Health Care Access and Use Among Adults With and Without Vision Impairment: Behavioral Risk Factor Surveillance System, 2018.

INTRODUCTION: Adults with vision impairment may have unique needs when accessing health care to maintain good health. Our study examined the relationship between vision status and access to and use of health care. METHODS: We analyzed data on adults aged 18 years or older who participated in the 2018 Behavioral Risk Factor Surveillance System. Vision impairment was identified by a yes response to the question "Are you blind or do you have serious difficulty seeing, even when wearing glasses?" Survey questions assessed health care access over the past year (having health insurance coverage, a usual health care provider, or unmet health care needs because of cost) and use of health care during that period (routine checkup and dental visit). We estimated age-adjusted prevalence of our outcomes of interest and used bivariate analyses to compare estimates of the outcomes by vision impairment status. RESULTS: The prevalence of self-reported vision impairment was 5.3%. Compared with adults without impaired vision, adults with vision impairment had a lower prevalence of having health insurance coverage (80.6% vs 87.6%), a usual health care provider (71.9% vs 75.7%), or a dental visit in the past year (52.9% vs 67.2%) and a higher prevalence of having an unmet health care need in the past year because of cost (29.2% vs 12.6%). CONCLUSION: Adults with vision impairment reported lower access to and use of health care than those without. Further research can better identify and understand barriers to care to improve access to and use of health care among this population.

Manhattan Vision Screening and Follow-Up Study in Vulnerable Populations: 1-Month Feasibility Results.

Purpose/Aim: In the United States, high rates of vision impairment and eye disease disproportionately impact those who lack access to eye care, specifically vulnerable populations. The objective of our study was to test instruments, implement protocols, and collect preliminary data for a larger 5-year study, which aims to improve detection of eye diseases and follow-up eye care in vulnerable populations using community health workers (CHW) and patient navigators. In the study, trained CHWs conducted vision screening and patient navigators scheduled on-site eye exams and arranged appointments for those referred to ophthalmology to improve adherence to follow-up eye care.Materials and Methods: Eligible individuals age 40-and-older were recruited from the Riverstone Senior Center in Upper Manhattan, New York City. Participants underwent on-site vision screening (visual acuity with correction, intraocular pressure measurements, and fundus photography). Individuals who failed the vision screening were scheduled with an on-site optometrist for an eye exam; those with ocular pathologies were referred to an ophthalmologist. Participants were also administered the National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ-8) and Stopping Elderly Accidents, Deaths, and Injuries (STEADI) test by community health workers.Results:Participants (n = 42) were predominantly older adults, with a mean age of 70.0 ± 9.8, female (61.9%), and Hispanic (78.6%). Most individuals (78.6%, n = 33) failed vision screening. Of those who failed, 84.8% (n = 28) attended the on-site eye exam with the optometrist. Ocular diagnoses: refractive error 13/28 (46.4%), glaucoma/glaucoma suspect 9/28 (32.1%), cataract 7/28 (25.0%), retina abnormalities 6/28 (21.4%); 13 people required eyeglasses.Conclusion: This study demonstrates the feasibility of using CHWs and patient navigators for reducing barriers to vision screening and optometrist-based eye exams in vulnerable populations, ultimately improving early detection of eye disease and linking individuals to additional eye care appointments. The full five-year study aims to further examine these outcomes.

Manhattan Vision Screening and Follow-up Study in Vulnerable Populations (NYC-SIGHT): Design and Methodology.

PRCIS: The Manhattan Vision Screening and Follow-up Study in Vulnerable Populations is a 5-year prospective, cluster-randomized study to improve detection and management of glaucoma and other eye diseases in vulnerable populations living in affordable housing developments. PURPOSE: To describe the study design and methodology of the Manhattan Vision Screening and Follow-up Study in Vulnerable Populations, which aims to investigate whether community-based vision screenings can improve detection and management of glaucoma, vision impairment, cataract, and other eye diseases among vulnerable populations living in affordable housing developments in upper Manhattan. MATERIALS AND METHODS: This 5-year prospective, cluster-randomized, controlled trial consists of vision screening and referral for follow-up eye care among eligible residents aged 40 and older. Visual acuity, intraocular pressure (IOP), and fundus photography are measured. Participants with visual worse than 20/40, or IOP 23 to 29 mm Hg, or unreadable fundus images fail the screening and are scheduled with the on-site optometrist. Those with an abnormal image and/or IOP ≥30 mm Hg, are assigned as "fast-track" and referred to ophthalmology. Participants living in 7 developments randomized to the Enhanced Intervention Group who fail the screening and need vision correction receive complimentary eyeglasses. Those referred to ophthalmology receive enhanced support with patient navigators to assist with follow-up eye care. Participants living in 3 developments randomized to the Usual Care Group who fail the screening and need vision correction are given an eyeglasses prescription only and a list of optical shops. No enhanced support is given to the Usual Care Group. All participants referred to ophthalmology are assisted in making their initial eye exam appointment. CONCLUSION: This study targets vulnerable populations where they live to ensure improved access to and utilization of eye care services in those who are least likely to seek eye care.

Eye Care Among US Adults at High Risk for Vision Loss in the United States in 2002 and 2017.

Importance: Timely eye care can prevent unnecessary vision loss. Objectives: To estimate the number of US adults 18 years or older at high risk for vision loss in 2017 and to evaluate use of eye care services in 2017 compared with 2002. Design, Setting, and Participants: This survey study used data from the 2002 (n = 30 920) and 2017 (n = 32 886) National Health Interview Survey, an annual, cross-sectional, nationally representative sample of US noninstitutionalized civilians. Analysis excluded respondents younger than 18 years and those who were blind or unable to see. Covariates included age, sex, race/ethnicity, marital status, educational level, income-to-poverty ratio, health insurance status, diabetes diagnosis, vision or eye problems, and US region of residence. Main Outcomes and Measures: Three self-reported measures were visiting an eye care professional in the past 12 months, receiving a dilated eye examination in the past 12 months, and needing but being unable to afford eyeglasses in the past 12 months. Adults at high risk for vision loss included those who were 65 years or older, self-reported a diabetes diagnosis, or had vision or eye problems. Multivariable logistic regression models incorporating sampling weights were used to investigate associations between measures and covariates. Temporal comparisons between 2002 and 2017 were derived from estimates standardized to the US 2010 census population. Results: Among 30 920 individuals in 2002, 16.0% were 65 years or older, and 52.0% were female; among 32 886 individuals in 2017, 20.0% were 65 years or older, and 51.8% were female. In 2017, more than 93 million US adults (37.9%; 95% CI, 37.0%-38.7%) were at high risk for vision loss compared with almost 65 million (31.5%; 95% CI, 30.7%-32.3%) in 2002, a difference of 6.4 (95% CI, 5.2-7.6) percentage points. Use of eye care services improved (56.9% [95% CI, 55.7%-58.7%] reported visiting an eye care professional annually, and 59.8% [95% CI, 58.6%-61.0%] reported receiving a dilated eye examination), but 8.7% (95% CI, 8.0%-9.5%) said they could not afford eyeglasses (compared with 51.1% [95% CI, 49.9%-52.3%], 52.4% [95% CI, 51.2%-53.6%], and 8.3% [95% CI, 7.7%-8.9%], respectively, in 2002). In 2017, individuals with lower income compared with high income were more likely to report eyeglasses as unaffordable (13.6% [95% CI, 11.6%-15.9%] compared with 5.7% [95% CI, 4.9%-6.6%]). Conclusions and Relevance: Compared with data from 2002, more US adults were at high risk for vision loss in 2017. Although more adults used eye care, a larger proportion reported eyeglasses as unaffordable. Focusing resources on populations at high risk for vision loss, increasing awareness of the importance of eye care, and making eyeglasses more affordable could promote eye health, preserve vision, and reduce disparities.

Self-Reported Oral Health Status Among Adults Aged 40+ Years With and Without Vision Impairment: National Health Interview Study, 2008.

PURPOSE: To examine self-reported oral health among adults aged 40 years and older with and without vision impairment. DESIGN: Cross-sectional, with a nationally representative sample. METHODS: We used publicly available data from the Oral Health Module, last administered in 2008, of the National Health Interview Survey. Outcome variables included fair/poor oral health status, mouth condition compared to others the same age, mouth problems (mouth sores, difficulty eating, dry mouth, bad breath, and/or jaw pain), teeth problems (toothache; broken/missing fillings or teeth; loose, crooked, or stained teeth; and/or bleeding gums), and lack of social participation. Using descriptive statistics and multivariate logistic regression, we examined the association (P < .05) between vision impairment and oral health outcomes by age group, sociodemographics, and other explanatory variables. RESULTS: Our study sample included 12,090 adults; 12.8% of adults aged 40-64 years reported vision impairment, and among them, 44.5% reported fair/poor oral health status and 47.2% reported any mouth problems. Among adults aged ≥65 years, 17.3% reported vision impairment, of whom 36.3% reported fair/poor oral health status and 57.3% reported any mouth problems. There is a strong association between vision impairment and poorer oral health of adults; adults aged 40-64 years with vision impairment reported 90%-150% greater odds of oral health problems, including fair/poor oral health status, mouth problems, and teeth problems, compared to people without vision impairment. CONCLUSIONS: Oral health disparities exist between adults with and without vision impairment. Targeted interventions are required to improve oral health in this vulnerable population.

Philadelphia Telemedicine Glaucoma Detection and Follow-Up Study: Cataract Classifications Following Eye Screening.

Background:Cataracts are a major cause of visual impairment and blindness in the United States and worldwide.Introduction:Risk factors for cataracts include age over 40 years, smoking, diabetes, low socioeconomic status, female sex, steroid use, ocular trauma, genetic factors, and exposure to ultraviolet-B light. Community-based telemedicine vision screenings can be an efficient method for detecting cataracts in underserved populations. The Philadelphia Telemedicine Glaucoma Detection and Follow-Up Study reports the prevalence and risk factors for cataracts in individuals screened and examined for glaucoma and other eye diseases.Materials and Methods:A total of 906 high-risk individuals were screened for glaucoma using telemedicine in seven primary care practices and four Federally Qualified Health Centers in Philadelphia. Participants with suspicious nerves or other abnormalities on fundus photographs, unreadable images, and ocular hypertension returned for an eye examination with an ophthalmologist at the same community location.Results:Of the participants screened through telemedicine, 347 (38.3%) completed a follow-up eye examination by an ophthalmologist. Of these, 267 (76.9%) were diagnosed with cataracts, of which 38 (14.2%) had visually significant cataracts. Participants who were diagnosed with visually significant cataract were more likely to be older (p < 0.001), have diabetes (p = 0.003), and worse visual acuity (p < 0.001).Discussion:Our study successfully detected and confirmed cataracts in a targeted, underserved urban population at high risk for eye disease.Conclusions:Telemedicine programs offer an opportunity to identify and refer individuals who would benefit from continuous follow-up eye care and treatment to improve visual function and quality of life.

Prevalence of Diabetic Retinopathy and Associated Mortality Among Diabetic Adults With and Without Chronic Kidney Disease.

PURPOSE: To estimate prevalence and severity of diabetic retinopathy (DR) among U.S. adults with diabetes and with or without chronic kidney disease (CKD), and assess associated risk of mortality. DESIGN: Cross-sectional study with national survey data. METHODS: The cohort included adults ≥40 years old with diabetes in the National Health and Nutrition Examination Surveys (NHANES) 2005-2008. Vital status was determined through December 31, 2011. We defined diabetes as hemoglobin A1c ≥6.5% or self-report and CKD by urinary albumin/creatinine ≥30 mg/g or glomerular filtration rate <60 mL/min/1.73 m2. The main outcomes were DR and mortality. RESULTS: Prevalence of DR was 27.8% (95% CI 24.3-31.7), 36.2% (95%CI 30.1-42.7), and 23.4% (95% CI 19.2-28.1), overall, with and without CKD. Prevalence of vision-threatening DR was 4.2% (95% CI 3.2-5.5), 8.2% (95% CI 5.4-12.2), and 2.0% (95% CI 1.2-3.5), respectively. In a multivariable adjusted model, DR was positively but nonsignificantly associated with CKD (OR = 1.1, 95% CI 0.7-1.7), was 40% higher per 1% increase in hemoglobin A1c (OR = 1.4, 95% CI 1.1-1.6), was 30% higher per 5 years additional diabetes duration (OR = 1.3, 95% CI 1.1-1.5), was 30% higher per 10 mm Hg increase in systolic blood pressure (OR = 1.3, 95% CI 1.1-1.5), and was 6-fold higher with insulin treatment (OR = 6.2, 95% CI 2.6-14.8). Compared with diabetic participants with neither DR nor CKD, those with DR and CKD had a 3.6-fold (95% CI 1.5-9.1) increased adjusted risk for all-cause mortality. CONCLUSIONS: Over one third of persons with diabetes and CKD had DR. The risk of death was higher with than without CKD and DR. Many of the studied risk factors associated with DR are modifiable.

Eye Care Utilization Among Insured People With Diabetes in the U.S., 2010-2014.

OBJECTIVE: Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults, and although screening with eye exams is effective, screening rates are low. We evaluated eye exam visits over a 5-year period in a large population of insured patients 10-64 years of age with diabetes. RESEARCH DESIGN AND METHODS: We used claims data from IBM Watson Health to identify patients with diabetes and continuous insurance coverage from 2010 to 2014. Diabetes and DR were defined using ICD-9 Clinical Modification codes. We calculated eye exam visit frequency by diabetes type over a 5-year period and estimated period prevalence and cumulative incidence of DR among those receiving an eye exam. RESULTS: Among the 298,383 insured patients with type 2 diabetes and no diagnosed DR, almost half had no eye exam visits over the 5-year period and only 15.3% met the American Diabetes Association (ADA) recommendations for annual or biennial eye exams. For the 2,949 patients with type 1 diabetes, one-third had no eye exam visits and 26.3% met ADA recommendations. The 5-year period prevalence and cumulative incidence of DR were 24.4% and 15.8%, respectively, for patients with type 2 diabetes and 54.0% and 33.4% for patients with type 1 diabetes. CONCLUSIONS: The frequency of eye exams was alarmingly low, adding to the abundant literature that systemic changes in health care may be needed to detect and prevent vision-threatening eye disease among people with diabetes.

Trends in Eye Care Use and Eyeglasses Affordability: The US National Health Interview Survey, 2008-2016.

Importance: Understanding eye care use over time is essential to estimate continued unmet health care needs and help guide future public health priorities. Objective: To update trends in using eye care and affording eyeglasses in the United States. Design, Setting, and Participants: This analysis of data from the US National Health Interview Survey included adults 18 years and older from 9 annual cross-sectional population-based samples ranging in size from 21 781 to 36 697 participants from 2008 to 2016. Data were analyzed from August 2017 to February 2018. Exposures: Visual impairment, defined as self-reported difficulty seeing despite wearing eyeglasses. Main Outcomes and Measures: Outcome measures included visits to an eye care professional and inability to afford eyeglasses when needed in the past year. Survey logistic regression, adjusted for age, sex, race/ethnicity, visual impairment status, education, employment, general health, poverty-income ratio, and vision insurance, was used to examine associations between survey year and eye care outcomes. Results: Analyses included 9 annual cross-sectional population-based samples pooled from 2008 to 2016, ranging in size from 21 781 to 36 697 participants aged 18 years or older. Compared with 2008, greater proportions of the US population were 65 years or older, Hispanic, or Asian in 2016. There was a significant trend for eye care use and difficulty affording eyeglasses from 2008 to 2016. In fully adjusted models, Americans were less likely to use eye care in 2014 compared with 2008 (odds ratio [OR], 0.90; 99.9% CI, 0.82-0.98; P < .001). Compared with 2008, Americans were also less likely to report difficulty affording eyeglasses from 2014 onwards (2014: OR, 0.82; 99.9% CI, 0.69-0.97; P < .001; 2015: OR, 0.81; 99.9% CI, 0.69-0.96; P < .001; 2016: OR, 0.70; 99.9% CI, 0.59-0.82; P < .001). After adjusting for all covariates, including survey year, those with visual impairment compared with those without were more likely to use eye care (OR, 1.54; 99.9% CI, 1.45-1.65; P < .001) but had greater difficulty affording eyeglasses (OR, 3.86; 99.9% CI, 0.58-0.72; P < .001). Women were also more likely to use eye care (OR, 1.42; 99.9% CI, 1.37-1.48; P < .001) and report difficulty affording eyeglasses (OR, 1.68; 99.9% CI, 1.56-1.81; P < .001) compared with men. Compared with non-Hispanic white individuals, black, Asian, and Hispanic individuals were less likely to use eye care, and Asian and black individuals were less likely to have difficulty affording eyeglasses. Conclusions and Relevance: These data indicate decreased difficulty affording eyeglasses among Americans from 2014 to 2016, possibly related to economic recovery and health care reform. However, the findings suggest women and racial/ethnic minorities are more likely to have lower use of eye care or inability to afford eyeglasses.

Costs of a community-based glaucoma detection programme: analysis of the Philadelphia Glaucoma Detection and Treatment Project.

BACKGROUND: Glaucoma is the foremost cause of irreversible blindness, and more than 50% of cases remain undiagnosed. Our objective was to report the costs of a glaucoma detection programme operationalised through Philadelphia community centres. METHODS: The analysis was performed using a healthcare system perspective in 2013 US dollars. Costs of examination and educational workshops were captured. Measures were total programme costs, cost/case of glaucoma detected and cost/case of any ocular disease detected (including glaucoma). Diagnoses are reported at the individual level (therefore representing a diagnosis made in one or both eyes). Staff time was captured during site visits to 15 of 43 sites and included time to deliver examinations and workshops, supervision, training and travel. Staff time was converted to costs by applying wage and fringe benefit costs from the US Bureau of Labor Statistics. Non-staff costs (equipment and mileage) were collected using study logs. Participants with previously diagnosed glaucoma were excluded. RESULTS: 1649 participants were examined. Mean total per-participant examination time was 56 min (SD 4). Mean total examination cost/participant was $139. The cost/case of glaucoma newly identified (open-angle glaucoma, angle-closure glaucoma, glaucoma suspect, or primary angle closure) was $420 and cost/case for any ocular disease identified was $273. CONCLUSION: Glaucoma examinations delivered through this programme provided significant health benefit to hard-to-reach communities. On a per-person basis, examinations were fairly low cost, though opportunities exist to improve efficiency. Findings serve as an important benchmark for planning future community-based glaucoma examination programmes.

Early Age-related Macular Degeneration with Cardiovascular and Renal Comorbidities: An Analysis of the National Health and Nutrition Examination Survey, 2005-2008.

PURPOSE: A cross sectional study was designed to examine the relationship of early age-related macular degeneration (AMD) with comorbidities of cardiovascular and renal conditions in the representative population using National Health and Nutrition Examination Survey (NHANES), 2005-2008. METHODS: Participants (≥40 years) who underwent retinal photography were included. Early AMD was defined by the retinal digital images. The comorbidities were self-reported stroke and heart disease (HD), including angina pectoris (AP), coronary heart disease (CHD), congestive heart failure (CHF), and myocardial infarction (MI). Chronic kidney disease (CKD) was determined based on self-report, estimation of glomerular filtration rate (GFR), or the level of urine albumin. RESULTS: The age-adjusted odds ratio (OR) and 95% CI for having early AMD for persons with the selected conditions were: 2.6 (1.9, 3.6) for any type of HD. When the conditions were considered separately, ORs (95% CIs) were: 2.0 (1.2, 3.4) for AP; 2.5 (1.6, 3.8) for CHD; 2.4 (1.6, 3.6) for MI; 2.3 (1.3, 3.9) for CHF; 3.3 (2.2, 5.0) for stroke; and 2.4 (1.8, 3.2) for CKD. Covariable-adjusted ORs (AOR) were attenuated for all examined conditions, but remained statistically significant. Having any single condition (AOR [95%CI]: 2.7 [1.5, 4.8]) was significantly associated with early AMD, as was having ≥ 2 conditions (AOR [95%CI]: 5.2 [3.0, 9.0]). The strongest association was between early AMD and the combination of HD and stroke (AOR [95% CI]: 6.3 [2.9, 13.8]). CONCLUSION: Cardiovascular and renal comorbidities are associated with early AMD in a representative sample of the US general population.

The Prevalence of Chronic Conditions and Poor Health Among People With and Without Vision Impairment, Aged ≥65 Years, 2010-2014.

PURPOSE: To examine the prevalence of 13 chronic conditions and fair/poor health among people aged ≥65 years in the United States with and without vision impairment. DESIGN: Cross-sectional study from the 2010-2014 National Health Interview Survey. METHODS: We examined hypertension, heart disease, high cholesterol, stroke, arthritis, asthma, chronic obstructive pulmonary disease, cancer, weak/failing kidneys, diabetes, hepatitis, depression, and hearing impairment. We used logistic regression to show the association between vision impairment and chronic conditions and the association between vision impairment and poor health for those with chronic conditions. RESULTS: People aged ≥65 years with vision impairment reported greater prevalence of chronic conditions compared to people without vision impairment. After controlling for covariates (age, sex, education, race, smoking, physical activity, and obesity), people with vision impairment were more likely than those without to report chronic conditions (hypertension: OR [odds ratio] 1.43; heart disease: OR 1.68; high cholesterol: OR 1.26; stroke: OR 1.99; arthritis; OR 1.71; asthma: OR 1.56; chronic obstructive pulmonary disease: OR 1.65; cancer: OR 1.23; weak/failing kidneys: OR 2.29; diabetes: OR 1.56; hepatitis: OR 1.30; depression: OR 1.47; hearing impairment: OR 1.91) (all P < .05). Among older people with chronic conditions, those with vision impairment and chronic conditions compared to people without vision impairment and chronic conditions were 1.66-2.98 times more likely to have fair/poor health than those without vision impairment (all P < .05). CONCLUSION: Higher prevalence of chronic conditions is strongly associated with vision impairment among the older people and poor health is strongly associated with vision impairment and chronic conditions.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Methods and Screening Results.

PURPOSE: To describe methodology and screening results from the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study. DESIGN: Screening program results for a prospective randomized clinical trial. METHODS: Individuals were recruited who were African-American, Hispanic/Latino, or Asian over age 40 years; white individuals over age 65 years; and any ethnicity over age 40 years with a family history of glaucoma or diabetes. Primary care offices and Federally Qualified Health Centers were used for telemedicine (Visit 1). Two posterior fundus photographs and 1 anterior segment photograph were captured per eye in each participant, using a nonmydriatic, autofocus, hand-held fundus camera (Volk Optical, Mentor, Ohio, USA). Medical and ocular history, family history of glaucoma, visual acuity, and intraocular pressure measurements using the ICare rebound tonometer (ICare, Helsinki, Finland) were obtained. Images were read remotely by a trained retina reader and a glaucoma specialist. RESULTS: From April 1, 2015, to February 6, 2017, 906 individuals consented and attended Visit 1. Of these, 553 participants were female (61.0%) and 550 were African-American (60.7%), with a mean age of 58.7 years. A total of 532 (58.7%) participants had diabetes, and 616 (68%) had a history of hypertension. During Visit 1, 356 (39.3%) participants were graded with a normal image. Using image data from the worse eye, 333 (36.8%) were abnormal and 155 (17.1%) were unreadable. A total of 258 (28.5%) had a suspicious nerve, 62 (6.8%) had ocular hypertension, 102 (11.3%) had diabetic retinopathy, and 68 (7.5%) had other retinal abnormalities. CONCLUSION: An integrated telemedicine screening intervention in primary care offices and Federally Qualified Health Centers detected high rate of suspicious optic nerves, ocular hypertension, and retinal pathology.

Applying RE-AIM to evaluate two community-based programs designed to improve access to eye care for those at high-risk for glaucoma.

INTRODUCTION: Glaucoma is a leading cause of vision loss and blindness in the U.S. Risk factors include African American race, older age, family history of glaucoma, and diabetes. This paper describes the evaluation of a mobile eye health and a telemedicine program designed to improve access to eye care among people at high-risk for glaucoma. METHODS: The RE-AIM (reach, efficacy, adoption, implementation, and maintenance) evaluation framework was used to harmonize indicators. Both programs provided community-based eye health education and eye services related to glaucoma detection and care. Each program reported data on participants and community partners. An external evaluator conducted site visit interviews with program staff and community partners. Quantitative and qualitative data were integrated and analyzed using the RE-AIM dimensions. DISCUSSION: By targeting high-risk populations and providing comprehensive eye exams, both programs detected a large proportion of new glaucoma-related cases (17-19%) - a much larger proportion than that found in the general population (<2%). The educational intervention increased glaucoma knowledge; evidence that it led people to seek eye care was inconclusive. CONCLUSIONS: Evaluation findings from the mobile eye health program and the telemedicine program may provide useful information for wider implementation in public health clinics and in optometrist clinics located in retail outlets.

Association Between County-Level Characteristics and Eye Care Use by US Adults in 22 States After Accounting for Individual-Level Characteristics Using a Conceptual Framework.

IMPORTANCE: Individual-level characteristics are associated with eye care use. The influence of contextual factors on vision and eye health, as well as health behavior, is unknown. OBJECTIVE: To examine the association between county-level characteristics and eye care use after accounting for individual-level characteristics using a conceptual framework. DESIGN, SETTING, AND PARTICIPANTS: This investigation was a cross-sectional study of respondents 40 years and older participating in the Behavioral Risk Factor Surveillance System surveys between 2006 and 2010 from 22 states that used the Visual Impairment and Access to Eye Care module. Multilevel regressions were used to examine the association between county-level characteristics and eye care use after adjusting for individual-level characteristics (age, sex, race/ethnicity, educational attainment, annual household income, employment status, health care insurance coverage, eye care insurance coverage, personal established physician, poor vision or eye health, and diabetes status). Data analysis was performed from March 23, 2014, to June 7, 2016. MAIN OUTCOMES AND MEASURES: Eye care visit and receipt of a dilated eye examination in the past year. RESULTS: Among 117 295 respondents who resided in 828 counties, individual-level data were obtained from the Behavioral Risk Factor Surveillance System surveys. All county-level variables were aggregated at the county level from the Behavioral Risk Factor Surveillance System surveys except for a high geographic density of eye care professionals, which was obtained from the 2010 Area Health Resource File. After controlling for individual-level characteristics, the odds of reporting an eye care visit in the past year were significantly higher among people living in counties with high percentages of black individuals (adjusted odds ratio [aOR], 1.12; 95% CI, 1.01-1.24; P = .04) or low-income households (aOR, 1.12; 95% CI, 1.00-1.25; P = .045) or with a high density of eye care professionals (aOR, 1.18; 95% CI, 1.07-1.29; P < .001) than among those living in counties with the lowest tertile of each county-level characteristic. The odds of reporting receipt of a dilated eye examination in the past year were also higher among people living in counties with the highest percentages of black individuals (aOR, 1.20; 95% CI, 1.07-1.34; P = .002) or low-income households (aOR, 1.17; 95% CI, 1.04-1.32; P = .01). However, the odds of reported receipt of a dilated eye examination in the past year were lower in counties with the highest percentages of people with poor vision and eye health compared with counties with lower percentages (aOR, 0.85; 95% CI, 0.77-0.94; P = .002). CONCLUSIONS AND RELEVANCE: Contextual factors, measured at the county level, were associated with eye care use independent of individual-level characteristics. The findings suggest that, while individual characteristics influence health care use, it is also important to address contextual factors to improve eye care use and ultimately vision health.

Falls Among Persons Aged ≥65 Years With and Without Severe Vision Impairment - United States, 2014.

In 2014, an estimated 2.8 million persons aged ≥65 years in the United States reported severe vision impairment* defined as being blind or having severe difficulty seeing, even with eyeglasses. Good vision is important for maintaining balance as well as for identifying low-contrast hazards, estimating distances, and discerning spatial relationships. Conversely, having poor vision increases the risk for falls (1,2). Falls among older adults are common and can cause serious injuries, disabilities, and premature death (1,3). To date, no state-level investigations have examined the annual prevalence of falls among persons with and without severe vision impairment. CDC analyzed data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS) to estimate the state-specific annual prevalence of falls among persons aged ≥65 years with and without self-reported severe vision impairment. Overall, 46.7% of persons with, and 27.7% of older adults without, self-reported severe vision impairment reported having fallen during the previous year. The state-specific annual prevalence of falls among persons aged ≥65 years with severe vision impairment ranged from 30.8% (Hawaii) to 59.1% (California). In contrast, the prevalence of falls among persons aged ≥65 years without severe vision impairment ranged from 20.4% (Hawaii) to 32.4% (Alaska). Developing fall-prevention interventions intended for persons with severe vision impairment will help states manage the impact of vision impairment and falls on health care resources, and can inform state-specific fall prevention initiatives.

The Association of Health-Related Quality of Life with Severity of Visual Impairment among People Aged 40-64 Years: Findings from the 2006-2010 Behavioral Risk Factor Surveillance System.

PURPOSE: To examine the association of health-related quality of life (HRQoL) with severity of visual impairment among people aged 40-64 years. METHODS: We used cross-sectional data from the 2006-2010 Behavioral Risk Factor Surveillance System to examine six measures of HRQoL: self-reported health, physically unhealthy days, mentally unhealthy days, activity limitation days, life satisfaction, and disability. Visual impairment was categorized as no, a little, or moderate/severe. We examined the association between visual impairment and HRQoL using logistic regression accounting for the survey's complex design. RESULTS: Overall, 23.0% of the participants reported a little difficult seeing, while 16.8% reported moderate/severe difficulty seeing. People aged 40-64 years with moderate/severe visual impairment had more frequent (≥14) physically unhealthy days, mentally unhealthy days, and activity limitation days in the last 30 days, as well as greater life dissatisfaction, greater disability, and poorer health compared to people reporting no or a little visual impairment. After controlling for covariates (age, sex, marital status, race/ethnicity, education, income, state, year, health insurance, heart disease, stroke, heart attack, body mass index, leisure-time activity, smoking, and medical care costs), and compared to people with no visual impairment, those with moderate/severe visual impairment were more likely to have fair/poor health (odds ratio, OR, 2.01, 95% confidence interval, CI, 1.82-2.23), life dissatisfaction (OR 2.06, 95% CI 1.80-2.35), disability (OR 1.95, 95% CI 1.80-2.13), and frequent physically unhealthy days (OR 1.69, 95% CI 1.52-1.88), mentally unhealthy days (OR 1.84, 95% CI 1.66-2.05), and activity limitation days (OR 1.94, 95% CI 1.71-2.20; all p < 0.0001). CONCLUSION: Poor HRQoL was strongly associated with moderate/severe visual impairment among people aged 40-64 years.

The Philadelphia Glaucoma Detection and Treatment Project: Detection Rates and Initial Management.

PURPOSE: To evaluate the detection rates of glaucoma-related diagnoses and the initial treatments received in the Philadelphia Glaucoma Detection and Treatment Project, a community-based initiative aimed at improving the detection, treatment, and follow-up care of individuals at risk for glaucoma. DESIGN: Retrospective analysis. PARTICIPANTS: A total of 1649 individuals at risk for glaucoma who were examined and treated in 43 community centers located in underserved communities of Philadelphia. METHODS: Individuals were enrolled if they were African American aged ≥50 years, were any other adult aged ≥60 years, or had a family history of glaucoma. After attending an informational glaucoma workshop, participants underwent a targeted glaucoma examination including an ocular, medical, and family history; visual acuity testing, intraocular pressure (IOP) measurement, and corneal pachymetry; slit-lamp and optic nerve examination; automated visual field testing; and fundus color photography. If indicated, treatments included selective laser trabeculoplasty (SLT), laser peripheral iridotomy (LPI), or IOP-lowering medications. Follow-up examinations were scheduled at the community sites after 4 to 6 weeks or 4 to 6 months, depending on the clinical scenario. MAIN OUTCOME MEASURES: Detection rates of glaucoma-related diagnoses and types of treatments administered. RESULTS: Of the 1649 individuals enrolled, 645 (39.1%) received a glaucoma-related diagnosis; 20.0% (n = 330) were identified as open-angle glaucoma (OAG) suspects, 9.2% (n = 151) were identified as having narrow angles (or as a primary angle closure/suspect), and 10.0% (n = 164) were diagnosed with glaucoma, including 9.0% (n = 148) with OAG and 1.0% (n = 16) with angle-closure glaucoma. Overall, 39.0% (n = 64 of 164) of those diagnosed with glaucoma were unaware of their diagnosis. A total of 196 patients (11.9%) received glaucoma-related treatment, including 84 (5.1%) who underwent LPI, 13 (0.8%) who underwent SLT, and 103 (6.2%) who were prescribed IOP-lowering medication. CONCLUSIONS: Targeting individuals at risk for glaucoma in underserved communities in Philadelphia yielded a high detection rate (39.1%) of glaucoma-related diagnoses. Providing examinations and offering treatment, including first-line laser procedures, at community-based sites providing services to older adults are effective to improve access to eye care by underserved populations.

Improving Access to Eye Care among Persons at High-Risk of Glaucoma in Philadelphia--Design and Methodology: The Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: The Wills Eye Glaucoma Research Center initiated a 2-year demonstration project to develop and implement a community-based intervention to improve detection and management of glaucoma in Philadelphia. METHODS: The glaucoma detection examination consisted of: ocular, medical, and family history; visual acuity testing; corneal pachymetry; biomicroscopy of the anterior segment; intraocular pressure (IOP) measurement; gonioscopy; funduscopy; automated visual field testing; and fundus-color photography. Treatment included laser surgery and/or IOP-lowering medication. A cost analysis was conducted to understand resource requirements. Outcome measures included; prevalence of glaucoma-related pathology and other eye diseases among high-risk populations; the impact of educational workshops on level of knowledge about glaucoma (assessed by pre- and post-test evaluation); and patient satisfaction of the glaucoma detection examinations in the community (assessed by satisfaction survey). Treatment outcome measures were change in IOP at 4-6 weeks and 4-6 months following selective laser trabeculoplasty treatment, deepening of the anterior chamber angle following laser-peripheral iridotomy treatment, and rate of adherence to recommended follow-up examinations. Cost outcomes included total program costs, cost per case of glaucoma detected, and cost per case of ocular disease detected. RESULTS: This project enrolled 1649 participants (African Americans aged 50+ years, adults 60+ years and individuals with a family history of glaucoma). A total of 1074 individuals attended a glaucoma educational workshop and 1508 scheduled glaucoma detection examination appointments in the community setting. CONCLUSIONS: The Philadelphia Glaucoma Detection and Treatment Project aimed to improve access and use of eye care and to provide a model for a targeted community-based glaucoma program.