Expanding Optometrist Scope of Practice Did Not Reduce Travel Times

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One of the arguments for expanding the scope of practice of optometrists to include some laser procedures is to increase accessibility and reduce the travel times for patients, particularly in states with large rural areas. The results of a scope-of-practice study of three procedures reported last week in JAMA Ophthalmology may sow a few doubts about that rationale.

Corresponding author Courtney E. Francis, M.D., an associate professor in the Department of Ophthalmology at the University of Washington, and colleagues, studied selective laser trabeculoplasty and laser peripheral iridotomy, both of which relieve intraocular pressure in the eye associated with glaucoma, and YAG laser capsulotomy, a procedure done after cataract surgery that clears vision by creating an opening in the sac-like capsule that holds the lens. All three are common, office-based procedure with excellent safety and efficacy records

The researchers used data Medicare Part B claims from 2016 to 2020 filed by optometrists and ophthalmologists in Oklahoma, Kentucky and Louisiana, which have expanded optometrist scope of practice to include those three procedures. Francis and colleagues also included claims from Arkansas, which expand optometrist scope of practice to include YAG laser capsulotomy in 2019, and Missouri, for comparison purposes.

Among their results was a finding that optometrists in Oklahoma provided a larger proportion of the three laser eye procedures, compared with the optometrists in Kentucky and Louisiana. One-third (33.2%) of the laser peripheral iridotomies, one-quarter (25.7%) of the selective laser trabeculoplasties and a little more than one-third (37.1%) of the YAG procedures were performed by optometrists. This makes sense. Oklahoma expanded scope for optometrists in 1998, several years before Kentucky did, in 2011, and Louisiana, in 2014.

Similarly, they found that optometrists accounted for a larger percentage of the healthcare professionals filing claims for the three procedures than the optometrists in Kentucky and Louisiana. In fact, optometrists in Oklahoma accounted for more than half (56.2%) of the claims filed for YAG capsulotomy. In Kentucky, the proportion was 29.6% and in Louisiana, 23.2%.

The study took an unexpected turn when Francis and colleagues started to dig into the travel times for the laser procedures, which they deduced using isochrone maps and traffic data. In Kentucky, the travel time to the optometrists performing the three laser procedures was longer, not shorter, than the travel time to the ophthalmologists. In Oklahoma, the median travel time to the optometrist for YAG procedure was 26.6 minutes compared with 20 minutes for the ophthalmologists

One of the argument for expanding the scope of practice of optometrists has been that they may practice in areas where no ophthalmologists do. In the discussion section of the paper, Francis and colleagues say that the isochrone maps show that most optometrists performing laser eye procedures are doing so where ophthalmologists already practice.

Notwithstanding the complex methods used to conduct this study, it has some notable limitations, however. It did not, for example, include Medicare Advantage members. Optometry and ophthalolmogy groups may have multiple locations but enter just one on Medicare claim, so the claim as a source of information about location and travel time may be misleading. And by design, the researchers focused only on travel not on other issues, such as cost or the quality of the care.

“This study of Medicare claims in the states of Oklahoma, Kentucky, Louisiana, Arkansas and Missouri found insufficient evidence to assert that optometric scope expansion increases geographic access and reduces driving time,” they concluded.