Spatial Vision Inequalities: A Literature Review of the Impact of Place on Vision and Eye Health Outcomes.

"Neighborhood and built environment" is one of the five domains of social determinants of health that has been outlined by Healthy People 2030, and this domain impacts an individual's well-being, health, and quality of life. Social risk factors (SRFs) in the neighborhood and built environment domain include unstable or unsafe housing, poor access to transportation, lack of green spaces, pollution, safety concerns, and neighborhood measures of inequity. In this narrative literature review, we assess the relationship between neighborhood and built environment SRFs and eye health and vision outcomes. We explain how mapping neighborhood-level SRFs may be used to advance health equity in the field of eye health and vision care.

Association of Contrast Sensitivity With Eye Disease and Vision-Related Quality of Life.

PURPOSE: To investigate contrast sensitivity (CS) as a screening tool to detect eye disease and assess its association with both eye disease and vision-related quality of life. DESIGN: Cross-sectional study. METHODS: Setting and population: Adults receiving care from a free clinic and a Federally Qualified Health Center in Michigan. MAIN OUTCOME MEASURES: Screening positive for eye disease and Visual Function Questionnaire (VFQ) score. OBSERVATION: Participants received a vision exam reviewed via telemedicine for disease, completed a demographic survey, and the 9-item VFQ. The ability of CS to predict eye disease was explored and area under the curve (AUC) is reported. Logistic and linear regression were used to investigate the continuous effect of CS on the probability of screening positive for eye disease and VFQ score, respectively, adjusting for age and visual acuity. RESULTS: 1159 included participants were, on average, 54.9 ± 14.5 years old, 62% identified as female, 34% as White, 54% as Black, 10% as Hispanic/Latino, and reported mean VFQ score of 79.7 ± 15.3. CS ranged from 0.00 to 1.95 log units (mean = 1.54 ± 0.24), 21% of eyes had glaucoma, 19% cataract, 6% DR, and 2% AMD. AUCs were 0.53 to 0.73. A 0.3 log unit decrease in better eye CS was associated with increased odds of glaucoma (odds ratio [OR] = 1.35, confidence interval [CI] = 1.09-1.67), cataract (OR = 1.35, CI = 1.05-1.72), DR (OR = 2.05, CI = 1.51-2.77), and AMD (OR = 2.08, CI = 1.10-3.91). A 0.3 log unit increase in better eye CS was associated with a 5.9 unit increase in VFQ. CONCLUSION: While CS alone is not sufficient to identify people with eye disease, it is an important measure of visual function that can add value to comprehensive eye screening.

Relationship between Unstable Housing, Food Insecurity, and Vision Status in the MI-SIGHT Community Eye Disease Screening Program.

PURPOSE: Assess rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program. DESIGN: Cross-sectional study. PARTICIPANTS: Adults ≥ 18 years without acute ocular symptoms. METHODS: MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical shop. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA] ≤ 20/50, best corrected visual acuity [BCVA] ≥ 20/40), URE without VI (PVA ≥ 20/40, had ≥ 2 lines of improvement to BCVA), and no or adequately corrected RE (PVA ≥ 20/40, < 2 line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared between groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing. MAIN OUTCOME MEASURES: PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50). RESULTS: Of 1171 participants enrolled in the MI-SIGHT program during the first year, the average age was 55.1 years (standard deviation = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 (10.3%); 96 had VI from URE (8.2%), 168 (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI from URE reported having a college degree and a larger percentage reported income < $10 000 compared to participants with no or adequately corrected RE (3.2% versus 14.2%, P = 0.02; 45.5% versus 21.6%, respectively, P < 0.0001. Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (VFQ9 composite score 67.3 ± 19.6 versus 77.0 ± 14.4 versus 82.2 ± 13.3, respectively; P < 0.0001). 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses. CONCLUSIONS: URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical shop with lower prices made eyeglasses accessible to low-income patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Visual Impairment from Uncorrected Refractive Error among Participants in a Novel Program to Improve Eye Care Access among Low-Income Adults in Michigan.

PURPOSE: To assess the rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program. DESIGN: Cross-sectional study. PARTICIPANTS: Adults ≥ 18 years without acute ocular symptoms. METHODS: MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical store. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA], ≤ 20/50; best-corrected visual acuity [BCVA], ≥ 20/40), URE without VI (PVA, ≥ 20/40; ≥ 2-line improvement to BCVA), and no or adequately corrected RE (PVA, ≥ 20/40; < 2-line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared among groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing. MAIN OUTCOME MEASURES: PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50). RESULTS: Of 1171 participants enrolled in the MI-SIGHT program during the first year, average age was 55.1 years (SD = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 participants (10.3%); 96 had VI from URE (8.2%), 168 participants (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI resulting from URE reported having a college degree, and a larger percentage reported income < $10 000 compared with participants with no or adequately corrected RE (3.2% vs. 14.2% [P = 0.02]; 45.5% vs. 21.6% [P < 0.0001], respectively). Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (9-item National Eye Institute Visual Function Questionnaire composite score, 67.3 ± 19.6 vs. 77.0 ± 14.4 vs. 82.2 ± 13.3, respectively; P < 0.0001). In total, 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses. CONCLUSIONS: URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical store with lower prices made eyeglasses accessible to low-income patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Emerging glaucoma treatments: are we seeing an improvement in adherence?

Introduction: Non-adherence to glaucoma medication and poor follow-up is a global health concern. Areas covered: Glaucoma remains one of the largest causes of irreversible blindness worldwide. Traditional treatment guidelines suggest topical eye drop medication as first line therapy followed by addition of supplementary medications before proceeding to more invasive glaucoma surgeries. Unfortunately, poor glaucoma self-management remains high, leading to disease progression and blindness. Recent advancements in the field of pharmacotherapies, surgeries, and behavioral approaches have taken aim at increasing support for glaucoma self-management. We review the current and emerging approaches towards glaucoma management, with the exception of bleb-based surgical approaches, to investigate if they have had an impact on adherence. Literature searches were conducted via MEDLINE (PubMed), Embase (Elsevier), Cochrane Library (Wiley), and Preprints from January 1st, 2018, to January 26th, 2023. Expert opinion: The ability to offer patients a multitude of choices enables patients to tailor their glaucoma treatment to their values and lifestyle. Offering personalized patient education and coaching to support chronic glaucoma self-management would better enable patient engagement in whichever treatment path is chosen. Currently, literature regarding the impact of these new advancements on treatment engagement is lacking; this field is ripe for additional intervention and assessment.

Recruiting Populations at Higher Risk for Glaucoma and Other Eye Diseases Experiencing Eye Health Disparities.

PURPOSE: We compared recruitment of participants at high risk for glaucoma and other eye diseases in three community-based studies designed to improve access to eye care in underserved populations in New York City, Alabama, and Michigan. METHODS: We used (1) participant data collected at enrollment (e.g. demographic, medical conditions, healthcare access, and method of hearing about study) and (2) interviews with study staff to assess effective recruitment strategies in enrolling people at high risk for eye disease. We analyzed participant data using descriptive statistics and interview data using content analysis to categorize responses to questions. RESULTS: In these community-based studies, all sites recruited greater proportions of populations with increased risk of eye disease compared to their estimates in the US population. High-risk characteristics varied based on the setting (i.e. Federally Qualified Health Centers or affordable housing buildings). Older adults represented 35% to 57%; 43% to 56% identified as Black; 1% to 40% as Hispanic/Latino; 20% to 42% reported a family history of glaucoma; 32% to 61% reported diabetes; and 50% to 67% reported high blood pressure. Social risk factors for under-utilization of eye care due to poverty included that 43% to 70% of participants had high school or lower education; 16% to 40% were employed; and 7% and 31% had no health insurance. From a qualitative perspective, active, personalized, culturally sensitive methods were most effective in recruiting participants. CONCLUSION: Implementing eye disease detection interventions in community-based settings facilitated recruiting individuals at high risk for glaucoma and other eye diseases.

Social Risk Factor Associations With Presenting Visual Acuity in Patients With Microbial Keratitis.

Importance: Neighborhood-level social risk factors may contribute to health disparities in microbial keratitis (MK) disease presentation. Understanding neighborhood-level factors may identify areas for revised health policies to address inequities that impact eye health. Objective: To investigate if social risk factors were associated with presenting best-corrected visual acuity (BCVA) for patients with MK. Design, Setting, and Participants: This was a cross-sectional study of patients with a diagnosis of MK. Patients presenting to the University of Michigan with a diagnosis of MK between August 1, 2012, and February 28, 2021, were included in the study. Patient data were obtained from the University of Michigan electronic health record. Main Outcomes and Measures: Individual-level characteristics (age, self-reported sex, self-reported race and ethnicity), presenting log of the minimum angle of resolution (logMAR) BCVA, and neighborhood-level factors, including measures on deprivation, inequity, housing burden, and transportation at the census block group, were obtained. Univariate associations of presenting BCVA (< 20/40 vs ≥20/40) with individual-level characteristics were assessed with 2-sample t, Wilcoxon, and χ2 tests. Logistic regression was used to test associations of neighborhood-level characteristics with the probability of presenting BCVA worse than 20/40 after adjustment for patient demographics. Results: A total of 2990 patients with MK were identified and included in the study. Patients had a mean (SD) age of 48.6 (21.3) years, and 1723 were female (57.6%). Patients self-identified with the following race and ethnicity categories: 132 Asian (4.5%), 228 Black (7.8%), 99 Hispanic (3.5%), 2763 non-Hispanic (96.5%), 2463 White (84.4%), and 95 other (3.3%; included any race not previously listed). Presenting BCVA had a median (IQR) value of 0.40 (0.10-1.48) logMAR units (Snellen equivalent, 20/50 [20/25-20/600]), and 1508 of 2798 patients (53.9%) presented with BCVA worse than 20/40. Patients presenting with logMAR BCVA less than 20/40 were older than those who presented with 20/40 or higher (mean difference, 14.7 years; 95% CI, 13.3-16.1; P < .001). Furthermore, a larger percentage of male vs female sex patients presented with logMAR BCVA less than 20/40 (difference, 5.2%; 95% CI, 1.5-8.9; P = .04), as well as Black race (difference, 25.7%; 95% CI, 15.0%-36.5%;P < .001) and White race (difference, 22.6%; 95% CI, 13.9%-31.3%; P < .001) vs Asian race, and non-Hispanic vs Hispanic ethnicity (difference, 14.6%; 95% CI, 4.5%-24.8%; P = .04). After adjusting for age, self-reported sex, and self-reported race and ethnicity, worse Area Deprivation Index (odds ratio [OR], 1.30 per 10-unit increase; 95% CI, 1.25-1.35; P < .001), increased segregation (OR, 1.44 per 0.1-unit increase in Theil H index; 95% CI, 1.30-1.61; P < .001), higher percentage of households with no car (OR, 1.25 per 1 percentage point increase; 95% CI, 1.12-1.40; P = .001), and lower average number of cars per household (OR, 1.56 per 1 less car; 95% CI, 1.21-2.02; P = .003) were associated with increased odds of presenting BCVA worse than 20/40. Conclusion and Relevance: Findings of this cross-sectional study suggest that in a sample of patients with MK, patient characteristics and where they live were associated with disease severity at presentation. These findings may inform future research on social risk factors and patients with MK.

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.

Social Deprivation and the Risk of Screening Positive for Glaucoma in the MI-SIGHT Telemedicine-Based Glaucoma Detection Program.

PURPOSE: To assess whether increased poverty is associated with increased risk of screening positive for glaucoma or suspected glaucoma in a large public screening and intervention program. DESIGN: Cross-sectional study from 2020 to 2022. PARTICIPANTS: Adults ≥ 18 years old without acute ocular symptoms. METHODS: Michigan Screening and Intervention for Glaucoma and eye Health through Telemedicine (MI-SIGHT) program participants' sociodemographic characteristics and area deprivation index (ADI) values were summarized from the clinical sites, which included a free clinic and a Federally Qualified Health Center (FQHC). The ADI, a composite measure of neighborhood deprivation (range, 1-10; 10 is worst deprivation), was assigned on the basis of the participants' addresses. Group comparisons were performed via 2-sample t tests or Wilcoxon Mann-Whitney tests for continuous measures and chi-square tests or Fisher exact tests with Monte Carlo simulation for categorical measures; Holm adjustment was used for multiple comparisons. MAIN OUTCOME MEASURES: Risk factors for screening positive for glaucoma or suspected glaucoma. RESULTS: Of the 1171 enrolled participants, 1165 (99.5%) completed the screening: 34% at the free clinic and 66% at the FQHC. Participants were on average aged 55.1 ± 14.5 years, 62% were women, 54% self-reported as Black/African-American, 34% White, 10% Hispanic or Latino, and 70% earned < $30 000 annually. The mean ADI was 7.2 ± 3.1. The FQHC had higher (worse) ADI than the free clinic (free clinic: 4.5 ± 2.9, FQHC: 8.5 ± 2.1, P < 0.0001). One-quarter (24%) of participants screened positive for glaucoma or suspected glaucoma. Screening positive for glaucoma or suspected glaucoma was associated with being older (P = 0.01), identifying as Black/African-American (P = 0.0001), having an established eyecare clinician (P = 0.0005), and not driving a personal vehicle to the appointment (P = 0.001), which is a proxy for increased poverty. Participants who screened positive had worse ADI than those who screened negative (7.7 ± 2.8 vs. 7.0 ± 3.2, P = 0.002). A larger percentage of White participants screened positive at the FQHC compared with White participants at the free clinic (21.3% vs. 12.3%, P = 0.01). FQHC White participants had worse ADI than free clinic White participants (7.5 ± 2.5 vs. 3.7 ± 2.7, P < 0.0001). CONCLUSIONS: Personal poverty, assessed as not driving a personal vehicle to the appointment, and neighborhood-level poverty were both associated with increased rates of screening positive for glaucoma or suspected glaucoma. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A scoping review of patients' barriers to eye care for glaucoma and keratitis.

In this scoping review, we examine underlying causes of loss to follow-up for chronic (glaucoma) and acute (corneal ulcers) eye conditions using the Penchansky and Thomas access to care framework. We explore barriers by World Health Organization income levels and by studying geographical location. We identified 6,363 abstracts, with 75 articles retrieved and 16 meeting inclusion criteria. One article discussed barriers to follow-up care for people with corneal ulcers, and the other 15 were for people with glaucoma. The most frequent barriers to care were affordability, awareness, and accessibility. The international studies had a greater percentage of studies report acceptability as a barrier to loss to follow-up. Countries with universal healthcare included affordability as a loss to follow-up barrier, emphasizing that cost goes beyond the ability to pay for direct treatment costs. Understanding and addressing barriers to follow-up care can aid the goal of continued care and decrease the risk of poor outcomes and vision loss.

Patient-Centered Outcomes After a Medication Adherence Intervention: a Pilot Study.

PRCIS: Self-determination theory (SDT) guided behavioral interventions are effective in improving several patient-centered metrics, including glaucoma-related distress. However, whether improvement in patient-centered metrics can drive an improvement in medication-taking behavior remains to be seen. OBJECTIVE: The 7-month Support, Educate, Empower (SEE) personalized glaucoma coaching program was previously shown to improve glaucoma medication adherence by 21 percent points. This study's goal was to assess the impact of the SEE program on self-determination theory (SDT) metrics and other patient-centered outcome measures. PARTICIPANTS AND METHODS: Glaucoma patients (≥40 y old, taking ≥1 medication) self-reporting poor medication adherence were recruited at the University of Michigan. Eight surveys (with 10 subscales) were completed before and after the 7-month SEE program. Three surveys assessed changes in SDT (Treatment Self-regulation Questionnaire, Healthcare-Climate Questionnaire, Perceived Competence) while the others assessed participants' Glaucoma Knowledge, Glaucoma Medication Self-efficacy, Glaucoma-related distress, Perceived benefits, confidence asking and getting questions answered. RESULTS: Thirty-nine participants completed the SEE program. Significant improvements were in 7 subscales, including all three SDT tenets of competence (mean change =0.9, SD =±1.2, adjusted P =0.0002), autonomy (0.5, ±0.9, 0.044), and relatedness ( P =0.002). Glaucoma-related distress (-2.0, ±3.2, 0.004), confidence in asking questions (1.1, ±2.0, 0.008), and confidence in getting questions answered (1.0, ±2.0, 0.009) also improved. Glaucoma-related distress was correlated with perceived competence ( r =-0.56, adjusted P =0.005), and an increase in perceived competence was associated with a decrease in glaucoma-related distress (ß=-0.43, 95% CI -0.67 - -0.20, adjusted P =0.007). CONCLUSIONS: The SEE program improved participants' autonomous motivation, perceived support, perceived competence, glaucoma-related distress, and competence. These results point to the promising potential of SDT-guided behavioral interventions in improving patient-centered metrics.

Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine Program: First-Year Outcomes and Implementation Costs.

PURPOSE: The Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (MI-SIGHT) program aims to engage people who are at high risk of glaucoma; we assess first-year outcomes and costs. DESIGN: Clinical cohort study. METHODS: Participants ≥18 years of age were recruited from a free clinic and a federally qualified health center in Michigan. Ophthalmic technicians in the clinics collected demographic information, visual function, ocular health history, measured visual acuity, refraction, intraocular pressure, pachymetry, pupils, and took mydriatic fundus photographs and retinal nerve fiber layer optical coherence tomography. Data were interpreted by remote ophthalmologists. During a follow-up visit, technicians shared ophthalmologist recommendations, dispensed low-cost glasses, and collected participant satisfaction. The primary outcome measures were prevalence of eye disease, visual function, program satisfaction, and costs. Observed prevalence was compared with national disease prevalence rates using z tests of proportions. RESULTS: Among 1171 participants, the average age was 55 years (SD 14.5 years), 38% were male, 54% identified as Black, 34% as White, 10% as Hispanic, 33% had less than or equal to a high school education, and 70% had an annual income <$30,000. The prevalence of visual impairment was 10.3% (national average 2.2%), glaucoma and suspected glaucoma 24% (national average 9%), macular degeneration 2.0% (national average 1.5%), and diabetic retinopathy 7.3% (national average 3.4%) (P < .0001). Seventy-one percent of participants received low-cost glasses, 41% were referred for ophthalmology follow-up, and 99% were satisfied or very satisfied with the program. Startup costs were $103,185; recurrent costs were $248,103 per clinic. CONCLUSIONS: Telemedicine eye disease detection programs in low-income community clinics effectively identify high rates of pathology.

A Qualitative Assessment of the Experiences with Eye Health and Barriers to Eyeglasses among U.S. Youth.

SIGNIFICANCE: Uncorrected refractive error is the main cause of visual impairment in U.S. youth and has profound impacts on individuals and society. Identifying and addressing barriers to eyeglasses in this population are critical to maximize youth academic performance, workplace productivity, and quality of life. PURPOSE: We aimed to understand youth experiences with eye health, assess the value that youth place on vision, and identify barriers to refractive correction directly from a nationwide sample of youth to inform interventions to address uncorrected refractive error in this population. METHODS: An open-ended poll was distributed to the MyVoice Text Message Cohort of U.S. youth eliciting youth experiences with eye health and barriers to wearing eyeglasses. Text message responses were coded using grounded theory. RESULTS: Of 1204 recipients, 88.3% (n = 1063) responded. The mean age ± standard deviation was 20.3 ± 2.4 years, 58.8% (n = 625) were male, 74.0% (n = 787) were White, and 41.4% (n = 440) reported low socioeconomic status. Four major themes emerged from the open-ended responses: (1) many youth have experienced problems with their eyes or eyesight (n = 699 [65.8%]); (2) many youth value their eyesight highly (n = 905 [85.1%]; e.g., "Eyesight is one of the most important aspects of my health, particularly in our digital world…"); (3) common reasons youth might not wear glasses even if they need them include concerns over appearance (n = 553 [52.0%]; e.g., "I thought every pair made me look ugly…"), cost (n = 171 [16.1%]), inconvenience (n = 166 [15.6%]), and discomfort (n = 104 [9.8%]); and (4) youth are open to purchasing eyeglasses online (n = 539 [50.7%]). CONCLUSIONS: Appearance, cost, inconvenience, and discomfort are critical barriers to wearing eyeglasses among U.S. youth. A multisectoral response is necessary to address these barriers.

The Support, Educate, Empower personalized glaucoma coaching trial design.

BACKGROUND: Glaucoma is a chronic disease that affects 3 million Americans. Glaucoma is most often asymptomatic until very late in its course when treatment is more difficult and extensive peripheral vision loss has already occurred. Taking daily medications can mitigate this vision loss, but at least half of people with glaucoma do not take their prescribed medications regularly. The purpose of this study is to improve glaucoma medication adherence among those with medically treated glaucoma and poor self-reported adherence using the Support, Educate, Empower personalized coaching program. METHODS/DESIGN: This study is a two-site randomized controlled trial enrolling 230 participants with poor self-reported glaucoma medication adherence. The trial has two arms, an intervention arm and a control arm. Participants in the intervention arm receive personalized glaucoma education and motivational interviewing-based coaching over 6 months from a trained non-physician interventionist for three in-person sessions with between visit phone calls for check-ins where current adherence level is reported to participants. Participants also can elect to have visual, audio, text or automated phone call medication dose reminders. Participants in the control arm continue usual care with their physician and receive non-personalized glaucoma educational materials via mail in parallel to the three in-person coaching sessions to control for glaucoma knowledge content. All participants receive a medication adherence monitor. The primary outcome is the proportion of prescribed doses taken on schedule during the 6-month period. The secondary outcome is glaucoma related distress. The exploratory outcome is intraocular pressure. DISCUSSION: The personalized education and motivational-interviewing-based intervention that we are testing is comprehensive in that it addresses the wide range of barriers to adherence that people with glaucoma encounter. Leveraging a custom-built web-based application to generate the personalized content and the motivational-interviewing-based prompts to guide the coaching sessions will make this program both replicable and scalable and can be integrated into clinical care utilizing trained non-physician providers. Although this type of self-management support is not currently reimbursed for glaucoma as it is for diabetes, this trial could help shape future policy change should the intervention be found effective.

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 Medication Adherence 1 Year after the Support, Educate, Empower Personalized Glaucoma Coaching Program.

PURPOSE: To assess the efficacy of the Support, Educate, Empower (SEE) glaucoma coaching program on medication adherence among poorly adherent patients with glaucoma for 12 months after cessation of the intervention. DESIGN: Uncontrolled intervention study with a pre-post design. PARTICIPANTS: The SEE cohort was recruited from the University of Michigan and included patients with glaucoma aged ≥ 40 years, taking ≥ 1 medication, who self-reported poor adherence. Electronic medication monitoring of those who completed the program continued for up to 1 year after the coaching intervention. METHODS: Adherence was monitored electronically (AdhereTech) during the 7-month program and 12-month follow-up period. Adherence was the percentage of doses taken on time. Participants were censored for surgery, change in glaucoma medications, or adherence monitor disuse. The SEE program included automated medication reminders, 3 in-person motivational interviewing-based counseling sessions with a glaucoma coach, and 5 phone calls with the coach for between-session support. There was no contact between the study team and participants during the 12-month follow-up after program cessation. Baseline participant characteristics were summarized with descriptive statistics. Paired t tests and Wilcoxon signed rank tests were used to investigate significant changes in monthly adherence during follow-up. MAIN OUTCOME MEASURES: Change in electronically monitored medication adherence over the 12 months following the conclusion of the SEE program. RESULTS: Of 48 participants, 39 (81%) completed the SEE program and continued electronic medication monitoring for up to 1 year after program cessation. The mean age of the participants was 64 years (standard deviation [SD], 10); of the 39 participants, 56% were male, 49% were Black, and 44% were White. The mean length of follow-up was 284 days (SD, 110; range, 41-365 days). Censoring occurred in 18 (56%) participants. The mean adherence during the follow-up period was 67% (SD, 22%). This was significantly lower than the adherence during the SEE program (mean, 81%; SD, 18%; P < 0.0001) but significantly higher than the baseline preprogram adherence (mean, 60%; SD, 18%; P = 0.0393). The largest monthly losses occurred at months 1 (mean, 7%; P = 0.0001) and 4 (mean, 6%; P = 0.0077). CONCLUSIONS: Glaucoma medication adherence decreased significantly in the year after cessation of the SEE coaching program but remained significantly higher than baseline adherence. To maintain excellent long-term medication adherence, intermittent reinforcement sessions may be necessary.

Seeing Red: Associations between Historical Redlining and Present-Day Visual Impairment and Blindness.

PURPOSE: Redlining was a discriminatory housing policy in the United States that began in 1933 and denoted neighborhoods with high proportions of Black individuals as "undesirable" and a high risk for lending, which therefore excluded people from obtaining traditional insured mortgages to purchase a home. Simultaneously, realtors discouraged Black individuals from purchasing homes in predominantly non-Black neighborhoods. This resulted in decreased home ownership and wealth accumulation among Black individuals and neighborhoods with high proportions of Black individuals. This study investigated rates of visual impairment and blindness (VIB) in neighborhoods that at one time were graded for redlining. DESIGN: Secondary data analysis of American Community Survey data and historical grades for redlining. PARTICIPANTS: United States census tracts (CTs) from 2010 with historical grades for redlining. METHODS: One-way analysis of variance, Kruskal-Wallis test, chi-square test, and logistic regression modeling. MAIN OUTCOME MEASURES: The main outcome was CT percentage of residents reporting VIB and the association with historical grades for redlining. Grades were converted to numeric values (1 to 4, with higher values indicating worse grade) and aggregated over a CT based on the distribution of grades within to obtain a redlining score. Logistic regression was used to model the effect of redlining on the probability of having VIB. RESULTS: Eleven thousand six hundred sixty-eight CTs were analyzed. Logistic regression found that a 1-unit increase in average redlining score was associated with a 13.4% increased odds of VIB after controlling for CT measures of age, sex, people of color (any non-White race), state, and population size (odds ratio [OR], 1.134; 95% confidence interval [CI], 1.131-1.138; P < 0.001). Similar results were observed for an additional model that adjusted for the estimated percentage of Black residents within a CT (OR, 1.180; 95% CI, 1.177-1.183; P < 0.001). CONCLUSIONS: Historical government-sanctioned residential segregation through redlining was found to be associated with higher proportions of people living with VIB in these neighborhoods today. Understanding how neighborhood segregation impacts eye health is important for planning improved mechanisms of eye care delivery to mitigate health disparities. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.