Loss to Follow up among Glaucoma Patients at a Tertiary Eye Center over 10 Years: Incidence, Risk Factors, and Clinical Outcomes

Factors associated with non-return after loss to follow up from glaucoma care: An IRIS® Registry (Intelligent Research in Sight) retrospective analysis

PURPOSE

Loss to follow-up (LTFU) in primary open-angle glaucoma (POAG) can lead to undertreatment, disease progression, and irreversible vision loss. Patients who become LTFU either eventually re-establish glaucoma care after a lapse or never return to the clinic. The purpose of this study is to examine a large population of POAG patients who became LTFU to determine the proportion that return to care and to identify demographic and clinical factors associated with non-return after LTFU.

DESIGN

Retrospective longitudinal cohort study PARTICIPANTS: Patients with a diagnosis of POAG with a clinical encounter in 2014 in the IRIS® Registry (Intelligent Research in Sight) METHODS: We examined follow-up patterns for 553,663 patients with POAG who had an encounter in the IRIS Registry in 2014 by following their documented clinic visits through 2019. LTFU was defined as exceeding one calendar year without an encounter. Within the LTFU group, patients were classified as returning after a lapse in care (return after LTFU) or not (non-return after LTFU).

MAIN OUTCOME MEASURES

Proportion of patients with non-return after LTFU and baseline demographic and clinical characteristics associated with non-return among LTFU POAG patients.

RESULTS

Among 553,663 POAG patients, 277,019 (50%) had at least one episode of LTFU over the 6-year study period. Within the LTFU group, 33% (92,471) returned to care and 67% (184,548) did not return to care. Compared to those who returned to care, LTFU patients with non-return were more likely to be older (age >80 years; RR=1.48; 95% CI: 1.47-1.50), to have unknown/missing insurance (RR=1.31; 95% CI: 1.30-1.33), and to have severe-stage POAG (RR=1.13; 95% CI: 1.11-1.15). Greater POAG severity and visual impairment were associated with non-return with a dose-dependent relationship in the adjusted model that accounted for demographic characteristics. Among those with return after LTFU, almost all returned within 2 years of last appointment (82,201; 89%) rather than 2 or more years later.

CONCLUSION

Half of POAG patients in the IRIS Registry had at least one period of LTFU, and two-thirds of LTFU POAG patients did not return to care. More effort is warranted to re-engage the vulnerable POAG patients who become LTFU.

Barriers to Care Among Glaucoma Patients With a Missed Appointment and Interest in a Navigator Program

PRCIS

Most glaucoma patients with missed appointments report barriers to care and social risk factors. One third expressed interest in engaging with a patient navigator program. Most expressed interest in rescheduling.

PURPOSE

The purpose of this study was to identify barriers to care among glaucoma patients with missed appointments and to assess their interest in a patient navigator program.

MATERIAL AND METHODS

A cross-sectional study involving adult glaucoma patients from an academic eye center who missed their scheduled appointment between April 18 and July 25, 2022. Participants were surveyed about reasons for missed appointments, barriers to care, social risk factors, and interest in consulting with our patient navigator program.

RESULTS

Of 172 patients with a missed glaucoma appointment, 73% (126/172) were contacted, and 40% (51/126) of those completed the survey. Participant age averaged 67±14 years, half were female (25/51, 49%), and most identified as Black (27/51, 53%) or White (21/51, 40%). Barriers to seeing a doctor including difficulty scheduling appointments (13/51, 26%), transportation (12/51, 24%), and cost or insurance barriers (8/51, 16%). Twenty-eight (55%) respondents reported at least one social risk factor. A positive association was found between having at least one risk factor and expressing interest in consulting our patient navigator (odds ratio=6.7, P =0.009). Overall, a third of respondents expressed interest in engaging with our patient navigator program (17/51, 33%). Two thirds of participants reported awareness of missed appointments (34/51, 67%), of whom 35% (12/34) reported having already rescheduled, 41% (14/34) expressed interest in rescheduling, and 24% (8/34) did not wish to return.

CONCLUSIONS

Glaucoma patients with missed appointments report barriers to care and face social risk factors. Telephone outreach may help to re-engage them with care, and patients expressed interest in a patient navigator program to address social needs.

The association between glaucoma treatment adherence with disease progression and loss to follow-up

Prospective cohort study from Brazil to evaluate glaucoma treatment adherence using a medication event monitoring system (MEMS) device and correlate with glaucoma progression and loss to follow-up (LTF) after one year of follow up. We included primary open glaucoma (POAG) patients treated with at least one ocular hypotensive eye drop. MEMS devices was used to monitor adherence for 60 days and evaluate the percentage of doses prescribed taken within the 60-day period. We classified patients according to rates of adherence: low adherence (less than 75% from MEMS measurements) and high adherence (more than 75% from MEMS measurements). We applied a questionnaire to investigated self-reported behavior towards treatment behaviors (glaucoma treatment compliance assessment tool, GTCAT). We also correlated rates of treatment adherence with clinical, demographical variables and the occurrence of glaucoma progression or LTF after one year of observation. We included 110 POAG patients and found that 28.18% of them were considered low adherent. We identify several variables associated with poor adherence such as glaucoma progression, LTF, younger age, low educational and income levels, absence of health insurance, years of disease and peak intraocular pressure. Several constructs from the self-reported GTCAT were also correlated with the rates of treatment adherence. To date, this is the first study in Latin America to evaluate glaucoma treatment adherence with MEMS devices and correlate adherence rates with glaucoma progression and LTF. We found a low-adherence rate of 28.18% and several additional risk factors were statistically associated with poor adherence.

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.