All ophthalmologists recognize the difficulty of treating glaucoma patients. As providers of ophthalmic care to an underserved population, we find that many of the same challenges exist here in Jackson County, Missouri, as in other similar demographic and geographic areas. They include, but are not limited to, the changing face of glaucoma patients, communication barriers, and access to care.
DEMOGRAPHIC AND GEOGRAPHIC CHANGES
One of the greatest challenges nationwide is the growing number of patients with glaucoma, in many of whom the disease is undiagnosed. The number of Americans with primary open-angle glaucoma (POAG) is conservatively expected to increase by more than 20% per decade to approximately 3.5 million individuals by 20201. Additionally, given the changing demographics of the country over the next decades, the single largest demographic group with POAG is predicted to transition from non-Hispanic white women to Hispanic men1.
The geographic distribution of POAG is also evolving. It has been estimated that, by 2050, some states will have as many as six patients with POAG per every 100 persons over the age of 40.1 Unfortunately, nearly 50% of cases of glaucoma may be undiagnosed.2 In the Visual Impairment Project in Australia, in over 60% of patients with probable or definite open-angle glaucoma, the disease was previously undiagnosed.3 There are likely tens of thousands of patients in the United States with early, undiagnosed glaucoma who have seen an eye care provider in the past year, not to mention the multitudes who have not had access to care.
COMMUNICATION
Contrary to glaucoma's often asymptomatic presentation and slow progression, the disease's treatment is not without side effects, which negatively affects patients' adherence and necessitates their effective education in the clinic. The “silence” of the disease can delay its treatment and make it difficult to control.
Communicating the necessity of screening, routine follow-up, testing, long-term medical therapy, and surgery is difficult under the best of circumstances. It becomes a major hurdle with the underserved patient population. The National Eye Health Education Program is doing important work to promote eye health literacy in specific patient populations, including older adults, Hispanics/Latinos, and African Americans.4 A culturally appropriate approach to outreach and glaucoma education is needed, one that includes “buy-in” from the larger community, support from family members, and brochures in languages besides English. To assist, the National Eye Health Education Program's website includes many educational resources and publications in English and Spanish.5
As a public health effort, the Centers for Disease Control's Vision Health Initiative is coordinating a framework of various providers, organizations, and state and federal agencies aimed at preventing vision impairment. The agency's plan specifically includes targeting glaucoma in at-risk African American and Hispanic populations.6
ACCESS TO CARE
Moving forward, a majority of potential glaucoma patients will be of Medicare age, but a large number will be younger and not qualify for this program. Estimates vary, but about 750,000 people between the ages of 40 and 60 are expected to have POAG by 2020.1 These patients have access to care through a variety of commercial insurance plans, government-sponsored health plans, and local medical coverage assistance programs.
In the Kansas City, Missouri, metropolitan area, many traditionally underserved patients come to Truman Medical Center (TMC) for their care. The majority of patients in the eye clinic have Medicare, Missouri Medicaid, and the TMC Discount. The last is a local medical coverage assistance program provided to legal residents of Jackson County who do not meet the eligibility requirements of other assistance programs. Each of these three insurance plans covers some, but not all, costs of clinic visits, medications, and surgeries. Even at drastically reduced prices, the long-term use of multiple glaucoma medications can still represent a significant financial burden, which again necessitates effective education and doctor-patient communication.
The implementation of the Affordable Care Act's health insurance marketplaces may improve patients' access to ophthalmic services, but the challenges of a growing glaucoma population, changing demographics, and communication barriers will remain. In addition, the need for local medical coverage assistance programs will probably continue. Patients may avail themselves of programs similar to the TMC Discount, for example, if
- they choose to pay the individual mandate penalty instead of buying insurance
- they are undocumented and therefore do not qualify for the insurance marketplaces
- they continue with lower-quality plans that predate the Affordable Care Act
- they live in states like Missouri that have not expanded Medicaid, and they fall into the gap between Medicaid coverage and insurance marketplace subsidies
The barriers to the treatment of glaucoma in the underserved patient population are great but not insurmountable. Multiple national initiatives are examining the changing face of the glaucoma patient and constructing tools and relationships to target at-risk populations with effective, culturally aware information. The challenge of providing these patients with access to care is also being addressed at a national and local level. As physicians invested in treating all patients with glaucoma, we welcome the increased attention and resources directed at better treating currently underserved glaucoma patients.
Eric N. Brown, MD, PhD, is a third-year ophthalmology resident at the University of Missouri, Kansas City School of Medicine. Dr. Brown may be reached at eric.n.brown@gmail.com.
Rohit Krishna, MD, is an associate professor of ophthalmology and director of glaucoma at the University of Missouri, Kansas City School of Medicine. Dr. Krishna may be reached at krishnar@sabateseye.com.
- Vajaranant TS, Wu S, Torres M, Varma R. The changing face of primary open-angle glaucoma in the United States: demographic and geographic changes from 2011 to 2050. Am J Ophthalmol. 2012;154(2):303-314.
- Quigley HA. Number of people with glaucoma worldwide. Br J Ophthalmol. 1996;80(5):389-393.
- Wong EY, Keeffe JE, Rait JL, et al. Detection of undiagnosed glaucoma by eye health professionals. Ophthalmology. 2004;111(8):1508-1514.
- National Eye Health Education Program. Effective Education to Target Populations. http://www.nei.nih.gov/ nehep/research/Effective_Education_to_Target_Populations.pdf. Accessed December 20, 2013.
- Glaucoma educational resource and materials. National Eye Institute website. http://www.nei.nih.gov/nehep/ programs/glaucoma/educational.asp. Accessed December 20, 2013.
- Centers for Disease Control and Prevention. Improving the Nation's Vision Health: a Coordinated Public Health Approach. http://www.cdc.gov/visionhealth/pdf/improving_nations_vision_health.pdf. Accessed December 20, 2013.
