneration and diabetic retinopathy were reported as less prevalent than cataracts or glaucoma by all states. 

 

As may be expected, the prevalence of cataracts, glaucoma, and macular degeneration all increased as the respondents’ ages increased.  Much more information, including information on access to care, was obtained from the data.  For a more detailed report of the findings, I direct you to the MMWR at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5549a1.htm .

 

This report is the first to estimate the self-reported prevalence of visual impairment, eye diseases, and access to eye care at the state level.  The results of this survey suggest that eye health promotion interventions with supporting public health policy are needed.  There is good reason for more states to gather vision data through use of the vision module in their BRFSS survey.  Eye and vision care professionals and non-governmental organizations interested in visual health need to work cooperatively by assisting with funding of the vision module where needed.  In addition, further collaboration will be needed to address visual health needs as they are revealed by the data.

Quality through Collaboration

In the last 30 years, the discussion surrounding quality of care has undergone numerous debates and controversies. The first 10 years, it was debated whether or not quality could be defined. The second 10 years, we debated whether or not quality could be measured. The last 10 years, we questioned whether or not the data were accurate, appropriate and legally safe to report. And today, we agree that good, solid, objective measurement is what is needed.

 

Quality Through Collaboration: the Future of Rural Health, an Institute of Medicine Call-to-Action report presents rural stakeholders with an unparalleled opportunity to improve and attract resources previously unavailable. In support of the IOM report, the National Rural Health Association has launched “Quality Through Collaboration: The NRHA Quality Initiative.” The NRHA is committed to working with rural America's health care and community leaders to address the Institute of Medicine's call to action. The prestige and clout of the Institute of Medicine are now available to the rural health care world as never before.

 

The public health and eye care community can be actively involved in addressing quality of care issues through collaborative efforts in rural areas by joining with the National Rural Health Association and its state affiliates. Rural areas offer a unique opportunity to lead in innovative research and policy initiatives. Policy makers should look to rural areas for new models of health care delivery and quality reform measures. Check out the NRHA Web site at www.nrharural.org for additional information on the NHRA Quality Initiative or membership at the state or national level.

Optometric Patients in General Practice Settings: Diagnoses, Treatments, and Referral Patterns

A study was commissioned by the National Board of Examiners in Optometry to examine similarities and variations in practice patterns and profiles among optometrists in different settings. This study provides insights into the most common diagnostic and therapeutic procedures performed, medications prescribed and referrals made in general optometric practices.

 

A representative sample of 480 Optometrists completed encounter forms for all patients seen during a two-day period in 2004. Data was obtained from 11,012 patients in rural, urban and suburban settings from practitioners in solo, group practices, commercial optical settings, HMOs, the VA, hospitals, and ophthalmology offices.

 

Refractive error was the most prevalent diagnostic category, reflective of the ocular problems found in the general population, and systemic conditions were the second largest diagnostic category. Although 12 percent of all patients were referred to an ophthalmologist for further care, other types of referrals were infrequent. Referrals to a primary care physician, lab or imaging or to a surgeon for refractive surgery accounted for only 8 percent of all referrals. Overall, referrals for refractive surgery represented fewer than 1 percent of all patients seen. Ocular disease treatment was found to be an integral part of the optometrist's practice, Prescribing topical ocular medications, both legend and over-the-counter, was a primary treatment option offered by optometrists to their patients. The most common medications prescribed were for glaucoma, with antibiotics, anti-inflammatory and anti-allergy drops making up the remainder, in descending frequency.

Challenges for a New Vision Care Section Aging and Visual Performance Working Group

At the APHA Vision Care Section Meeting in November, a new working group was formed to assess the growing concern over the provision of health care to the 68 million people who will be 65 or older by 2030.  In Healthy People 2010 it was noted that the leading causes of visual impairment in the population who were 65 in 1985-6 were cataract, AMD, diabetic retinopathy, and glaucoma.  These eye diseases occur as co-morbidities with systemic conditions of hypertensive cardiovascular disease, diabetes and stroke.  In an informal survey that I performed in my nursing home practice of more than 1,500 patients whose ages ranged from 33 - 103 (median ~80), there was 22 percent AMD, 44 percent hypertensive retinal changes, 11 percent glaucoma suspects, 8 percent glaucoma, 8 percent diabetic retinopathy, 53 percent cataract and 11 percent atherosclerotic retinal changes.  Dry eye and central retinal vein occlusion were also prevalent in this population.  These data are simply approximations at this point as we are looking for trends in my current patient population that mimic the existing data.

 

The charge of the working group that was created by the Vision Care Section is to recruit health care providers from different disciplines to explore efforts to accommodate the health care needs of the growing population of aging patients. Several questions need to be answered.  What are we doing in our academic institutions?  How is industry preparing?  What is current practice?  We know, for example, that of the 125 medical schools in the country, only five currently have gerontology programs.  Further, only 20 percent of nursing homes in the United States report having eye care services for their residents.  This finding is particularly troublesome since the Vision Care Section sponsored an APHA resolution in 1995 that specifically charges nursing homes and skilled care facilities to provide eye care for their residents. A starting point for the "Vision Care Section Aging and Visual Performance Working Group" may be to update the existing resolution.

 

National optometric organizations are addressing the eye care needs of an aging population. The Association of Schools and Colleges of Optometry has recently created a committee that is charged to poll the existing optometric programs to determine their curriculum for gerontology. There may also be additional courses in pathology, pharmacology, low vision and other courses that complement the gerontology efforts. The 2006 American Academy of Optometry meeting included three sessions on the "boomers" and issues that surround the provision of eye care for this population.  The Public Health and Environmental Health Section has brought this issue to the forefront. A position paper on this topic is being discussed. The American Optometric Association has also demonstrated interest in this topic supporting optometry's involvement with the White House Council on Aging and the National Council on Aging.

 

 The Vision Care Section's Aging and Visual Performance Working Group has the opportunity to interlink optometric organizations with APHA and other national organizations to address a crucial public health issue that will have tremendous benefit to the patients we serve. Contact William A. Monaco at  flightsight@earthlink.net if you are interested in participating.