Key Points
Question
Were adults at high risk of eye disease using eye care services before participating in the Screening and Intervention for Glaucoma and Eye Health Through Telemedicine Program?
Findings
In a cross-sectional study including 1171 participants in an eye care program, 55% had not had an eye examination in 2 or more years. Of those screening positive for glaucoma, cataract, diabetic retinopathy, or age-related macular degeneration, 41% to 54% had not had an eye examination in 2 or more years.
Meaning
These results suggest that free eye disease screenings in primary care clinics within underserved communities engaged people at risk of eye disease and underuse of eye care; this approach may enhance eye disease detection and treatment, potentially reducing vision loss in the US.
Abstract
Importance
Underuse of eye care services leads to underdiagnosed and undertreated eye disease.
Objective
To assess the reasons for underuse of eye care and whether a novel, free eye disease screening program is engaging adults who are both at high risk of eye disease and were underusing eye care services.
Design, Setting, and Participants
In a population-based cross-sectional study, adult participants from the first year of the Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (MI-SIGHT) Program were included. The participants were recruited from primary care clinics serving 2 low-income communities. Recruitment occurred between June 28, 2020 and June 27, 2021 at the free clinic, and between January 27, 2021 and January 26, 2022 at a federally qualified health clinic. Data were analyzed from December 7, 2022, to May 29, 2024. Participants received comprehensive eye disease screening and completed surveys assessing health and prior eye care use. Risk factors for eye disease included age 65 years and older, diabetes, personal or family history of eye disease, and self-identifying as Black or African American individuals who were aged 50 years or older. Underuse of eye care was defined as no eye examination in 2 or more years.
Main Outcomes and Measures
Percentage of participants who were at high risk of eye disease and underused eye care services before accessing this program.
Results
A total of 1171 MI-SIGHT participants were a mean (SD) age of 55 (14.5) years; 437 (38%) identified as male; 591 (54%) self-identified as Black or African American, 101 (10%) as Hispanic or Latino, and 371 (34%) as White; 492 (43%) had high school education or less, and 696 (70%) reported an annual household income of less than $30 000. Characteristics of participants reporting not having had an eye examination in 2 years or more included 23% (n = 151) of participants 65 years and over, 33% (n = 214) of participants who self-reported diabetes, 25% (n = 130) of participants reporting a family history of glaucoma, 3% (n = 14) of those with self-reported glaucoma; and 33% (n = 202) of Black or African-American participants aged 50 years and older. In participants who reported not having had an eye examination in 2 or more years, 21% (n = 137) screened positive for glaucoma, 20% (n = 129) for cataract, 6% (n = 38) for diabetic retinopathy, and 1% (n = 9) for age-related macular degeneration. Reported reasons for why participants had not had an eye examination included no insurance (175 of 627 [28%]), no reason to go (no problem) (135 of 627 [22%]), and cost of eye examination (101 of 627 [16%]).
Conclusions and Relevance
The findings of this study suggest that placing eye disease detection programs in primary care clinics in underserved areas may improve eye disease detection and treatment, possibly mitigating needless vision loss in the US.
This cross-sectional study examines the use of free eye care services for screening to identify eye disease.
Introduction
Routine eye examinations are important components of preventive health care, as they allow for timely detection of disease and prompt intervention to prevent visual impairment. Routine examination is recommended every 1 to 2 years for individuals aged 65 years and older and yearly for those with diabetes, a family history of glaucoma, or known eye disease.1 Medicare Part B covers annual glaucoma testing for high-risk individuals, including those with diabetes, a family history of glaucoma, Black or African American (hereinafter, Black) persons aged 50 years or older, and Hispanic persons aged 65 years or older.2 Routine eye examination for those older than 65 years may lead to better long-term vision outcomes.3,4 Individuals aged 65 years or older who visit an ophthalmologist or optometrist regularly (every 1-2 years) have a lower probability of experiencing a decline in vision or developing blindness.3,4
In the US, the most common causes of visual impairment include cataract, age-related macular degeneration (AMD), glaucoma, diabetic retinopathy (DR), and uncorrected refractive error.5 In 2017, the Vision and Eye Health Surveillance System Study Group estimated that 7 million US residents had visual impairment (best-corrected visual acuity of 20/40 or worse) or blindness (best-corrected visual acuity of 20/200 or worse).6 The prevalence of vision loss and blindness is expected to increase as the US population grows and ages. A study by Varma and colleagues7 estimated that individuals with visual impairment or blindness will more than double between the years 2015 and 2050. Fortunately, many causes of visual impairment can be treated. However, despite the projected increase in the prevalence of visual impairment, many who would benefit from eye examinations do not use eye care services.8 Inadequate access to eye care and affordability of care are barriers both for correcting refractive error by prescribing glasses and detecting and treating eye disease.9,10,11
The Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (MI-SIGHT) Program12 provides telemedicine-based eye disease detection to residents of 2 lower-income Michigan communities through primary care clinics. The MI-SIGHT Program was funded by the Centers for Disease Control and Prevention to test this novel model for glaucoma and other eye disease detection within communities at high risk for eye disease due to having large proportions of Black people who are at higher risk for glaucoma and large proportions of people living in poverty who may have multiple barriers to accessing high-quality eye care. In this study, we investigated whether the MI-SIGHT Program was reaching the intended population—people who are both at high risk of eye disease and who have not been adequately using eye care services—to understand whether this program represents a nationally scalable approach to improving use of eye care. We also aimed to identify the main reasons why individuals underused (with underuse of eye care defined as no eye examination in 2 or more years) or did not use eye care services before participating in the MI-SIGHT Program.
Methods
This cross-sectional study was approved by the institutional review board at the University of Michigan and adhered to all tenets of the Declaration of Helsinki.13 The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies was used (eFigure in Supplement 1).14 This study included participants from the MI-SIGHT Program during the first year of recruitment. The MI-SIGHT Program is housed at 2 sites: a free clinic in Ypsilanti, Michigan (Hope Clinic), and a federally qualified health clinic (FQHC) in Flint, Michigan (The Hamilton Community Health Network). Participant recruitment included referral by community clinic health care professionals and staff, contacting current clinic patients overdue for their annual diabetic eye examination by telephone, local advertisements, and community outreach.15 Recruitment occurred between June 28, 2020 and June 27, 2021 at the free clinic, and between January 27, 2021 and January 26, 2022 at the FQHC. Residents were eligible to participate if they were aged 18 years or older. Exclusion criteria included major eye pain, sudden decrease in vision within the past week, binocular diplopia, cognitive impairment, pregnancy, incarceration, or intent to move outside of driving distance to the clinic within 6 months. Participants provided written informed consent and received no incentives aside from a free eye disease screening.
Participants completed surveys about demographic characteristics, health history, history of eye disease, and past eye care service use. Additionally, 2 survey questions asked about participants’ past eye care service use (Figure 1). Following survey completion, an ophthalmic technician conducted a comprehensive eye disease screening with ocular imaging. A detailed description of the methods of the MI-SIGHT Program has been published.16 Examination data and images were transmitted to remote ophthalmologists at the University of Michigan through the electronic health record (EPIC). After reviewing participants’ data, the ophthalmologists documented screening results for refractive error, glaucoma, cataract, DR, AMD, or other eye disease. Details of screening criteria for each condition have been reported.16 Participants then returned to clinics to receive results, recommendations for and assistance accessing follow-up, and low-cost prescription eyeglasses (if ordered) from the ophthalmic technician.
Figure 1. Survey Questions Asking About Past Eye Care Service Use .
Statistical Analysis
Demographic characteristics, health history, and screening results of the participant sample were summarized with descriptive statistics including mean (SD), frequency, and percentage. Descriptive statistics were also used to summarize responses to survey questions about prior eye care service use, overall and stratified by groups recommended to have routine eye disease screenings by the American Academy of Ophthalmology (AAO) (age ≥65 years, diabetes, family or personal history of eye disease, and Black individuals age ≥50 years).1 Descriptive statistics were used to summarize reasons for not using eye care. All percentages are reported on the sample without missing data. All statistical analyses were performed using SAS, version 9.4 (SAS Institute). Data were analyzed from December 7, 2022, to May 29, 2024.
Results
The MI-SIGHT Program served 1171 individuals during the first year. Participants’ mean (SD) age was 55 (14.5) years (24% [285 of 1171] aged ≥65 years); 38% (437 of 1158) identified as male; 62% (721 of 1158) as female; 54% (591 of 1093) self-identified as Black, 10% (101 of 968) as Hispanic or Latino, and 34% (371 of 1093) as White; 43% (492 of 1151) had a high school education or less, 70% (696 of 993) reported an annual household income of less than $30 000; 20% (228 of 1142) reported having no health insurance and 35% (385 of 1109) reported having Medicaid insurance. In addition, 38% of participants (433 of 1138) had self-reported diabetes, 27% (250 of 917) had a family history of glaucoma, and 5% (46 of 917) had a previous diagnosis of glaucoma. Screening identified 24% of participants (284 of 1163) as screening positive for glaucoma or suspected glaucoma, 21% (250 of 1165) for cataract, 5% (61 of 1165) for visually significant cataract, 7% (85 of 1165) for DR, and 2% (23 of 1165) for AMD. When stratified by age, 29% (10 of 34) of individuals identifying as Black aged 30 to 39 years and 27% (23 of 86) of those aged 40 to 49 years screened positive for glaucoma or suspected glaucoma, as did 28% (7 of 25) of individuals identifying as White aged 30 to 39 years and 11% (6 of 53) of those aged 40 to 49 years. Other eye disease was more prevalent among participants older than 60 years (Table 1).
Table 1. Prevalence of Eye Disease in Participants Recruited During the First Year of the MI-SIGHT Program.
| Age range, y | Glaucoma | Any cataract | DR | AMD | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No./total No. | Prevalence, % | P valuea | No./total No. | Prevalence, % | P valuea | No./total No. | Prevalence, % | P valuea | No./total No. | Prevalence, % | P valuea | |
| Overall | ||||||||||||
| 18-19 | 4/16 | 25 | .01 | 1/16 | 6 | .87 | 0/16 | 0 | .77 | 0/16 | 0 | .69 |
| 20-29 | 11/67 | 16 | .02 | 0/67 | 0 | >.99 | 1/67 | 1 | .81 | 0/67 | 0 | .84 |
| 30-39 | 25/89 | 28 | <.001 | 3/89 | 3 | >.99 | 4/89 | 4 | .28 | 0/89 | 0 | .88 |
| 40-49 | 36/184 | 20 | <.001 | 7/185 | 4 | >.99 | 11/185 | 6 | .03 | 0/185 | 0 | .95 |
| 50-59 | 79/324 | 24 | <.001 | 45/324 | 14 | .93 | 29/324 | 9 | <.001 | 4/324 | 1 | .65 |
| 60-69 | 81/328 | 25 | <.001 | 121/328 | 37 | <.001 | 27/328 | 8 | <.001 | 9/328 | 3 | .03 |
| 70-79 | 34/122 | 28 | <.001 | 67/123 | 55 | <.001 | 11/123 | 9 | <.001 | 5/123 | 4 | .01 |
| 80-89 | 13/31 | 42 | <.001 | 6/31 | 19 | .36 | 2/31 | 6 | .17 | 5/31 | 16 | <.001 |
| 90-99 | 1/2 | 50 | .02 | 0/2 | 0 | .74 | 0/2 | 0 | .60 | 0/2 | 0 | .57 |
| Black | ||||||||||||
| 18-19 | 2/10 | 20 | .11 | 1/10 | 10 | .72 | 0/10 | 0 | .72 | 0/10 | 0 | .65 |
| 20-29 | 6/33 | 18 | .03 | 0/33 | 0 | .55 | 1/33 | 3 | >.99 | 0/33 | 0 | .76 |
| 30-39 | 10/34 | 29 | <.001 | 1/34 | 3 | .21 | 2/34 | 6 | .99 | 0/34 | 0 | .76 |
| 40-49 | 23/86 | 27 | <.001 | 5/86 | 6 | .03 | 6/86 | 7 | >.99 | 0/86 | 0 | .87 |
| 50-59 | 46/170 | 27 | <.001 | 29/170 | 17 | <.001 | 14/170 | 8 | .49 | 1/170 | 1 | .84 |
| 60-69 | 56/162 | 35 | <.001 | 79/162 | 49 | <.001 | 13/162 | 8 | <.001 | 2/162 | 1 | .61 |
| 70-79 | 27/73 | 37 | <.001 | 44/73 | 60 | .002 | 7/73 | 10 | <.001 | 4/73 | 5 | .003 |
| 80-89 | 8/20 | 40 | <.001 | 4/20 | 20 | .05 | 2/20 | 10 | .36 | 3/20 | 15 | <.001 |
| 90-99 | 1/1 | 100 | <.001 | 0/1 | 0 | .57 | 0/1 | 0 | .67 | 0/1 | 0 | .55 |
| White | ||||||||||||
| 18-19 | 1/3 | 33 | .07 | 0/3 | 0 | .63 | 0/3 | 0 | .78 | 0/3 | 0 | .58 |
| 20-29 | 2/15 | 13 | .28 | 0/15 | 0 | .77 | 0/15 | 0 | .96 | 0/15 | 0 | .68 |
| 30-39 | 7/25 | 28 | <.001 | 1/25 | 4 | .10 | 2/25 | 8 | .96 | 0/25 | 0 | .73 |
| 40-49 | 6/53 | 11 | .28 | 1/53 | 2 | .44 | 2/53 | 4 | >.99 | 0/53 | 0 | .82 |
| 50-59 | 21/102 | 21 | <.001 | 12/102 | 12 | <.001 | 10/102 | 10 | .92 | 2/102 | 2 | .35 |
| 60-69 | 22/125 | 18 | <.001 | 30/125 | 24 | <.001 | 12/125 | 10 | .02 | 6/125 | 5 | .001 |
| 70-79 | 1/36 | 3 | .90 | 18/37 | 49 | .59 | 1/37 | 3 | <.001 | 1/37 | 3 | .27 |
| 80-89 | 4/9 | 44 | <.001 | 2/9 | 22 | .71 | 0/9 | 0 | .34 | 2/9 | 22 | <.001 |
| 90-99 | 0/1 | 0 | .62 | 0/1 | 0 | .57 | 0/1 | 0 | .67 | 0/1 | 0 | .55 |
Abbreviations: AMD, age-related macular degeneration; DR, diabetic retinopathy; MI-SIGHT, Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine.
P values for a 1-sample 1-sided test of proportion for whether the age-stratified observed prevalence rates are larger than national estimates for glaucoma (9%), cataract (17%), diabetic retinopathy (3.4%), and age-related macular degeneration (1.5%).
Prior eye care service use was low (Figure 2). Most participants (55% [613 of 1116]) reported they had not had their eyes examined in 2 or more years, and 5% (51 of 1116) reported they had never had their eyes examined. About one-third (30% [338 of 1116]) of participants reported they had their eyes examined in the past year, and 10% (114 of 1116) reported they had their eyes examined between 1 and 2 years ago. Additionally, 44% of participants (407 of 932) reported they had not had their pupils dilated in more than 2 years, and 12% (113 of 932) reported that they had never had their pupils dilated (Figure 2). Characteristics of participants reporting not having had an eye examination in 2 or more years or never included age 65 years or older, 23% (151 of 664); self-reported diabetes, 33% (214 of 648); family history of glaucoma, 25% (130 of 518); self-reported glaucoma, 3% (14 of 518); and Black individuals aged 50 years or older, 33% (202 of 617). In participants who reported not having had an eye examination in 2 or more years or never, 21% screened positive for glaucoma (137 of 661), 20% for cataract (129 of 660), 6% for diabetic retinopathy (38 of 664), and 1% for macular degeneration (9 of 660).
Figure 2. Self-Reported Past Eye Care Utilization Among First-Year Participants in the Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine Program.
Among participants who met the criteria for recommended routine eye care screening by the AAO, the distribution of prior eye care service use is reported in Table 2. Of participants aged 65 years or older, 55% (151 of 272) reported not having their eyes examined in 2 or more years. Among participants with diabetes, 61% (256 of 420) reported not having had their eyes examined in over a year. Furthermore, 79% (277 of 352) reported not having a dilated pupil examination in over a year, including 35% (122 of 352) who reported not having a dilated pupil examination in 2 years and 7% (24 of 352) who reported never having a dilated pupil examination. Of participants who reported a family history of glaucoma, 63% (154 of 244) reported not having their eyes examined in the past year or more, including 53% (130 of 244) who reported not having their eyes examined in 2 years or more or never. In participants who self-reported glaucoma, 39% (17 of 44) reported not having their eyes examined in the past year, including 32% (14 of 44) who had not had their eyes examined in greater than or equal to 2 years, and 56% (23 of 41) reported not having a dilated pupil examination in the past year. Of Black participants who were aged 50 years or older, 63% (259 of 408) reporting not having their eyes examined in the past year or more, and 77% (252 of 326) reported not having a dilated pupil examination in the past year or more.
Table 2. Distribution of Self-Reported Eye Care Use Among Participants Who Screened Positive for Eye Disease or Other Risk Factors.
| Question and nonmissing sample No. | No. (%) a | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Self-reported | Screened | |||||||||
| Age ≥65 y (n = 285) | Diabetes (n = 433) | Family history of glaucoma (n = 250) | Self-reported glaucoma (n = 46) | Black race, age ≥50 y (n = 427) | Any eye disease (n = 512)b | Glaucoma (n = 284) | Cataract (n = 250) | DR (n = 85) | AMD (n = 23) | |
| When was the last time you had your eyes examined by any doctor or eye care provider? | ||||||||||
| Nonmissing sample No.c | 272 | 420 | 244 | 44 | 408 | 489 | 269 | 241 | 83 | 22 |
| Within the past month | 11 (4) | 16 (4) | 11 (5) | 5 (11) | 20 (5) | 26 (5) | 15 (6) | 12 (5) | 5 (6) | 0 |
| 1 mo to <1 y | 75 (28) | 148 (35) | 79 (32) | 22 (50) | 129 (32) | 148 (30) | 90 (33) | 65 (27) | 29 (35) | 10 (46) |
| 1 y to <2 y | 35 (13) | 42 (10) | 24 (10) | 3 (7) | 57 (14) | 57 (12) | 27 (10) | 35 (15) | 11 (13) | 3 (14) |
| ≥2 y | 148 (54) | 201 (48) | 125 (51) | 14 (32) | 195 (48) | 239 (49) | 125 (47) | 124 (52) | 34 (41) | 9 (41) |
| Never | 3 (1) | 13 (3) | 5 (2) | 0 | 7 (2) | 19 (4) | 12 (5) | 5 (2) | 4 (5) | 0 |
| How long has it been since you last visited an eye doctor to have your eyes dilated? | ||||||||||
| Nonmissing sample No.c | 228 | 352 | 203 | 41 | 326 | 407 | 228 | 195 | 70 | 18 |
| This year | 53 (23) | 75 (21) | 42 (21) | 18 (44) | 74 (22) | 87 (21) | 54 (24) | 36 (19) | 19 (27) | 5 (28) |
| Within 2 y | 52 (23) | 131 (37) | 70 (35) | 14 (34) | 101 (30) | 119 (29) | 68 (30) | 53 (27) | 27 (39) | 6 (33) |
| ≥2 y | 114 (50) | 122 (35) | 72 (36) | 9 (22) | 129 (41) | 164 (40) | 83 (36) | 93 (48) | 19 (27) | 7 (39) |
| Never | 9 (4) | 24 (7) | 19 (9) | 0 | 22 (7) | 37 (9) | 23 (10) | 13 (7) | 5 (7) | 0 |
Abbreviations: AMD, age-related macular degeneration; DR, diabetic retinopathy.
Percentages are reported on the nonmissing sample.
Any eye disease was defined as any 1 or more of glaucoma, cataract, DR, or AMD.
Sample number reduced due to nonresponse.
Among participants who screened positive for eye disease, the distribution of prior eye care service use is reported in Table 2. Of participants who screened positive for glaucoma, 46% (125 of 269) reported having their eyes examined 2 or more years ago and 4% (12 of 269) reported never having their eyes examined. Participants who screened positive for other eye diseases also reported decreased eye care service use: 54% (129 of 241) of participants with cataract, 46% (38 of 83) with DR, and 41% (9 of 22) with AMD reported that their last eye examination was 2 or more years ago or that they never had an eye examination. Additionally, 82% (159 of 195) of those with cataract, 73% (51 of 70) of those with DR, and 72% (13 of 18) of those with AMD reported their last dilated pupil examination was 1 year ago or more (Table 2).
Reasons cited for not using eye care services varied (Table 3). The most prevalent responses included no insurance (28% [175 of 627]), no reason to go (no problem) (22% [137 of 627]), and cost of eye examination (16% [101 of 627]). Of individuals who reported no reason to visit an eye care professional, 28% (38 of 135) were aged 65 years or older, 32% (43 of 133) reported having diabetes, and 21% (24 of 115) reported a family history of glaucoma.
Table 3. Self-Reported Reasons for Not Using Eye Care.
| Question | No. (%) | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Overall | Age ≥65 y | Diabetes | Family history of glaucoma | Self-reported glaucoma | Glaucoma | Cataract | DR | AMD | |
| What is the main reason you have not visited an eye care professional in the past 12 mo? | |||||||||
| Participants, No.a | 627 | 145 | 198 | 124 | 13 | 128 | 124 | 37 | 8 |
| Cost of eye examination | 101 (16) | 22 (15) | 20 (10) | 25 (20) | 1 (8) | 22 (17) | 20 (16) | 4 (11) | 0 |
| No insurance | 175 (28) | 30 (21) | 50 (25) | 27 (22) | 4 (31) | 28 (22) | 33 (27) | 7 (19) | 3 (38) |
| Do not have/know an eye doctor | 37 (6) | 4 (3) | 14 (7) | 5 (4) | 2 (15) | 6 (5) | 6 (5) | 3 (8) | 1 (13) |
| Cannot get to the office/clinic | 12 (2) | 1 (1) | 6 (3) | 3 (2) | 0 | 0 | 1 (1) | 3 (8) | 0 |
| Could not get an appointment | 9 (1) | 3 (2) | 1 (1) | 0 | 0 | 4 (3) | 4 (3) | 0 | 0 |
| No reason to go (no problem) | 135 (22) | 38 (26) | 43 (22) | 24 (19) | 0 | 26 (20) | 20 (16) | 8 (22) | 1 (13) |
| Have not thought of it | 60 (10) | 15 (10) | 31 (16) | 13 (11) | 2 (15) | 15 (12) | 16 (13) | 3 (8) | 1 (13) |
| Other | 98 (16) | 32 (22) | 33 (17) | 27 (22) | 4 (31) | 27 (21) | 24 (19) | 9 (24) | 2 (25) |
| What is the main reason you have not had a dilated eye examination? | |||||||||
| Participants, No.b | 417 | 110 | 117 | 77 | 8 | 85 | 92 | 17 | 5 |
| Cost of eye examination | 62 (15) | 15 (14) | 12 (10) | 19 (25) | 1 (13) | 12 (14) | 12 (13) | 2 (12) | 1 (20) |
| No insurance | 112 (27) | 20 (18) | 28 (24) | 18 (23) | 3 (38) | 19 (22) | 21 (23) | 4 (24) | 2 (40) |
| Do not have/know an eye doctor | 15 (4) | 4 (4) | 4 (3) | 2 (3) | 3 (38) | 5 (6) | 5 (5) | 1 (6) | 0 |
| Cannot get to the office/clinic | 7 (2) | 1 (1) | 3 (3) | 1 (1) | 0 | 1 (1) | 1 (1) | 2 (12) | 0 |
| Could not get an appointment | 7 (2) | 3 (3) | 1 (1) | 0 | 0 | 3 (4) | 3 (3) | 0 | 0 |
| No reason to go (no problem) | 103 (25) | 30 (27) | 31 (27) | 19 (25) | 0 | 15 (18) | 20 (22) | 2 (12) | 0 |
| Have not thought of it | 49 (12) | 12 (11) | 21 (18) | 8 (10) | 1 (13) | 13 (15) | 9 (10) | 1 (6) | 1 (20) |
| Other | 62 (15) | 25 (23) | 17 (15) | 10 (13) | 0 | 17 (20) | 21 (23) | 5 (29) | 1 (20) |
Abbreviations: AMD, age-related macular degeneration; DR, diabetic retinopathy.
Sample reduced due to nonresponse and because this question is only asked of participants who responded that it has been more than 1 year since the last time they had their eyes examined by any physician or eye care clinician.
Sample reduced due to nonresponse and because this question is only asked of participants who responded that it has been more than 2 years since they last visited an eye care clinician to have their pupils dilated.
Discussion
Our analysis observed that people who took part in our MI-SIGHT free eye disease screening program were both underusing eye care service and were at high risk of eye disease. In critiques of free community-based eye disease detection programs, people express concerns that the programs only reach individuals who already use eye care services and know they have eye disease and who are coming to seek a second opinion. Among MI-SIGHT Program participants at risk of eye disease who should have regular eye examinations according to the AAO, over half reported their most recent eye examination was more than 2 years ago (55% of those aged ≥65 years, 51% of individuals with diabetes, and 53% of those with a family history of glaucoma). Additionally, among those who screened positive for any eye disease, 53% had not had an eye examination in at least 2 years, suggesting the utility of placing eye disease detection programs in existing clinics within communities that have high rates of poverty and concomitant underuse of eye care services.
The AAO recommends comprehensive eye examinations for people aged 65 years or older every 1 to 2 years, as this age group has a higher risk of eye disease.17,18 According to a study on self-reported eye care use among US adults, 87% of respondents aged 65 to 80 years reported having an eye examination within the past 2 years.19 Among MI-SIGHT participants from communities where 70% lived in poverty, this rate was much lower (40.5%).20 These data speak to the need to improve access to eye care services in communities with high rates of poverty.
Medicare covers glaucoma screening examinations for Black individuals aged 50 years or older2 because the prevalence of open-angle glaucoma among Black individuals is approximately 3 times higher than in White individuals and Black people also present with disease earlier.21 Black people have higher rates of visual impairment and blindness both overall and specifically from glaucoma.5,22 In our study, half of Black participants older than 50 years reported not having had an eye examination in at least 2 years. In comparison, in a national survey, 85% of Black participants aged 50 to 80 years reported having had an eye examination in the past 2 years.19 Additionally, in the cohort in the present study, the prevalence of screening positive for glaucoma or suspected glaucoma was 29% among Black participants aged 30 to 39 years and 28% among White participants aged 30 to 39 years, suggesting that the screening age for glaucoma, especially in communities with high rates of poverty, may need to be lowered. In the US, glaucoma detection and treatment have generally improved in recent years. In a study by Malihi et al23 of residents in Olmstead County, Minnesota, the proportion of patients with open-angle glaucoma that progressed to blindness decreased significantly when comparing those diagnosed between 1965 and 1980 and 1981 and 2000 (25.8% vs 13.5%). These findings are likely the result of increasing awareness of glaucoma and improvements in medical and surgical treatment. About half (51%) of MI-SIGHT participants who screened positive for glaucoma reported last having an eye examination 2 or more years ago or never. While glaucoma detection and management have improved in recent years, those with limited access to eye care services will not reap these benefits. According to the AAO, patients with primary open-angle glaucoma should receive follow-up examinations at least yearly.24 In this sample, 32% of those who self-reported a history of glaucoma had not received an eye examination within the past 2 years. Moving eye disease detection programs into primary care clinics that serve people who live in poverty, such as free clinics and FQHCs, may help people at high risk of disease obtain better access to eye care.
The AAO recommends annual screenings for DR beginning 5 years after the onset of type 1 diabetes and at the time of diagnosis for type 2 diabetes.25 Yet 79% of MI-SIGHT participants with diabetes reported not having a dilated pupil examination within the past year. In studies by Kelly et al26 and Cheng et al,27those living with economic and social deprivation were more likely to have poor control of their blood glucose levels—an important risk factor for DR. The majority of the participants in the MI-SIGHT Program live with low incomes and in neighborhoods with high levels of deprivation,28 so they are at high risk of poor glucose level control and subsequent development of DR.
Although most participants in this study (80%) had health insurance, many reported the cost of an eye examination (16%) and lack of insurance (28%) as barriers to eye care use. This highlights that many people believe they have inadequate insurance for vision care. In focus groups investigating barriers to eye care for high-risk individuals, cost and lack of insurance made up nearly 30% of the responses.11 Focus group participants suggested that including routine eye examinations with other preventive health care practices in the primary care setting, such as in yearly physical examinations, could help overcome some of these cost-related barriers.11 The Affordable Care Act eliminated cost-sharing for several forms of preventive health, including several cancer screenings, well-visits, and routine vaccines.29 Eliminating cost-sharing has been shown to increase health care use30 and may represent an avenue for increasing the rates of eye examination. Even when people have health insurance, Medicare, for example, covers only medically necessary eye care and not routine eye examinations and glasses. As it may be difficult for a person to discern what types of eye care are deemed medically necessary, they may avoid seeking eye care due to cost concerns. Michigan Medicaid covers routine eye examinations and glasses or contact lenses; aligning Medicare coverage with Michigan Medicaid policies would likely increase eye care use.
The second most common reason participants reported not having had an eye examination in the past year was having no reason to go, even among participants with a known history of diabetes (22%) or a family history of glaucoma (19%). In a survey of an urban, multiethnic population, although 61% of respondents reported having health insurance that covers eye care, 24% of respondents reported that no health care professional had ever mentioned the need for an eye examination. Those who received advice to have an eye examination were 3.9 times more likely to report having an eye examination within the past 2 years.9 Primary care physicians may be able to motivate people at high risk of eye disease to engage in eye care. If primary care physicians who provide care in medically underserved communities at FQHCs are able to refer people to internal, highly accessible eye disease–screening programs, this may also improve use of eye care in this underserved population.11
Strengths and Limitations
The strengths of this study include the fact that the eye disease screening programs were placed in locations with high levels of poverty, which is a major risk factor for underusing eye care services, and the large sample size. However, there are biases present that limit the findings. Bias may be present from survey data, including social desirability bias, which is the tendency for people to answer questions in a way that is perceived favorably by others. Participants included any person who wanted to participate in a free eye health screening program, possibly increasing the chances of inclusion bias. In this case, those who are more conscious of their health may be more likely to participate, leading to underestimates of eye disease. Conversely, there may be volunteer bias in which those with a family history of eye disease may be more likely to participate and screen positive, leading to an overestimate of eye disease. Moreover, this study is not representative of all people in Michigan or the US as it did not use a stratified random sampling technique.
Conclusions
This cross-sectional study highlights the fact that placing eye disease detection programs in an FQHC and a free clinic may promote use of eye care services by people who are both at high risk of eye disease and at high risk of underusing eye care services. Our findings underscore barriers to eye care among people living in poverty. Policy change, such as implementing technology-based eye disease detection programs in FQHCs, expanding Medicare to include coverage for glasses, and eliminating cost-sharing for screening eye examinations, is needed to improve eye disease detection and treatment, especially in communities with high rates of poverty. Such strategies may help mitigate needless vision loss and blindness in the US.
eFigure. STROBE Flow Chart of Participant Sample
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure. STROBE Flow Chart of Participant Sample
Data Sharing Statement