Barriers to Attending Eye Appointments among Underserved Adults

Dear Editor,

Uninsured people have considerably less access to eye doctors and treatments for eye diseases. In a partnership between the Hope Clinic, a non-profit medical clinic for uninsured individuals, and the University of Michigan's ophthalmology department, free comprehensive ophthalmic examinations are offered once every two months on a Saturday. We conducted a study on the population that availed this facility in the past[1] and, after three years, we were concerned about the rate of clinic non-attendance. We conducted a study on the barriers facing those adults who failed to keep their appointments at the University despite multiple reminders.

The study adhered to the Tenets of the Declaration of Helsinki. The approval from the University of Michigan Institutional Review Board was obtained. We then identified the adults missing at least one eye appointment over a 20-month period. We attempted to contact these patients three times using their available telephone number to participate in the study. Interviews were conducted using a semi-structured interview guide, which included questions on the reason for the visit, barriers to their attendance, and plans for re-scheduling appointments.

The clinic non-attendance rate was 23.4%. Of the 80 unique patients, 52.5% were unreachable and 18.8% did not wish to participate. Twenty-three patients were interviewed of whom 43.5% were female and the mean age of the group was 53.9 years. They missed an average of 1.2 appointments. Some patients stated more than one reason for missing their appointment. The reasons for missing the appointment included lack of transportation (34.8%), work conflicts (34.8%), illness (26.1%), dependent care (13%), and other causes (21.6%). When going to their appointments, thirteen participants typically drove themselves, six typically found a ride, three used public transportation, and one walked. Research in other outreach settings has revealed cost, provider availability, and absence of perceived need to be additional limiting factors.[1,2]

Michigan is a large state, and clinics are typically far from the homes of the underserved population.[3,4] We concluded that addressing access problems stemming from transportation needs would increase our program's effectiveness.

Communication was also clearly a barrier. 52.5% of the target population was not reachable for the study implying that phone call appointment reminders would be equally ineffective. Vulnerable patients are often a hard-to-reach population without a stable phone number. Gower et al found that nearly 60% of free eye clinic patients in Ohio were unreachable because either the phone was not working or an incorrect number was on record.[5]

The care we provide needs to be more convenient for these patients. One innovative method of providing care is through tele-ophthalmology consultation during a patient's visit to their primary care doctor.[4] On-site providers or paraprofessionals could interact with the remote ophthalmologist to guide disease management. The partnership is currently designing this approach. Another option is to identify local eye care providers willing to bring their equipment and go to Hope Clinic to see patients without insurance on a volunteer basis, although this approach has its own challenges. Our goal is to use these new insights to improve care to people with limited resources.

Financial Support and Sponsorship

National Eye Institute K23EY023596 (MAW), K23EY025320 (PANC); and Research to Prevent Blindness (PANC).

Conflicts of Interest

There are no conflicts of interest.