1. In a cluster-randomized trial of a community-based program adults living in public housing in New York City, vision screening and imaging followed by optometric exam were used to refer 66.1% of screened subjects to ophthalmology.

2. The cost of the intervention per case of newly detected eye disease was $274.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Disparities in access to eye care are profound and fall along racial, ethnic, and socioeconomic lines, resulting in higher rates of eye disease and poor vision in Black, Hispanic, and low-income communities. This study, Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (NYC-SIGHT), used a community-level approach to attempt to address these disparities by identifying patients with eye disease before they might otherwise present to care and connecting them with treatment. A total of 708 adults recruited from public housing in New York City underwent vision screening, intraocular pressure (IOP) measurement, and fundus photography. The 78.4% who failed screening were scheduled for examination by an optometrist; 86% of scheduled patients attended. A total of 468 people (66.1% of those screened) were referred to ophthalmology, including 26.6% with suspected glaucoma. The cost was calculated at $181 per person screened, or $274 per detected case. The program modeled here was relatively straightforward, but actively recruiting high-risk patients, in this case residents of public housing, effectively identified patients in need of eye care, with only 30% reporting having an eye doctor at baseline and a striking majority failing vision or IOP screening. Conducting screening and follow-up optometric exam on-site in housing developments also seems to have led to high retention. The long-term outcomes of this program in New York City and other locations, including the effects of complimentary eyeglasses provision and patient navigators on retention and eye health outcomes, will help inform design of similar community-based programs.

Click to read the study in AJO

Relevant Reading: Improving access to eye care: A systematic review of the literature

In-Depth [randomized controlled trial]: This study is a prospective, cluster-randomized trial planned for 5 years; the baseline results are reported. Housing developments were randomized to intervention or usual care in a 2:1 ratio. Subjects aged 40 or older living in each development were recruited. The mean age of screened patients was 68.6 years; 65% were female, 52% African American, 42% Hispanic, and 95% had health insurance. Screenings and optometry exams all took place in on-site community rooms or senior centers. Screening failure was defined as corrected visual acuity of 20/40 or worse, IOP 23 mmHg or higher, or abnormal or unreadable fundus photo. Subjects with an abnormal fundus photo or IOP of 30 mmHg or greater at screening were immediately referred to ophthalmology rather than undergoing optometry exam. Fundus photographs were undilated and read by ophthalmologists via telemedicine; 24.7% were unreadable. Subjects in both groups underwent the same screening program, but the intervention group received free eyeglasses at optometry exam and assistance with ophthalmology appointment scheduling from patient navigators. Cost was calculated using staff time costs based on activity-based costing, equipment, supplies, and travel costs. In total, staff spent a mean of 40 minutes with each subject.

Image: PD

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