The United States had 139,688 physician assistants (PAs) in 2019.1 Thirty-five percent of all PAs were working primarily in primary care, urgent care, and emergency medicine.2 For PAs specializing in ophthalmology, we previously reported on an example of integrating a PA into an ophthalmology consult service and evaluated the scope of practice for PAs in ophthalmology across the United States.3,4 Little is known about the extent of PA involvement in vision and ocular care outside ophthalmology.
We hypothesize that PAs working in nonophthalmology settings, such as the ED, urgent care centers, and primary care setting, may frequently encounter patients with ophthalmologic problems. An estimated 24 million people in the United States have had an eye injury in their lifetime.5 Patients with eye injuries frequently go to their primary care provider and/or to the ED.6-9 Furthermore, nonemergency conditions account for almost half of all eye-related ED visits.9 Four baseline goals from Healthy People 2030 address vision: to reduce vision loss from diabetic retinopathy, glaucoma, cataract, and from age-related macular degeneration.10 The International Council of Ophthalmology recommends that patients with diabetes be screened regularly for diabetic retinopathy.11 With the dearth of ophthalmologists, these screenings may be done by other clinicians, such as PAs in the office setting.4
With ED visits for urgent and nonurgent eyecare and the potential need for nonophthalmologists to participate in diabetic retinopathy screenings, PAs, particularly those in primary care, emergency medicine, urgent care, endocrinology, hospital medicine, and internal medicine, may encounter ocular or vision issues at some point in their career. This potentially increases the role of PAs in the provision of eyecare. To date, no published research has examined the prevalence of PAs engaged in vision and ocular care, what training they have had in this area, and what training may be needed. This study evaluated the characteristics, training, and self-reported skills and abilities in vision and ocular care of PAs who do not specialize in ophthalmology.
METHODS
We developed a survey on vision and ocular care in the PA profession for distribution among PAs. The vision and ocular care survey was designed by a study team including physicians and PAs and was not previously validated. The survey consisted of 53 multiple-choice as well as Likert-scale questions, covering topics including vision and ocular care experience, training, and self-reported current and desired skill and ability levels in eight specific skills and abilities. The Johns Hopkins University School of Medicine institutional review board determined that this survey study did not constitute human subjects research, and thus was exempt from review.
The survey had two parts: a general PA survey that focused on practice demographics followed by an optional secondary PA survey on vision and ocular care. The general survey, which was unrelated to the current research and not reported on in this study, was distributed to 5,763 PAs in the United States randomly selected from the American Academy of Physician Associate' (AAPA's) PA database; and included AAPA members and nonmembers.
This study focused on practicing PAs who filled out the vision and ocular care survey after completing the general survey. PAs who were practicing or had practiced in ophthalmology were excluded from this analysis because their responses were previously published.7 Survey participants were informed that voluntary completion of the survey served as their consent to participate in the study. All survey questions were optional.
The survey was distributed electronically using Alchemer between March and April 2019, during which four electronic reminders were sent. Response data were downloaded and analyzed using SPSS Statistics version 27. Because all questions were optional, percentages and sample sizes are reported for data not listed in tables.
Before data analysis, participants were categorized as involved in eyecare if they reported that they performed all three of the following services with patients more than once per month: provided information on, answered questions about, and initiated discussions regarding vision care and ocular health. All other participants were categorized as uninvolved in eyecare.
Vision and ocular care practice patterns and training were analyzed with descriptive statistics, including z-tests for column proportions where appropriate for between-group significance testing and comparison. For eight different skills and abilities, current versus desired skill and ability levels were measured with a scale of 1 to 5, with 1 indicating no skill and ability and 5 indicating strong skill and ability. Given the ordinal nature of the data, an ordinal logistic (cumulative proportional odds) regression was performed with skill and ability level as the dependent variable, skill, and ability type (current versus desired) as a within-subjects repeated measure, and PA type (PAs not involved in eyecare versus those involved in eyecare) as a between-subjects predictor, with an interaction term (skill and ability type by PA type). In addition to frequencies and proportions of skill and ability levels across factors, odds ratios and 95% confidence intervals (CIs) were calculated for the ordinal logistic regression model. Odds ratios are in reference to the opposite category (for example, desired is in reference to current, and involved in eyecare is in reference to not involved in eyecare). For interaction effects, odds ratios are for the desired versus current skill and ability levels among PAs involved in eyecare versus PAs not involved in eyecare. When odds ratios are greater than 1 and confidence intervals do not include 1, the odds of the factor being higher than the reference group are significantly greater.
RESULTS
At the conclusion of a separate general study, 537 PAs were solicited to complete the vision and ocular care survey. The vision and ocular care survey had a response rate of 71.1% (382 of the PAs who completed the general PA survey agreed to participate in the secondary vision and ocular care survey). Of the original random sample of PAs, 6.6% were included in the final vision and ocular survey. This resulted in a sample of 335 PAs after excluding 47 responses from PAs who were practicing or had practiced in ophthalmology.
Of the 335 PAs in the analysis, 19.4% reported primarily practicing in primary care (family medicine, general internal medicine, or general pediatrics), 15.5% in emergency medicine or urgent care, and 63.3% in another medical or surgical specialty; 1.8% did not indicate their primary specialty. Nearly half of the PAs (49%) worked in a physician office or clinic setting, 36.1% worked in a hospital, and 14.9% worked in other settings or did not report their primary work setting. Participant sex demographics were not collected.
Among all participants, average experience as a PA was 10.4 years (SD = 9.1). One quarter (23%) of PAs were categorized as involved in eyecare and reported a mean 10.8 years of experience as a PA (SD = 9.3); they practiced primarily in primary care (46.8%) and emergency medicine and urgent care (24.7%). The remainder of the participants (77%) were categorized as not involved in eyecare; these PAs reported an average of 8.8 years of experience (SD = 8) and had less representation in primary care (11.2%) and emergency medicine and urgent care (12.8%).
PAs involved in eyecare engaged in vision and ocular care services more frequently than PAs not involved in eyecare (Figure 1). PAs involved in eyecare provided vision and ocular health information more frequently than PAs not involved in eyecare (chi-square [2, N = 333] = 214, P < .001), were asked questions about vision and ocular health (chi-square [2, N = 332] = 215.86, P < .001), and initiated discussion about vision care and ocular health or concerns (chi-square [2, N = 330] = 214, P < .001). Additionally, compared with PAs not involved in eyecare, PAs involved in eyecare more frequently referred patients to vision and ocular healthcare providers for care (chi-square [2, N = 330] = 141.7, P < .001) and were challenged with and unsure of the best response to a patient's vision care and ocular health questions or concerns (chi-square [2, N = 327] = 46.18, P < .001). These results validated the categorizations made by the authors for comparison in this study.
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FIGURE 1.: Frequency of vision and ocular care
Among all PAs, 84.4% reported that they knew where to refer patients who were looking for vision and ocular care. This significantly differed by PA type, with 92.2% of PAs involved in eyecare reporting that they knew where to refer patients, compared with 82.1% of PAs not involved in eyecare (chi-square [1, N = 334] = 214, P = .032). Among PAs who reported knowing where to refer patients, 39.9% referred patients to ophthalmologists, 0.4% referred to optometrists, and 59.8% referred to both. No difference was found in referral patterns between PAs involved in eyecare and PAs not involved in eyecare (chi-square [2, N = 281] = 0.49, P = .781).
Vision and ocular care training
Among all PAs, 72.3% received vision and ocular care training in PA school, 8.2% received training outside PA school, and 22.6% received no training (Figure 2). This did not differ between PAs involved in eyecare and PAs not involved in eyecare (chi-square [3, N = 328] = 2.64, P = .451).
FIGURE 2.: Source of vision and ocular care training
Of the 235 participants who reported receiving vision care training in PA school, 92.8% indicated that training consisted of lectures, clinical exposure (51.5%), self-directed education or research (19.6%), pharmaceutical-provided education that is not continuing medical education (CME; 8.1%), and other (3.8%); this did not differ between PAs involved in eyecare and PAs not involved in eyecare (chi-square [5, N = 235] = 7.73, P = .172).
Of the 27 participants who reported receiving vision care training outside PA school, 40.7% indicated that training consisted of lecture or CME, clinical exposure (85.2%), self-directed education or research (44.4%), pharmaceutical-provided education that is not CME (0%), and other (22.2%); this did not differ between PAs involved in eyecare and PAs not involved in eyecare (chi-square [4, N = 27] = 6.17, P = .187).
Needs assessment
The frequencies of the current and desired skill and ability levels across eight skills and abilities are shown in Tables 1 and 2. Among all PAs, there were significantly greater odds of reporting higher desired skill and ability levels than current levels for all eight skills and abilities, ranging from an odds ratio of 1.8 (CI, 1.49-2.18) for checking visual acuity to an odds ratio of 4.48 (CI, 3.42-5) for fundus examination with direct ophthalmoscope to visualize nerve and/or retina (Table 3). PAs involved in eyecare had significantly greater odds of reporting higher desired and current skill and ability levels compared with PAs not involved in eyecare, with the exception of slit-lamp examination (OR, 1.55; CI, 0.97-2.48) and fundus examination with direct ophthalmoscope to visualize nerves and/or retina (OR, 1.30; CI, 0.87-1.96). Finally, skill and ability type (desired versus current) and PA type (involved versus not involved in eyecare) interacted for six out of eight skills and abilities, such that the difference between desired and current skill and ability levels were significantly larger among PAs involved in eyecare for six out of eight skills and abilities. However, this interaction was not significant for two of the eight skills and abilities: checking pupils, extraocular movements, and confrontation visual fields (OR, 1.41; CI, 0.79-2.54) and checking visual acuity (OR, 1.45; CI, 0.83-2.54).
TABLE 1. -
Frequencies for PAs involved in eyecare
|
|
|
Self-reported skill and ability levels (% of N) |
| Skill and ability |
Factor |
N |
1: None |
2 |
3 |
4 |
5: High |
| Identify patients with key risk factors for vision and ocular disease |
Current |
69 |
1.5 |
5.9 |
51.5 |
32.4 |
8.8 |
| Desired |
69 |
0 |
0 |
13.2 |
26.5 |
60.3 |
| Identify signs of vision and ocular health emergencies |
Current |
69 |
0 |
13.2 |
30.9 |
30.9 |
25 |
| Desired |
69 |
0 |
0 |
2.9 |
20.6 |
76.5 |
| Discuss potential risks/benefits of common interventions to treat common vision/ocular diseases |
Current |
69 |
0 |
23.5 |
47.1 |
26.5 |
2.9 |
| Desired |
69 |
0 |
5.9 |
11.8 |
32.4 |
50 |
| Check pupils, extraocular movements, and confrontation visual fields |
Current |
69 |
0 |
0 |
7.4 |
27.9 |
64.7 |
| Desired |
69 |
0 |
0 |
0 |
14.7 |
85.3 |
| Check visual acuity |
Current |
69 |
0 |
1.5 |
5.9 |
25 |
67.6 |
| Desired |
69 |
0 |
0 |
2.9 |
11.8 |
85.3 |
| Slit lamp examination |
Current |
69 |
35.4 |
26.2 |
16.9 |
16.9 |
4.6 |
| Desired |
69 |
9.2 |
3.1 |
12.3 |
23.1 |
52.3 |
| Fundus examination with direct ophthalmoscope to visualize nerve and/or retina |
Current |
69 |
2.9 |
48.5 |
26.5 |
19.1 |
2.9 |
| Desired |
69 |
1.5 |
8.8 |
10.3 |
17.6 |
61.8 |
| Remove foreign bodies from the ocular surface |
Current |
69 |
14.7 |
22.1 |
30.9 |
19.1 |
13.2 |
| Desired |
69 |
4.4 |
7.4 |
10.3 |
13.2 |
64.7 |
TABLE 2. -
Frequencies for PAs not involved in eyecare
|
|
|
Self-reported skill and ability levels (% of N) |
| Skill and ability |
Factor |
N |
1: None |
2 |
3 |
4 |
5: High |
| Identify patients with key risk factors for vision and ocular disease |
Current |
231 |
13.9 |
33.8 |
30.6 |
15.7 |
6 |
| Desired |
231 |
11.6 |
14.8 |
17.1 |
29.6 |
26.9 |
| Identify signs of vision and ocular health emergencies |
Current |
231 |
10.6 |
23.1 |
32.9 |
24.1 |
9.3 |
| Desired |
231 |
6.9 |
11.6 |
15.3 |
23.6 |
42.6 |
| Discuss potential risks/benefits of common interventions to treat common vision/ocular diseases |
Current |
231 |
17.1 |
37 |
27.8 |
15.3 |
2.8 |
| Desired |
231 |
10.2 |
22.2 |
17.6 |
21.8 |
28.2 |
| Check pupils, extraocular movements, and confrontation visual fields |
Current |
230 |
4.2 |
10.2 |
18.6 |
30.7 |
36.3 |
| Desired |
230 |
5.1 |
3.3 |
13 |
21.9 |
56.7 |
| Check visual acuity |
Current |
225 |
3.8 |
10 |
21.9 |
26.7 |
37.6 |
| Desired |
225 |
4.7 |
4.7 |
15.6 |
21.3 |
53.6 |
| Slit lamp examination |
Current |
226 |
47.6 |
24.1 |
14.6 |
9.9 |
3.8 |
| Desired |
226 |
24.9 |
12.2 |
19.2 |
16 |
27.7 |
| Fundus examination with direct ophthalmoscope to visualize nerve and/or retina |
Current |
229 |
15.4 |
39.3 |
26.2 |
13.6 |
5.6 |
| Desired |
229 |
9.3 |
15.9 |
20.1 |
18.7 |
36 |
| Remove foreign bodies from the ocular surface |
Current |
229 |
38.3 |
20.1 |
20.6 |
12.6 |
8.4 |
| Desired |
229 |
21.5 |
8.4 |
18.2 |
17.3 |
34.6 |
TABLE 3. -
Current vs. desired skill and ability levels by PA type
| Results displayed are for eight separate ordinal logistic regressions. Odds ratios are in reference to the opposite category (for example, desired is in reference to current, and involved in eyecare is in reference to not involved in eyecare). For interaction effects, odds ratios are for the desired versus current skill and ability levels among PAs involved in eyecare versus that of PAs not involved in eyecare. When odds ratios are greater than 1 and CIs do not include 1, the odds of the factor being higher than the reference group are significantly greater. Using “check visual acuity” as an interpretation example, all PAs as a group had significantly greater odds of reporting a higher desired skill and ability level than current level (OR, 1.8; CI, 1.49-2.18), PAs involved in eyecare had significantly greater odds of reporting a higher desired and current skill and ability level compared with PAs not involved in eyecare (OR, 3.8; CI, 2.22-5), and the odds of desired skill and ability levels being higher than current levels were significantly different based on whether the PA was involved in eyecare versus not involved in eyecare (OR, 1.45; CI, 0.83-2.54). The measurement scale ranged from 1 to 5. |
|
|
|
CI |
Significance testing |
| Skill and ability |
Factor |
OR |
Lower |
Upper |
Wald chi-square |
P |
| Identify patients with key risk factors for vision and ocular disease (N = 300) |
Desired |
3.7 |
2.87 |
4.76 |
103.05 |
<.001 |
| Involved in eyecare |
2.92 |
2 |
4.28 |
30.64 |
<.001 |
| Desired vs. current level by PA type |
1.87 |
1.13 |
3.1 |
5.83 |
016 |
| Identify signs of vision and ocular health emergencies (N = 300) |
Desired |
4.05 |
3.16 |
5.2 |
121.39 |
<.001 |
| Involved in eyecare |
2.58 |
1.66 |
4.02 |
17.76 |
<.001 |
| Desired vs. current level by PA type |
2.2 |
1.16 |
4.18 |
5.82 |
.016 |
| Discuss potential risks/benefits of common interventions to treat common vision/ocular diseases (N = 300) |
Desired |
3.74 |
2.94 |
4.75 |
116.41 |
<.001 |
| Involved in eyecare |
2.41 |
1.66 |
3.5 |
21.39 |
<.001 |
| Desired vs. current level by PA type |
1.72 |
1.06 |
2.79 |
4.74 |
.03 |
| Check pupils, extraocular movements, and confrontation visual fields (N = 299) |
Desired |
2.14 |
1.74 |
2.63 |
51 |
<.001 |
| Involved in eyecare |
3.53 |
2.11 |
5 |
22.83 |
<.001 |
| Desired vs. current level by PA type |
1.41 |
0.79 |
2.54 |
1.35 |
.246 |
| Check visual acuity (N = 294) |
Desired |
1.8 |
1.49 |
2.18 |
36.96 |
<.001 |
| Involved in eyecare |
3.8 |
2.22 |
5 |
23.82 |
<.001 |
| Desired vs. current level by PA type |
1.45 |
0.83 |
2.54 |
1.71 |
.191 |
| Slit-lamp examination (N = 292) |
Desired |
4.02 |
3.12 |
5 |
116.42 |
<.001 |
| Involved in eyecare |
1.55 |
0.97 |
2.48 |
3.29 |
.07 |
| Desired vs. current level by PA type |
2.38 |
1.36 |
4.18 |
9.12 |
.003 |
| Fundus examination with direct ophthalmoscope to visualize nerve and/or retina (N = 298) |
Desired |
4.48 |
3.42 |
5 |
118.24 |
<.001 |
| Involved in eyecare |
1.3 |
0.87 |
1.96 |
1.61 |
.205 |
| Desired vs. current level by PA type |
2.59 |
1.46 |
4.58 |
10.61 |
.001 |
| Remove foreign bodies from the ocular surface (N = 298) |
Desired |
3.6 |
2.86 |
4.53 |
118.71 |
<.001 |
| Involved in eyecare |
2.11 |
1.38 |
3.23 |
11.75 |
.001 |
| Desired vs. current level by PA type |
1.84 |
1.13 |
2.98 |
6.03 |
.014 |
DISCUSSION
In our sample of 335 PAs, we found that 77 (23%) were involved in eyecare more than once per month by providing patient information, answering questions, and initiating discussions about vision care and ocular health. In terms of specialties where this may be more common, most PAs involved in eyecare practiced primarily in primary care or emergency and urgent care. A fair percentage (28.6%) of PAs primarily practicing in other fields reported involvement in eyecare. Other specialties where eyecare may be more common include endocrinology, hospital medicine, and internal medicine. This may be explained by how PA scope of practice is defined by that of their collaborating physicians as well as the frequency that patients experience eye-related injury and the demand for screenings in the clinic setting.5,10-12 In addition, PAs have the option to practice outside their primary specialties on a part-time basis, such as a PA in orthopedics working part-time shifts in the ED. Thus, we feel it is important for all PAs to have access to postgraduate training or additional CME in vision and ocular care.
With regard to the frequency that PAs are involved in eyecare, 20% of PAs involved in eyecare performed all of the three aforementioned services on a daily basis, in addition to referring patients to a vision and ocular healthcare specialist (Figure 1). This is significant, considering how these PAs escalate vision care through a referral after talking with patients. PAs working in eyecare and/or referring patients for additional care aligns with the recommendation of the International Council of Ophthalmology and the National Academies of Sciences, Engineering, and Medicine (NASEM) 2016 initiative to make vision health a key objective in healthcare.11,13
Furthermore, most PAs, whether involved or not involved in eyecare, reported having vision and ocular care training in PA school (Figure 2). None of the 246 accredited PA schools appeared have components dedicated to visual sciences and ophthalmology in either didactics as of 2016 or clinicals as of 2017.14,15 Thus, PA exposure to vision and ocular care during PA school was likely integrated throughout the curriculum rather than as a standalone component. Furthermore, the Physician Assistant National Certifying Examination provides a blueprint for required knowledge expected of all PAs. This includes 7% of all content to be on the eyes, ears, nose, and throat. Under eye disorders, PAs are expected to know about a variety of conjunctival, corneal, lacrimal, lid, neuro-ophthalmic, orbital, retinal, traumatic, and vascular disorders as well as vision abnormalities.16 Undergraduate medical curricula also has minimal time dedicated to ophthalmology.17
Only a minority of PAs reported receiving vision care training outside of PA school (Figure 2). Despite this, across each of the areas assessed, PAs rated their existing knowledge to be lower than their desired knowledge, highlighting their desire to know more. As a group, all PAs desired higher skill and ability levels than their current levels for all eight vision and ocular care skills and abilities (Table 3). Except for slit-lamp and fundus examinations, PAs involved in eyecare had significantly higher odds of reporting higher desired and current skill and ability levels compared with PAs not involved in eyecare. This can be attributed to how the slit lamp and fundus examinations are highly specialized, typically learned in an ophthalmology residency, and require specialized equipment not readily available to PAs. However, availability and training in the use of nonmydriatic fundus cameras may allow PAs to contribute to ophthalmic care by facilitating the screening of a range of ocular diagnoses.18 With the exception of checking pupils, extraocular movements, confrontation visual fields, and visual acuity, the odds of desired skill and ability levels being higher than current levels were significantly different based on whether the PA was involved in eyecare or not. This can be attributed to how the six other skills and abilities are essential for effective delivery, triage, and referral of vision and ocular care. These findings highlight the need for PAs to have access to postgraduate training and additional CME in vision and ocular care and underlines their interest in these opportunities.
This study demonstrated that PAs have an interest in learning more about vision and ocular care and having more CME opportunities on this topic. Additional CME for PAs focusing on vision and ocular care can supplement the training in PA programs. PAs work in specialties that often treat patients presenting with vision and ocular disease. Thus, PAs have an integral role in the Healthy People 2030 goals to reduce vision loss from diabetic retinopathy, glaucoma, cataract, and from age-related macular degeneration.10 Health disparities also may be closed through proactive eyecare from PAs. Notably, children in poorer communities and those who are Black or Hispanic are less likely to have been diagnosed with strabismus compared with children in affluent communities. Additionally, patient age at first cataract surgery and the age-standardized surgery rates have varied considerably among some US communities.19,20 Above all, PAs can support the NASEM initiative to make vision health a key objective in healthcare.13
For comparison, CME for oral health is readily available to PAs through the Society of Teachers of Family Medicine's Smiles for Life: A National Oral Health Curriculum.21 To our knowledge, no similar organized CME for vision health exists for PAs. The oral health curriculum has been promoted among PAs by the PA Leadership Initiative in Oral Health following a call for the integration of oral health into primary care by the NASEM in 2011.22,23 Oral health is already part of the PA didactic curriculum, and PAs who received oral health instruction in PA school were 2.79 times more likely to integrate oral health into practice.13,24 Similarly, in 2016 the NASEM announced a call to action to make vision health a key objective in healthcare.13 Our data show that PAs have a desire to improve their current skills and abilities in vision and ocular care. We hope this combination will lead to vision health becoming a core competency in PA education and training and lead to the development of PA CME for vision health.
LIMITATIONS
Although this study provided information about PAs involved in eyecare outside ophthalmology, the small sample size of 335 PAs may limit its generalizability. Additional studies will be needed to confirm our findings. Another limitation of the study is that the PA vision and ocular care training, skills, and abilities are self-reported and were not objectively confirmed with this study design. The self-reported training received in vision and ocular care may be affected by respondent response (or propensity to respond), recall bias, and the quality and amount of training actually received. Additional studies are needed to evaluate PA training in vision and ocular care and assess the true level of PA skills and abilities.
CONCLUSIONS
PAs outside ophthalmology provide vision and ocular care but have varying amounts of training and desire higher skill and ability levels in vision and ocular care. These circumstances can be addressed through further development of vision and ocular care in PA school curricula and development of ongoing PA CME in vision and ocular care. Through earlier and appropriate referrals, PAs with adequate training in vision and ocular care may improve patient outcomes.13 In partnership, ophthalmologists and PA institutions may develop vision and ocular care training for PA schools and CME to contribute to making vision health a key objective in healthcare.
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