Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Methods and Screening Results.

PURPOSE: To describe methodology and screening results from the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study. DESIGN: Screening program results for a prospective randomized clinical trial. METHODS: Individuals were recruited who were African-American, Hispanic/Latino, or Asian over age 40 years; white individuals over age 65 years; and any ethnicity over age 40 years with a family history of glaucoma or diabetes. Primary care offices and Federally Qualified Health Centers were used for telemedicine (Visit 1). Two posterior fundus photographs and 1 anterior segment photograph were captured per eye in each participant, using a nonmydriatic, autofocus, hand-held fundus camera (Volk Optical, Mentor, Ohio, USA). Medical and ocular history, family history of glaucoma, visual acuity, and intraocular pressure measurements using the ICare rebound tonometer (ICare, Helsinki, Finland) were obtained. Images were read remotely by a trained retina reader and a glaucoma specialist. RESULTS: From April 1, 2015, to February 6, 2017, 906 individuals consented and attended Visit 1. Of these, 553 participants were female (61.0%) and 550 were African-American (60.7%), with a mean age of 58.7 years. A total of 532 (58.7%) participants had diabetes, and 616 (68%) had a history of hypertension. During Visit 1, 356 (39.3%) participants were graded with a normal image. Using image data from the worse eye, 333 (36.8%) were abnormal and 155 (17.1%) were unreadable. A total of 258 (28.5%) had a suspicious nerve, 62 (6.8%) had ocular hypertension, 102 (11.3%) had diabetic retinopathy, and 68 (7.5%) had other retinal abnormalities. CONCLUSION: An integrated telemedicine screening intervention in primary care offices and Federally Qualified Health Centers detected high rate of suspicious optic nerves, ocular hypertension, and retinal pathology.

A randomized, controlled trial to test the effectiveness of a glaucoma patient navigator to improve appointment adherence.

PURPOSE: Patients with glaucoma who do not keep their follow-up eye care appointments are at risk for developing more severe ocular disease. The primary aim of the current study was to evaluate whether the use of a patient navigator altered adherence to follow-up eye care appointments in community-versus office-based settings. PATIENTS AND METHODS: Patients diagnosed with a glaucoma-related condition following a comprehensive eye examination at 43 community sites in Philadelphia, PA, USA, were enrolled in this prospective, randomized, controlled trial. Patients were randomized into three groups for a 1-year period: Group 1 (G1) received follow-up eye care in a community-based setting with assistance from a patient navigator; Group 2 (G2) received follow-up eye care in an office-based setting with assistance from a patient navigator; and Group 3 (G3) received follow-up eye care in an office-based setting without a patient navigator (usual care). Adherence rates were compared among these three groups using a chi-squared test at a significance level of 0.05. RESULTS: A total of 155 patients with glaucoma-related diagnoses were enrolled. The mean age (±standard deviation) was 71.2 (±10.0) years. Patients were predominantly female (65.8%, n=102/155) and African-American (71.6%, n=111/155). The mean (±standard deviation) number of follow-up visits during the 1-year study period was 1.3 (±1.3) for G1, 1.6 (±1.3) for G2, and 1.3 (±1.1) for G3 (P=0.48). Appointment adherence, defined as attendance of ≥1 follow-up visit, was 69.8% (n=37/53) for G1, 82.5% (n=47/57) for G2, and 73.3% (n=33/45) for G3, (P=0.28). Sub-analysis of adherence rates for patients who attended ≥2 follow-up visits were 91.3% (n=21/23) for G1, 74.3% (n=26/35) for G2, and 66.7% (n=18/27) for G3, (P=0.11). CONCLUSION: Help from a patient navigator did not increase the likelihood of keeping ≥1 follow-up appointment in an office-based setting. Adherence rates for follow-up appointments reached close to 70% or above in a self-selected patient population.

The Philadelphia Glaucoma Detection and Treatment Project: Detection Rates and Initial Management.

PURPOSE: To evaluate the detection rates of glaucoma-related diagnoses and the initial treatments received in the Philadelphia Glaucoma Detection and Treatment Project, a community-based initiative aimed at improving the detection, treatment, and follow-up care of individuals at risk for glaucoma. DESIGN: Retrospective analysis. PARTICIPANTS: A total of 1649 individuals at risk for glaucoma who were examined and treated in 43 community centers located in underserved communities of Philadelphia. METHODS: Individuals were enrolled if they were African American aged ≥50 years, were any other adult aged ≥60 years, or had a family history of glaucoma. After attending an informational glaucoma workshop, participants underwent a targeted glaucoma examination including an ocular, medical, and family history; visual acuity testing, intraocular pressure (IOP) measurement, and corneal pachymetry; slit-lamp and optic nerve examination; automated visual field testing; and fundus color photography. If indicated, treatments included selective laser trabeculoplasty (SLT), laser peripheral iridotomy (LPI), or IOP-lowering medications. Follow-up examinations were scheduled at the community sites after 4 to 6 weeks or 4 to 6 months, depending on the clinical scenario. MAIN OUTCOME MEASURES: Detection rates of glaucoma-related diagnoses and types of treatments administered. RESULTS: Of the 1649 individuals enrolled, 645 (39.1%) received a glaucoma-related diagnosis; 20.0% (n = 330) were identified as open-angle glaucoma (OAG) suspects, 9.2% (n = 151) were identified as having narrow angles (or as a primary angle closure/suspect), and 10.0% (n = 164) were diagnosed with glaucoma, including 9.0% (n = 148) with OAG and 1.0% (n = 16) with angle-closure glaucoma. Overall, 39.0% (n = 64 of 164) of those diagnosed with glaucoma were unaware of their diagnosis. A total of 196 patients (11.9%) received glaucoma-related treatment, including 84 (5.1%) who underwent LPI, 13 (0.8%) who underwent SLT, and 103 (6.2%) who were prescribed IOP-lowering medication. CONCLUSIONS: Targeting individuals at risk for glaucoma in underserved communities in Philadelphia yielded a high detection rate (39.1%) of glaucoma-related diagnoses. Providing examinations and offering treatment, including first-line laser procedures, at community-based sites providing services to older adults are effective to improve access to eye care by underserved populations.

Improving Access to Eye Care among Persons at High-Risk of Glaucoma in Philadelphia--Design and Methodology: The Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: The Wills Eye Glaucoma Research Center initiated a 2-year demonstration project to develop and implement a community-based intervention to improve detection and management of glaucoma in Philadelphia. METHODS: The glaucoma detection examination consisted of: ocular, medical, and family history; visual acuity testing; corneal pachymetry; biomicroscopy of the anterior segment; intraocular pressure (IOP) measurement; gonioscopy; funduscopy; automated visual field testing; and fundus-color photography. Treatment included laser surgery and/or IOP-lowering medication. A cost analysis was conducted to understand resource requirements. Outcome measures included; prevalence of glaucoma-related pathology and other eye diseases among high-risk populations; the impact of educational workshops on level of knowledge about glaucoma (assessed by pre- and post-test evaluation); and patient satisfaction of the glaucoma detection examinations in the community (assessed by satisfaction survey). Treatment outcome measures were change in IOP at 4-6 weeks and 4-6 months following selective laser trabeculoplasty treatment, deepening of the anterior chamber angle following laser-peripheral iridotomy treatment, and rate of adherence to recommended follow-up examinations. Cost outcomes included total program costs, cost per case of glaucoma detected, and cost per case of ocular disease detected. RESULTS: This project enrolled 1649 participants (African Americans aged 50+ years, adults 60+ years and individuals with a family history of glaucoma). A total of 1074 individuals attended a glaucoma educational workshop and 1508 scheduled glaucoma detection examination appointments in the community setting. CONCLUSIONS: The Philadelphia Glaucoma Detection and Treatment Project aimed to improve access and use of eye care and to provide a model for a targeted community-based glaucoma program.

The impact of educational workshops on individuals at risk for glaucoma in the Philadelphia Glaucoma Detection and Treatment Project.

OBJECTIVES: The purpose of this study was to investigate the impact of educational workshops, led by community health educators, on the level of knowledge, perceived risk of glaucoma, and rate of attendance in a subsequent glaucoma detection examination. METHODS: Participants attended an educational workshop about glaucoma and completed an 8-question pre- and post-test to assess knowledge. A paired samples t-test assessed mean differences in composite pre- and post-test scores, correct responses for each question, and perceived risk of glaucoma after the workshop. RESULTS: Seven hundred and seven (707) pre- and post-test surveys were completed. There was a significant increase in the level of knowledge about glaucoma as reflected in the pre- and post-test composite scores (M=3.86, SD=1.95 vs. M=4.97, SD=1.82, P<0.001). In the 5 largest community sites, 44% (n=221/480) of the participants who attended an educational workshop scheduled a glaucoma detection examination appointment and 76% (n=160/211) of these participants completed this eye examination in the community setting. CONCLUSIONS: Educational workshops increased knowledge and awareness about glaucoma and were helpful in recruiting patients for community-based glaucoma detection examinations. PRACTICE IMPLICATIONS: We recommend including educational workshops when conducting community-based outreach programs.

Effect of Behavioral Intervention on Dilated Fundus Examination Rates in Older African American Individuals With Diabetes Mellitus: A Randomized Clinical Trial.

IMPORTANCE: African American individuals are at high risk of diabetes mellitus and diabetic retinopathy but have suboptimal rates of dilated fundus examinations (DFEs). Early intervention is crucial for the prevention of diabetic retinopathy in this high-risk population. OBJECTIVE: To test the efficacy of behavioral activation for diabetic retinopathy prevention on rates of DFEs in older African American individuals with diabetes mellitus. DESIGN, SETTING, AND PARTICIPANTS: Masked randomized clinical trial at 2 urban medical centers from October 1, 2010, to May 31, 2014. Participants included 206 African American individuals 65 years and older with diabetes mellitus who had not obtained a DFE in the preceding 12 months. INTERVENTIONS: Participants were randomized to either behavioral activation for diabetic retinopathy prevention, a behavioral intervention designed to provide education, facilitate identifying and addressing health care barriers, and promote goal setting to improve rates of DFEs, or supportive therapy, a control condition. MAIN OUTCOMES AND MEASURES: The primary outcome was medical documentation of a DFE at 6 months' follow-up. Secondary outcomes included the Risk Perceptions and Risk Knowledge Survey of Diabetes Mellitus, Diabetes Self-Care Inventory, Patient Health Questionnaire 9, and National Eye Institute Vision Function Questionnaire 25 scores and hemoglobin A1c levels. RESULTS: More participants in the behavioral activation for diabetic retinopathy prevention group (87.9%) obtained a DFE compared with those in the supportive therapy group (34.1%) by the 6-month follow-up assessment (P < .001). Overall, participants in the behavioral activation for diabetic retinopathy prevention group were 2.5 times more likely to obtain a DFE compared with those in the supportive therapy group (risk ratio = 2.58; 95% CI, 1.91-3.48; P < .001). The intervention had no short-term effect on secondary outcomes of hemoglobin A1c levels, depression, or the Risk Perceptions and Risk Knowledge Survey of Diabetes Mellitus or National Eye Institute Vision Function Questionnaire 25 composite scores; however, both groups had improved adherence to diabetes mellitus self-care behaviors from baseline to 6-month follow-up. CONCLUSIONS AND RELEVANCE: Behavioral activation for diabetic retinopathy prevention significantly increased rates of DFEs in older African American individuals with diabetes mellitus. Behavioral interventions may have the potential to positively affect screening for diabetic retinopathy in at-risk populations. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01179555.