You Can Provide Cost-Effective Glaucoma Care
Our panel of experts tells you how to streamline your glaucoma practice while also improving the quality of patient care.
Compiled by Jerry Helzner, Associate Editor

"Too many ophthalmologists look at the glaucoma segment of their practices as a loss leader," says Alan L. Robin, M.D., P.A. "That doesn't have to be the case. Glaucoma is an area in which you can definitely deliver the highest quality care in a cost-effective manner."

In this article, Dr. Robin and other experts will provide you with recommendations to improve the quality and profitability of your glaucoma practice. They address screening, patient flow, examinations, trabeculectomies, laser treatments and nerve fiber layer (NFL) analysis.

Before we turn to our experts, note that many of the basic business philosophies that are part of conducting a cost-effective glaucoma practice also apply to your general ophthalmology practice. That means providing an office layout that promotes efficiencies and smooth patient flow. You should make it simple for your staff to retrieve information with an easy-to-use computer system and create employee-friendly arrangements for storing charts and finding forms. When you have such a system, the following recommendations specific to glaucoma care will be of even more value in saving time and reducing costs.

Screening TIP: Alan L, Robin, M.D., P.A., associate professor of ophthalmology and international health, Johns Hopkins University, clinical professor of ophthalmology, University of Maryland

If you have a typical ophthalmology practice, probably about one-third of your patients should be screened for glaucoma. You should screen everyone in the following groups:

• African Americans above the age of 50
• Caucasians and Hispanics above the age of 60
• anyone with a family history of glaucoma
• anyone who hasn't had an eye exam after the age of 40
• anyone with a cup-to-disk ratio greater than 0.5
• anyone with a cup-to-disk asymmetry greater than 0.2

I use FDT (Frequency Doubling Technology) or the Oculus Easyfield perimeter for screening. These are more sensitive and specific as screening methods compared with intraocular pressure (IOP) or cup-to-disk ratios. They're also much more accurate. For example, with the FDT test, four major signs indicate a patient is glaucoma-suspect:

• any defect in the central five locations
• two mild or moderate defects in the outer 12 spots
• one severe defect in the outer 12 spots
• a test-completion time of more than 90 seconds.

An FDT instrument is also simple to operate. A technician can set up the basic screening test correctly with little training. FDT provides time-effective screening -- about 90 seconds for most patients. It costs about $7,000 to buy and will pay for itself if you diagnose three new glaucoma cases a month.

FDT screening will give you the answers to two important questions: "Should I continue and perform a threshold visual field on this patient?" and "If so, which visual field test (C-24-2 or C-10-2) should I use?"

When using the FDT perimeter, I prefer the Swedish Interactive Threshold Algorithm (SITA) standard test. The SITA fast standard test takes about 5 minutes, as compared to about 10 minutes for the FastPack test and 16 minutes for traditional visual field testing.

I believe in the shorter test for two main reasons. One, the information you get in the first few minutes is the most valuable information you'll get from a visual field test. Two, SITA is a much less stressful, more patient-friendly test that saves you time, as well. You'll need an HFA-2 machine to do the SITA fast visual field test. But it will enable you to do three visual fields in an hour instead of two.

The Oculus Easyfield, at a cost similar to the FDT, has the advantage of performing both suprathreshold screening perimetry and threshold perimetry with the same instrument, which may make it more cost-effective for your office.

You can be reimbursed for doing visual fields on glaucoma-suspect patients. These include individuals with a 0.6 cup-to-disk ratio nerve fiber layer loss, cup-to-disk asymmetry, or an IOP higher than 25.

Patient Flow TIP: Eve J. Higginbotham, M.D., professor and chair, Department of Ophthalmology, University of Maryland School of Medicine

One of the difficulties in seeing glaucoma patients is trying to complete a number of tests in one visit. If a patient comes in for a visual field as a part of his visit, it's more time efficient if the person who's doing the visual field first screens the patient and then does the visual field, rather than dropping off the patient and waiting for someone else to complete the field.

We were able to decrease the length of visits by 20% by dividing our technicians into those taking new patients who need visual fields and those taking return patients who may need visual fields. Either another technician or the physician calls in the pressure checks directly. If you construct a flow chart of the visit from a patient's perspective, you will identify steps that contribute to hidden waiting time and should be eliminated.

Simply reducing the number of times a patient must change providers can lead to a significant reduction in the time the patient spends in your practice.

Chart Review TIP: Murray Johnstone, M.D., in private practice in Seattle, Wash., and consultant in glaucoma, the Swedish Medical Center

Chart review can be time consuming with glaucoma patients because they often have complex medical histories, and take multiple systemic medications. They also often take multiple ocular medications and have had multiple laser or operating room procedures in one or both eyes. Integrating all the information related to the patient's past experience and current status is essential, but can be difficult. Well-organized charting approaches simplify management of these patients.

For a patient who is newly diagnosed or enters the practice with a history of glaucoma, it's extremely helpful to develop a new glaucoma patient entry sheet. We color code the sheet and place a colored tag at the right edge of the sheet. This permits immediate access to our entry assessment.

The glaucoma entry sheet contains specific sites that address each of the major glaucoma-related issues, such as date of initial glaucoma diagnosis, prior glaucoma surgeries, prior glaucoma medications discontinued because of allergy, intolerance or ineffectiveness, and systemic issues relevant to glaucoma. The sheet also contains a location for drawing the initial gonioscopic finding, as well as an optic nerve head drawing. Using this system, we quickly refamiliarize ourselves with the patient's presenting status.

Tracking of prior surgeries can be complex and require a lengthy chart review. We employ a simple tool: use of the chart jacket to record the information. We assign a specific color code to each type of laser or OR procedure and place the appropriately colored tag along the top of the chart jacket. The date of surgery is underneath the tag. Comprehension of colored icons is almost instantaneous and much more rapid than reading. In seconds, I have a complete grasp of the prior surgical history by simply glancing at the chart jacket. An example of the usefulness is the specific color coding of first and second-stage argon laser trabeculoplasty (ALT), which can be grasped immediately without the need to search through the chart each time.

Medical decisions require integration of multiple inputs: current IOP, current medications, prior response to initiation of medications, systemic contraindications, prior lack of response, intolerance or allergy to medications and diurnal swings. All of them are integrated into a flow sheet, which we update at each visit. The flow sheet carries not only the current medications, but also embeds and carries forward systemic contraindications and prior experience with ocular medications.

Carrying forward the relevant systemic and ocular medication information about the patient is especially valuable because it minimizes the need to go backward through the chart at each visit. Brief looks at the chart cover, entry sheet, the pattern of pressures on the flow sheet, and a review of new flow sheet entries provide a relatively complete and rapid summary of the patient's history. More importantly, the updating and correlation of pressure with other relevant issues within the flow sheet allows an easily comprehensible integration of all the issues.

Trabeculectomy TIP: Alan S. Crandall, M.D., professor of ophthalmology, University of Utah

Trabeculectomy is considered the gold standard of surgical glaucoma management. Fortunately, I've found several ways to reduce my costs for performing the procedure by 25 to 30% while still delivering high-quality care for the patient.

One fairly simple thing I do is use a half-drape for the patient at about one-third the cost of a full drape. It's easy to use a half-drape and still maintain a sterile field.

I also use topical anesthetics, which I've found to be just as effective as a retrobulbar injection. I use three drops of .075% bupivacaine hydrochloride (Marcaine) and then put 2% lidocaine gel (Anestacon) in the upper cul de sac. We're saving time by using topical anesthetics instead of blocks. As a precautionary measure, I also put in a hep lock in case intravenous medications, such as relaxants, are needed.

I use three operating rooms, with one anesthesiologist supervising three nurse anesthetists.

I perform approximately 300 trabeculectomies a year, averaging about 30 minutes each in an ASC. With reimbursement ranging from $750 to about $1,250, depending on your location, you can see that the savings you can generate from these suggestions can flow directly to your bottom line.

Lasers TIP: Reay H. Brown, M.D., in private prac- tice in Atlanta, Ga.

Most doctors are still using argon lasers for trabeculoplasty. I have a number of reasons for preferring a solid-state laser. Several solid-state lasers are available, but I use the Iris 532. Compared to an argon laser, which requires a dedicated room, water cooling and lots of upkeep and maintenance, the 532 has these advantages:

• smaller, lightweight and portable
• connects to a regular wall outlet; ready for use in seconds
• can be used in a regular exam room
• disconnects from a slit lamp in seconds
• doesn't require water cooling
• extremely sturdy and reliable with easy maintenance
• replacement laser available by overnight mail.

My experience is that trabeculoplasty is a highly effective -- but currently very underused -- procedure. With most of my glaucoma patients, I try one medication and if that doesn't provide enough of a benefit, the next step is laser treatment. The procedure provides a good result and generally produces no side effects. I see trabeculoplasty as a win-win-win situation because it's cost-effective, time-effective and produces real benefits for the patient.

Optic Nerve & Nerve Fiber Layer Imaging TIP: Thomas W. Samuelson, M.D., attending surgeon, Minnesota Eye Consultants and Phillips Eye Institute, Minneapolis, Minn., clinical associate professor, University of Minnesota

When should we use optic nerve and nerve fiber layer analysis? Glaucoma suspects and individuals with early glaucoma are the best candidates for these tests. Optic nerve and nerve fiber imaging can help us make decisions in this group of patients. I believe that one of the most glaring deficiencies in glaucoma management involves accurate diagnosis of glaucoma in the pre-perimetric stage, or prior to manifest visual field loss.

Research shows that a large percentage of ganglion cells are lost before abnormality is detected on traditional achromatic field testing. Even when early visual field changes are identifiable, they are highly variable and often aren't reproducible. This is where optic nerve and nerve fiber layer imaging can help us by telling us what's going on anatomically.

You can now be reimbursed for testing with the various imaging systems (most widely accepted are the GDx from Laser Diagnostic Technologies, the Heidelberg unit and OCT from Humphrey), so it's now economically feasible to own or lease this technology. However, these tests must be used judiciously with select patients.

These tests often help achieve cost savings because they may allow you to follow glaucoma suspects without treating them. The disc exam is equivocal. Unfortunately, IOP is notoriously nonspecific and insensitive. Many clinicians would treat borderline cases out of concern they were missing early damage. NFL analysis adds additional information to help make the decision whether to initiate treatment. Borderline patients may include those who have asymmetrical cupping. These scans may reveal that the disc asymmetry results from asymmetric optic nerve head diameter, a finding that's often overlooked clinically. NFL analysis also helps differentiate physiological cupping from pathological cupping. (See this month's "Practice Watch" for glaucoma care coding tips.)

The search for better methods continues

The wide range of recommendations outlined above aren't the final word on making glaucoma care more efficient. These doctors are continuing to seek ways to deliver quality treatment in a more time- and cost-effective manner.

"I'm always trying to optimize the use of my time," concludes Dr. Johnstone. "It can be frustrating, but it's always a good feeling to discover what you can do better."