Study Identifies Obstacles to Care for Vulnerable Adult Population


A large proportion of high-risk, uninsured/underinsured individuals do not obtain eye examinations although they screened positive for possible vision problems, according to research published in the Journal of Health Care for the Poor and Underserved.1

To investigate the barriers to care in this population and to formulate a strategy to address them, the Centers for Disease Control and Prevention provided a grant to Prevent Blindness America to conduct a 2-year evaluation of the effectiveness of a vision screening program at the Physician’s Free Clinic (PFC) in Columbus, Ohio. Prevent Blindness Ohio (PBO), a nonprofit affiliate of Prevent Blindness America, trained and equipped first- and second-year medical students to provide vision screening as part of the registration intake process at the PFC. The program also provided patients with educational materials about vision health in multiple languages and facilitated the provision of eye examinations.

Patients who attended a vision screening and were referred for an examination but did not attend were contacted and asked whether they were interested in receiving a free, complete eye examination available during the hours of the free clinic and at an offsite center within three blocks of the PFC. Those who missed their appointments were asked why they did not show up and what would make it easier to attend. The primary reason given for missed appointments was a lack of transportation. Other reasons for missing the examination included forgetting the appointment and scheduling conflicts.

According to the investigators, the results of the study suggest that multiple elements should be considered when establishing a vision care system for a vulnerable population. One approach to improving the rate of follow-up in this population would be the immediate, on-site evaluation of those who are referred for an eye examination. Other considerations include telephone and mail reminders of future appointments in patients’ native languages, longer hours of operation, and decreased waiting time.

The results of the study did not surprise Jeffrey Henderer, MD, a professor of ophthalmology and the Dr. Edward Hagop Bedrossian chair of ophthalmology at Temple University School of Medicine in Philadelphia. Dr. Henderer has conducted free glaucoma screenings at senior centers throughout Philadelphia.

“After screening a couple thousand people over several years, I abandoned the project because the followup rates were quite low, even with vouchers to pay for transportation,” Dr. Henderer told Glaucoma Today. “The most common reason patients cited for missing an appointment was, ‘I forgot.’ For this reason, subsequent screening efforts have been designed with the goal of bringing the office to the patient. Since 2010, our Temple University School of Medicine medical studentrun outreach effort has provided fairly comprehensive eye care in one of Philadelphia’s public health clinics, including refraction, slit-lamp and dilated examinations, screening field testing, and prescription medications if needed. In the past year, this effort was merged with an outreach project funded by the Centers for Disease Control through Wills Eye Hospital, which brings slitlamp examinations, gonioscopy, standard automated perimetry, fundus photography, and YAG laser capability (for peripheral iridotomy and selective laser trabeculoplasty) to the clinic to provide on-site diagnosis and treatment. In less than 1 year, the project has examined more than 1,000 patients and provided glaucoma care to dozens.”

Dr. Henderer continued, “After more than a decade of community glaucoma screenings, my experience has been that the most effective way to ‘screen’ for glaucoma is to not screen at all but to try and replicate a thorough office examination (with treatment options) in the field. Yes, [this approach] is more time consuming and expensive, but outreach efforts that do not lead to care are probably not a productive use of resources.”

  1. Gower EW, Silverman E, Cassard SD, et al. Barriers to attending an eye examination after vision screening referral within a vulnerable population. J Health Care Poor Underserved. 2013;24(3):1042-1052.

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