RobOCTNet: Robotics and Deep Learning for Referable Posterior Segment Pathology Detection in an Emergency Department Population.

Purpose: To evaluate the diagnostic performance of a robotically aligned optical coherence tomography (RAOCT) system coupled with a deep learning model in detecting referable posterior segment pathology in OCT images of emergency department patients. Methods: A deep learning model, RobOCTNet, was trained and internally tested to classify OCT images as referable versus non-referable for ophthalmology consultation. For external testing, emergency department patients with signs or symptoms warranting evaluation of the posterior segment were imaged with RAOCT. RobOCTNet was used to classify the images. Model performance was evaluated against a reference standard based on clinical diagnosis and retina specialist OCT review. Results: We included 90,250 OCT images for training and 1489 images for internal testing. RobOCTNet achieved an area under the curve (AUC) of 1.00 (95% confidence interval [CI], 0.99-1.00) for detection of referable posterior segment pathology in the internal test set. For external testing, RAOCT was used to image 72 eyes of 38 emergency department patients. In this set, RobOCTNet had an AUC of 0.91 (95% CI, 0.82-0.97), a sensitivity of 95% (95% CI, 87%-100%), and a specificity of 76% (95% CI, 62%-91%). The model's performance was comparable to two human experts' performance. Conclusions: A robotically aligned OCT coupled with a deep learning model demonstrated high diagnostic performance in detecting referable posterior segment pathology in a cohort of emergency department patients. Translational Relevance: Robotically aligned OCT coupled with a deep learning model may have the potential to improve emergency department patient triage for ophthalmology referral.

Do African American patients with glaucoma ask their eye providers the questions they have?

PURPOSE: The objective of this study was to describe what questions patients checked on a glaucoma question prompt list and how often patients asked the same checked questions during medical visits. DESIGN: A randomized controlled trial was conducted to test the effectiveness of a pre-visit video/glaucoma question prompt list intervention to increase African American patient question-asking during medical visits. METHODS: Adult African American patients with glaucoma and a history of non-adherence to glaucoma medications were enrolled and randomized into intervention and usual care groups from three glaucoma practices. Visits were audio-recorded, transcribed, and coded for the questions patients asked during their visits. Researchers collected the pre-visit question prompt lists from the intervention group and compared their checked questions to the questions patients asked during their visit. RESULTS: Ninety-three subjects were randomized to the question prompt list intervention group. Subjects checked an average of 6.77 questions on the prompt list. Of the subjects who checked at least one question, 54.8% asked their provider at least one of the questions they checked. The most common questions asked about glaucoma medications that they had checked were "What time(s) of day should I take my drops?" (50.0%, 9 out of 18) and "How many times a day do I use my glaucoma medicines?" (50.0%, 3 out of 6). CONCLUSION: Although African American subjects with glaucoma have questions about glaucoma and their medications, few asked all their questions during visits. Future research should focus on how to improve question asking using a question prompt list.

A Previsit Intervention's Influence on Glaucoma Topics Discussed between Black Patients and Providers.

PURPOSE: The objectives of this study were to conduct a randomized controlled trial testing the effectiveness of a previsit glaucoma video/question prompt list intervention, and to examine the impact on how often providers educate Black patients about glaucoma and glaucoma medication topics during visits. DESIGN: A randomized controlled trial of a glaucoma question prompt list/video intervention. PARTICIPANTS: Black patients with a diagnosis of glaucoma who are taking 1 or more glaucoma medications and report being nonadherent. METHODS: One hundred eighty-nine Black patients with glaucoma were enrolled and assigned to either a usual care or an intervention group where they watched a video emphasizing the importance of asking questions and received a glaucoma question prompt list to complete before clinic visits. Visits were audio-taped and patients were interviewed after visits. MAIN OUTCOME MEASURES: Whether the provider educates about different glaucoma and glaucoma medication topics. RESULTS: Patients in the intervention group were significantly more likely to ask providers 1 or more questions about glaucoma and its treatment. Providers were significantly more likely to educate intervention patients about their diagnosis (P = 0.001), intraocular pressure (P = 0.03), the likelihood of the need for long-term therapy (P = 0.001), and the physical changes associated with glaucoma (P = 0.001) than usual-care patients. Providers were also significantly more likely to educate intervention patients about the purpose of their medications (P = 0.03) and side effects (P = 0.001) than usual-care patients. Providers only educated 29% of patients about adherence (33% of intervention group patients and 25% of usual-care patients). Few providers educated patients about barriers and fears/concerns in using glaucoma medications, the cost of medications and insurance coverage, how to administer eye drops, and nasolacrimal occlusion. CONCLUSIONS: The intervention significantly increased provider education about many glaucoma and glaucoma medication topics. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

African American patient-provider communication about glaucoma vision quality-of-life.

BACKGROUND/OBJECTIVES: Little is known about African American patient-provider communication about glaucoma-related quality-of-life. The objectives of this study were to: (a) examine associations between patient socio-demographics and vision quality-of-life, (b) describe the extent to which eye care providers and patients discuss glaucoma-related quality-of-life, and (c) examine associations between patient and provider characteristics, whether the patient was in the intervention or usual care group, and whether the patient and provider discuss one or more glaucoma-related quality-of-life domains. METHODS: Adult African American patients with glaucoma who reported non-adherence to glaucoma medications were enrolled from three sites. Patients completed a vision quality-of-life VFQ-25 assessment. Patients were randomized into intervention and control groups with intervention group members receiving a glaucoma question prompt list and watching a video before a provider visit. Audio recordings from these visits were transcribed and assessed for glaucoma-related quality-of-life discussions. RESULTS: One hundred and eighty-nine patients were enrolled. Glaucoma-related quality-of-life was discussed during 12.3% of visits (N = 23). Patients initiated discussion 56.5% (N = 13) of the time and providers 43.5% (N = 10) of the time. Patients with worse health literacy (p < 0.001), more depressive symptoms (p < 0.05), and more severe glaucoma (p < 0.001) were significantly more likely to have worse vision-related quality-of-life. Glaucoma-related quality-of-life was significantly more likely to be discussed when African American patients saw African American providers (p < 0.05). CONCLUSION: Patients and providers rarely discussed the patient's glaucoma-related quality-of-life. The intervention did not significantly increase communication about glaucoma-related quality-of-life. Residency programs should consider enhancing training regarding discussing patients' quality-of-life.

Barriers to Care Among Glaucoma Patients With a Missed Appointment and Interest in a Navigator Program.

PRCIS: Most glaucoma patients with missed appointments report barriers to care and social risk factors. One third expressed interest in engaging with a patient navigator program. Most expressed interest in rescheduling. PURPOSE: The purpose of this study was to identify barriers to care among glaucoma patients with missed appointments and to assess their interest in a patient navigator program. MATERIAL AND METHODS: A cross-sectional study involving adult glaucoma patients from an academic eye center who missed their scheduled appointment between April 18 and July 25, 2022. Participants were surveyed about reasons for missed appointments, barriers to care, social risk factors, and interest in consulting with our patient navigator program. RESULTS: Of 172 patients with a missed glaucoma appointment, 73% (126/172) were contacted, and 40% (51/126) of those completed the survey. Participant age averaged 67±14 years, half were female (25/51, 49%), and most identified as Black (27/51, 53%) or White (21/51, 40%). Barriers to seeing a doctor including difficulty scheduling appointments (13/51, 26%), transportation (12/51, 24%), and cost or insurance barriers (8/51, 16%). Twenty-eight (55%) respondents reported at least one social risk factor. A positive association was found between having at least one risk factor and expressing interest in consulting our patient navigator (odds ratio=6.7, P =0.009). Overall, a third of respondents expressed interest in engaging with our patient navigator program (17/51, 33%). Two thirds of participants reported awareness of missed appointments (34/51, 67%), of whom 35% (12/34) reported having already rescheduled, 41% (14/34) expressed interest in rescheduling, and 24% (8/34) did not wish to return. CONCLUSIONS: Glaucoma patients with missed appointments report barriers to care and face social risk factors. Telephone outreach may help to re-engage them with care, and patients expressed interest in a patient navigator program to address social needs.

Glaucoma Fellows-in-Training Recent Surgery Trends.

PURPOSE: The volume of microinvasive glaucoma surgery (MIGS) has increased dramatically in recent years, from 31 059 in 2013 to 69 420 in 2018. We investigated the impact of this trend on trainees by determining the proportion of glaucoma surgeries performed by fellows-in-training comprised by MIGS, trabeculectomies, and aqueous shunts. DESIGN: Retrospective analysis. PARTICIPANTS: Fellows-in-training at Glaucoma Fellowship Programs certified by the Association of University Professors of Ophthalmology Fellowship Compliance Committee (AUPO-FCC) METHODS: We analyzed aggregate summaries of surgeries performed by fellows as reported to the AUPO-FCC from the academic years (AYs) beginning in 2014 through AY 2020. Each report lists the average number of procedures performed per surgery type per fellow. We combined these averages to create a sum "average number surgeries performed" across glaucoma surgeries and computed the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of surgeries performed per year. MAIN OUTCOME MEASURES: Average number of procedures performed for each surgery type as well as the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of procedures performed per year. RESULTS: Average number of MIGS performed is significantly greater in later years compared with earlier years (P < 0.001). The average number of trabeculectomies performed between AYs 2014 and AY 2020 ranged from 21.8 to 31.9 and decreased, on average, by - 0.80 year-to-year. The average number of aqueous shunts performed between AY 2014 and AY 2020 ranged from 44.7 to 49.5, with an average increase of + 0.8 year-to-year. The total average number of procedures performed (across all 3 surgical subtypes) increased on average by + 4.8 procedures each year. CONCLUSIONS: Since 2014, fellows are performing increasing numbers of MIGS procedures, whereas the total number of trabeculectomies and aqueous shunt surgeries performed each year remain similar, resulting in a net increase in total number of procedures performed per fellow each year. This suggests the increase in MIGS is not associated with a substantial decline in trabeculectomies or aqueous shunts performed by glaucoma fellows. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Qualitative Analysis of Barriers and Facilitators to Glaucoma Medication Adherence in a Randomized Controlled Trial Intervention.

OBJECTIVE: In the Medication Adherence In Glaucoma To Improve Care trial, 200 veterans with medically-treated glaucoma were randomized to an intervention designed to improve glaucoma medication adherence or to usual care. In the 6 months after intervention, the mean proportion of doses taken on schedule was higher for participants in the intervention group compared with controls (0.85 vs. 0.62, P < 0.001). The purpose of this study was to use a mixed-methods approach to compare barriers and facilitators with adherence among participants through qualitative analysis of structured interviews. DESIGN: This is an analysis of interviews conducted from patients participating in a clinical trial. PARTICIPANTS: Participants from the intervention arm were separated into quartiles based on medication adherence according to the electronic monitor to sample from high and low responders to the intervention. We interviewed 23 participants; 11 participants with low adherence and 12 with high adherence. METHODS: Interviews were conducted over telephone and transcribed. Staff members used grounded theory to conduct content analysis and code the transcribed interviews. The iterative process produced categories of common barriers and facilitators for medication adherence. MAIN OUTCOME MEASURES: The frequency of responses addressing common barriers and facilitators were compared between participants with high and low adherence. RESULTS: In the lowest- and highest-adherence groups, a difficult schedule was the most cited barrier for regular drop usage (63.6% and 58.3%, respectively). In the lowest and highest-adherence groups, the most cited facilitator for adherence was use of the smart bottle (100% and 91.7%, respectively). In the lowest-adherence group, 72.7% of participants cited that improved ability to administer drops was a benefit from the intervention. In the highest-adherence group, 75% of participants cited increased disease knowledge and formation of habits as facilitators from the intervention. Of the 22 of 23 participants who mentioned the smart bottle, 100% cited that they had increased adherence and would continue using the smart bottle. CONCLUSIONS: Using dosing reminders and personalized patient education may be important avenues for addressing difficulties with adhering to an eye drop schedule to improve glaucoma self-management. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Systematic analysis of levels of evidence supporting American Academy of Ophthalmology Preferred Practice Pattern guidelines, 2012-2021.

BACKGROUND: Despite the increased emphasis on evidence-based medicine, the current state of evidence behind ophthalmology clinical practice guidelines is unknown. The purpose of this systematic analysis was to understand the levels of evidence (LOE) supporting American Academy of Ophthalmology (AAO) Preferred Practice Pattern (PPP) guidelines, assess changes over time, and compare LOE across ophthalmology subspecialties. METHODS: All current PPP guidelines and their immediate predecessors were comprehensively reviewed to identify all recommendations with LOE provided (I [randomized controlled trials], II [case-control or cohort studies], and III [nonanalytic studies]). RESULTS: Twenty-three out of 24 current PPPs had a prior edition. Among the PPPs with a prior edition, the number of recommendations with LOE decreased from 1254 in prior PPPs to 94 in current PPPs. The number of recommendations with LOE I decreased from 114 to 83, LOE II decreased from 147 to 2, and LOE III decreased from 993 to 9. However, the proportion of LOE I recommendations increased from 9 to 88%, driven by a disproportionate decrease in reporting of evidence lower than LOE I. Subgroup analysis by subspecialty showed similar trends (LOE I recommendations in prior PPPs vs current PPPs: retina: 57 [12%] vs 19 [100%]; cornea: 33 [5%] vs 24 [100%]; glaucoma: 9 [23%] vs 17 [100%]; cataract: 13 [17%] vs 18 [100%]). CONCLUSIONS: Trends in LOE reporting in PPP guidelines indicate an increasing emphasis on evidence from randomized controlled trials from 2012 to 2021. The decline in the number of recommendations with LOE reported suggests an area for improvement in future guidelines as the presence of LOE is crucial to facilitate interpretation of clinical practice guidelines.

Improving Black Patient Question-Asking and Provider Education During Glaucoma Visits.

PURPOSE: The objectives of this study were to conduct a randomized, controlled trial testing the effectiveness of a previsit glaucoma video/question prompt list intervention to increase Black patient question-asking and provider education about glaucoma and glaucoma medications during visits. DESIGN: A randomized, controlled trial of a glaucoma question prompt list/video intervention. PARTICIPANTS: Black patients with a glaucoma diagnosis who were currently taking 1 or more glaucoma medications and reported being nonadherent. METHODS: One hundred and eighty-nine Black patients with glaucoma were enrolled into a randomized, controlled trial and assigned to either a usual care or an intervention group where they watched a video emphasizing the importance of asking questions and received a glaucoma question prompt list to complete before clinic visits. Visits were audiotaped and patients were interviewed after visits. MAIN OUTCOME MEASURES: Outcome measures were if the patient asked 1 or more questions about glaucoma and glaucoma medications and the number of glaucoma and glaucoma medication areas the provider educated the patient about during the visit. RESULTS: Patients in the intervention group were significantly more likely to ask 1 or more questions about glaucoma than patients in the usual care group (odds ratio, 5.4; 95% confidence interval [CI], 2.8-10.4). Patients in the intervention group were significantly more likely to ask 1 or more questions about glaucoma medications than patients in the usual care group (odds ratio, 2.8; 95% CI, 1.5-5.4). Patients in the intervention group were significantly more likely to receive more areas of education about glaucoma from their providers during visits (ß = 0.94; 95% CI, 0.49-1.4). Patients who asked 1 or more questions about glaucoma medications were significantly more likely to receive more areas of education about glaucoma medications from providers (ß = 1.8; 95% CI, 1.2-2.5). CONCLUSIONS: The intervention increased patient question-asking about glaucoma and glaucoma medications and provider education about glaucoma. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Provider use of a participatory decision-making style with African American patients with glaucoma.

OBJECTIVE: To examine whether non-adherent African American patients with glaucoma who received a question prompt list and video intervention were more likely to be given treatment options, have their input included into treatment regimens, and rate their providers as using more of a participatory decision-making style. METHODS: African American patients with glaucoma taking one or more glaucoma medications and reported being non-adherent were randomized to a pre-visit video and glaucoma question prompt list intervention or usual care. RESULTS: 189 African American patients with glaucoma participated. Providers gave patients treatment choices during 5.3% of visits and included patient input into treatment regimen decisions during 2.1% of visits. Male patients and patients with more years of education were significantly more likely to rate their providers as using more of a participatory decision-making style. CONCLUSION: African American patients with glaucoma rated their providers high on using a participatory decision-making style. Yet, providers infrequently presented non-adherent patients with medication treatment options, and it was rare for providers to include patient input into treatment decisions. PRACTICE IMPLICATIONS: Providers should provide non-adherent patients with different glaucoma treatment options. Non-adherent African American patients with glaucoma should be encouraged to ask their providers for different medication treatment options.

Accessibility and Cultural Inclusivity of Online Glaucoma-Based Video Content for Patient Education.

PRCIS: This study is the first to evaluate the ease of access, understandability, and cultural inclusivity of online glaucoma-related video content for patient education. Overall, materials were found to be poorly understandable and not culturally representative. PURPOSE: The purpose of this study is to assess the ease of access, readability, actionability, and cultural inclusivity of glaucoma-specific patient education videos found online. DESIGN: Cross-sectional study. SUBJECTS: Twenty-two glaucoma-based patient education videos were reviewed for this study. METHODS: A survey of glaucoma specialists identified commonly recommended patient education Web sites, which were analyzed for video content. Web sites were reviewed by 2 independent reviewers for glaucoma-based patient education videos. Videos with content designated for medical providers, dedicated to research, or affiliated with private practices were excluded. Videos that were not glaucoma-specific or longer than 15 minutes were also excluded. The Patient Education Materials Assessment Tool was used to score videos for understandability and actionability reviewing content, word choice, organization, layout, and use of visual aids. Videos were also reviewed for cultural inclusivity and accessibility measures including language availability. Agreement analysis with a kappa coefficient (κ) over 0.6 was established with the first 5 videos between 2 independent reviewers and scoring discrepancies were resolved via a third independent reviewer. RESULTS: From 10 recommended Web sites, 22 videos met inclusion criteria for evaluation. The average Patient Education Materials Assessment Tool score was 68.3% (SD = 18.4) for understandability (κ=0.63). Most videos (64%) were accessed within 3 clicks from the homepage. Only 3 videos were available in another language (Spanish). Most actors and images were White individuals (68.9%), followed by Black (22.1%), then Asian (5.7%) and other/ambiguous (3.3%). CONCLUSIONS: There is room for improvement regarding language accessibility, understandability, and cultural inclusivity of glaucoma-based, publicly available patient education video content.

How Medication Adherence Affects Disease Management in Veterans with Glaucoma: Lessons Learned from a Clinical Trial.

INTRODUCTION: We conducted a secondary, real-world clinical assessment of a randomized controlled trial to determine how a glaucoma medication adherence intervention impacted the clinical outcomes of participants at 12 months post-randomization. Participants included veterans at a VA eye clinic with medically treated glaucoma who reported poor adherence and their companions, if applicable. METHODS: The treatment group received a glaucoma education session with drop administration instruction and virtual reminders from a "smart bottle" (AdhereTech) for their eye drops. The control group received a general eye health class and the smart bottle with the reminder function turned off. Medical chart extraction determined if participants in each group experienced visual field progression, additional glaucoma medications, or a recommendation for surgery or laser due to inadequate intraocular pressure control over the 12 months following randomization. The main outcome measure was disease progression, defined as visual field progression or escalation of glaucoma therapy, in the 12 months following randomization. RESULTS: Thirty-six versus 32% of the intervention (n = 100) versus control (n = 100) groups, respectively, experienced disease intensification. There was no difference between the intervention and control groups in terms of intensification (intervention vs. control group odds ratio: 1.20; 95% confidence interval: [0.67, 2.15]), including when age, race, and disease severity were accounted for in the logistic regression model. Those whose study dates included time during the COVID-19 pandemic were evenly distributed between groups. CONCLUSIONS: A multifaceted intervention that improved medication adherence for glaucoma for 6 months did not affect the clinical outcomes measured at 12 months post-randomization. Twelve months may not be long enough to see the clinical effect of this intervention or more than 6 months of intervention are needed.

Cost-Utility Analysis of a Medication Adherence-Enhancing Educational Intervention for Glaucoma.

OBJECTIVE: To evaluate the cost utility of a glaucoma medication-enhancing intervention compared to standard of care over a lifetime from the United States Department of Veterans Affairs (VA) payer perspective. DESIGN: Model-based cost-utility analysis of a glaucoma medication-enhancing intervention from a randomized clinical trial. SUBJECTS: Veterans with glaucoma, or suspected glaucoma who were prescribed topical glaucoma medications, had their visual field assessed within the last 9 months, and endorsed poor glaucoma medication adherence. METHODS: Veterans were randomized either to a behavioral intervention to promote adherence or to a standard of care (control) session about general eye health. A decision analytic model was developed to simulate lifelong costs and quality-adjusted life years (QALYs) for an intervention tested in a randomized clinical trial at a single VA eye clinic. Costs included direct medical costs that the VA payer would incur, as informed initially by the clinical trial and then by published estimates. Health-state quality of life was based on published utility values. Scenario analyses included addition of booster interventions, a 3% decline in chance of staying medication adherent annually, and the combination of the two. Analyses were also conducted in the following subgroups: those with companion versus not, and those with once-daily versus more than once-daily dosing frequency. MAIN OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER). RESULTS: Compared to standard of care, the intervention dominated resulting in lower costs ($23 339.28 versus $23 504.02) and higher QALYs (11.62 versus 11.58). Among the 4 subgroups, the intervention dominated for 3 of them. In the fourth subgroup, those with more than once-daily dosing, the ICER was $2625/QALY. Compared to standard of care, an intervention with booster interventions led to an ICER of $3278/QALY. Assuming both a 3% annual loss in chance of continuing to be adherent and addition of booster interventions, the ICER increased to $71 371/QALY. CONCLUSIONS: From a VA payer perspective over a lifetime, the glaucoma medication-enhancing behavioral intervention dominated standard of care in terms of generating cost savings and greater QALYs. FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found after the references.

Glaucoma Knowledge and Disease Severity in a Veteran Population: The Medication Adherence in Glaucoma to Improve Care (MAGIC) Study.

PURPOSE: To assess the relationship between glaucoma knowledge and disease severity. DESIGN: Substudy of a randomized controlled trial at a single Veterans Affairs (VA) eye clinic. PARTICIPANTS: Veterans with medically treated open-angle glaucoma who self-reported poor medication adherence. METHODS: Participants completed a glaucoma knowledge assessment using the 10-question National Eye Health Education Program (NEHEP) Eye-Q Test on glaucoma knowledge. Disease severity was determined using visual field criteria. Multiple linear regression was used to assess the association of NEHEP Eye-Q score and disease severity, adjusting for age, number of glaucoma medications, race, sex, and VA Care Assessment Needs (CAN) score. MAIN OUTCOME MEASURES: In this cross-sectional, preintervention analysis, the main outcome was glaucoma knowledge as measured by the NEHEP Eye-Q Test. RESULTS: Among the 200 study participants, glaucoma severity was mild in 53 (27%), moderate in 56 (28%), severe in 74 (37%), and indeterminant in 17 (9%). The NEHEP Eye-Q scores were low across all severity levels. Scored out of 10, the mean (standard deviation) NEHEP Eye-Q scores were 6.06 (1.57) for mild, 6.21 (1.47) for moderate, 6.28 (1.82) for severe, and 5.88 (1.93) for indeterminate stage. There was no evidence of a significant association between NEHEP scores and disease severity categories (P = 0.78). A regression model did not identify a significant estimated association between NEHEP Eye-Q scores and disease severity after adjusting for age, CAN risk score, number of glaucoma medications, race, and sex. CONCLUSIONS: There was no difference in level of glaucoma knowledge based on disease severity. Education-based interventions may benefit patients across all glaucoma stages. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Factors Associated with Ophthalmology Referral and Adherence in a Teleretinal Screening Program: Insights from a Federally Qualified Health Center.

Background: Early detection of ophthalmic conditions such as diabetic retinopathy (DR) and glaucoma is crucial to preventing vision loss. Previous studies have evaluated teleretinal screening programs for DR in well-insured populations. The purpose of this retrospective study was to evaluate a teleretinal screening program in a population of uninsured and underinsured patients seen in a Federally Qualified Health Center (FQHC). Methods: We conducted a retrospective chart review of patients (age ≥18) who underwent teleretinal imaging (TRI) at a FQHC between January 2015 and September 2019. TRI gradings and patient demographic and clinical information were abstracted. Factors associated with referral for a dilated eye exam by an ophthalmologist, adherence to recommended follow-up dilated eye exam, and ophthalmology visit attendance were examined. Results: 3130 TRIs were graded in 2216 eyes (1107 patients). 65.2% (N = 722) self-identified as Hispanic and 56.3% (N = 623) required interpreter services. Follow-up dilated fundus examination (DFE) was recommended for 388 TRIs, 49% (N = 190) of which were completed within 1 year. Adherence to the recommended ophthalmology exam was not associated with any baseline clinical or demographic characteristics (p > 0.05). Older age, male sex, hypertension, proteinuria, and higher A1c were significantly associated with greater odds of ophthalmology referral based on TRI (all p < 0.05), after adjusting for covariates. Less severe diabetic retinopathy, no insurance coverage, and Hispanic ethnicity were associated with lower odds of attending an ophthalmology visit, regardless of follow-up recommendations based on TRI (all p < 0.05). Conclusion: In an FQHC serving predominantly uninsured and underinsured patients, only 49% of recommended DFE were completed within one year. Less severe diabetic retinopathy, lack of insurance coverage, and Hispanic ethnicity were associated with a lower likelihood of having a DFE regardless of recommendation. These results suggest that greater system-level efforts are needed to increase adherence to follow-up eye exams after TRI to ensure sight-saving care for underserved populations.

Within-Trial Cost-Effectiveness of an Adherence-Enhancing Educational Intervention for Glaucoma.

PURPOSE: To assess the within-trial cost-effectiveness of a behavioral intervention to improve glaucoma medication adherence. DESIGN: Prospective cost-effectiveness analysis of randomized, controlled trial data. METHODS: The study setting was a Veterans Affairs (VA) eye clinic. The patient population comprised veterans with medically treated glaucoma and self-reported poor adherence. Participants were randomized to a personalized educational session with a reminder bottle to promote medication adherence or to a control session on general eye health. Costs were assessed from the perspective of the VA payor at 6 months using the VA Managerial Cost Accounting System. Probabilistic sensitivity analyses were conducted using bootstrapped samples. The main outcome measures were the proportion of participants attaining ≥80% adherence as measured by electronic monitor, total intervention and medical resource costs, and incremental cost-effectiveness ratios comparing intervention to control at 6 months. RESULTS: Of 200 randomized participants, 95 of 100 assigned to the intervention and 97 of 100 assigned to the control had adherence outcomes at 6 months, and the proportion of adherent patients was higher in the intervention group compared to control (0.78 vs 0.40, P < .0001). All participants had costs at 6 months. The total cost at 6 months was $1,149,600 in the intervention group (n = 100) compared to $1,298,700 in the control group (n = 100). Thus, in a hypothetical cohort of 100 patients, the intervention was associated with cost savings (-$149,100) and resulted in 38 additional patients achieving medication adherence. CONCLUSIONS: An adherence-enhancing behavioral intervention was effective and cost saving at 6 months.

Aiding Adherence to Glaucoma Medications: A Systematic Review.

PURPOSE: To provide a comprehensive assessment of the strategies studied to date that focus on improving glaucoma medication adherence. METHODS: A systematic review of the literature was conducted in MEDLINE (PubMed), Embase (Elsevier), and Scopus (Elsevier) from inception to March 1, 2021, of publications describing a device or strategy used to improve glaucoma medication adherence. RESULTS: 42 studies described by 50 papers were included. Five categories were identified: reminder systems, medication simplifications, behavioral change programs, education, and alternative engagement strategies. CONCLUSION: Most studies (40 of the 42) addressed the question of improved adherence directly, with 26 finding improved adherence. Notably, 14 examined the clinical effects of the intervention, either in terms of intraocular pressure (IOP) or visual fields. Only three found an improvement in IOP. None demonstrated a between group difference in visual field progression.

Health Literacy and Success with Glaucoma Drop Administration.

PURPOSE: To assess the relationship between health literacy and successful glaucoma drop administration. DESIGN: Substudy of a single-site interventional randomized controlled trial. PARTICIPANTS: Veterans receiving care at the Durham Veterans Affairs Eye Clinic who had a diagnosis of open-angle glaucoma were recruited if they endorsed poor drop adherence. METHODS: Participants underwent a health literacy evaluation using the Rapid Estimate of Adult Literacy in Medicine (REALM) as well as a qualitative assessment of eye drop administration technique using 3 different criteria: (1) the drop was instilled in the eye, (2) only 1 drop was dispensed, and (3) the bottle was not potentially contaminated. A multivariate logistic regression model was used to assess the association of REALM score and successful drop administration, adjusting for age, disease severity, and Veterans Administration Care Assessment Needs (CAN) score. MAIN OUTCOME MEASURES: Successful drop administration. RESULTS: Of the 179 participants with REALM scores and observed drop administration, 78% read at a high school level (HSL) or more and 22% read at less than HSL. Of the 179 participants, 87% (n = 156) successfully instilled the drop into the eye (criterion 1). A greater proportion of participants who read at HSL or more successfully instilled the drop in the eye compared with those reading at less than HSL (90.6% vs. 75.0%; P = 0.02). Rates of success with criterion 1 were similar across different levels of visual field severity. Care Assessment Needs scores were not statistically significant between those who did and those did not have successful overall drop technique. CONCLUSIONS: Poor health literacy may be associated with decreased successful drop instillation in the eye in patients with glaucoma. Screening for and considering health literacy in developing interventions to improve glaucoma self-management may improve treatment adherence in a vulnerable population.

Improved Glaucoma Medication Adherence in a Randomized Controlled Trial.

PURPOSE: To test the effectiveness of an intervention designed to improve glaucoma medication adherence. DESIGN: Randomized, controlled trial at a Veterans Affairs (VA) eye clinic. PARTICIPANTS: Veterans with medically treated glaucoma who reported poor adherence and their companions if applicable. METHODS: Participants, and their companions if applicable, were randomized to receive an intervention to improve medication adherence that included glaucoma education, personalized disease management suggestions, and a reminder aid, or the control arm that received education regarding general eye health. MAIN OUTCOME MEASURES: The average proportion of prescribed glaucoma medication doses taken on schedule over the 6 months after randomization according to an electronic monitor between participants in the 2 arms. RESULTS: The mean proportion of prescribed doses taken on schedule was higher in the intervention group compared with controls (0.85 vs. 0.62, P < 0.0001). The difference in proportions between the 2 groups did not vary in regressions models adjusted for companion status, frequency of dosing, and race. The longitudinal model indicated that the intervention group had significantly higher adherence during the first month after randomization and continued to stay higher through 6 months (month by treatment interaction, P = 0.003). CONCLUSIONS: A multifaceted intervention can help improve glaucoma medication adherence.

Acceptance of a Pre-visit Intervention to Engage African American Glaucoma Patients during Visits.

SIGNIFICANCE: The glaucoma question prompt list/video intervention was well received by patients. Eighty-seven percent of patients recommended that other patients should watch the educational video before their visits, and 89% said that other patients should complete the question prompt list before visits. PURPOSE: The objectives of this study were to (a) describe patient feedback on a glaucoma question prompt list/video intervention designed to motivate African American patients to be more engaged during visits and (b) examine patient demographics associated with acceptance of the intervention. METHODS: We are conducting a randomized controlled trial of a glaucoma question prompt list/video intervention. African American patients with glaucoma were enrolled and assigned to a control group or an intervention group where they watched a video emphasizing the importance of asking questions and received a prompt list to complete before visits. All patients were interviewed after visits and are being followed up for 12 months. RESULTS: One hundred eighty-nine African American patients with glaucoma were enrolled into the larger trial. Of the 93 patients randomized to the intervention group, 89% said that patients should complete the prompt lists before visits, and 87% recommended that patients should watch the video before visits. Older patients were significantly less likely to believe that other patients should watch the video before their visits (t = -3.7, P = .04). Patients with fewer years of education were significantly more likely to rate the video as being more useful than patients with more years of education (Pearson correlation, -0.27; P = .01). Patients who reported being less adherent on the visual analog scale were more likely to rate the video as being more useful (Pearson correlation, -0.23; P = .03). CONCLUSIONS: This study demonstrates that the question prompt list/video was accepted by the majority of African American patients who received the intervention.