Eileen L. Mayro

Non-adherence to eye care in people with diabetes

Objective Evaluate individual factors that impact adherence to eye care follow-up in patients with diabetes. Design and methods A 4-year retrospective chart review was conducted for 1968 patients with diabetes over age 40 from an urban academic center. Data collected included demographics, insurance, visual acuity, smoking status, medications, dates of dilated fundus examinations (DFE), and reported hemoglobin A1C and blood glucose levels. The primary outcome was timely DFE follow-up adherence following the initial eye exam visit. Results Overall, 41.6% of patients adhered to initial follow-up eye care recommendations. Multivariable analysis demonstrated that patients with severe diabetic retinopathy (DR) were more adherent than patients with mild DR (OR 1.86). Other variables associated with increased adherence were visual impairment and reported A1C or blood glucose. Smoking was associated with decreased adherence. Ethnicity and insurance were also significantly associated with adherence. Longitudinal follow-up rates were influenced by additional factors, including ethnicity and neighborhood deprivation index. Conclusions Patients with moderate to severe DR and/or visual impairment were more likely to adhere to timely DFE follow-up. This could relate to the presence of visual symptoms and/or other systemic manifestations of diabetes. Smokers were less likely to adhere to timely DFE follow-up. One hypothesis is patients who smoke have other symptomatic health problems which patients prioritize over asymptomatic ocular disorders. In order to reduce vision loss from DR, practitioners should be aware that patients with mild and moderate DR, patients with normal vision, and smokers are at greater risk for poor follow-up eye care adherence.

Evaluation of a Web-Based Training in Smoking Cessation Counseling Targeting U.S. Eye-Care Professionals

Background. Smoking causes blindness-related diseases. Eye-care providers are uniquely positioned to help their patients quit smoking. Aims. Using a pre-/postevaluation design, this study evaluated a web-based training in smoking cessation counseling targeting eye-care providers. Method. The training was developed based on the 3A1R protocol: “Ask about smoking, Advise to quit, Assess willingness to quit, and Refer to tobacco quitlines,” and made available in the form of a web-based video presentation. Providers (n = 654) at four academic centers were invited to participate. Participants completed pretraining, posttraining, and 3-month follow-up surveys. Main outcomes were self-reported improvement in their motivation, confidence, and counseling practices at 3-month follow-up. Generalized linear mixed models for two time-points (pretraining and 3-month) were conducted for these outcomes. Results. A total of 113 providers (54.0% males) participated in the study (17.7% response rate). At the 3-month evaluation, 9.8% of participants reported improvement in their motivation. With respect to the 3A1R, 8% reported improvement in their confidence for Ask, 15.5% for Advise, 28.6% for Assess, and 37.8% for Refer. Similarly, 25.5% reported improvement in their practices for Ask, 25.5% for Advise, 37.2% for Assess, and 39.4% for Refer to tobacco quitlines (p < .001 for all except for Refer confidence p = .05). Discussion. Although participation rate was low, the program effectively improved providers’ smoking cessation counseling practices. Conclusions. Including training in smoking cessation counseling in ophthalmology curriculums, and integrating the 3A1R protocol into the electronic medical records systems in eye-care settings, might promote smoking cessation practices in these settings.

Improving Follow-Up Adherence in a Primary Eye Care Setting

Lack of patient adherence with eye appointments can decrease ocular outcomes. This prospective, randomized, single-blinded controlled study assessed the effectiveness of multiple interventions in improving follow-up adherence to recommended eye appointments. Patients due for follow-up appointments were randomly assigned to usual care, automated intervention, or personal intervention. Automated-intervention patients and personal-intervention patients received a call one month prior to the recommended follow-up date, and a mailed appointment reminder letter. The call was automated for automated-intervention patients and personalized for personal-intervention patients. The primary outcome was adherence to the follow-up appointment. The secondary outcome was rate of appointment scheduling. Patients in the personal-intervention group had greater adherence to follow-up recommendations (38%) than patients in the usual care group (28%) and the automated-intervention group (30%). Personal intervention significantly increased appointment scheduling (51%) over usual care (32%) and automated intervention (36%). These results support systems-level changes to improve patient follow-up adherence in urban primary eye care settings.

Reaching the Unreachable: Novel Approaches to Telemedicine Screening of Underserved Populations for Vitreoretinal Disease

ABSTRACT Telemedicine involves electronic communication between a physician in one location and a patient in another location to provide remote medical care. Ophthalmologists are increasingly employing telemedicine, particularly in retinal disease screening and monitoring. Telemedicine has been utilized to decrease barriers to care and yield greater patient satisfaction and lower costs, while maintaining high sensitivity and specificity. This review discusses common patient barriers to eye care, innovative approaches to retinal disease screening and monitoring using telemedicine, and eye care policy initiatives needed to enact large-scale telemedicine eye disease screening programs.

A randomized, controlled trial to test the effectiveness of a glaucoma patient navigator to improve appointment adherence

Purpose Patients with glaucoma who do not keep their follow-up eye care appointments are at risk for developing more severe ocular disease. The primary aim of the current study was to evaluate whether the use of a patient navigator altered adherence to follow-up eye care appointments in community-versus office-based settings. Patients and methods Patients diagnosed with a glaucoma-related condition following a comprehensive eye examination at 43 community sites in Philadelphia, PA, USA, were enrolled in this prospective, randomized, controlled trial. Patients were randomized into three groups for a 1-year period: Group 1 (G1) received follow-up eye care in a community-based setting with assistance from a patient navigator; Group 2 (G2) received follow-up eye care in an office-based setting with assistance from a patient navigator; and Group 3 (G3) received follow-up eye care in an office-based setting without a patient navigator (usual care). Adherence rates were compared among these three groups using a chi-squared test at a significance level of 0.05. Results A total of 155 patients with glaucoma-related diagnoses were enrolled. The mean age (±standard deviation) was 71.2 (±10.0) years. Patients were predominantly female (65.8%, n=102/155) and African-American (71.6%, n=111/155). The mean (±standard deviation) number of follow-up visits during the 1-year study period was 1.3 (±1.3) for G1, 1.6 (±1.3) for G2, and 1.3 (±1.1) for G3 (P=0.48). Appointment adherence, defined as attendance of ≥1 follow-up visit, was 69.8% (n=37/53) for G1, 82.5% (n=47/57) for G2, and 73.3% (n=33/45) for G3, (P=0.28). Sub-analysis of adherence rates for patients who attended ≥2 follow-up visits were 91.3% (n=21/23) for G1, 74.3% (n=26/35) for G2, and 66.7% (n=18/27) for G3, (P=0.11). Conclusion Help from a patient navigator did not increase the likelihood of keeping ≥1 follow-up appointment in an office-based setting. Adherence rates for follow-up appointments reached close to 70% or above in a self-selected patient population.