Increased Near Activities Function Associated With Increased Glaucoma Medication Adherence Among Support, Educate, Empower (SEE) Participants.

PRECIS: Higher levels of near vision-related quality of life (VRQoL) were associated with higher adherence to glaucoma medications after adjusting for important confounding variables among participants in the Support, Educate, Empower (SEE) personalized glaucoma coaching pilot study. PURPOSE: To investigate the association between VRQoL and glaucoma medication adherence. MATERIALS AND METHODS: Subjects were recruited for the SEE program, a prospective noncontrolled cohort study examining the impact of a personalized coaching program on glaucoma medication adherence. Glaucoma patients seen at the University of Michigan over 40 years old, taking ≥1 glaucoma medication, and self-reported poor adherence on 2 validated scales were recruited. Demographic details and VRQoL using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) were collected. Participants' medication use for each prescribed glaucoma medication was captured electronically using a medication events monitoring system. The association between VRQoL and medication adherence was assessed with Pearson correlation coefficient (r) and linear regression. RESULTS: Among the 95 eligible participants 49.5% were female, 55.3% were Caucasian, and mean age (±SD) was 63.8±10.5 years. Mean adherence to glaucoma medication was 73.8%±21.0%. Mean NEI VFQ-25 composite score was 81.6±14.5. Better medication adherence was significantly and positively correlated with better functioning in domains of ocular pain (r=0.20, P=0.048), near activities (r=0.29, P=0.004), and role difficulties (r=0.22, P=0.036). Linear regression models adjusting for known correlates of medication adherence (age, sex, race, income), showed a 10-unit increase in self-perceived near activities function was associated with a 2.2% increase in medication adherence (95% confidence interval, 1.0%-5.4%; P=0.0056). CONCLUSION: Better self-perceived near activities function was associated with increased glaucoma medication adherence.

Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (MI-SIGHT): Baseline Methodology for Implementing and Assessing a Community-based Program.

PRECIS: The Michigan Screening and Intervention for Glaucoma and eye Health through Telemedicine (MI-SIGHT) program leverages community-engaged research, telemedicine, and health coaching to overcome key logistical and psychosocial barriers to improve glaucoma screening in underserved communities. PURPOSE: To describe the methodology of the implementation and evaluation of the MI-SIGHT Program. METHODS: The MI-SIGHT Program uses community engagement, telemedicine, and health coaching to overcome key logistical and psychosocial barriers to glaucoma identification and care among underserved populations. The MI-SIGHT Program will be evaluated in 2 community clinics: Hamilton Community Health Network, a federally qualified health center in Flint, Michigan, and the Hope Clinic, a free clinic in Ypsilanti, Michigan. A Community Advisory Board including the research team and health care providers, administrators, and patients from both clinics will guide program implementation. An ophthalmic technician at the community clinics will conduct screening tests for glaucoma and eye disease. The data will be transmitted through electronic health record to be reviewed by an ophthalmologist who will make recommendations for follow-up care. The ophthalmic technician will conduct a return visit to fit low-or no-cost glasses, help arrange follow-up with an ophthalmologist, and provide education. Those diagnosed with glaucoma or suspected glaucoma will be randomized to standard education or personalized glaucoma education and coaching. Costs will be assessed. RESULTS: The authors hypothesize that the MI-SIGHT Program will detect a higher prevalence rate of glaucoma than that found in the general population, improve upon presenting visual acuity, enhance vision-related quality of life, and demonstrate that personalized glaucoma education and coaching improve adherence to follow-up care. CONCLUSION: The MI-SIGHT Program may serve as a model for glaucoma screening and care in high-risk communities.

Facilitators and Barriers to Glaucoma Screening Identified by Key Stakeholders in Underserved Communities: A Community-engaged Research Approach.

PRCIS: Community-engaged research (CER) enables researchers to identify community-specific barriers and facilitators to program implementation. Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust, and community-specific barriers, such as Language and Convenience/Access, were identified. PURPOSE: The aim was to identify the facilitators and barriers to implementing glaucoma screening programs in 2 community clinics. METHODS: A concurrent mixed-methods process analysis using CER. Key stakeholders-including patients, providers, and staff members-from 2 community clinics were interviewed using a semistructured interview guide. Interviews had 2 parts: (1) asking patients about community-based facilitators and barriers to implementing glaucoma screening and care and (2) eliciting feedback about a personalized coaching program. The transcripts were coded using Grounded Theory. Number of participants and number of representative citations were counted per theme. The qualitative analysis was coded using Dedoose 8.3.17 (Los Angeles, CA). RESULTS: Thematic saturation was reached after coding 12 interviews. 30 participants were interviewed, 13 from Hamilton Clinic (Flint, MI; 8 patients, 5 providers and staff members) and 17 from Hope Clinic (Ypsilanti, MI; 6 patients, 11 providers and staff members). The most commonly cited themes were: Priorities (98 citations, 30 participants), Knowledge (73, 26) Transportation (63, 26), Cost (60, 23), and Convenience/Access (63, 22). Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust were identified alongside community-specific barriers such as Language and Convenience/Access. Participants rated their likelihood to follow up with an ophthalmologist after participating in the personalized coaching program at a mean of 8.83 (on a scale of 1 to 10 with 10 being the most confident). CONCLUSIONS: CER enables researchers to identify community-specific barriers and facilitators, allowing more effective program implementation.

Predicting Adherence With the Glaucoma Treatment Compliance Assessment Tool.

PRéCIS:: Univariate and multivariable models using the Glaucoma Treatment Compliance Assessment Tool (GTCAT) statements identified multiple, patient-specific factors associated with adherence that could be used to inform personalized interventions to optimize glaucoma adherence. PURPOSE: The purpose of this study was to determine the health behavior factors related to glaucoma adherence in patients with self-reported poor adherence. METHODS: A research coordinator used the Chang Adherence Measure and the Morisky Medication Adherence Scale to identify subjects with poor self-reported glaucoma medication adherence and enrolled them in a 3-month study to electronically monitor medication adherence. At enrollment, the coordinator administered the GTCAT. We calculated the percentage of prescribed doses taken over a 3-month period using an electronic dose monitor (AdhereTech). We used Rasch analysis, and univariate and multivariable regression to determine the GTCAT statements that predicted electronically monitored adherence. RESULTS: The mean adherence was 73.8% (SD=21.04%, range: 13% to 100%). Rasch analysis showed that the GTCAT had a good overall fit and no differential bias (Anderson likelihood ratio test >0.05). Multiple GTCAT statements were associated with adherence, which represented increased knowledge, increased cues-to-action, decreased barriers, less depression, and increased self-efficacy (P<0.09 for each). The full GTCAT or a subset of statements had a high association with adherence (R range: 0.44 to 0.51, P<0.005 for all). The GTCAT identified >50% of patients who wanted more education about glaucoma; >68% who did not use reminders; and >40% who reported having difficulty using the eye drops. CONCLUSIONS: The GTCAT identified multiple factors associated with adherence. Clinicians and researchers could use this tool to identify specific barriers to adherence and develop potential interventions to improve adherence.

Integrating Patient Education Into the Glaucoma Clinical Encounter: A Lean Analysis.

PURPOSE: The main purpose of this study was to use Lean analysis to identify how often and when wait times occur during a glaucoma visit to identify opportunities for additional patient engagement. METHODS: This prospective observational time-motion study measured process and wait times for 77 patient visits from 12 ophthalmologists at an academic glaucoma clinic over a 3-month period. Value stream maps visually diagramed the process of a clinical visit from the patient's perspective. Descriptive statistics were calculated for process times, wait times, and the frequency of 10+ minute wait times during each part of the visit. Key stakeholders participated in a root cause analysis to identify reasons for long wait times. The main outcome measure was average times (hours: minutes: seconds) for process times and wait times. RESULTS: Twenty-nine new visit (NV) patients and 48 return visit (RV) patients were included. Total time in clinic was 187.1±44.5 (mean±SD) minutes for NV patients and 102.0±44.7 minutes for RV patients. Wait time for NV patients was 63.7±33.4 minutes (33.1% of total appointment time) and for RV patients was 52.6±31.6 minutes (49.4% of the total appointment time). All NV patients and 87.5% of RV patients had at least one 10+ minute wait time during their clinic visit and the majority (75.9% NV, 60.4% RV) had >1. CONCLUSIONS: Currently, sufficient wait time exists during the visit for key portions of glaucoma education such as teaching eye drop instillation.

Early and sustained alterations in cerebral metabolism after traumatic brain injury in immature rats.

Although studies have shown alterations in cerebral metabolism after traumatic brain injury (TBI), clinical data in the developing brain is limited. We hypothesized that post-traumatic metabolic changes occur early (<24 h) and persist for up to 1 week. Immature rats underwent TBI to the left parietal cortex. Brains were removed at 4 h, 24 h, and 7 days after injury, and separated into ipsilateral (injured) and contralateral (control) hemispheres. Proton nuclear magnetic resonance (NMR) spectra were obtained, and spectra were analyzed for N-acetyl-aspartate (NAA), lactate (Lac), creatine (Cr), choline, and alanine, with metabolite ratios determined (NAA/Cr, Lac/Cr). There were no metabolic differences at any time in sham controls between cerebral hemispheres. At 4 and 24 h, there was an increase in Lac/Cr, reflecting increased glycolysis and/or decreased oxidative metabolism. At 24 h and 7 days, there was a decrease in NAA/Cr, indicating loss of neuronal integrity. The NAA/Lac ratio was decreased ( approximately 15-20%) at all times (4 h, 24 h, 7 days) in the injured hemisphere of TBI rats. In conclusion, metabolic derangements begin early (<24 h) after TBI in the immature rat and are sustained for up to 7 days. Evaluation of early metabolic alterations after TBI could identify novel targets for neuroprotection in the developing brain.

Why Patients With Glaucoma Lose Vision: The Patient Perspective.

PURPOSE: To explore why glaucoma patients believe that glaucoma continues to cause vision loss despite the availability of effective treatment. METHODS: Nine focus groups were conducted in 3 geographically and ethnically diverse areas of the United States (Los Angeles, CA; Rochester, MN; Durham, NC) that included 56 participants, 31 with poor vision and 25 with good vision. Content analysis was used to identify important themes. Semiquantitative analysis was used to measure the frequency of each theme. RESULTS: A total of 474 relevant comments were made in the 9 focus groups. Focus groups elicited 305 comments about barriers to glaucoma management including issues with adherence (30%), the doctor-patient relationship (21%), knowledge about glaucoma (19%), personal support systems (19%), and barriers to health care delivery such as cost and insurance (11%). A total of 101 comments were made regarding feelings about glaucoma and 58 comments were made regarding beliefs about disease and treatment. CONCLUSIONS: These focus groups brought up many issues surrounding barriers to glaucoma treatment, perceived susceptibility to glaucoma, perceived benefits to treatment, and the emotional response to living with glaucoma. There is a need to create a more comprehensive chronic disease management approach for patients with glaucoma to address both the concrete and emotional issues identified in these focus group discussions.

Assessing the Role of the Family/Support System Perspective in Patients With Glaucoma.

PURPOSE: To investigate the role of the family/friends support system for patients with glaucoma and their perspective on barriers to effective glaucoma management. METHODS: Six focus groups were conducted in 3 geographically and ethnically diverse areas of the United States (Los Angeles, CA; Rochester, MN; Durham, NC) that included 31 participants; 68% (21/31) were family members and friends of glaucoma patients with poor vision and 32% (10/31) were support system individuals of patients with good vision. Content analysis was used to identify important themes. Semiquantitative analysis was used to measure the frequency of each theme. RESULTS: A total of 134 relevant comments were made in the 6 focus groups and 72% of relevant comments were made by individuals providing support for patients with poor vision. Family members and friends mentioned the following areas of concern regarding patients' glaucoma care: patient education (19.4%), doctor-patient relationship (17.9%), their own lack of involvement in the patient's medical care (17.2%), frustration with glaucoma and with the patient (14.9%), patient dependency on caregivers (14.9%), patient frustration with the disease (10.4%), and sex differences in coping mechanisms (5.2%). CONCLUSIONS: Support system individuals tend to be minimally involved in the patient's glaucoma status and care. This is especially true for support system members of patients with glaucoma who maintain good vision and those who do not have any other personal experiences with difficulties from glaucoma. Many of these family members express an interest in acquiring more education about glaucoma and becoming more involved in the patient's glaucoma care.

Telemedicine and Diabetic Retinopathy: Review of Published Screening Programs.

BACKGROUND: Diabetic Retinopathy (DR) is a leading cause of blindness worldwide even though successful treatments exist. Improving screening and treatment could avoid many cases of vision loss. However, due to an increasing prevalence of diabetes, traditional in-person screening for DR for every diabetic patient is not feasible. Telemedicine is one viable solution to provide high-quality and efficient screening to large number of diabetic patients. PURPOSE: To provide a narrative review of large DR telemedicine screening programs. METHODS: Articles were identified through a comprehensive search of the English-language literature published between 2000 and 2014. Telemedicine screening programs were included for review if they had published data on at least 150 patients and had available validation studies supporting their model. Screening programs were then categorized according to their American Telemedicine Association Validation Level. RESULTS: Seven programs from the US and abroad were identified and included in the review. Three programs were Category 1 programs (Ophdiat, EyePacs, and Digiscope), two were Category 2 programs (Eye Check, NHS Diabetic Eye Screening Program), and two were Category 3 programs (Joslin Vision Network, Alberta Screening Program). No program was identified that claimed category 4 status. Programs ranged from community or city level programs to large nationwide programs including millions of individuals. The programs demonstrated a high level of clinical accuracy in screening for DR. There was no consensus amongst the programs regarding the need for dilation, need for stereoscopic images, or the level of training for approved image graders. CONCLUSION: Telemedicine programs have been clinically validated and successfully implemented across the globe. They can provide a high-level of clinical accuracy for screening for DR while improving patient access in a cost-effective and scalable manner.