This study presents the vision screening, assessment, common ophthalmologic knowledge, and referral practices of primary care providers in a single GME ambulatory network and the potential impacts on the accesses to, quality, and continuity of care provided to patients. The continuously changing nature of residency programs and health systems structure offers a unique environment to study these vital measures. Regardless of the historical indicators used, or the level of training possessed, the results indicate the potential for improvement in vision screening, assessment, base knowledge, and referral for appropriate ophthalmologic care among GME primary care providers.
The results of this study share similarities to the Continuity of Care in Resident Outpatient Clinics: A Scoping Review of the Literature 8. Examining continuity of care in resident clinics presents a challenge due to the rapid turnover in physicians and different levels of knowledge. The goal of the literature review was an attempt to understand the viable methods to nurture the continuity between resident physicians and patients. The results of this study can be used as a basis to cultivate the continuity of patient care between primary care providers and ophthalmologists within the GME network. This in turn could have a significant impact on the access to and quality of care provided to patients.
It was encouraging that approximately 75% of patients received some form of visual screening at their annual examination (Table 1), even though none of the previously sited FM/IM specialty college guidelines mandate it be done. Visual screening could encompass anything from Snellen visual acuity testing to asking the patient if they have seen an eye doctor in the past year. However, a minority of respondents (16%) indicated they asked patients about their family history of ocular disease. Family history of ocular disease is regarded as one of the primary risk factors in determining if an individual should have an ophthalmologic screening exam as indicated by the AAO.1 Similarly, visual acuity testing was only performed in one out of four patients (Table 2). A potential reason for the results are the different guidance criteria regarding vision screening and ocular disease assessment between specialty collages. The AAO recommends all individuals over age 40 have a complete ocular examination and those over age 65 a complete exam every one to two years.1 Further, individuals with risk factors that have potential visual impact should have a baseline examination. The AAFP and ACP do not include visual screening as part of an adult yearly examination for any age 3-5. They also do not provide specific guidance for ophthalmologic evaluation for diabetic and hypertensive patient
When patients did receive vision screening and/or assessment indicating decreased acuity, all providers (100%) reported they requested an ophthalmology referral (Table 3). However, not all arranged the referral for the patient (12%), and the majority of those providers (58%) indicated they did not communicate to the patient that they should seek an ophthalmology evaluation (Table 3). This calls into question how those who did not directly arrange an ophthalmology referral or suggest it to the patient felt that they “referred” the patient to ophthalmology. These results indicate that when primary care providers have data concerning a patient’s visual status, they make appropriate referrals. This fact alone is strong evidence that visual screening should be part of the routine initial examination protocol for all adults and annually for individuals older than 65 years or those with historic or systemic risk factors.
In this particular survey population, it was interesting that a significant percentage of respondents indicated they did not know where to refer (42%) their patients for ophthalmologic evaluation (Table 4). All FM residents within the surveyed GME system spend two weeks of their training rotating through the ophthalmology service in their PGY3 year. It is possible a large percentage of the respondents that indicated they did not know where to refer patients were junior residents that had not yet completed their ophthalmology rotation. Additionally, IM residents within the system do not rotate through the ophthalmology service. It may be of benefit that all primary care residents rotate with the ophthalmology service early in their training or are provided didactic instruction regarding ophthalmology referral criteria and locations within the GME system. This would increase access to care for patients with ophthalmologic concerns.
It is also notable that 7% of patients were referred to other medicine providers for ophthalmologic evaluation. Due to the anonymous nature of the survey, it is unknown if these referrals were from FM providers to IM providers or if a junior resident was referring the patient to a more senior resident. It is also possible this is a result of providers being unaware of ophthalmology referral services available within the GME system.
It was very encouraging that 100% of the respondents referred diabetic patients for ophthalmologic evaluation (Table 5). While the diabetic referral percentage is very encouraging, the percentage for hypertension was low (16%). The AAO visual screening recommendations for individuals with hypertension are the same as those with DM 1. According to the guidelines, the risk factors that should precipitate referral for a complete ophthalmic examination are DM, HTN, and family history of eye disease. It is interesting to note that some primary care providers considered cataracts and glaucoma “systemic” diseases. This suggests a potential knowledge gap within this area. As outlined in the “Knowledge” section of the RCGFMR, residents should understand ocular manifestations and complications of systemic diseases, as well as guidelines for appropriate intervals for vision evaluation.10 The inclusion of the later is surprising as the ACGME program requirements and college for FM physicians provides no guidance as to these intervals in healthy or diseased individuals. 3, 4
The “Knowledge” section of the RCGFMR also states that residents should understand the effects of drugs and toxins on ocular function and disease.6 Almost half the respondents (42%) were unsure what medications could have potential ocular implications and warrant an ophthalmology referral for evaluation (Table 5). A low percentage (20%) recognized that plaquenil requires ocular monitoring, specifically automatized visual field testing prior to starting medication and then annually while on the medication1. As detailed above, this represent a potential knowledge gap that could affect quality of care, as well as patient safety.
The anonymous design of the survey was a limiting factor in the study. The distributional data between family and internal medicine residents and attendings would provide another level of analysis. However, for this particular study, we felt the potential increase in response rate using the anonymous survey design would add more value to the results than being able to compare responses between provider types. In future studies, being able to obtain such acuity in the data would provide insight into if attendings were also unaware of referral guidelines and/or resources or if training level or residency type were the primary variables. As the design of ACGME resident training programs are top down, a deficiency in attending knowledge surrounding these topics could certainly influence the residents’ knowledge base. Further, being able to compare the responses of residents that had an ophthalmology rotation versus those that did not within and between medicine specialties would also provide useful data on the effectiveness of specialty rotations in primary care GME training. This would have particular utility in determining how residents work in interspecialty teams to provide continuity of care, which can directly impact the quality of care and patient safety.
Based on the data, we propose two recommendations to improve primary care residents training in ophthalmic concerns and potentially increase access to and quality of care within a GME ambulatory health system. First, maximization of the historical indicators and visual screening used by primary care providers. Screening is a vital tool for physicians to gauge the health of our patients, thereby decreasing the likelihood of missing pathology. Every patient should be questioned about visual history and function at every annual or new patient visit. Visual acuity is recommended to be assessed at all initial visits or annually in those above 65 or with risk factors. Those who present with visual symptoms or complains should also receive Snellen acuity testing. Visual impairment is associated with falls in several studies, and those studies suggest patients having a screening at least every two years, and any refractive error corrected9, 11. Due to the overall 1-year mortality being around 21.2% for hip fractures, annual assessment in susceptible populations would likely have an impact on quality of care and patient safety.12.
The second recommendation is education of primary care providers regarding ophthalmologic issues as outlined in the RCGFMR about the available ophthalmology referral options within the GME network at the onset of their training. To achieve this, annual didactics and interdisciplinary meetings between ophthalmology and primary care providers should be scheduled13. The interdisciplinary meetings are a two-fold solution. First, these meetings are an educational opportunity for specialists and primary care providers to share knowledge about topics. Second, to educate new providers within the GME network of available resources for referral and assistance in co-managing patients.