Barriers to Receiving Follow-Up Eye Care and Detection of Non-Glaucomatous Ocular Pathology in the Philadelphia Glaucoma Detection and Treatment Project

Novel Methods of Identifying Individual and Neighborhood Risk Factors for Loss to Follow-Up After Ophthalmic Screening

PRCIS

Residence in a middle-class neighborhood correlated with lower follow-up compared with residence in more affluent neighborhoods. The most common explanations for not following up were the process of making an appointment and lack of symptoms.

PURPOSE

To explore which individual-level and neighborhood-level factors influence follow-up as recommended after positive ophthalmic and primary care screening in a vulnerable population using novel methodologies.

PARTICIPANTS AND METHODS

From 2017 to 2018, 957 participants were screened for ophthalmic disease and cardiovascular risk factors as part of the Real-Time Mobile Teleophthalmology study. Individuals who screened positive for either ophthalmic or cardiovascular risk factors were contacted to determine whether or not they followed up with a health care provider. Data from the Social Vulnerability Index, a novel virtual auditing system, and personal demographics were collected for each participant. A multivariate logistic regression was performed to determine which factors significantly differed between participants who followed up and those who did not.

RESULTS

As a whole, the study population was more socioeconomically vulnerable than the national average (mean summary Social Vulnerability Index score=0.81). Participants whose neighborhoods fell in the middle of the national per capita income distribution had a lower likelihood of follow-up compared with those who resided in the most affluent neighborhoods (relative risk ratio=0.21, P -value<0.01). Participants cited the complicated process of making an eye care appointment and lack of symptoms as the most common reasons for not following up as instructed within 4 months.

CONCLUSIONS

Residence in a middle-class neighborhood, difficulty accessing eye care appointments, and low health literacy may influence follow-up among vulnerable populations.

Barriers to Eye Care for Adults in the United States and Solutions for It: A Literature Review

Vision loss and blindness is a significant public health concern that has had a profound impact on various communities in the United States. Both anticipated and unforeseen barriers have been linked to the rising rates of vision loss and blindness in the country. Extensive research has identified numerous barriers that put many Americans at a disadvantage when trying to seek high-quality eye care services. Not only do the barriers to eye care services create problems for eye health, but also create a poor quality of life. Therefore, understanding and identifying barriers to eye healthcare services is incredibly important. In addition to understanding and identifying barriers, it is also important to identify solutions to the problems created by these barriers. A systematic review of articles characterizing the barriers to eye care was completed which resulted in the identification of the major barriers that affect Americans. The review of previous research was also used to identify available solutions for problems associated with the barriers to eye care services. The major barriers identified were cost, insurance, transport and accessibility, eye health care literacy, and communication. Because of the identification of the major barriers, solutions were also identified. Health education and increased vision screenings were found to be the most used forms of solutions by healthcare professionals promoting good eye health. Telemedicine has also been cited as a possible solution to the growing problem of visual impairment and blindness within the American population.

Targeted Telephone-Based Outreach Reconnects Glaucoma Patients With Subspecialty Care

PRCIS

A personalized telephone-based intervention is a cost-effective method to return overdue patients with open angle glaucoma (OAG) to subspecialty care. Patients who accepted care overwhelmingly preferred in-person appointments with their provider instead of hybrid visits with telehealth.

PURPOSE

To evaluate the effectiveness of a telephone-based outreach strategy to reconnect OAG patients with subspeciality care.

PATIENTS AND METHODS

Established patients with OAG who were seen before March 1, 2021, but had not returned for care in the following year were contacted via a telephone-based intervention. Patients lost to follow-up (LTF) were offered the option of an in-person visit or a hybrid telehealth visit, which combined in-office testing of vision, intraocular pressure, and optic nerve imaging with a virtual consultation with their glaucoma specialist on a separate date.

RESULTS

Of 2727 patients with OAG, 351 (13%) had not returned for recommended care. Outbound calls reached 176 of those patients (50%). Nearly half of all patients contacted readily accepted care, with 71 scheduling in-person appointments (93%) and 5 selecting hybrid visits (6.6%). Medication refills were requested by 17 of those 76 patients, representing nearly a third of the 56 patients who were treated with topical glaucoma medications. Assessment of the program 90 days later found that 40 patients had returned for care, 100 patients had transferred or declined further care, and 40 patients were identified as deceased, lowering the LTF rate to 6.4%, with 15 patients still scheduled for future visits. On the basis of an average call duration of 2.8±2.0 minutes, the added cost of returning a patient with OAG to care by the program was $28.11.

CONCLUSIONS

Providing targeted outreach by telephone is an effective and cost-efficient strategy to reconnect OAG patients LTF with subspecialty care.

Disparities in Eye Care Access and Utilization: A Narrative Review

This narrative review summarizes the literature on factors related to eye care access and utilization in the United States. Using the Healthy People 2030 framework, this review investigates social determinants of health associated with general and follow-up engagement, screenings, diagnostic visits, treatment, technology, and teleophthalmology. We provide hypotheses for these documented eye care disparities, featuring qualitative, patient-centered research. Lastly, we provide recommendations in the hopes of appropriately eliminating these disparities and reimagining eye care.

Follow-Up Adherence After Community Health Vision Screening Programs: A Review of the Literature

Objective  Although the purpose of community eye screening programs is to reduce health care disparities, the effectiveness of these programs is limited by the follow-up adherence of their participants. The aim of this review is to investigate factors that may promote or hinder participants from attending follow-up ophthalmological exams after community eye screenings and identify interventions to increase follow-up rates. Methods  For literature review, PubMed, Web of Science, Embase, Proquest/Global Health Library, and Google Scholar databases were searched to identify studies of community eye screenings published between January 2000 and May 2023. Data from these articles were analyzed to identify barriers and facilitators of follow-up adherence after community eye screenings in the United States and to examine strategies used to increase follow-up rates. Only published manuscripts were included. We excluded studies of school screenings and clinic-based screenings. Results  A total of 28 articles were included. Follow-up rates ranged from 12.5 to 89%. Nineteen articles reviewed facilitators and barriers to follow-up. Eighteen articles were non interventional and seven (see Table 1 and 2 , respectively) articles described interventions that were tested to improve follow-up rates after screening. Interventions included prescheduled appointments, transportation assistance, patient education, and patient navigators. Conclusion  Several interventions are promising to increase follow-up adherence in community eye screenings, but more evidence is needed. Future research should focus on randomized trials of isolated interventions to improve follow-up adherence of disadvantaged populations, although this may be limited given ethical considerations and documented lack of follow-up after screening.

Assessment of patient follow-up from student-run free eye clinic to county ophthalmology clinic

The Ophthalmology Student Interest Group at Indiana University School of Medicine provides a free student-run eye screening clinic for an underserved community in Indianapolis. Patients with abnormal findings are referred to the ophthalmology service of the local county hospital for further evaluation. This retrospective chart review studied 180 patients referred from our free eye clinic to follow up at the ophthalmology service of a local county hospital from October 2013 to February 2020. This study investigated factors impacting follow-up of patients by analyzing demographics, medical history, insurance coverage, and final diagnoses at follow-up. Thirty-five (19.4%) of 180 patients successfully followed up at the local county hospital with an average time to follow-up of 14.4 (± 15.9) months. Mean patient age was 51 (± 13.6) with nearly equal numbers of males and females. The most common diagnoses at follow-up included refractive error (51.4%), cataract (45.7%), and glaucoma (28.6%). Patients with diabetes diagnoses or Healthy Indiana Plan insurance coverage had increased probability of follow-up. This study reveals gaps in timely follow-up to the local county hospital, demonstrating the current limitations of our free clinic in connecting patients to more definitive care and the need for an improved referral process.

An Initiative to Improve Follow-up of Patients with Glaucoma

Purpose

This study describes the implementation of an electronic medical record (EMR)-based initiative aimed at reducing the number of patients with glaucoma-related diagnoses lost to follow-up (LTF) and reviews its short-term outcomes.

Design

Retrospective, comparative case series.

Participants

Patients with glaucoma-related diagnoses seen 1 year prior at the Lahey Medical Center and who had not returned within the 6-month period between January 1, 2020, and June 30, 2020, which spanned the outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic in the United States.

Methods

An EMR-based tool was designed to identify patients suspected of being LTF with glaucoma-related diagnoses. Providers were enlisted to review the EMR for each of these patients and re-engage them, as appropriate. One month later, the initiative was evaluated by means of a retrospective chart review. Binary logistic regression analysis was used to identify demographic, clinical, and sociomedical factors associated with being LTF.

Main Outcome Measures

Patients who completed a telemedicine or in-person appointment, or had a future scheduled or ordered return appointment, were considered re-engaged.

Results

Of the 3551 patients seen during the study period, 384 patients were identified as LTF (11%), with 60 identifying COVID-19 as the reason for canceling their visit (16%). Patients who lived farther from the eye clinic (P < 0.001) or who had a history of canceling or missing an appointment (P < 0.001) were more likely to be LTF. Patients with open-angle glaucoma (P = 0.042) or who had completed a visual field (P < 0.001) or ophthalmic imaging (P < 0.001) within the past year were less likely to be LTF. One month after the re-engagement initiative, 124 LTF patients (32%) had been re-engaged (40% through telemedicine), 238 patients (62%) had future scheduling orders in place, and 22 patients (6%) had no active plan for future follow-up.

Conclusions

An EMR-based tool is an effective method for identifying patients at risk of being LTF and provides an opportunity for providers to recall and re-engage patients. Use of telemedicine to recontact LTF patients shows promise of improving the management of glaucoma, enhancing clinical productivity, and documenting treatment plans, thereby potentially reducing medicolegal liability.

Evaluating Well-being of Individuals With Chronic Visual Conditions Requiring Regular Eyecare During COVID-19 Lockdown: A Cross-Sectional Study

OBJECTIVES

To assess health-related quality of life (HRQoL) and its predictors among individuals with chronic vision conditions during COVID-19 lockdown.

METHODS

A cross-sectional, survey-based study targeted Jordanian adults with a variety of chronic vision conditions requiring regular ophthalmic follow-up. Outcome measures included HRQoL measured by the 12-item Short-Form Health Survey (SF-12), mental health symptoms measured by the Depression Anxiety Stress Scale, and vision ability measured by the National Eye Institute Visual Functioning Questionnaire (VFQ-25) General Vision and Role Limitation subscales. Data were analyzed descriptively and using a multiple variable linear regression model to identify HRQoL predictors.

RESULTS

A total of 203 participants with a mean age of 52.09 (±15.41) years participated, and SF-12 mean scores were 58.15 for the physical component and 57.48 for the mental component. The level of HRQoL was significantly associated with VFQ-25 Role Limitation subscale, diabetes, the need of ophthalmic follow-up, and stress. The regression model explained 47.1% of the variance in HRQoL (r2=0.471, F=35.57, P<0.001).

CONCLUSIONS

Jordanian individuals with chronic vision conditions demonstrated low levels of HRQoL during COVID-19 lockdown. Participants also showed high levels of mental health symptoms and reported low accessibility to ophthalmic care. Access to nonurgent ophthalmic care in individuals with chronic vision diseases should be carefully planned in future pandemics.

Interventions to promote access to eyecare for non-dominant ethnic groups in high-income countries: a scoping review

PURPOSE

People who are distinct from the dominant ethnic group within a country can experience a variety of barriers to accessing eyecare services. We conducted a scoping review to map published interventions aimed at improving access to eyecare for non-Indigenous, non-dominant ethnic groups residing in high-income countries.

METHODS

We searched MEDLINE, Embase and Global Health for studies that described an intervention to promote access to eyecare for the target population. Two authors independently screened titles and abstracts followed by review of the full text of potentially relevant sources. For included studies, data extraction was carried out independently by two authors. Findings were summarised using a combination of descriptive statistics and thematic analysis.

RESULTS

We screened 5220 titles/abstracts, of which 82 reports describing 67 studies met the inclusion criteria. Most studies were conducted in the USA (90%), attempted to improve access for Black (48%) or Latinx (28%) communities at-risk for diabetic retinopathy (42%) and glaucoma (18%). Only 30% included the target population in the design of the intervention; those that did tended to be larger, collaborative initiatives, which addressed both patient and provider components of access. Forty-eight studies (72%) evaluated whether an intervention changed an outcome measure. Among these, attendance at a follow-up eye examination after screening was the most common (n=20/48, 42%), and directly supporting patients to overcome barriers to attendance was reported as the most effective approach. Building relationships between patients and providers, running coordinated, longitudinal initiatives and supporting reduction of root causes for inequity (education and economic) were key themes highlighted for success.

CONCLUSION

Although research evaluating interventions for non-dominant, non-Indigenous ethnic groups exist, key gaps remain. In particular, the paucity of relevant studies outside the USA needs to be addressed, and target communities need to be involved in the design and implementation of interventions more frequently.

A Randomized Trial to Improve Adherence to Follow-up Eye Examinations Among People With Glaucoma

Introduction

Appointment nonadherence is common among people with glaucoma, making it difficult for eye care providers to monitor glaucoma progression. Our objective was to determine whether the use of patient navigators, in conjunction with social worker support, could increase adherence to recommended follow-up eye appointments.

Methods

A randomized, controlled trial evaluated the effectiveness of an intervention that used patient navigators and social workers to improve patient adherence to follow-up eye care compared with usual care. Participants with glaucoma and other eye diseases (N = 344) were identified at primary care clinics in community settings through telemedicine screening of imaging and then randomized to enhanced intervention (EI) or usual care (UC). Data on participants’ visits with local ophthalmologists were collected for up to 3 years from randomization. Groups were compared for timely attendance at the first visit with the local ophthalmologist and adherence to recommended follow-up visits.

Results

Timely attendance at the first visit was higher for EI than UC (74.4% vs 39.0%; average relative risk [aRR] = 1.85; 95% CI, 1.51–2.28; P < .001). Rates of adherence to recommended annual follow-up during year 1 were 18.6% in the EI group and 8.1% in the usual care group (aRR = 2.08; 95% CI, 1.14–3.76; P = .02). The aRR across years 2 and 3 was 3.92 (95% CI, 1.24–12.43; P = .02).

Conclusion

An intervention using patient navigators and social workers doubled the rate of adherence to annual recommended follow-up eye care compared with usual care in community settings, and was effective at increasing connections with local ophthalmologists. Interventions to further improve long-term adherence are needed.

Teleophthalmology Screening for Early Detection of Ocular Diseases in Underserved Populations in Israel

Background: The purpose of this study was to investigate the feasibility and effectiveness of an innovative telemedicine community-based intervention to increase detection of previously undiagnosed ocular diseases in high-risk populations in Israel. Methods: A team comprising an ocular technician, a project manager, and a driver was sent to underserved areas in Israel. Patient demographics, ocular, and medical information were recorded. Visual acuity (VA), intraocular pressure and fundus photographs were obtained. The data were transferred to the Ophthalmology Reading Center in Tel-Aviv Medical Center, where it was interpreted by an ophthalmologist. A letter was sent to the patients indicating examination results. It instructed them to return for a follow-up examination if indicated. Results: A total of 124 individuals underwent telemedicine remote screening examinations in 10 locations. The mean age was 79.9 ± 7.2 years, with female predominance of 67%. The major pathologies detected were (1) reduction in VA >6/12 in at least one eye (n = 48, 38.7%); (2) glaucoma suspicion in the optic disk (n = 18, 14.5%); (3) ocular hypertension >21 mmHg (n = 15, 12.1%); (4) age-related macular degeneration (AMD; n = 15, 12.1%); (5) diabetic retinopathy (n = 6, 4.8%); (6) visually significant cataract (n = 6, 4.8%); and (7) other pathologies (n = 11, 8.9%); 97.7% of the patients reported high satisfaction rates (they were satisfied or very satisfied from the project model). Conclusions: Our pilot telemedicine screening project effectively detected ocular diseases in underserved areas in Israel and helped improve access to eye care. This project has the potential of reaching a national level, allow for early diagnosis, and prevent vision loss and blindness in underserved areas.

The Vision Detroit Project: Visual Burden, Barriers, and Access to Eye Care in an Urban Setting

Purpose: Vision loss and blindness are among the top ten disabilities in the United States, yet access and utilization of eye care remains low. Vision Detroit aimed to address eye-care disparities via community-based screenings. By investigating burden of eye disease and barriers to eye-care utilization in an underserved urban community, we may direct efforts to improve access.Methods: Twenty-three screenings were conducted from March 2015-November 2017. Patient information gathered at screenings were demographics, medical and social history, eye exam/referral history, insurance status, primary care physician (PCP) status, and patient-perceived eye-care barriers.Results: Three-hundred-eighty patients were screened, 42% African American and 51% Hispanic. Average age was 53 ± 16.4 years, 70% reported vision problems, 50% reported over two years of vision problems, and average habitual visual acuity in best-seeing eye was 20/37. Eye-care underutilization was reported in 61% of type-2 diabetics. Older age and PCP recommendations/referrals were associated with increased utilization in all patients. Insurance was the most common barrier (53%); of the 55% insured, 31% reported financial barriers. Employed patients were more likely than unemployed to report a time barrier (odds ratio = 1.76, 95% confidence interval 1.03-3.01). Those with high school or less education reported "unaware of need", "unsure where to go", "transportation", and "insurance" as barriers more often.Conclusions: Visual burden was pervasive, yet access was suboptimal. Financial, logistical, and awareness barriers were common. PCP referral and older age were associated with increased utilization. Those less educated reported more barriers, highlighting the need to address fiscal concerns and eye-health education.

Philadelphia glaucoma detection and treatment project: ocular outcomes and adherence to follow-up at a single health centre

OBJECTIVES

To determine ocular outcomes and factors associated with adherence to ophthalmic follow-up in a medically underserved population at a single health centre in Philadelphia.

DESIGN

Retrospective chart review.

PARTICIPANTS

Patients from a community glaucoma screening program.

METHODS

Chart review was conducted for participants who received a complete eye examination at the Philadelphia District Health Center 5 between January 1, 2012 and May 31, 2014 within the Philadelphia Glaucoma Detection and Treatment Project. Multivariate logistic regression was used to determine factors related to ophthalmic follow-up adherence.

RESULTS

A total of 249 participants completed an eye examination (mean age = 57.7 ± 6.9 years). Most were African American (n = 220; 88.4%); female (n = 129; 51.8%). Forty-seven participants (18.9%) received glaucoma-related diagnoses, 20 (8.0%) were prescribed ocular medication, and 26 (10.4%) underwent laser therapy. Ninety (36.1%) attended their recommended follow-up eye examination at the health centre. Glaucoma-related diagnosis (p ≤ 0.001), recommendation of a 4- to 6-week follow-up period (p < 0.001), prescribed eye drops (p < 0.001), or received laser therapy (p = 0.047) were factors most predictive of ophthalmic follow-up adherence.

CONCLUSIONS

The collaborative effort of eye care providers and health centres offers an important opportunity to detect, treat, and manage glaucoma and other ocular pathology in medically underserved communities. Having a glaucoma-related diagnosis, initiating treatment, and scheduling regular follow-up visits are the most important factors influencing adherence to follow-up eye appointments.

Awareness of ocular diagnosis, transportation means, and barriers to ophthalmology follow-up in the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study

Purpose: The purpose of this study was to assess factors affecting follow-up eye care in participants enrolled in the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study, such as awareness of ocular diagnosis, availability of transportation methods, and reasons for missing eye care appointments. Methods: The sample included 172 participants who were randomized to the intervention group and contacted by the social worker. Results: A total of 155 participants completed the assessment form, which was used as an instrument to assess factors affecting adherence to follow-up eye care. The main reasons for missing eye exam appointments were feeling ill (38.1%, n = 59) and forgetting the appointment (34.2%, n = 53). In addition, 45 (29.2%) participants were unaware of or did not comprehend the severity of their ocular diagnosis. Common methods of transportation included public transportation (31.6%, n = 49), driving (29.7%, n = 46), and being driven (27.7%, n = 43) to their appointment. Conclusion: These results suggest that individuals in need of eye care may benefit from additional assistance of a social worker regarding ongoing eye exam appointment reminders and in-depth explanation of their ocular diagnosis.

Self-reported Use of Eye Care Among Adult Chinese Americans: The Chinese American Eye Study

PURPOSE

To identify the prevalence and determinants of self-reported eye care use among Chinese Americans.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 4582 Chinese Americans 50 years and older residing in Monterey Park, California.

METHODS

Multivariable logistic regression analyses based on Andersen's Behavioral Model of Health Services Use were conducted to identify predisposing, enabling, and need variables associated with self-reported eye care use.

MAIN OUTCOME MEASURES

Prevalence of self-reported use assessed as eye care visit in the past 12 months, dilated eye examination in the past 12 months, and ever having had a dilated examination, and odds ratios for factors associated with these measures.

RESULTS

Overall, 36% of participants reported an eye care visit and 21% reported a dilated examination in the past 12 months. Forty-eight percent reported ever having had a dilated eye examination. Older age, female sex, preference for English, more education, health and vision insurance, a usual place for health care, currently driving, a greater number of comorbidities, and lower vision-specific quality-of-life (NEI VFQ-25) scores were associated with higher odds of reporting use of eye care.

CONCLUSIONS

Use of eye care among Chinese Americans was found to be as low as what is reported for African Americans and Hispanics, and lower than what is reported for whites. Multiple modifiable factors are associated with use of eye care among the rapidly growing Chinese American population. Culturally sensitive interventions targeting these factors should be a priority. Further research is needed to investigate how findings from this group of Chinese Americans reflect other Asian Americans that are different in language and ethnicity.