You're Only In Up To Your Knees

Even after two decades of TPAs, optometrists remain in the shallow end of the therapeutic treatment pool.

John Murphy,
Senior Editor

What are you prescribing for?

It's almost 2001, about 25 years since West Virginia became the first state to institute an optometric TPA act. Since then, every state has approved some form of therapeutic prescribing authority. In 45 of 50 states now, optometrists can prescribe glaucoma drugs.

Gaining the rights to prescribe drugs has been a hard-fought battle in almost every state. Before you go on to fight for further privileges, take a minute to determine where you stand now. Here's a look at the state of therapeutics for optometrists-how many of your colleagues are TPA-certified, which drugs they prescribe most, how much they're earning by providing this treatment and how many 'scripts they are writing.

TPA Certification
Therapeutic agents are useful for the optometrist only if he or she is certified to prescribe them. The good news is that almost all optometrists in the United States are DPA certified (about 95%). The rest of the story-encouraging news rather than bad news-is that about three-quarters are also TPA certified. This information comes from the Results of the First National Census of Optometrists, submitted to the AOA by Project HOPE Center for Health Affairs, and is the most recent information available that analyzes TPA certification, albeit from 1998.

Randall Thomas, O.D., of Concord, N.C., a frequent lecturer on pharmaceuticals and co-author of Review of Optometry's Clinical Guide to Ophthalmic Drugs, says that in terms of prescribing therapeutics, many optometrists are still getting their feet wet. As a group, he says, O.D.s are "probably up to their kneecaps." Yet they could be qualified enough to be in up to their eyeballs. "We're doing so much better, but we have so far yet to go."

Parts of the country are in deeper than others. By region, the Midwest leads the pack in TPA certification; 87% of O.D.s there have it, says the National Census report. The South is similar, with 86% of O.D.s certified. Then comes the West, with 65%, and the Northeast, with 45%. Of course, one must consider the scope of the TPA laws within each region (see "Optometric Therapeutic Authority, State by State."). For example, in Pennsylvania where the TPA law is just four years old and is more limited than in most other states, only 15% of docs are certified. In Oklahoma on the other hand, 91% are.

These data do support the notion that O.D.s in rural areas-where it's not so easy for patients to get to an ophthalmologist-assume greater patient care. In general, more optometrists in non-metropolitan counties are TPA-certified vs. their city-dwelling colleagues.

Interestingly, the fewer ophthalmologists in town, the more certified O.D.s there are. For example, when the ratio of optometrists to ophthalmologists in an area is 1-1 or fewer, only 70% of those optometrists are TPA certified. But in areas with no ophthalmologists, 87% of O.D.s are TPA certified. "Clearly, the ability to prescribe drugs for therapeutic purposes is an important part of an O.D.'s practice in markets with relatively fewer ophthalmologists," says the National Census report.

Also interesting, optometrists younger than 35 are more inclined to be TPA-certified (85%) than any other optometric age group.

TPA-Derived Revenue
Over the past 20 years, optometrists have lobbied aggressively for TPA privileges. But the fruits of that labor appear to be professional satisfaction rather than personal gain. In February 1998, Review of Optometry's National Panel, Doctors of Optometry survey reported that 7 in 10 doctors earn less than 10% of their practice gross from treating disease, and more than half earn less than 5%.

No data are available to pinpoint more recent numbers for therapeutic-based revenue, concedes Richard Edlow, O.D., chair of the AOA's Information Data Committee. But when pressed, Dr. Edlow came up with a "very ballpark" figure of about 8.25% of the average optometrist's gross practice revenue coming from therapeutic treatment. That's about $35,000 of gross.

It's more of a guess than science, he says, and only partially based on the statistics he's seen. Here's how he came up with it: Average gross income for O.D.s was $420,077 in 2000, reports Review of Optometry's National Panel, Doctors of Optometry income survey (see page 44).

Dr. Edlow estimates that about one-third of average gross practice income comes from professional services. Of that number, he says, probably about 25% is medically-oriented income. (Thus, $420,077 x 33.3% x 25% = $35,006.) Dr. Edlow says that the Information Data Committee is planning on expanding its surveys to track optometrists' thera- peutic usage, and maybe will derive income information from that. Thus, optometrists will be able to benchmark their prescription writing (and therapeutically-derived income) to help determine where their practice stands, and where it should be headed.

Favorite Pharmaceuticals
The areas of growth for optometric prescriptions are allergies, glaucoma and dry eye treatment, predicts Bobby Christensen, O.D., a lecturer on therapeutics and a private practitioner in Midwest City, Okla. "We'll witness growth [in prescriptions] with these conditions ... because these ailments are chronic problems, and quite frankly you don't really ever fix them."

(Unless otherwise indicated, the prescription data below come from NDC Health Information Services.)
  • Allergy. The growth in optometrists' anti-allergy prescriptions in the past year has increased 37%, the biggest growth of any category. It's probably due mostly to the new and newer treatments available, and three of those newer drugs (Patanol, Zaditor, Alrex) are already among O.D.s' top five allergy drugs: Patanol (olopatadine), Zaditor (ketotifen fumarate), Livostin (levocabastine), Alocril (nedocromil) and Alrex (loteprednol).

    Patanol is a top drug that's safe and comfortable, but "if these other medications are effective, we'll probably see a decrease in the use of Patanol just from the competition," says Daryl Mann, O.D., who runs a secondary-care practice in Chattanooga, Tenn.

    Meanwhile, NSAID prescriptions have dropped by more than 10%. "One way to interpret that would be that optometrists as a group have probably been less than totally impressed in the use of NSAIDs for the treatment of inflammation and allergy," Dr. Mann says. He also speculates that doctors may now be using Lotemax (loteprednol)-a "safer" steroid-instead of an NSAID. The data seem to bear that out; Lotemax prescriptions have more than doubled in the past year.

  • Glaucoma. Optometrists have written 25% more prescriptions for glaucoma medications this year compared with 1999. The lion's share of that can be chalked up to Xalatan (latanoprost), which has edged out TobraDex (tobramy- cin/dexamethasone) as optometrists' most-prescribed drug overall.

    Xalatan is not approved as a first-line therapy, but a lot of doctors are using it that way, and understandably so, Dr. Christensen says, because it's effective and has good compliance. He adds that he prefers Betoptic-S (betaxolol suspension) or Alphagan (brimonidine) as his first-line and second-line therapies. Indeed, Alphagan is optometrists' fourth most prescribed drug overall. Dr. Christensen favors it in part because of its potential neuroprotective ability.

  • Dry Eye. It doesn't require a prescription drug, but dry eye is one of the most common conditions that optometrists treat. According to our annual Ophthalmic Product Research (OPR) surveys, the dry eye agents that optometrists prescribe most often are (in descending order): Refresh PM, GenTeal, AKWA Tears, Refresh and TheraTears.

Rx Writing
The average O.D. writes about nine or so 'scripts a week, our OPR survey shows. "We're getting new and better ophthalmic pharmaceuticals almost each quarter, and there seems to be a flurry of drugs coming to market to really enhance our care," Dr. Thomas says. Perhaps that's one reason why optometrists have increased their prescription writing by 20% in the past year, NDC data show.

But even these bigger numbers are probably under-reported, Dr. Mann says. There are a few reasons why. For one, the agencies that track who's writing prescriptions use DEA numbers, but optometrists in some states cannot get these numbers. Also, in some ophthalmologist-owned practices, the prescription is credited to the ophthal- mologist owner, not the optometrist employee who writes it. Lastly, optometrists are giving out sample bottles for some conditions instead of writing prescriptions.

Bottom line, "these are exciting times, and optometry's just beginning to really immerse itself in these newer therapeutic modalities," Dr. Thomas says. So if you're not yet in up to your knees (or even if you are), start wading in further, he encourages.

Up North and Down Under—TPAs at a Glance

Other countries look to the United States for leadership in TPA legislation. Here's a look at what's happening at two opposite points on the globe:

Australia. The Aussies haven't been busy just with the Olympics. The first Australian optometrists (those in the state of Victoria) should be prescribing drugs in a month or so, the Optometrists Association of Australia reports. Optometrists in Victoria had passed a TPA act in 1996. Since then, the state board drew up qualifications and has just administered the first TPA course. The TPA act in Victoria permits essentially all topicals, but no oral or injectible drugs. Tasmania has also passed a similar TPA act earlier this year, and the states of Queensland and New South Wales are pushing legislation. Other states are taking a "wait-and-see" approach based on what happens in Victoria.

Canada. Optometrists in Quebec were able to amend their act in June to prescribe therapeutics. The specific medications and treatments are still being discussed, the Canadian Association of Optometrists says. Elsewhere, optometrists in Alberta, New Brunswick and the Yukon are able to prescribe topicals, remove foreign bodies and comanage glaucoma. Saskatchewan optometrists can use topicals except those for glaucoma, posterior uveitis and in some cases anterior uveitis. Optometrists in Nova Scotia can use topicals except steroids and glaucoma drugs. The remaining provinces have no TPAs. "Optometrists really provide the bulk of primary eye care," says Glenn Campbell, executive director of CAO. "In parts of Canada, access to ophthalmology is just very difficult in terms of distance and waiting time ... It just makes sense for optometrists to be prescribing and treating."

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Optometrists' Top 10 Most Prescribed Pharmaceuticals
  Prescriptions, Year Ending September 1999 Retail Dollars, Year Ending September 1999 Prescriptions, Year Ending September 2000  Retail Dollars, Year Ending September 2000
Xalatan 300,000 $13,934,000 415,000 $20,679,000
Tobradex 338,000 $12,131,000 400,000 $16,460,000
Patanol 212,000 $11,315,000 297,000 $17,542,000
Alphagan 116,000 $4,987,000 158,000 $7,596,000
Ciloxan 95,000 $2,975,000 124,000 $4,301,000
Ocuflox 77,000 $2,520,000 109,000 $3,789,000
Tobramycin 100,000 $1,292,000 106,000 $1,373,000
Prednisolone Acetate 81,000 $1,550,000 96,000 $1,861,000
Timoptic XE 101,000 $3,075,000 85,000 $2,669,000
Polymixin B/Trimethoprim 71,000 $1,327,000 84,000 $1,546,000
Source: NDC Health Information Services
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Pharmaceuticals Prescribed by Optometrists, by Category
Prescriptions, Year Ending September 1999 Prescriptions, Year Ending September 2000 Percentage Change

Total Prescriptions
3,105,000 3,725,000 20.0%
 Glaucoma 912,000 1,144,000 25.4%
  • latanoprost, alpha-agonists & miotics
419,000 576,000 37.5%
  • beta-blockers
 411,000 484,000 17.7%
  • carbonic anhydrase inhibitors
 82,000 84,000 2.4%
Antibiotics  537,000  624,000 16.2%
Antiallergy  339,000  466,000 37.5%
Antivirals 391,000 452,000 15.6%
Corticosteroids and Steroid Combinations 253,000 275,000 8.7%
 NSAIDs 86,000 77,000 -10.5%
Source: NDC Health Information Services
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Optometric Therapeutic Authority, State by State
 State Allergy
Oral Pain Medications
Alabama T, O T, O T, O T, O yes
Alaska T T T T no
Arizona T, O T, O T T, O ‡ yes
Arkansas T, O T, O T, O T, O yes
California T, O T, O T T yes †
Colorado T, O T, O T, O T, O ‡ yes
Connecticut T, O T, O T, O T, O yes
Delaware T, O T, O T, O T yes †
District of Columbia T, O T, O T, O T, O ‡ yes
Florida T T T T no
Georgia T T T T yes
Guam T, O T, O T, O T, O yes
Hawaii T T no T ‡ no
Idaho T, O T, O T, O T, O yes
Illinois T T T T yes †
Indiana T,O T, O T, O T, O ‡ yes †
Iowa T, O T, O T, O T yes
Kansas T, O T, O T, O T, O yes
Kentucky T, O T, O T, O T, O yes
Louisiana T, O T, O T T no
Maine T, O T, O T T, O ‡ yes
Maryland T T, O T T ‡ no
Massachusetts T T no T no
Michigan T T T T no
Minnesota T T T T no
Mississippi T T T T no
Missouri T, O T, O T, O T, O yes
Montana T, O T, O T, O T, O yes
Nebraska T, O T, O T T, O ‡ yes
Nevada T, O ‡ T, O T, O T yes
New Hampshire T T, O no T ‡, O ‡ yes
New Jersey T T T T no
New Mexico T, O T, O T, O T, O ‡ yes
New York T T T T no
North Carolina T, O T, O T, O T, O yes
North Dakota T, O T, O T, O T, O yes
Ohio T, O T, O T, O T no
Oklahoma T, O T, O T, O T, O yes
Oregon T T T T nos
Pennsylvania T T, O no T ‡ yes
Puerto Rico no no no no no
Rhode Island T T T T no
South Carolina T, O T, O T, O T yes
South Dakota T T T T yes
Tennessee T, O T, O T, O T, O yes
Texas T, O T, O T, O T, O ‡ yes
Utah T, O T, O T, O T, O yes
Vermont T T no T no
Virginia T T T, O T yes
Washington T T T T no
West Virginia T, O T, O T, O T, O yes
Wisconsin T, O T, O T, O T, O yes
Wyoming T, O T, O T, O T, O ‡ yes
T = Topical pharmaceutical agents. O = Oral pharmaceutical agents. ‡ = No steroids. † = No controlled narcotics.

Sources: American Optometric Association; California Optometric Association.

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© Review of Optometry OnLine

November 15, 2000
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