Improving Patient Experience and Practice Workflow With an Interventional Glaucoma Approach
In the sixth segment of The Interventional Glaucoma Project series, host Matt Jensen, of MJM / Marjen, is joined by the Omni Eye Group team: Arkadiy Yadgarov, MD, and practice administrator Kathy Disner. The group talks about how care for patients with glaucoma has evolved to offer more interventional approaches that are optimal for patients and practices. Dr. Yadgarov and Kathy both share how the practice made a commitment to interventional glaucoma and the steps they took to advance their operations, including staff training, partnering with referring optometrists, and creating a dashboard to track practice outcomes.
Watch segment 1, featuring Dr. Mark Gallardo.
Watch segment 2 and segment 3, featuring Charles and Dr. Blake Williamson.
Watch segment 5, featuring the Thomas Eye Group: Dr. Philip Garza and Ben Seals.
Matt Jensen:
Hi everybody, and welcome to another session of The Interventional Glaucoma Project. I’m here joined today by my friends in Atlanta, Dr. [Arkadiy] Yadgarov, who has been with the practice 8 years now, [a] glaucoma specialist, along with his practice administrator, Kathy Disner, and we’ve become close over the last couple of years as we’ve been really learning how to implement new strategies for interventional glaucoma at the point of care.
Now, I’m excited for our conversation today, gang, because going from what your wishes are, Dr. Yadgarov, to how do we actually get that done in real time, it’s really the big question that practices have. Maybe first, I’ll just have you give a little bit of an introduction of what you’ve seen in your own practice, Dr. Yadgarov, and how you like to practice. Then I’ll do the same with you, Kathy.
Arkadiy Yadgarov, MD:
Yeah. I’m a glaucoma specialist, but I do both cataracts and glaucoma care for patients here in Atlanta for the past 8 years. Essentially, I’ve been very fortunate to be part of the change in the way glaucoma has been cared for, where it had been predominantly an eye drop-treating condition.
Then with the advent of cataract/MIGS, we started to think about medication reduction, but it really hadn’t been until recently, in the past 5 years, where we started to think, well, can we do it without cataract surgery? Can we think about standalone glaucoma procedures that then allow medication reduction?
The key here is medication reduction. We always obviously want to think about pressure control. Drops have pressure control, but patients are miserable on it. Now you have an opportunity to do the exact same thing, which is pressure control, but with making patients happier. That’s the big why of why I’ve gotten so involved, is you’re finally dealing with happier patients, and that’s what it’s about.
You could just manage glaucoma how we’ve been doing it for 30 years and have patients on 2 to 3 bottles with red, dry eyes and get by. That’s how it had been. There’s nothing wrong with that, but you’re really not doing what’s best for the patient because now we have tools that are just substantially better at helping patients than we’ve had before.
Matt Jensen:
Yeah. Before I go to you, Kathy, I just want to ask a clarifying question because it’s not just that patients are miserable on them. I mean, there’s some side effects that we all know of. There’s some redness and some I call it the sinking eyes and those kinds of things, but aren’t there just a lot of patients who don’t even fill their scripts or aren’t adherent to it?
Arkadiy Yadgarov, MD:
That’s a good point. That’s a good point. Yeah. A lot of those patients don’t always necessarily truthfully tell you that. You’re right, even if you take away the quality of life issue, which is dexterity issues, problems getting the drops in, redness, there’s a whole cohort of patients that are getting worse because they’re just not compliant. We have tons of studies and literature that confirms that there’s about a 50% non-compliance rate on average.
You’re absolutely right. There’s 2 huge elephants in the room with the current status quo, one being non-compliance, non-adherence, so forgetfulness, and just issues getting refills or access. Then you have all the other patients that just wish there was another way.
Matt Jensen:
Right. When we sift all those things out, depending on the research that you’re referencing, it doesn’t bode well for that being a first-line defense, right? Frustrated patients.
Arkadiy Yadgarov, MD:
Right. Right. Well, first-line defense is one thing, but maintaining patients on it is another. You should be able to give patients now alternatives, and your practice should be able to have educational tools and a streamlined way for the patient to have transparency. Well, what does that look like? Where does this get done? What’s the cost going to be? Not just the physician has to be in, but the whole practice has to be part of that mindset.
Matt Jensen:
Well, and Kathy, you’re no stranger to this. You’ve been putting the good wishes of the doctors and their oath out in real time and surrounding them with professionals to where they can do the best right thing for the patient at the point of care. I always talk about that, at the point of care, right where that patient shakes the hand of the doctor in the exam room.
How do we set Dr. Yadgarov off up for success? Maybe talk about how you’ve done that over your career at Omni Eye Services, and then also just share a little bit about yourself.
Kathy Disner:
I am the practice administrator here in Omni Atlanta. I’ve been here many, many years. I’ve seen the practice grow. I’ve seen ophthalmology change over the years in how you treat. There’s been nothing more exciting in the last couple of years than the glaucoma and the whole IG evolution of how to treat a glaucoma patient.
My role, my staff’s role is to prepare Dr. Yadgarov’s clinic to be as efficient, productive, and successful as possible for him. That’s everything from front desk, getting your payers in line, what payers pay for what procedures, what is the patient’s out-of-pocket expectations for the patient. Then into the exam with all of the techs, have tech templates as far as vocabulary, their understanding of procedures so they can communicate with the patient. Goes to the billing department. How do you bill these procedures now? How do you get paid? How do you maximize your reimbursement? It’s all changed a little bit, but we just go with the flow, the new changes, the new procedures, and it’s been exciting for glaucoma.
Matt Jensen:
Yeah. I want to transition that because while you’ve done that for all your doctors, interventional glaucoma is a new category. In a minute, we’re going to talk about the current state of customer experience when drops have been first-line therapy. Before we do, I mean, you also have to, as the administrator, you have to set up your own reporting, like how are we doing? Talk to me about the importance of that kind of dashboard that drives decision-making.
Kathy Disner:
The dashboard is important because that’s going to give an instant visibility of how your performance is, everything from bottlenecks in the office, timing of patient exams, how long is the tech taking, how long is the MD taking, surgery scheduling. Patients are here for a long time, and if we can expedite that exam, we’re going to lower their anxiety and their frustration, and it’s just going to be a lot smoother. The dashboard will guide us all the way.
Matt Jensen:
Give us a sense just from memory of some of the bullets that are on your dashboard. What are you measuring?
Kathy Disner:
I’m measuring time involved with patients, conversion rates, are we conversion to an SLT, to a MIG, revenue producing. It’s going to go from everywhere from clinic insurance verifications, authorizations done in a timely manner, all the way through patient procedures.
Matt Jensen:
That’s really helpful. Of course, the revenue produced is one thing, but it’s also for that patient who may be getting off a drop or 2, or maybe the SLT in this case is the first-line treatment before they go on drops. It’s also helping stymie the progression of that disease state.
That’s where I want to go next. Dr. Yadgarov, when we first met, you were participating in a group discussion on with, as complicated as glaucoma can be, when everybody’s answering the question of, “Well, what should I do here?” The answer from glaucoma specialists tends to be, “Well, it depends.”
But yet, coming up with a protocol that you can share with your team. I know you guys are a big referral hub, so with your referring doctors on if/then statements for each progression of the disease, mild, moderate, severe, and how you might change your procedural pathway. Talk to me about how important that was and how did you develop it?
Arkadiy Yadgarov, MD:
Yeah, I mean, it is important because when there’s no good organization, doctors are always going to default to habits. What have been the habits? It’s drops. It’s just nothing…drops and drops and then more drops. You have to break that habit. In order to break that habit, you have to create an algorithm in order to help operationalize how we’re going to go along this new paradigm.
Essentially, we had a group of doctors that got together and said, “Okay, well, what’s the best algorithm we can think of that makes sense for mild, moderate, and advanced?” Then, “What’s the first step? What’s the second step? What’s the third step? Then why?” Is it safety, and then efficacy, and then tissue sparing, or tissue non-sparing?
I thought that was an amazing feat and has absolutely helped both guide me and especially referring doctors who manage glaucoma in terms of, well, what exactly is IG? Now you can show them, this is IG. It’s a mindset and it’s an algorithmic mindset of don’t necessarily think of drops, think of what’s the next interventional step, and use drops as a bridge.
I think it has absolutely been a benefit to create this algorithm, but I think the next step for sure in order to promote it and incorporate it is we have to really take it out there and educate. I was fortunate enough to already have a mindset. I didn’t have the algorithm. I had the mindset of, this makes sense, IG makes sense, but I don’t really know…SLT first, and then what do I do next?
Now we made this consensus protocol and it makes sense to me, but the next step I think between a doctor and another doctor is making sure that the next doctor understands the mindset as well. We are a huge optometric referral center. That’s a lot of how we get our referrals.
That’s going to be now a big part of our mission going forward, is being able to now educate the optometrists who do manage glaucoma, and again, have been doing the habits of what we’ve learned for the past 20 years, which are drops, and more drops, and more drops, and re-educating and having that consensus algorithm to help.
Matt Jensen:
Yeah, just having a roadmap that before we begin our journey, here’s basically how we might get there. We might deviate based on the uniqueness of that patient. I think that’s really helpful.
Kathy, have you utilized what the doctors came up with there in staff training or in your OD events to try to communicate to the broader neighborhood how that protocol works?
Kathy Disner:
Definitely with our OD network. The conversation starts at the OD’s office as far as expectations, alternatives to all of their drops, and so forth. When they come to see us, they’ve already set the stage. Now, we’ve trained our staff as far as what an IG evaluation is. How is that different than a glaucoma evaluation? It’s just a whole different mindset.
Patients come in expecting to be scheduled for some sort of interventional procedure. Training our techs, giving our techs a template as far as how they talk to a patient. Our techs spend more time talking to the patients typically than the MD does themselves.
Arkadiy Yadgarov, MD:
That’s true.
Matt Jensen:
Of course, of course.
Kathy Disner:
We want to speak the same language. We want to use the same vocabulary. We want the same verbiage. We want the same message every time somebody else is talking to that patient throughout their exam journey.
That puts confidence in the techs because they know how to communicate with the patient, and it puts the patient at ease because they’re hearing the same message. Then hopefully, it’s going to save time for the MD counseling the patient because the patient has heard the same message starting with the referring optometrist, through our entire staff, through their exam journey, and now into the physician’s office.
Arkadiy Yadgarov, MD:
That’s a great analogy. I just wanted to interject.
Matt Jensen:
Go ahead.
Arkadiy Yadgarov, MD:
A great analogy for that is the centers that have done very well with IOL efficiencies. The best, highest volume surgical facilities typically already have that similar style of operational efficiency. The OD has already educated on the multifocals, and then they come in and the technician has already maybe given them some information about it while the patient’s asking.
It’s all kind of just boom, and then the MD is there, and the patient is ready. The MD doesn’t have to talk much. I think the IG evaluation now is this new and very analogous mindset of the OD initiates it, and the patient is expecting to go into the operating room or procedure to help their condition.
Matt Jensen:
Kathy, what I was going to ask you as a follow-up to what you were saying is, we’re kind of demonizing drops here a little bit, aren’t we? I mean, are drops really the big bad wolf? I’m sure your team loves to do drops as much as they like to set up a procedure, right?
Kathy Disner:
No, because they know what’s ultimately coming and the burden of their task of all of the prescription refills, counseling the patient on the drops, this one’s got a red cap, this one’s got a yellow cap, this one’s got a purple cap. That’s probably the part of their job that they hate most, getting prior authorization for the drug refills. They know ultimately they want to see the patient benefit from a procedure. That’s going to make their job less stressful as far as that piece of it goes.
Matt Jensen:
It’s a big loss in the practice for all of the lost time, and the phone calls, and the back and forth. The patient gets frustrated and administration gets frustrated.
Kathy, on the topic of drops, we’ve noticed for a long time, and you just talked about patients being frustrated with the burden of drops, and we’ve known that for a long time. Yet, we’re starting to understand and we certainly experience how frustrating it can be the burden of drops on the practice. To administer those things, and the phone calls, and the callbacks, etc.
I’m curious, with the growth of your IG program, are you noticing a lightning of that load? Does the team feel it?
Kathy Disner:
We are beginning to feel it, albeit not all patients are completely drop-free. That’s our future, that’s what we’re hoping for. The multiple drops on patients is freeing up a lot of staff time as far as that goes.
Matt Jensen:
It’s a reduction in that burden, at least.
Kathy Disner:
A reduction. It has not eliminated it, but extremely reduced the amount of time, the volume of calls, follow-up, and so forth. It’s noticeable.
Matt Jensen:
Dr. Yadgarov, how about you? Have you noticed a reduction in the amount of time spent, the burden of drops?
Arkadiy Yadgarov, MD:
Yes. Yeah, and I’ll give you some examples. Typically, let’s say I talk to a patient for a follow-up visit. At the end of the talk, I ask my usual, “Hey, do you need refills? What’s the pharmacy?” Then my scribe will take that information and then stay with a patient after I leave and have to call in, click the button, click the pharmacy, ERx, send, all the extra steps, and then the patient goes, “Wait, no, I don’t want that Publix pharmacy. I want the other Publix pharmacy.” Another extra 2 minutes.
Now I go into a room, a patient who’s had, let’s say, an iDose, or an SLT, or a cataract/MIGS, and they’re off their glaucoma meds, it’s, “Hey, you’re doing well. I’ll see you in 6 months.” There’s no more, “Do you need a refill? Are you still using your drops? Did you use it last night?” All of that all of a sudden becomes gone. Makes the visit a lot more efficient and I would say easier on both the doctor and the scribe staff in terms of moving along.
The patients are happier. They have no complaints. They don’t have to talk about the glaucoma drop. I think it’s been amazing.
Matt Jensen:
Because I know that this has led to maybe a different style of how your work is organized. We don’t know what’s behind the door. We don’t know where this could go next.
Kathy Disner:
Something that we’ve started to track is we have an IG capacity calculator. We try and figure out how many IG [evaluations], how many SLTs, block time for MIG surgery. We’re going that route to see what Dr. Yadgarov’s schedule can handle, what resources we need to increase his volume. It’s new.
We thought we could handle…we can handle the volume, but it changes. It changes. The patient flow changes. You need to spend a little bit more time with them. Surgery scheduling, billing has been a challenge, new procedures and so forth, but we keep up determining the capacity of his practice, and where we grow and what resources we know to continue that increase.
Matt Jensen:
Capacity calculator, that’s some great admin mind right there, right, Kathy? That is very, very smart from an administrative level, knowing what you have by way of throughput. I’d like to just ask also, as you’re seeing these patients, because there’s certainly new patients who come in from referrals, but are you able to do much reaching back out to people who maybe had cataract surgery a couple of years ago and now that there’s standalone options, they’re a candidate for it?
Say more about that, Dr. Yadgarov.
Arkadiy Yadgarov, MD:
To some degree, that’s where we rely a lot on the staff optometrists as well. They’re seeing a lot of these follow-up visits, and that’s why it has to be a team approach. But yes, every patient that comes and sees me for follow-up and sees a staff optometrist follow-up, we’re all on the same page, which is that if a patient is on drops, delve into that. Are you having any issues, any compliance things, irritation?
That way, that immediately becomes a conversation for, let’s do a procedure for it. Absolutely, that is actually…if you think about it, the majority of doctors who have been practicing for many, many years will have a lot of those patients who are just there for follow-ups every 6 to 12 months, and then the rest would be the new patients. I will say a new patient is a good area to build into, but the follow-up patients are actually a lot easier because they already know who you are, you’ve already done work on them, and so they trust you.
I think that’s actually a great place for standalone MIGS. I think the newer patients tend to be easier on the cataract/MIGS because they tend to be new, they’re phakic, or sometimes you have to start with drops, build a relationship before you move into the MIGS discussions, even the standalone.
Matt Jensen:
Kathy, this is kind of a jump-ball for you, because with that growth of procedural volume, I’m curious what other investments you’ve had to make in your infrastructure. Have you had to invest in any kind of diagnostics, or capacity, or staffing, or things like that to make sure that this goes well? Or are you able to do it with the ship you had?
Kathy Disner:
We have not increased FTEs at all. Dr. Yadgarov may wish to have a few more techs or whatever in clinic, but it hasn’t put the burden on the practice as far as patient flow and so forth. Some people…
Arkadiy Yadgarov, MD:
But I will tell you, one thing that we’ve I think invested wisely in, we hired one of our optometric residents who…and I think in any future hires for any practice, if you find, whether it’s an MD or an OD, that is already geared toward the interventional mindset, having them join your practice is going to be a huge benefit because ultimately, as a surgeon, if the volumes do increase, then I have to focus more on what I can do, which is the surgeries.
Then the clinical volumes start now being handed off to either non-surgical-heavy MDs or to the optometrists. That’s kind of where it would head to once you get enough volume to move that way.
Matt Jensen:
Do you like being in the OR more?
Arkadiy Yadgarov, MD:
Yeah. I mean, I think those who believe in the IG probably ought to have that kind of mindset, which it is, I mean, once you get comfortable in the OR and efficient, it is. It’s nice because surgically speaking, you’re making a difference right when you’re doing it and then all the aftercare is gravy.
Matt Jensen:
Yeah. You’re practicing to the top of your license and so are your colleagues in the optometric world, so that’s great.
This will be my last question, and it’s for both of you. I’ll start with you, Kathy. If you are talking to a practice administrator, or in your case, Dr. Yadgarov, a glaucoma specialist or even a comprehensive ophthalmologist, and they’re interested in becoming more interventional, what’s their best first step?
Kathy Disner:
Preparing their staff, educating their staff, and that begins with appointment schedulers, understanding what somebody is calling asking for. What is an IG eval? Then check-in staff, just the resources, the communication, understanding what the patient is going to…how long the exam is.
Then I always try and teach my techs to use empathy as a clinical skill. That’s going to reduce anxiety. It’s going to put the patient at ease. They’re going to have more trust in what the techs are telling the patient. They typically open up more as far as the burden they personally are having [on] drops, and we can document that. That way, the patient…you bring empathy into the exam room, the patient isn’t going to feel like they’re being judged. It’s just, most patients have an intolerance and they’re non-compliant, and so forth.
I think that piece of it with the techs, getting the tech templates, the scripts, everybody comfortable as far as what to say, how to communicate, get the message, everybody needs to be on board. That’s everybody in the office, like I said, from the phone schedulers all the way through the MD. Set yourself up for success as far as that goes.
Know what your payer contracts are, what procedures each payer will allow so when the patient comes in, there’s no confusion because the patient doesn’t want to have any chaos as far as when they’re scheduling the procedure. Get everybody on board, same message, be prepared, and you’ll do great.
Matt Jensen:
Yeah. What’s 1 thing you would share with folks if they were just starting to embark on becoming more IG?
Arkadiy Yadgarov, MD:
Yeah. Partner with a company. Their company will help the practice administrator. Let them help you. Partner up with them, and you’ll just see how much easier it is. You don’t have to do this yourself. Have a team behind you.
Matt Jensen:
The other thing I’ll mention, so first of all, both of you have very great answers as far as those first steps. Kathy, one of the things that I’ve enjoyed watching is how you’re also mentoring other practice leaders, because one, it’s one thing to do it in your own clinic, but also to help share the story at the national and regional meetings to other administrators on how to implement.
The same opportunity comes for you, Dr. Yadgarov, when it comes to podium power and time teaching. I can’t stress enough how important that is to all of us out in the field who are just trying to help people preserve their sight and stop the progression of this disease.
I’d like to thank you both for being a part of today’s discussion. Kathy Disner, practice administrator at Omni Eye Services, and of course, Dr. Yadgarov, thanks for being great guests. Thanks everybody for being good listeners. Thanks for listening to The Interventional Glaucoma Project.
INDICATIONS AND USAGE
iDose TR (travoprost intracameral implant) is indicated for the reduction of intraocular pressure (IOP) in patients with open angle glaucoma (OAG) or ocular hypertension (OHT).
IMPORTANT SAFETY INFORMATION for iDose® TR (travoprost intracameral implant) 75 mcg
Dosage and Administration
For ophthalmic intracameral administration. The intracameral administration should be carried out under standard aseptic conditions.
Contraindications
iDose TR is contraindicated in patients with active or suspected ocular or periocular infections, patients with corneal endothelial cell dystrophy (e.g., Fuch’s Dystrophy, corneal guttatae), patients with prior corneal transplantation, or endothelial cell transplants (e.g., Descemet’s Stripping Automated Endothelial Keratoplasty [DSAEK]), patients with hypersensitivity to travoprost or to any other components of the product.
Warnings and Precautions
iDose TR should be used with caution in patients with narrow angles or other angle abnormalities. Monitor patients routinely to confirm the location of the iDose TR at the site of administration. Increased pigmentation of the iris can occur. Iris pigmentation is likely to be permanent.
Adverse Reactions
In controlled studies, the most common ocular adverse reactions reported in 2% to 6% of patients were increases in intraocular pressure, iritis, dry eye, visual field defects, eye pain, ocular hyperaemia, and reduced visual acuity.
Please see full Prescribing Information.
You are encouraged to report all side effects to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. You may also call Glaukos at 1-888-404-1644.
IMPORTANT SAFETY INFORMATION for iStent infinite®
INDICATION FOR USE. The iStent infinite® Trabecular Micro-Bypass System Model iS3 is an implantable device intended to reduce the intraocular pressure (IOP) of the eye. It is indicated for use in adult patients with primary open-angle glaucoma in whom previous medical and surgical treatment has failed. CONTRAINDICATIONS. The iStent infinite is contraindicated in eyes with angle-closure glaucoma where the angle has not been surgically opened, acute traumatic, malignant, active uveitic, or active neovascular glaucoma, discernible congenital anomalies of the anterior chamber (AC) angle, retrobulbar tumor, thyroid eye disease, or Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS. Gonioscopy should be performed prior to surgery to exclude congenital anomalies of the angle, PAS, rubeosis, or conditions that would prohibit adequate visualization that could lead to improper placement of the stent and pose a hazard. MRI INFORMATION. The iStent infinite is MR-Conditional, i.e., the device is safe for use in a specified MR environment under specified conditions; please see Directions for Use (DFU) label for details. PRECAUTIONS. The surgeon should monitor the patient postoperatively for proper maintenance of IOP. Three out of 61 participants (4.9%) in the pivotal clinical trial were phakic. Therefore, there is insufficient evidence to determine whether the clinical performance of the device may be different in those who are phakic versus in those who are pseudophakic. ADVERSE EVENTS. The most common postoperative adverse events reported in the iStent infinite pivotal trial included IOP increase ≥ 10 mmHg vs. baseline IOP (8.2%), loss of BSCVA ≥ 2 lines (11.5%), ocular surface disease (11.5%), perioperative inflammation (6.6%) and visual field loss ≥ 2.5 dB (6.6%). CAUTION: Federal law restricts this device to sale by, or on the order of, a physician. Please see DFU for a complete list of contraindications, warnings, precautions, and adverse events.
PM-US–3008
Matt Jensen, Kathy Disner, and Dr. Arkadiy Yadgarov were compensated by Glaukos for their time.
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