Feasibility of Glaucoma Detection Programs for At-Risk Populations Using Existing Health Care Infrastructure

Abstract

Purpose:

To summarize the glaucoma detection and maintenance programs that utilize existing health care infrastructure to promote up-scalable programs

Methods/Results:

Healthcare infrastructure that already exists may facilitate glaucoma detection. This infrastructure includes retail-based optometry practices and federally qualified health centers (FQHC). Persons who are at-risk for glaucoma are disproportionately represented within the patient populations served by much of this infrastructure, thus suggesting that it could be useful for deploying glaucoma screening programs. Glaucoma screening within FQHCs reveals a very high prevalence of glaucoma and related disease in the patients seeking care at these facilities. These telemetric-based care delivery programs have a high patient acceptance. A simulated telemedicine program modelled after a telemedicine program based in Walmart Vision Centers for the diagnosis of glaucoma indicated that there was moderate diagnostic agreement between an ophthalmologist’s telemedicine diagnosis and an ophthalmologist’s in-person diagnosis. There was also moderate agreement between an optometrist’s telemedicine diagnosis and the ophthalmologist’s in-person diagnosis.

Conclusion:

Telemetric care delivery programs that capitalize on existing infrastructure within a retail-based care setting or FQHCs may provide a promising setting to cost effectively screen for glaucoma and other eye diseases that is potentially expandable nationwide.

Précis:

Targeted glaucoma screening strategies performed within retail care based clinics and Federally Qualified Health Centers uncover a high prevalence of glaucoma.

Introduction

The at-risk population for glaucoma in the U.S. is large, with older age as the primary risk factor as well as African Americans or Hispanics ≥ 40 years old, Asians, non-Hispanic whites ≥ 50 years old, older persons with diabetes, and those with a family history of glaucoma.⁵ POAG is at least 4-5 times more common in African Americans, progresses more rapidly and appears about 10 years earlier as compared to those of European descent.^6-8 Moreover, while the number of patients with glaucoma will nearly double over the next 20 years, the number of US ophthalmologists is expected to grow only 0.67%.^3,4 Fortunately, vision loss from glaucoma can be prevented by early detection, consistent follow-up, and control of intraocular pressure with medication or surgery. Thus, there is an enlarging need for more efficient screening and management strategies that can deliver equivalent care.

In 2022, the United States Preventive Services Task Force (USPSTF) issued an opinion that there is insufficient evidence to assess the balance of benefits and harms of screening for primary open angle in adults.⁹ However as Newman-Casey and colleagues have pointed out,¹⁰ since estimates indicate that 50% of those with glaucoma remain undiagnosed and thus untreated,¹¹ there is strong rationale for identifying targeted screening strategies for glaucoma in populations that are at-risk.

In the general US population, the prevalence of glaucoma is rather low at 2%.¹ This low prevalence is problematic for general screening as even with the most sensitive and specific approaches, it is difficult to achieve a reasonable post-test probability of disease for general population screening. Moreover, despite widespread efforts at screening with a variety of methodologies, there has never been a community controlled-trial to determine the impact of false negatives, which could have an untoward impact on health-seeking behaviors and potentially increase disease burden on those most vulnerable. Moreover, all of the groups identified by age and race as at higher risk of glaucoma are in a group that is recommended to receive yearly general eye exams, thus screening may be less impactful than addressing barriers to eye examination. For these reasons, we have explored screening and remote disease management strategies in existing eye-care and medical care settings that may have a high prevalence of the disease and are delivering routine care enabling the potential for continued remote management.

In this article we describe healthcare infrastructure that already exists in the US where populations at-risk for glaucoma routinely seek medical care. We provide two examples of screening glaucoma programs designed to address this glaucoma detection screening need: specifically, eye care services available in the retail care setting and within Federal Qualified Health Centers (FQHC). Given the nation-wide distribution of these settings, interventions developed within these programs are potentially more scalable for broad deployment than other approaches.

Methods

This study will review current efforts encompassed within two projects both funded by the Centers for Disease Control and Prevention: the Eyecare Quality and Accessibility Improvement in the community (EQUALITY) project¹² and the Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (INSIGHT) projects (https://sightstudies.org).^13,14 These studies were designed to test the implementation of screening and/or care initiatives within potentially expandable programs to determine if they are accepted by patients and providers, effective in detecting disease, and cost effective to implement. EQUALITY was based in existing vision clinics within a national retail chain (Walmart) while Michigan-SIGHT (MI-SIGHT) and Alabama-SIGHT (AL-SIGHT) were based at federally qualified health centers (FQHC).

Retail-Based Primary Eye Care Clinics (EQUALITY)

Several large retailers have implemented primary optometric care clinics within their facilities, including Walmart, Costco, and Target. While these retailers are based in urban and suburban areas, some such as Walmart are also located in more rural areas in small cities throughout the US. These retailers have become the primary, go-to retailer for a variety of shopping needs including eye care services and optical dispensaries. In a recent demonstration program, we studied a glaucoma detection program implemented at two Walmart Vision Centers located within Walmart Supercenters in rural Alabama. Each clinic is independently owned and operated by an optometrist who had an established practice at the Vision Center seeing between 4000-7000 patients per year. Fifty percent or more of the patients seen in these clinics are African American. We selected Walmart Vision Centers as our clinical setting because in the communities where we were based, Walmart is a popular retailer with community residents seeking groceries, household items, clothing, prescription and over-the-counter medications, and car care. Thus, this retailer has a high level of familiarity to residents of the region. The optometrist, in addition to managing all of their regular patients, conducted comprehensive eye examinations on patients who met any of the following criteria which suggest elevated risk for glaucoma: (1) African Americans ≥40 years old, (2) Whites ≥50 years old, (3) persons of any age or race/ethnicity with diabetes, (4) persons of any age or race/ethnicity with a glaucoma associated diagnosis (GAD) (glaucoma suspect (GS), ocular hypertension (OHT), and POAG), (5) persons with a self-reported family history of any relative believed to be diagnosed with glaucoma. In addition to a comprehensive eye examination including an optic nerve evaluation under dilated conditions, the optometrist also administered visual field testing and optical coherence tomography. Based on this examination, the optometrist determined if GAD was present, and provided follow-up care. If treatment was medical, the optometrist managed the care. If surgical treatment was appropriate, the patient was referred to the UAB Glaucoma Service at the Callahan Eye Hospital.

All clinical information was telemetrically transmitted to an ophthalmologist fellowship-trained in glaucoma at the University of Alabama at Birmingham (UAB) who reviewed the assessments performed at the Walmart Vision Center by the optometrist. The ophthalmologist then communicated their impressions and recommendations to the treating optometrist. We conducted a simulated telemedicine program to examine glaucoma diagnostic agreement between the glaucoma specialist conducting an in-person comprehensive examination including OCT, fundus images, and visual field testing and an optometrist reviewing the information provided through telemedicine.¹⁵

Federally Qualified Health Centers (AL-SIGHT)

FQHCs are pivotal safety-net primary care providers in the US serving medically underserved areas and populations. They provide services regardless of a patient’s ability to pay and use a sliding scale fee based on income. A recent report by the National Academies of Science, Engineering and Medicine (NASEM) indicated that primary eye care services (through optometrists or ophthalmologists) are rarely available at FQHCs; the report estimated that fewer than 3% of FQHC patients receive vision care services, representing 0.89% of all FQHC clinic visits.²¹ Given the increased interest in telemedicine services in ophthalmology over the past two decades and the COVID-19 pandemic which facilitated the use of telemedicine, two trials, namely the SIGHT studies, examined how a telemedicine program linked to FQHCs could facilitate the detection and management of glaucoma. MI-SIGHT was based at a FQHC in Flint, Michigan where 64.7% of participants were African American.¹³ Ophthalmic technicians performed a variety of eye screening assessments including refraction, visual acuity, fundus photos, and retinal nerve fiber OCT. Remote ophthalmologists at the University of Michigan reviewed and interpreted the results, and identified 26.5% of those screened as being GAD.²² This GAD detection rate was much higher than the national rate of 9%. This demonstrates that telemedicine programs when conducted within the FQHC environment could identify high rates of glaucomatous pathology if a gold-standard validation were to be performed.

AL-SIGHT was carried out in three FQHC in a rural region: Centreville (Bibb County), Maplesville (Chilton County), and Marion (Perry County).¹⁴ These FQHCs are in part of Alabama that borders or is part of the Black Belt named for its rich black soil that supported cotton agriculture. In the 19^th century the agricultural workers were enslaved African Americans. Today this region’s population is over 50% African American and is one of the poorest regions in nation.

Ophthalmic technicians in AL-SIGHT did both structural and functional optic nerve testing, and also assessed visual acuity, autorefraction, intraocular pressure, and fundus imaging. Using telemedicine, ophthalmologists at the University of Alabama at Birmingham reviewed and interpreted the results.

Results:

Retail-Based Primary Eye Care Clinics (EQUALITY):

Diagnostic agreement between telemedicine and direct examination was moderate (kappa 0.41 (95% CI 0.28 – 0.54)). We also examined diagnostic agreement between the in-person glaucoma-fellowship trained ophthalmologist and two other glaucoma-fellowship trained ophthalmologist who each independently reviewed the telemedicine data. They also displayed similar levels of agreement to the in-person ophthalmologist (kappa 0.49, 95% CI 0.37-0.61 and kappa 0.44, 95% CI 0.32-0.56). These results suggest the potential feasibility of glaucoma screening using telemedicine.

For patients diagnosed with GAD, patient satisfaction in the Walmart Vision Center was evaluated using the Patient Satisfaction Questionnaire – 18.¹⁶ Items addressed a variety of domains including general satisfaction with the doctor, technical quality, interpersonal manner, communication, financial aspects, time spent with doctor, and accessibility and convenience. Higher scores represent a higher level of satisfaction (scores on a 1 – 5 range). Patient satisfaction was high with an average score of 4.6.¹⁷ What was particularly interesting is that African Americans (about half of those diagnosed with GAD) expressed significantly greater satisfaction with the program than did whites. Additionally, we also evaluated patients’ knowledge about telemedicine using the Preferences for Telemedicine Questionnaire.¹⁸ Knowledge of telemedicine among patients was variable, with one-third to one-half having favorable attitudes about it.¹⁹ Patients who were more favorable were those who were younger than age 60, more educated, and traveled greater distances from the home.

The challenge for using this infrastructure is that patients covered the cost of their comprehensive eye examination (either by health insurance or self-pay). Furthermore, the telemedicine portion was provided free of charge to the patient, meaning that the funding agency covered the cost of ophthalmologist’s telemedicine reading and the IT technology that supported the telemedicine program. Some alternative source of funding for these screenings will be needed for this approach to be viable. That said, the advantage of these programs is that they are situated in a retail setting, usually near where patients live, where they regularly go for grocery and other types of shopping, which is convenient. Previous attempts at developing retail-based health care have not always been successful. Most recently, Walmart has redeployed “Walmart health” across several pilot stores based on a flat fee model for basic health care.²⁰ It remains to be seen if this approach will be feasible to expand nationwide. The potential to combine eye care outreach with retail-based efforts to deliver healthcare is promising if screening and treatment can safely be performed in these settings with acceptable patient satisfaction.

Federally Qualified Health Centers (AL-SIGHT)

In the AL-SIGHT study, remote diagnosis indicated that there 30% of participants had GAD,²³ similar to MI-SIGHT results. Furthermore, of those who were referred for follow-up examination because of GAD (and who were not under current ophthalmology care), approximately 70% participated in that care.

The high pre-test probability of GAD seen within the participating FQHCs along with the high rate of patient follow-up for definitive care is promising in that current detection performance of automated detection strategies may function well enough to effectively screen this at-risk disadvantaged population. Together the MI-SIGHT and AL-SIGHT projects demonstrate that targeted glaucoma screening in communities at high-risk for glaucoma and associated disorders generates a high rate of pathology in a setting that is readily scalable.

Conclusion:

While retail settings and FQHCs are promising sites for implementation of telemetric screening and disease management strategies on a larger scale, their deployment is limited within current common payment models which cannot adequately support these efforts within most existing systems that deliver health care in the United States. Both EQUALITY and INSIGHT projects were supplemented with federal funding and would likely not be expandable within existing fee-for-service models that predominate the United States health care market.

Moreover, these settings are dependent on a successful business model being developed and deployed. Unfortunately, achieving a sustainable model has been elusive with retailers like WalMart failing at several attempts to expand health care offerings. Retail settings also face the threat of a growing dependence on online sales which may ultimately impact the access to patients.

Population-based health care management programs and unique capitated markets may provide additional opportunities to employ telemedicine strategies as there may be greater incentive to reduce overall costs to deliver care and not maximize billing for services. Ultimately, well-designed implementation studies within large employer programs, encapsulated health care delivery systems (Veteran Administration, state and federal prison systems, large self-insured companies, FQHCs) and healthcare networks that are forward thinking in their investments in preventative care are needed to define how to generalize and expand these efforts.