Exploration of Factors Influencing Participation of Primary Eye Care Clinicians in Low Vision Services.

Perspectives on low vision service in Canada: A pilot study

Purpose To characterize practice patterns of low vision services among Optometrists in Ghana. Methods The nationwide cross-sectional survey identified entities through the Ghana Optometrists Association (GOA) registry and utilized a semi-structured questionnaire to consolidate survey information that comprises practitioners’ demographics, available services, diagnostic equipment, barriers to service provision and utilization, and interventions. Results 300 Optometrists were identified, with 213 surveyed (71% response rate). About fifty percent (52.6%) were in private practice, and more than two-thirds (77%) did not provide low vision services. Most (≥70%) reported lack of assistive devices, and basic eye care examination kits as the main barriers to low vision service provision. Similarly, practitioners reported unawareness of the presence of low vision centres (76.1%), and high cost of low vision aids (75.1%) as the prime perceived barriers for patients to utilize low vision services. Continuous professional development and public education (89–90%) were suggested as interventions to improve the uptake of low vision services. After statistical adjustment, private facility type (Adjusted odds ratio [AOR] = 0.35, p = 0.010) and lack of basic eye examination kits (AOR = 0.32, p = 0.002) were significantly associated with reduced odds of low vision service provision. Conversely, ≥15 years of work experience (AOR = 6.37, p = 0.011) was significantly associated with increased odds of low vision service provision. Conclusions Overall, the results indicate inadequate low vision coverage and service delivery. Government policies must be directed towards equipping practitioners with equipment and subsidize patient cost of treatment to optimize low vision care.

Background: Utilisation of low vision services remains low in Australia. This study investigates low vision service provision by optometrists in Victoria and assesses the optometric human resource potential.Methods: An eight‐item questionnaire was sent to 1,050 optometrists in Victoria in December 2006. It investigated key characteristics of the optometrists and their practices, the extent of their low vision training and service provision and the influence of Medicare item 10942 on low vision service provision.Results: Although only 97 replies were received they represented a significant proportion of optometrists who had undertaken postgraduate training in low vision. Almost 86 per cent of respondents worked in private practice settings. Although 87.6 per cent and 30.9 per cent had undergraduate and postgraduate low vision training, respectively, only 63.9 per cent of all respondents reported that they provided low vision services. The majority who replied to the impact of Medicare item 10942 question indicated that its introduction had not changed their low vision provision. Those who did not provide low vision services reported referrals to other low vision services as their main reason for not doing so.Conclusions: The majority of respondents represent a potential source of low vision service providers. Further work needs to explore their possible involvement in low vision care.

2005 APA Gold Award: Improving Treatment Engagement and Integrated Care of Veterans

Background: Only a small percentage of people with low vision in Australia receive comprehensive low vision rehabilitation services. In an attempt to examine reasons for this under-utilisation of low vision services, the referral criteria used by Australian ophthalmologists and optometrists were investigated. This paper reports the results for optometric referrals; the results for the ophthalmological referrals have been reported elsewhere. Method: A survey was sent to a random sample of 800 optometrists in Australia. Information requested included the vision loss criteria used for referral of patients to services for visually impaired people, the frequency of prescription of low vision devices (LVDs), frequency of referrals and perceptions of the availability and quality of low vision services. Results: The response rate was 36 per cent. Optometrists reported that only 4.7 per cent of their patients have low vision. Optometrists frequently prescribe LVDs but the majority infrequently refer patients to low vision or rehabilitation services. The rate of referral is influenced by their referral criterion and the perceived availability and quality of low vision services. Conclusions: Optometrists do not manage many patients with low vision because the patients are usually referred to ophthalmologists for management of the underlying eye disease. However, many optometrists could adopt a lesser degree of vision loss as their referral criteria for low vision services and encourage ophthalmologists to do the same. With improved communication between the eye care practitioners and low vision services, patients will be referred to low vision services earlier, before vision loss severely affects their daily lives.

People in need of low vision rehabilitation services often experience delays in referral to services. This study investigates referral criteria of Australian ophthalmologists, the frequency of referral of their patients with low vision and their perceptions of low vision services. A survey was sent to a representative, random sample of 200 ophthalmologists. They were asked about criteria used for the referral of their patients with low vision. The survey included questions on the frequency with which they prescribed low vision devices (LVD) and referral of their patients to low vision and rehabilitation services and peer support groups. Perceptions of the quality and availability of low vision services were also investigated. The response rate was 82%. Approximately 11% of ophthalmologists' patients have low vision. It is uncommon for ophthalmologists to prescribe LVD but 67% refer most of their patients with low vision. It is less common for them to refer to rehabilitation services (29%) or peer support services (18%). The perceived local availability of services influences the rate of referral. Ophthalmologists who used the criteria of moderate low vision (< 6/21 to < 6/60) are more likely to refer more of their patients than those who use the criteria of severe low vision. Australian ophthalmologists refer most of their visually impaired patients to low vision services, but infrequently to rehabilitation services or peer support groups. Differences in perceived need for low vision services indicated by the criteria used for referral, and the perceived availability, influence the rate at which ophthalmologists refer their patients for services. Ophthalmologists are encouraged to refer patients with permanent visual loss to low vision services earlier.

BackgroundUK low vision services are historically fragmented. Lack of standardised commissioning or clinical framework means many people with sight loss cannot access fit for purpose services. The Adult Low Vision...

Physicians refer patients to MTM pharmacists at Fairview

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Visual impairment (blindness or low vision) is a leading cause of disability among older adults and is most often due to age-related macular degeneration (AMD). The prevalence of AMD is rapidly increasing with the aging of the population; from 1991 to 1997, it increased from 5.0% to 27.1% in a cohort of Medicare beneficiaries (Crews, 1991; Lee, Feldman, Ostermann, Brown, & Sloan, 2003). It is predicted that 2.95 million people will have AMD by 2020 (Eye Diseases Prevalence Research Group, 2004). Compared to older people with typical vision, those with AMD report greater difficulty with a variety of daily activities (Williams, Brody, Thomas, Kaplan, & Brown, 1998). For example, in a community sample of 872 older people, those with AMD were 9.7 times more likely to have impairments in instrumental activities of daily living (such as taking medication and shopping) than were people with typical vision (Rovner & Ganguli, 1998). Unfortunately, there is no cure for AMD, nor can lost vision be restored. Although there are interventions to slow the progression of the condition, treatment is primarily rehabilitative. Services for people with low vision include low vision rehabilitation, occupational therapy, social support programs, and orientation and mobility training. Assistive devices include magnifiers, large-print materials (such as books, clocks, and calculators), audio materials (such as books and magazines), electronic reading devices, and speech-output systems. Despite the availability of these rehabilitative services and devices, they are underutilized. A series of focus groups that were conducted by the National Eye Institute (NEI) indicated that many older persons with low vision have little or no awareness of these services, and, as a consequence, few take advantage of them (National Eye Institute, 2001). Similar findings were reported in the Lighthouse National Survey on Vision Loss (Lighthouse International, 1995). Among adults with low vision, only 30% were using optical devices, 21% were using large-print reading materials, and 6% received rehabilitation. The most common reason for the lack of utilization of low vision devices and services was the participants’ unawareness of them. Ophthalmologists may not be informing and educating their patients about these resources. Some studies have reported that ophthalmologists refer only 28%–35% of appropriate patients to low vision rehabilitation services (Greenblat, 1988). Leinhaas and Massof (2001) found that only 15% of ophthalmologists and 21% of optometrists “always or often” prescribed low vision devices, and only 44% of ophthalmologists and 27% of optometrists “always or often” referred patients for low vision services. The goal of the current study was to obtain more detailed information on the use of low vision services and devices by older adults with AMD and to determine whether knowledge and use of such services are related to the severity of vision loss.

A Note on the Partnership Between Psychiatry and Primary Care

Purpose: Demographic transformations within the UK population combine to contribute to a substantial increase in demand for low vision (LV) services, creating a pressing need to reconsider the appropriate methods for service provision. In this study, we evaluate the feasibility of using telephone triage to assess the need for, and timing of, LV follow-up appointments. Methods: A cohort of new patients attending the LV Clinic at Manchester Royal Eye Hospital (MREH) was recruited, independent of vision or visual impairment (VI) registration status. Four weeks after this initial clinic assessment, each patient was telephoned and a structured review was conducted. All patients were subsequently followed up at 3 months in the LV clinic. Results: A total of 52 patients were recruited, with the corrected ‘better-eye’ visual acuity (VA) ranging from 0.18 logMAR (6/9.5 + 1) to 1.36 logMAR (6/152 + 2) with a mean of 0.66 logMAR (6/30 + 2). In total, 36 patients completed all aspects of the study. At telephone review, 70 (93%) of the low vision aids (LVAs) loaned were reported to have been used on at least one occasion. Ten patients (22%) were deemed to not require follow-up, 15 (33%) were judged to benefit from an earlier (1 month) review, and 16 (35%) were judged to require 3-month follow-up. Reminding patients at telephone review provided a significant increase in adherence with advice to bring any loaned devices to clinic review ( p &lt; 0.01). Face-to-face clinic review outcomes at 3 months permitted some insight into the effectiveness of telephone triage. Conclusions: Implementing telephone review is feasible for triaging LV follow-up requirements. A number of patient issues can be dealt with immediately and effectively at telephone review, potentially negating the need for a face-to-face clinic review for some patients while identifying a more pressing need for earlier review in others, factors that might improve cost-effectiveness of service provision if subjected to formal health economic evaluation.

This study evaluated the rate at which patients with visual impairment primarily from corneal disease were referred for low vision (LV) services and assessed the visual outcomes from completed evaluations. This 1-year retrospective, cross-sectional study included patients with corneal disease limiting best-corrected visual acuity (BCVA) to ≤ 20/40. Outcome measures included the change in BCVA achieved after distance refraction by a LV specialist. Incremental costs per quality-adjusted life years (QALY) gained were calculated upon the better-seeing eye, by using a willingness-to-pay threshold of USD 50,000/QALY. Of 3230 patients, 143 (4.4%) had visual impairment from corneal disease. The median age of those patients was 80 years (IQR: 66-88 years) and 64.3% were male. Just over half were referred for LV evaluations (53.2%), and most completed appointments (96.1%). Patients more likely to be referred had better vision in their worse-seeing eye (0.961 logMAR vs. 1.451 logMAR, P = 0.002) and were more frequently diagnosed with corneal dystrophies, degenerations, or ectatic disease (51.3% vs. 26.9%, P = 0.003) compared with other corneal conditions, but they were less likely to have immunologic conditions (2.6% vs. 13.4%, P = 0.016). In total, two-thirds of patients achieved improved BCVA for their better-seeing eye, with 32% gaining ≥ 2 lines. This translated into an average gain of 0.04 QALYs/patient at a cost of USD 3128/QALY. The estimated net monetary benefit was USD 1923/LV evaluation completed. Referring patients with corneal disease to LV services resulted in significant improvements in visual function at a reasonable cost.

The aim of this thesis was to identify factors influencing the referral pathways to low vision services (LVS) in high-income countries. In the five studies described in this thesis, we employed different methods and perspectives to gain more insight into barriers and facilitators in the LVS referral pathways in two high-income countries, namely the Netherlands and Germany, at the individual, interpersonal, organizational, community, and public policy level. In the first study, both the perspectives of people with visual impairment and eye care professionals in the Netherlands were examined through semi-structured interviews regarding barriers and facilitators in LVS referral procedures and service delivery. The second study was based on Dutch healthcare claims data. It investigated the national trends between 2015 and 2018 in LVS utilization and identified socio-demographic, clinical, contextual characteristics and general healthcare utilization of patients associated with the downward trend in the uptake of LVS in the Netherlands. The third study examined predictors of receiving LVS The aim of the fourth study was to get more insight into the role of having other conditions in addition to the eye disease in LVS access. Both, the third and the fourth study were based on Dutch healthcare claims data as well. The fifth study investigated LVS in terms of low vision aids (LVAs) provision, and trends in user characteristics based on population-based healthcare claims data of the city of Cologne, North Rhine-Westphalia, Germany. The results of this thesis showed that there are various facilitators and barriers on individual, interpersonal, organizational, community and public-policy level that influence the referral pathways to LVS in high-income countries. Implications for policy and clinical practice include focus on patient groups, such as those who lack self-advocacy and who have a low socio-economic status, adequate and timely LVS information provision by eye care professionals, and possible explanations for fewer or later LVS needs in patients with visual impairment. Future research should, among others, focus on investigating the role of low vision optometrists as referrers towards multidisciplinary LVS provision, evaluating the feasibility and effectiveness of (digital) clinical decision support systems or communication aids for patients, and in general, LVS referral and provision by comparing more (high income) countries to find out best practices.

The aim of this study was to determine whether the new, primary care based, Welsh Low Vision Service (WLVS) improved access to low vision services in Wales and was effective. The impact of the WLVS was determined by measuring the number of low vision appointments; travel time to the nearest service provider; and waiting times for low vision services for 1 year before, and for 1 year after, its establishment. Change in self-report visual function (using the 7 item NEI-VFQ), near visual acuity, patient satisfaction and use of low vision aids were used to determine the effectiveness of the service. Following instigation of the WLVS, the number of low vision assessments increased by 51.7%, the waiting time decreased from more than 6 months to less than 2 months for the majority of people, and journey time to the nearest service provider reduced for 80% of people. Visual disability scores improved significantly (p < 0.001) by 0.79 logits and 97.42% patients found the service helpful. The extension of low vision rehabilitation services into primary care identified a considerable unmet burden of need as evidenced by the substantial increase in the number of low vision assessments provided in Wales. The new service is effective and exhibits improved access.