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`Gonzalez et al
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`As optometry continues to evolve and expand, the
`prescribing of medications is starting to play a more important
`role in the day-to-day life of an optometrist. Data suggest that
`patients are not visiting their optometrist solely for glasses or
`contact lenses (Gonzalez, unpublished data, poster presenta-
`tion, American Academy of Optometry, 2010–2011). Con-
`versely, the management of ocular surface diseases and contact
`lens complications aids in the retailing of eyewear products.
`Furthermore, it has been argued that prescription audits
`can be used to reflect a group’s competence in pharmacologi-
`cal therapy, and these audits may be useful in determining
`management paradigms and creating policy decisions.7
`In an effort to better understand the utilization of medi-
`cations by US optometrists, we developed a self-reporting
`survey that would ask questions inquiring optometrists’
`ophthalmic medication prescribing behaviors during an
`average clinic day.
`
`Methods
`An online-based, self-reporting survey was conducted from
`September 26, 2012 to October 3, 2012 as part of a project,
`and was approved by the ethics board. The survey was Web-
`based.8 The authors decided to use a convenience-based
`sampling method and distributed the survey via email to 81
`known practicing optometrists obtained from the primary
`author’s email database. It was also posted on a verified
`optometry-only online bulletin board (ODwire.org) where
`it was seen by 429 optometrists.
`Our response rate was 21%, based on our sample size of 510
`optometrists, and 107 responses were obtained. Assuming that
`there is a population of 35,000 optometrists currently practicing
`in the US, this represents a 95% confidence level. The study has
`a confidence interval (margin of error) of 9.8%. There was no
`duplication of responses, and this was tabulated by recording
`the Internet protocol addresses of the respondents, and matching
`them to make sure there were no duplicate responses.
`The survey was designed by the primary author and it
`consisted of ten questions, of which the authors decided
`to report on the first five questions, as these were the most
`relevant to the topic of this paper.
`Both email and posted versions of the survey were worded
`in an introductory manner to avoid bias on the part of the
`subject. The survey read:
`
`An optometry student is doing a senior project and has asked
`me to post this in ODwire. It is a 10 question survey that
`will take you less than 2 minutes to complete. Here is the
`link: http://www.surveymonkey.com/s/SMKLNVN.
`
`The first five questions were as follows: Question 1: “Do
`you have prescriptive authority?”; Question 2: “How long
`have you practiced Optometry?”; Question 3: “Have you writ-
`ten a prescription for any ophthalmic medications today?”;
`Question 4: “In a typical day, on average how many times
`do you write a prescription for an Ophthalmic Medication?”;
`Question 5: “How likely are you to write a prescription for
`these medications today?”.
`Questions 6–9 were on the subject of the number of
`pharmaceutical sales representatives seen by the office,
`the number of times these representatives visited the
`office, the perceived value of the interaction, as well as
`the optometrists’ perceptions of the representatives’ knowl-
`edge and product presentation, and the optometrists’ concerns
`when prescribing medications.
`The first four questions were designed to get a repre-
`sentation of the type of practice and optometrist that are
`responding. The first question was designed to identify
`optometrists with prescribing authority; if a respondent
`answered “no” to the first question, the survey was terminated
`for that particular participant.
`The second question was designed to obtain a sample
`of the number of years the optometrist was in practice; the
`third question was designed to verify whether the participant
`was an active prescriber, or a more casual prescriber; and
`the fourth question was used to try and see how active our
`group’s prescribing practices were.
`The fifth question was based on a Likert-type scale, and
`it was designed to determine how likely the respondents
`were to write a prescription for a particular medication. The
`medications were based on and grouped using the US Food
`and Drug Administration’s general guidelines of groups used
`and approved for topical use in the eye.
`
`Results
`The survey was answered by 107 anonymous prescribing
`optometrists who self-reported that they, indeed, had prescrip-
`tive authority (Table 1). None of the respondents answered
`“no”, to the first question; therefore, none of the optometrists
`were deemed ineligible to participate in the study. Of the
`107 respondents, 24.3% had been in practice 7 years or less,
`
`Table 1 Do you have prescriptive authority?
`Answer options
`Response percentage
`Yes
`100%
`No
`0%
`Answered question
`Skipped question
`
`Response count
`107
`0
`107
`0
`
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`Clinical Optometry 2014:6
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`Optometrists’ ophthalmic medication prescribing
`
`21.5% had been in practice between 8–15 years, 20.6% had
`been in practice for 16–24 years, while 33.6% had practiced
`optometry for over 24 years (Table 2). The authors believe this
`is a good representation of the various generational groups
`of practicing optometrist.
`When we asked the optometrists if they had written a pre-
`scription at the time of taking the survey, 24.3% replied that
`they had not written a prescription for any medication, while
`75.7% of respondents reported that they had (Table 3).
`We asked the respondents to report the average amount
`of prescriptions they would write in a given day; 26.2% of
`respondents wrote one or less prescriptions a day, while the
`majority of respondents (36.4%) wrote two to three prescrip-
`tions in their average day at the clinic. A total of 18.7% of
`respondents wrote 4–6 prescriptions, while 20 respondents,
`accounting for 18.7% of the responses, wrote seven or more
`prescriptions a day (Table 4).
`In order to find out what our doctors were prescribing, we
`asked, “How likely are you to write a prescription for these
`medications?”. The answers then ranked by the percentage
`(Table 5) of responses for “Very likely” and “Somewhat
`likely”, as compared to the overall response rate.
`We then proceeded to present the major ophthalmic drug
`categories by adding the “Very likely” and the “Somewhat
`likely” responses and calculating the percentage of the
`population that is likely to prescribe that given medication
`during their clinic day. The most likely prescribed medica-
`tions were those in the “dry eye” product category, with
`90% of participants responding that they were “Very likely”
`or “Somewhat likely” to prescribe within this group. The
`second most common response pertained to antihistamines
`with 80%.
`Overall, 75% of respondents in the ophthalmic OTC
`groups were “Very likely” or “Somewhat likely” to prescribe
`a product in this category. The fourth and fifth categories of
`drugs that were most likely to be prescribed were both the
`combination steroid/anti-infective and anti-infective cat-
`egories, with 86% and the anti-infective category with 84%
`of respondents very or somewhat likely to prescribe during
`their clinical day.
`
`Table 3 have you written a prescription for any ophthalmic
`medications today?
`
`Answer options
`Yes
`No
`Answered question
`Skipped question
`
`Response percentage
`75.7%
`24.3%
`
`Response count
`81
`26
`107
`0
`
`Ophthalmic steroid products were likely to be prescribed
`by 81% of respondents (either “Very likely” or “Somewhat
`likely”). The intraocular pressure (IOP)-lowering cat-
`egory had 54% of respondents who were “Very likely” or
`“Somewhat likely” to prescribe these products.
`The following categories of prescription medications all
`showed that fewer than 50% of respondents were likely to
`prescribe the following medications during a given day at the
`clinic. The nonsteroidal anti-inflammatory product group had
`36% of respondents who were “Very likely” or “Somewhat
`likely” to prescribe these agents. The antiviral product group
`had 12% of respondents who were “Very likely” or “Some-
`what likely” to prescribe these agents. The antifungal product
`group showed the lowest value, with only 2% of respondents
`indicating that they were “Very likely” or “Somewhat likely”
`to prescribe these agents (Table 5).
`In the last section, there was an opportunity for
`respondents to record a written response. Some respondents
`replied in the last section that they could not prescribe these
`medications, hence the count is less than 107. There were two
`respondents who did not respond to the antiviral, antifungal,
`and IOP-lowering agents category items. One of these respon-
`dents noted that his or her state had limitations in the pre-
`scription of antiviral, glaucoma, and antifungal medications.
`One respondent did not reply to the anti-infective or steroid
`medication categories, mentioning that he used combination
`drops in both instances. Lastly, three respondents noted that
`they do not write prescriptions for OTC products.
`
`Table 4 In a typical day, on average, how many times do you
`write a prescription for an ophthalmic medication?
`
`Table 2 how long have you practiced optometry?
`Answer options
`Response percentage
`Response count
`0–7 years
`24.3%
`26
`8–15 years
`21.5%
`23
`16–24 years
`20.6%
`22
`Over 24 years
`33.6%
`36
`Answered question
`107
`Skipped question
`0
`
`Answer options
`0–1
`2–3
`4–6
`7–8
`Over 8
`Answered question
`Skipped question
`
`Response percentage
`26.2%
`36.4%
`18.7%
`14.0%
`4.7%
`
`Response count
`28
`39
`20
`15
`5
`107
`0
`
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`Table 5 how likely are you to write a prescription for these medications today?
`Somewhat
`Somewhat
`Answer options
`Very
`likely
`likely
`unlikely
`64
`32
`7
`50
`36
`18
`50
`28
`11
`45
`45
`15
`45
`46
`13
`43
`43
`19
`24
`33
`28
`10
`28
`46
`3
`10
`47
`1
`1
`17
`
`Dry eye product
`Antihistamine
`Ophthalmic over-the-counter
`Combination (anti-infective + steroid)
`Anti-infective
`Steroid
`Intraocular pressure-lowering
`Anti-inflammatory (nonsteroid)
`Antiviral
`Antifungal
`
`Very
`unlikely
`4
`3
`15
`2
`2
`1
`20
`23
`45
`86
`
`Very or somewhat
`likely (%)
`0.90
`0.80
`0.75
`0.84
`0.86
`0.81
`0.54
`0.36
`0.12
`0.02
`
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`Response
`count
`107
`107
`104
`107
`106
`106
`105
`107
`105
`105
`
`Discussion
`From the data compiled, we can see that a high percentage of
`the optometrists studied are indeed very likely to prescribe
`medications for their patients. The most common medications
`prescribed on a daily basis are for dry eye. This coincides
`with what we would predict to be most prescribed. Based on
`the annual dry eye report for 2010,6 over 50% of non-contact
`lens wearers and contact lens wearers do experience dry eye.
`Perhaps it is evident that optometrists today are comfortable
`managing dry eye syndrome through medical therapy and
`through the primary use of OTC eye drops.
`It is very common that optometrists consult patients who
`present with complaints of allergies, as this represents a very
`common complaint in the general population.9–11 A total of
`80% of respondents stated that they are likely to write a
`prescription for antihistamine medications.
`It is interesting to note that 75% of prescriptions written
`are for OTC products. This represents a large segment of
`medications, as it includes both dry eye products and allergy
`products. The responses would suggest that there is an active
`recommendation for a specific product.
`Other responses pertaining to the types of medications
`that are prescribed seem to be in line with less often seen eye
`conditions. In particular, 86 and 84% of respondents reported
`they are “Somewhat likely” to prescribe either a combina-
`tion steroid anti-infective or an anti-infective, respectively.
`Eighty-one percent (81%) of the respondents are “Likely” or
`“Very likely” to prescribe a steroid during their clinic day,
`while 54% reported being “Somewhat likely” to prescribe
`an IOP-lowering agent in the management of glaucoma. An
`interesting point is that combination drugs were more likely
`to be prescribed than steroids or anti-infectives alone.
`Fungal and viral infections are less commonly seen in
`clinical practice and, as expected, these medications are
`the least likely to be prescribed on a daily basis. Only 2%
`
`of respondents reported they are “Very likely” or “Likely”
`to prescribe an anti-fungal agent, while 12% reported being
`“Somewhat likely” or “Likely” to prescribe an antiviral.
`It is worth noting that many states have some laws that
`limit the ability for optometrists to use these medications.
`
`Conclusion
`Although limited, the survey on the self-reported prescribing
`habits of optometrists is very insightful and points to the fact
`that a majority of optometrists are indeed reporting using their
`prescriptive authority as part of their work in their clinical
`day. It is not surprising that the types of drugs prescribed
`appear to be prescribed at a rate similar to the incidence of
`dry eye, allergies, and eye infections.
`Although the study has limitations, such as the fact that
`there are no clear geographical distributions, there is a lack
`of correlation with current prescribing laws, and the findings
`do not account for variability in practice settings, it is the first
`time that optometrists have been surveyed via a self-report
`about their prescription habits of certain medications.
`The authors understand this is a basis for further
`inferential studies, and agree that more data should be
`gathered that focus on variables such as practice settings
`and geography. More information should also be gath-
`ered on the number of patient encounters among those
`optometrists with the highest prescribing trends, their
`patients’ population profiles, and their clinical settings.
`By studying the process of pharmaceutical utilization by
`US optometrists, we can gather information that would
`be helpful in guiding the evolving trends in this field,
`and in better understanding both the role and impact of
`optometry in health care.
`
`Disclosure
`The authors report no conflicts of interest in this work.
`
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`
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