Low Vision Service Provision by Optometrists: a Canadian Nationwide Survey

Low Vision Service Provision by Optometrists: A Canadian Nationwide Survey

Norris Lam, OD, MSc, FAAO, Susan J. Leat, PhD, FCOptom, FAAO, and Alison Leung, OD

University of Waterloo School of Optometry and Vision Science, Waterloo, Ontario, Canada (all authors)

Short title:Low Vision Optometric Service in Canada

2 tables; 4 figures; 1 appendix

Received: June 5, 2014; accepted October 10, 2014.

ABSTRACT

Purpose. To document the degree to which Canadian optometrists are involved in the provision of low vision (LV) care and their referral patterns. To investigate the barriers to providing optometric low vision services (LVS).Methods. Practicing optometrists across Canada were randomly sampled and invited to participate in a questionnaire that included questions on personal profile, primary practice profile, levels of LV care offered, patterns of referral and barriers to provision of LV care. Questions included a combination of multiple choice and open-ended formats, and included hypothetical cases.Results. 459 optometrists responded (response rate = 24.8%). Optometrists estimated that 1% (range 0-100%) of their patients were LV patients yet also estimated that 10% of their patients had acuity equal to or worse than 20/40.Thirty-five percent of respondents indicated that their primary practice offered LV care, 75.6% would manage a patient with minimum disability and simple goals themselves while 10.7% would manage a patient with more than minimal visual disability who needed more specialized LV devices (e.g. telescopes, electronic aids and custom-designed microscopes).84.3% of optometrists would assess for basic magnification and lighting in a hypothetical patient with early ARMD, while 15% would undertake full LV rehabilitation in advanced ARMD. Optometrists commonly referred to CNIB (formerly the Canadian National Institute for the Blind), yet only 10.7% of respondents almost always received a written report after referral. Those who would not undertake LV assessment stated that they lacked the knowledge, equipment or experience, that LV assessment is too time consuming and the cost is too prohibitive. Conclusions. This is the first comprehensive study of LVS provision by optometrists in Canada.In order for optometrists to become more involved in LV services, there is a need for more LV education, provincial health coverage of optometric LVS, and better collaboration and communication between LV providers.

Key words: low vision, low vision services, visual impairment, rehabilitation, service provision, barriers

The Canadian population is ageing. From 2006 to 2011, the rate of growth of Canadians aged 54 and older was more than double the 5.9% increase for the entire population.1With an ageing population, recent studies have documented a higher incidence of age-related vision loss in Canada. The 2006 Participation and Activity Limitation Survey2 indicated that Canadians aged 75 plus were significantly more likely than the younger respondents aged 15 to 24 to have a “severe seeing limitation” (30.5% vs. 16.7%). Similarly, the CanadianCommunity Health Survey3 in 2003 found that while Canadians aged 65 and older made up 14% of the population, they accounted for 23% of all people with vision problems. Similar trends are occurring in other developed countries. The US Beaver Dam Eye Study, the only large-scale, population-based study on the long-term incidence of vision loss, found that over a 15-year period, people aged 75 and older were 12.8 times more likely to develop low vision (LV) and 20.6 times more likely to become legally blind compared with those younger than 75 years of age.4

Vision impairment has an adverse impact on social participation and is known to be a strong predictor of self-reported difficulty with activities of daily living.5It is associated with the risk of falls6, hip fractures,6,7and depression.8The social, personal, economic and societal cost of vision loss is tremendous.9It is not clear that health care systems are prepared to deal with the increased prevalence of people with vision loss.

According to the Canada Health Act,10each Provincial and Territorial government has the primary jurisdiction for the administration and delivery of health care. Consequently, there is no systematiccoverage for routine eye examinations. Most provinces only cover optometric routine eye examination on an annual or biannual basis for those under 18 or 19 and/or ≥65 years, while in some provinces there is no coverage.11Neither is there any consistent provision or coverage for low vision service(LVS). LVS may be provided by independent optometrists or ophthalmologists, in hospital settings, within CNIB (formerly known as the Canadian National Institute for the Blind) premises or within educational institutions. Remuneration for optometric LVS also varies, ranging from no coverage to an inadequate or modest fee($40.33in British Columbia,12$55.21 in Alberta13and $84 in Nova Scotia14 as of 2014). There is also variation in provincial coverage for LVS provided by ophthalmologists, ranging from no coverage to a fee in Ontario, Saskatchewan and Newfoundland. Coverage for low vision devices also varies among provinces. For example, in Quebec, patients may receive LV devices on-loan free-of-charge when examined within a government-run rehabilitation center.15 In Alberta, financial subsidy for low vision aids is available only to patients who meet certain visual criteria and who are registered clients of CNIB.16 In Ontario, the Assistive Devices Program17partially covers the cost of devices prescribed by a registered authoriser (who may be an optometrist, ophthalmologist or CNIB low vision service provider).

The CNIB is a nationwide charity that also offers low vision assessment, in addition to emotional and wellness support, mobility training, independent living services, assistive technology services and an accessible library.18CNIB Low Vision Specialists may perform low vision assessments independently,11or in collaboration with an optometrist or ophthalmologist.15,19To become a Low Vision Specialist, one must fulfil the requirements of an in-house training program, which “includes self-study, completion of the Johns Hopkins LV Training Program, practicum, one-year mentorship and final exam”.19When this survey was undertaken, people with any level of vision loss who were experiencing visual disability could gain access to CNIB throughself-referral or referral by an eye care professional. While services are “free-of-charge” to eligible clients, program delivery and availability varies locally and financial support is dependent on public donation and government funding.20In conclusion, provision of LVS across Canada is highly variable. Canadians who suffer from vision loss deserve to receive higher quality and more effective LVS. There is a tremendous need to build an effective model for vision rehabilitation in Canada.

A first step is to determine a more accurate picture of the current provision of LVS by each type of provider. The purpose of this present study is a survey of the extent of provision of LVS offered by optometrists, their referral patterns and their perception of the quality of LVS in their local communities and the barriers to providing more LVS.

METHODS

The study was approved and received ethics clearance through the Office of Research Ethics at the University of Waterloo and adhered to the tenets of the Declaration of Helsinki. The survey was designed after a careful review of previous literature of provision of LVSby eye care professionals.21-23The30-item questionnaire included information in the following sections: A. personal profile; B. primary practice profile; C. level of LVS offered and barriers to provision of low vision care; and D. referral patterns. For comparisons, some questions were adopted from previously published LV surveys.22-24A unique aspect of our questionnaire was the use of three hypothetical clinical cases (C5-C7) and two open-ended questionsthat allowed respondents to comment on LV education and the current provision of LVS. Six practicing optometrists were asked to complete the draft survey. As a result of their feedback, questions were adjusted in cases where they thought there was ambiguity. A summary of the final questionnaire can be seen in the Appendix (available at [LWW insert link]).

A complete list of practicing optometrists (n=4608) was obtained from each provincial regulatory body of optometrists. Due to the absence of a directory for practicing optometrists in the Canadian Territories, we were not able to include these optometrists. Optometrists to be invited were randomly selected from each list. The sampling rate was lowered to 30% for the more populated provinces (Ontario, Quebec, Alberta and British Columbia) but was 100% for the less populated provinces (Manitoba, Saskatchewan and the Eastern Provinces) to give more equal final numbers of responses, allowing for statistical comparisons between different regionsin a subsequent part of this study (Table 1).

In October 2010, the selected optometrists were invited to participate either by email (if available) or by regular mail, with a cover letter and anenclosed postage-paid return envelope. Only an English version of the questionnaire was sent. We faxed follow-up letters with the original questionnaire approximately six weeks after initial contact to increase response rate. It was noticed that the email questionnaire generated few responses. Therefore, additional paper questionnaires were mailed to optometrists in provinces where the response rate was below 20% and who had initially received only the email version of the survey. By January 2011, the questionnaire collection had been completed.

Data analysis: Descriptive statistics were used with non-parametric statistics to determine medians for the multiple-choice questions. A modification of quantitative analysis was used for the open ended questions. In Questions C11, C12 and C14, respondents were asked to select only the answers that apply and rank in order of importance of the answers. However, many respondents only selected the applicable answers by checking the box beside the multiple choice instead of ranking their choices. Therefore, ranking was discarded and instead, the frequency of choices was counted.

RESULTS

Of the 1851 optometrists sampled, 459 (24.8%) responded. Table 1 provides an overview of the responses by province and region.The proportion of female respondents was 48.8%. The years of practice of the respondents followed a bimodal distribution with one peak (25%) at 0-5 years and another at 26 or more years (25%). The modal city population of their primary practice was 500,000+ (25% of respondents). The most frequent type of practice for optometrists was private group practice or cost-sharing practice (56%), with one being themodal number of optometrists practising in the respondent’s primary practice at one time (40%). In a typical week, the modal response (37%) was that ≥120 patients would be seen in their primary practice.

When asked to estimate the percentage of LV patients seen in their primary practice, the mode and median were 1%. In contrast, Canadian optometrists estimated that a modal value of 10% of their patients had best corrected visual acuity (BCVA) in the better eye of 6/12 and poorer while 90% of their patients had BCVA of better than 6/12 (Figure 1).

Provision of Low Vision Services

Thirty-five percent (161/459) of respondents indicated that there was an optometrist(s) within their primary practice who offered LVcare. The most common type of LVS available within a day’s travel for respondent’s patients was CNIB (n=402), followed by local optometrists (n=309) and multi-disciplinary clinics (n=178). In the “others” option (n=17), respondents indicated that other LVS included the respondent’s clinic itself offering LVS (n=4), hospital (n=4), opticians (n=2), private nurse (n=2), orthoptist (n=1), “low vision clinic close by” (n=1), “independent LV consultant” (n=1) and vision aid store (n=1).

In the three hypothetical case scenarios, we asked how the respondent would manage a hypothetical patient with early macular degeneration (Figure 2A), advanced macular degeneration (Figure2B) and homonymous hemianopia (Figure2C) with specific visual disability(s).When dealing with a patient with early macular degeneration, most optometrists (84.3%) stated that they would undertake vision rehabilitation themselves (i.e. assessing for lighting and magnification).The responses become more diversified when dealing with a patient with multiple visual goals and a diagnosis of advanced macular degeneration or hemianopia. For the patient with advanced macular degeneration, 15% of optometrists would undertake the full LV rehabilitation themselves. Notably for the patient with hemianopia, over 25% of optometrists would provide information about reading techniques, appearing not to address the mobility difficulties. However,further analysis showed that only 5.2% (n=24) of these respondents did not check off another response (i.e. referral to specialized LVS); i.e. they are mostly giving information plus another management.

The level(s) of LVS respondents would provide is depicted in Fig 3 (Question C10). Most respondents (90.6%) wouldrecognize a LV case. Of thosewho did not checked off this choice, the majority of them (32/43) did check off a higher level(s) of LVS, implying that these respondents must be recognizing a LV case. Thus we may assume that only 2.4% would not recognise or provide LV rehabilitation for a patient with LV.Fewer would assess for visual disability (58.2%). The percentage of optometrists who would manage a patient who has more than minimum visual disabilities with more specialized devices (i.e. telescope, electronic LV aids, and custom-designed microscopes) was fewer still (10.7%). Only 3.5% of the respondents would manage a patient with complex goals (i.e. vocational, requiring multiple interventions).

Regarding availability of low vision equipment and devices, 55.4% of respondents had either a logMAR or Feinbloom distance visual acuity chart and 37.1% had the Lighthouse continuous text card or equivalent for near visual acuity. 38% had either a computer generated contrast sensitivity chart (24.7%) or the Pelli-Robson or other paper contrast sensitivity chart (14%). The range of LV devices that respondents had available in their practice can be seen in Table 2, together with the results of Lim et al.24

If the respondents did not manage many patients with minimal amount of visual disability and simple goals using high powered additions and lighting (Level D) or simple optical devices such as magnifiers and filter lenses (Level E) in Question C10 (shown in Figure 3), they were asked to indicate the reasons for not providing this level of management (Figure4A). We chose to explore these levels further, as these are the levels of LV care which can be provided in the optometrists’ offices and may be deemed primary care low visionservices.25,26The most common three reasons were the lack of LV devices (75.3%), the lack of LV equipment (70.7%) and the lack of experience (58.2%).If they responded that their reason for not providing LV was lack of equipment or devices, they were askedtheirreasons for not acquiringLV equipment or devices (Figure4B). The most common three reasons included financial non-viability (60.5%), the lack of demand (58.2%) and the respondent’s lack of interest (45.0%).They were then asked what needs to change for them to be willing to manage more patients with LVand the results are shown in Figure4C. The most common reason was more equipment (64.6%), followed by a fee for LVS (55.6%), more education on LV (48.2%) and funding for devices (47.1%).

Referral Patterns

Most optometrists referred to CNIB (81.9%) while the proportions who referred to local optometrists and ophthalmologists (30.7%) andto multi-disciplinary LVS (30.1%) were almost equal. A small proportion of optometrists did not refer at all (2.0%).The respondents generally rated the availability (40.7% and27.2%) and quality (41.2 and 23.2%) of LVS as good or fairrespectively. However, the frequency of receiving a report back after referral was low. Only 23.6% of respondents almost always or often received a written report from these agencies or individuals while 37.1% of respondents almost never or rarely received one.

Nearly a quarter (22.5%) of respondents would not refer a patient until the BCVA was worse than 6/60 with the majority referring when BCVA was 6/21 to better than 6/60. Fewer optometrists answered the question regarding referral for visual field loss (n=398) compared with the question regarding referral criteria for BCVA (n=436). Of those who did answer, 13.1% would initiate a referral for a LVS only when their patients had a total visual field diameter of less than 20°, although the modal value for referral was when the field was between 35-49°(38.9%).

Written Comments

There were 192 written comments to Question 13 which asked whether the respondent felt that they would benefit from more education on LV, and if so what topics and format would be best. While 30% said they were simply not interested, approximately 70% (n=134) of respondents were opened to more education and/ormade comments about what format such education might take. Optometrists disclosed that training had been/could be done through local LV sales representatives. One optometristmentioned that he and his colleagues “do LV seminars in [their] city”. Many respondents suggested a practical approach, which may include training/workshops with actual LV devices, labs about “real cases” and working a day at a multi-disciplinary LV clinic. The overwhelming themes of the training were practicality and feasibility of providing all or part of the LV optometric service. Optometrists were interested in topics ranging fromhow to set-up a LV clinic, what equipment would be the most useful to patients at a reasonable cost, and how to perform LV assessment in a timely and cost-efficient manner. Respondents were curious to learn about the latest devices (including high tech devices). They also suggested a refresher course on general optical principles and dispensing techniques.Topics of how to manage the psychological aspect of LV and patients’ expectations were also suggested.

There were 113 written comments to the open-ended question about the provision of LV services. These comments provided the respondent’s insight to the topics of accessibility, inter-professional collaboration and fee coverage. Almost one-third (n=7) of comments on good accessibility were made by respondents from Quebec, who complimented government-run LVS. Optometrists who commented on poor accessibility noted that even when there was a LVS available within one or two hour’s travel time, the patient “often cannot drive and has difficulty finding someone to go with them” (Quebec optometrist) and that it is still “too far for seniors” (Ontario optometrist).Accessibility was also hindered due to “long drive over difficult roads… in the winter months” (British Columbia [BC] optometrist) and a long waitlist at the local CNIB (Ontario optometrist).

The comments on inter-professional collaborationswere wide-ranging. Collaborations appeared to occur between optometrists and CNIB in BC and Manitoba, where CNIB would come to their primary practice area and do LV exams and equipment demonstration. Other respondents in BC mentioned referrals to an ex-worker of CNIB after CNIB had closed down and referrals toLV companies “who accept referrals and have a variety of devices available”.