Barbara Boughton

November 09, 2009

November 9, 2009 (San Francisco, California) — In the first study of its kind in the United States, researchers have found that long wait times in clinics, appointment-scheduling difficulties, and issues with medical interpreters are among the chief barriers to clinical follow-up among established glaucoma patients, according to research presented here at the American Academy of Ophthalmology Joint Annual Meeting with the Pan-American Association of Ophthalmology.

“We undertook this study because there is likely a correlation between poor outcomes with glaucoma and problems with follow-up care,” said Yohko Murakami, from Stanford University School of Medicine in California. Only one previous study, by Kosoko and colleagues, has looked at factors that contribute to poor follow-up care among glaucoma patients, but that article, published in 1998, had a significant portion of patients only suspected of having glaucoma. It also focused on risk factors for poor follow-up, as opposed to barriers to follow-up care, for established glaucoma patients.

Healthcare providers often assume that the primary reasons for poor follow-up are financial costs, insurance issues, or other personal or health issues that take precedence over glaucoma care, Ms. Murakami said. However, the most prevalent barriers identified by her team at Stanford and the University of California at San Francisco actually centered on clinic management issues.

In this case-control study, 152 established glaucoma patients at San Francisco General Hospital (SFGH) treated between August 2008 and January 2009 were surveyed. Outcomes of those with poor follow-up were compared with those with good follow-up.

Results of the study indicated that the most common barriers to attending follow-up visits were long waiting times for 75% of patients, difficulty scheduling appointments for 38% of patients, and comorbid medical or physical conditions for 29% of patients. Orthopaedic problems and mobility issues that made use of public transportation difficult were the most significant types of comorbidity contributing to poor follow-up, and more than 45% of the patients used more than one mode of public transportation to travel to the clinic, Ms. Murakami explained.

SFGH is both a county hospital and a teaching hospital for UCSF residents located in the heart of San Francisco and serves an ethnically diverse population. Although it offers interpreter services, 37% of Latino patients and 32% of Asian patients cited language and interpreter issues as significant barriers to follow-up care. Spanish- and Mandarin-speaking interpreters are in high demand at SFGH, and patients reported experiencing additional wait times and inconvenience associated with using these interpreters, Ms. Murakami said.

“A new phone interpreter system has reduced these wait times, but other issues associated with using an interpreter, such as a disconnect in the doctor-patient relationship and suboptimal patient counseling on the nature of glaucoma and importance of follow-up, may still be a barrier to follow-up care for some patients,” said Bradford Lee, MD, a coinvestigator in the study from Stanford University.

Financial costs of care were significantly more likely to affect follow-up care among Asian patients (22%) compared with Latinos (11%), whites (11%), and blacks (3%), according to the researchers.

Some patients were not aware that blindness can be a complication of glaucoma. Those who did understand this were more likely to pursue follow-up care. “That’s why patient education is so important,” Ms. Murakami said.

The researchers recommended that solutions to improve glaucoma follow-up care should focus on reducing wait times, facilitating appointment scheduling, and developing innovations to streamline care for non–English-speaking patients.

“This study is one that needed to be done,” commented James Tsai, MD, MBA, Robert R. Young Professor and chairman of the Department of Ophthalmology and Visual Science at Yale University School of Medicine, New Haven, Connecticut. “It illustrates that the issue of long wait times is important. Follow-up is vital for glaucoma patients, because proper management demands assessing the progression of the disease over time. If patients can’t get continued follow-up, that means effective management of the disease is limited,” he said.

Ms. Murakami, Dr. Lee, and Dr. Tsai have disclosed no relevant financial relationships.

American Academy of Ophthalmology Joint Annual Meeting With the Pan-American Association of Ophthalmology (AAO-PAAO): Abstract PO145. Presented October 25, 2009.