Bringing Eye Care to the Community

L. Jay Katz, MD; Lisa A. Hark, PhD, RD; Jonathan S. Myers, MD


April 13, 2015

Editorial Collaboration

Medscape &

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Taking to the Streets of Philadelphia

L. Jay Katz, MD: This is a collaboration today between Medscape Ophthalmology and Wills Eye Hospital. I am Jay Katz, director of the Glaucoma Service at Wills Eye Hospital. I am joined by my two esteemed colleagues.

Lisa A. Hark, PhD, RD: I'm Dr Lisa Hark, director of the Glaucoma Research Center at Wills Eye Hospital.

Jonathan S. Myers, MD: I'm Dr Jonathan Myers, also from the Wills Eye Hospital Glaucoma Service.

Dr Katz: We are going to talk about an exciting public health initiative that was carried out here in Philadelphia through Wills Eye Hospital and funded by the Centers for Disease Control and Prevention (CDC). The aim of the project was to identify patients in the community who were at high risk for glaucoma and get them into the healthcare system. Dr Hark, can you tell us about the background and how the program was set up?

Dr Hark: We were able to partner with 42 community sites in Philadelphia—senior centers, the Philadelphia Corporation for Aging, and various other organizations that helped us connect with seniors. We took all of the equipment out into the field and were able to do a full comprehensive eye exam to detect glaucoma in seniors. African American patients had to be older than 50 years, and others had to be older than 60 years. Through that program, we were successfully able to conduct examinations on about 1600 patients in the community setting.

Screening Seniors for Glaucoma

Dr Katz: Dr Myers, can you tell us what the examination consisted of and how glaucoma was diagnosed in these patients?

Dr Myers: It was remarkable. This outreach program gave us the opportunity to educate patients before they were screened. We were able to test visual acuity, conduct a slit lamp exam, measure intraocular pressure, and do visual field testing. It was a fairly complete evaluation in the field because we were able to take our ophthalmologic equipment out to the patients and the community centers.

Dr Katz: That's a great point about the educational seminar. Can you talk more about that? Traditionally, when screening programs are developed to identify people with glaucoma, the show rate is not very good. But for this program the show rate was quite good. Do you have those numbers handy?

Dr Hark: The difference between our program and other programs is that we did a full exam in the community setting. Most programs only checked pressures and looked in the retina. We did a full comprehensive exam. Also, before the exam, to recruit patients we conducted educational workshops. For about 45 minutes while the seniors were having lunch in a community setting, we gave them a glaucoma awareness workshop. We told them what glaucoma is and why they were at risk. Why do you need to get tested? Then we signed people up to do the exam, sometimes that same day or on another day when we would come back. That was a very successful way to recruit people for this exam.

We also took walk-ins, so even if they didn't have an appointment, we had plenty of people who were already there. That was very successful. We actually screened or examined more people than were scheduled because of all the walk-ins.

Dr Myers: In this study, more than 500 people who weren't even scheduled for exams were able to be accommodated, essentially as walk-ins to the screening program. A total of 1600 people were able to be included in this outreach program.

Dr Hark: We weren't originally planning to accommodate walk-ins, but in the beginning of the project we had to make a decision: Will we accommodate walk-ins? It turned out to be really good, particularly when we had patients who didn't show up or who rescheduled. That worked out really well.

Same-Day Treatment and Follow-up

Dr Katz: Were you surprised at the number of patients who had true pathology, either glaucoma or some other eye problem?

Dr Hark: Yes, absolutely.

Dr Myers: It was very impressive, although it was a high-risk community. Almost half of the patients had pathology worthy of further evaluation and treatment.

Dr Hark: The unique thing about this program is that we also offered follow-up for anyone who was diagnosed with an eye problem in the community setting. In addition to initially examining the patients and identifying the problem, we came back for at least two follow-up visits to each site. The first was in 4-6 weeks for those who had glaucoma or who had received a laser treatment. Then we came back to each site (more than 40 sites in Philadelphia) for a 4- to 6-month follow-up. Many of these patients were able to see a doctor for two visits and the show rate has been extraordinarily high: More than 75% of the patients who were identified returned for at least one follow-up visit. We were very pleased about that.

Dr Myers: For this type of research, that is extraordinarily high. The other impressive aspect was that many of the patients with narrow angles were treated that same day with bilateral laser treatment. Moreover, 60% of people with open-angle glaucoma who were given the option elected to have selective laser trabeculoplasty that same day. That really helps these people, even if they weren't in the cohort that was followed up as planned.

Dr Hark: We offered patients the opportunity to come back to Wills over the next few years, if they want to, or we refer them to their local ophthalmologist. Community outreach is very helpful. If you do a full exam, you are going to detect a lot of pathology (particularly glaucoma), and working in senior centers is a very good place to do this because it is an underserved area. You go where the people are, and they are very willing to schedule this. Conducting the workshop was very helpful.

Dr Katz: It's a wonderful program—identifying people with disease and ensuring that they receive treatment. We look at the numbers and we are impressed and satisfied with what we have accomplished in terms of reaching out. But what about the patients? How happy were they in terms of satisfaction with being part of that program? Did they enjoy participating in this endeavor?

Dr Hark: They did.

Dr Myers: It's remarkable that the patients were extremely satisfied, and more than 95% of patients were satisfied with the examination and the convenience. The only aspect that was not rated extremely high was the question about how long the exam took. On the other hand, these people had a full exam as well as treatment on the same day. Still, satisfaction was very high.

Dr Hark: They appreciated having a physician—an ophthalmologist—come to the senior center where they were. It made a huge difference. We have raised awareness and they are very happy with the program.

Expanding Into the Primary Care Setting

Dr Katz: This was a great experience for us at Wills in terms of learning how to reach out into the community and trying to get people into the system to receive care at an early stage of their disease. What is the next extension? Where are we going from here? Do the two of you want to comment about future projects?

Dr Hark: The CDC has funded us for another 5 years to do the same project in primary care settings. We are partnering with Temple University, Philadelphia Health Management Corporation, and Health Federation of Philadelphia. We are partnering with seven primary care offices and 10 health centers treating underserved patients in Philadelphia, primarily the African American community, which has very high rates of glaucoma. We are going to be examining the patients in the primary care setting with a new hand-held camera, looking at their optic nerves and retinas and then transmitting the images back to Wills with our telemedicine infrastructure. Any individual who is diagnosed with an eye disease will be invited back to the primary care office and they will be seen by our team. Our ophthalmologists will go out with the same mobile unit and do the full exam that has been described.

Dr Myers: I am excited about this project because we are going out into the community where the patients are. We are making it easy for them to be screened and we are coordinating this with local ophthalmologists, so that patients who have disease are referred to ophthalmologists in their own communities, hopefully increasing the rate at which they return and increasing acceptance of the program by the community ophthalmologists. It's a win-win-win strategy.

Dr Hark: We are testing the use of a patient navigator and social worker. We are going to be randomizing the patients who are enrolled in the study to their local ophthalmologist, either with or without a patient navigator–social worker. We are very excited to see whether that helps people to receive follow-up in the community. Follow-up adherence is one of the biggest barriers to glaucoma care in underserved populations.

Go Where the Patients Are

Dr Katz: If you were going to give advice to others across the United States in other communities after learning from our experiences with the outreach program in our area, what words of wisdom would you share with others about how to set up similar programs?

Dr Myers: My takeaways have been that if you can get to where the patients are and make it easy for them to do follow-up, that helps the retention rate. Offering laser on the day of diagnosis can be very well accepted when presented in a non-threatening fashion after the patient has had some education.

Dr Hark: Raising awareness is key. Many of these patients have a family history of glaucoma in grandparents, uncle, brother, or sister, but they still don't admit that it could affect them because they have no symptoms. Raise awareness. Help them to get tested. Bring the testing to them, and then bring the follow-up to them as well because the follow-up is very important. Helping them to make an appointment, and doing simple things such as navigating the system and helping them get to that appointment, have been beneficial.

Dr Katz: That is an excellent summary of where we are. Dr Myers, Dr Hark, and others have done a great job of trying to adapt the way we look for patients and the way that we get them into the system. Part of that is the education, thinking outside the box in terms of how we identify patients and have follow-up. Using the existing technology, such as telemedicine, may be a very important part of what we will be doing in the future.

Thank you for your wonderful words and comments on this project through the CDC here at Wills.

This was a joint collaboration today between Wills Eye Hospital and Medscape Ophthalmology. Thank you.