Beyond Accessibility in Exploring Access to Eye Care to Achieve Vision Health Equity

Shaffer et al¹ used the Medicare part B claims, a large data set from the Centers for Medicare and Medicaid, to determine if expanding laser eye surgery privileges to optometrists was associated with improved patient access to laser procedures. Shaffer et al reported that the expansion of optometrists’ ability to perform laser eye surgery procedures did not provide shorter drive times for patients when receiving laser eye surgeries. Distance and drive time are concerns for patients who have limited access to care, especially patients from low-resource communities. However, beyond accessibility, the theory of access framework from Penchansky and Thomas² includes affordability, acceptability, availability, and adequacy and has now been expanded to include awareness and patient-level factors.^2,3 Understanding how each dimension impacts access will be critical to reduce eye health disparities.

Accessibility focuses on the location of the eye care service, the target of the research by Shaffer et al.¹ For this dimension, researchers examined geographical considerations, including where the patients lived, distances (geographical, economic, and social), drive times, and transportation resources.² Patients living in poorly resourced neighborhoods or in rural areas may have few transportation options, further exacerbated by the distance to the closest eye care facility. Alternate options, such as taxi or rideshare services, exist but have a high direct cost.

Affordability focuses on the direct eye care costs to the patient.² Affordability includes not only a patient’s ability to pay out-of-pocket costs (medical insurance copays, medication costs, and prescription eyeglass costs) but their lost productivity due to missed work and other costs, such as for transportation and lodging.² Poor patients are affected globally by these issues, even if they have access to universal health care.³

Acceptability describes the expectations of patients.² Patients may find that a service is unacceptable due to a poor physician-patient relationship, lack of adequate communication with the eye care clinician, or minimal patient education from the eye care clinician about eye diagnoses and treatment. Patients who identify as racial and ethnic minorities and patients with lower socioeconomic status are more likely to report lack of respect in the patient-physician relationship.⁴ Lack of respect may be associated with reduced uptake of essential eye care services thus perpetuating eye health disparities.⁴

Availability focuses on the supply and demand; in other words, if the type of eye care services needed is matched to the available services offered.² In local community health centers, frequented by at-risk populations, eye care services are lacking or, if available, do not reflect care for the eye diseases that are prevalent in these populations, such as glaucoma care.⁵ Preventive care in community health centers is often unattainable, leading to poor health, including lower life expectancy, high morbidity, higher functional limitations, higher health care expenditures, and worse health status.⁶ Community health centers need clinicians from partnering eye clinics that accept public insurance and are available for all patients.⁵ The American Academy of Ophthalmology has presented data recently indicating that eye care services are limited at Federally Qualified Health Centers with fewer than one-third of Federally Qualified Health Centers with any eye services even though FQHCs are the medical home for 1 in 11 people in the US.

Adequacy refers to the capacity of an organization’s structure toreceive and facilitate services. For example, persons who work during the same hours the eye care facility is open may need flexible office hours, including after-hour times, walk-in slots, and weekend appointments. In a recent example, 1 patient with severe bacterial keratitis could only come to the emergency department for care because they lacked work flexibility and feared losing their job. Adequacy also measures a facility’s equitable, diverse, and inclusive resources, such as wheelchair accessibility and the racial, linguistic, and cultural concordance of clinicians and patients.

Awareness is the final dimension, expanded from the original framework by Saurman et al.² Awareness focuses on information and communication about available eye care services. For example, if eye clinicians implement a mobile eye clinic, everyone involved must know whom the service is for (underserved communities), what it does (screenings and providing eyeglasses when needed), when itwill be available (dates and times), how and where to use the service (locations and appointments vs walk-ins), and why the service should be used (prevention of eye disease, detection of chronic disease, addressing refractive error, etc). Communication should help patients understand and then use eye care services that fit their needs and should target at-risk populations. Implementing awareness campaigns to disseminate information can lead to better eye health literacy regarding the importance of receiving an eye examination for prevention of vision-threatening eye diseases and can ensure that partnerships thrive. Many patients are unaware offree or near-free services provided in their communities due to limited budgets for communication.

Patient-level factors also impact access to eye care when situations in a patient’s life prevent them from accessing care. For example, a patient may have an eye appointment scheduled but is unable to attend due to illness, limited time off of work, or lack of alternate caregiving. In our experience, a patient with severe fungal keratitis needed to bring her mother, who was older and had a disability, for her urgent care appointments for 6 months because she had no other means of help. Patient-level factors may continuously deter patients from seeking both immediate and prevention eye care services.

Thus, multidimensional approaches are needed to understand where access to eye care services is lacking. Research can grow beyond geographical access.⁶ The article by Shaffer et al1 used zip code to assess accessibility by measuring driving distance. Additional neighborhood-level factors can be used to assess additional dimensions of access.⁷ Electronic health records contain home addresses that can be mapped onto Census tract and Census block data, which are publicly available. These Census data can be used to assess dimensions of access, such as accessibility, by measuring neighborhood-level household car access and public transportation. Adequacy could be measured by poverty indices and the percentage of the population that does not speak English as their first language. Affordability could be measured by measuring other neighborhood-level factors, such as the cost of fuel, copays for eye care, and median income within a neighborhood. Several other factors lend themselves to qualitative data collection. Qualitative interviews provide information on acceptability (measurements of the patient–eye care professional relationship), awareness (measuring eye care and vision health literacy), and patient-level factors (ability to take time off from work or caregiver challenges). To best serve patients, clinicians, researchers, and eye care facilities will need to examine the broader dimensions of access to determine whether eye care services, such as laser surgery, are accessible to patients.