A Population Health Approach to Glaucoma Screening

Educational Objectives

The goal of this program is to improve glaucoma screening using population health approach. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize that population prevalence influences false discovery rate in glaucoma screening.
2. Identify high-risk patients for glaucoma screening.
3. Engage high-risk populations to screen, diagnose, and manage glaucoma.

Summary

Glaucoma screening: population-specific disease prevalence affects the false discovery rate (FDR) in screening; the US Preventive Services Task Force (USPSTF) does not support screening for glaucoma, as screening everyone leads to an excessive number of false positives

Epidemiology: the prevalence of glaucoma in the United States is projected to increase from 2.7 million to 7.3 million by 2050; ≈50% of patients with glaucoma remain undiagnosed

Nonsupport for screening: as the USPSTF does not support glaucoma screening, universities cannot partner with federally qualified health centers (FQHCs) that serve underserved communities without attracting Anti-Kickback statutes; endorsement of screening by USPSTF, especially in specific populations, would enable partnerships between academic centers and FQHCs to care for underserved people; although treatment of glaucoma is important, high-risk population for screening has not been identified

Population prevalence and FDR: in the United Kingdom (prevalence of glaucoma >50 yr of age, 0.9%), Hamid et al (2022) found that screening with intraocular pressure measurement, central corneal thickness, visual field, and eye examination has a sensitivity of 73% and a specificity of 96%, and the positive predictive value (PPV) is 14% and FDR is 86%; PPV and FDR are influenced by prevalence; in the United States, the prevalence (>18 yr of age) is 1.4%, and the PPV is 21% and the FDR is 79%; if the prevalence in the top decile of patients after evaluation of polygenic risk score (PRS) for glaucoma is 4%, the PPV doubles (43%), with an FDR of 57%; prevalence of glaucoma is higher in populations with poor social determinants of health (SDH); in populations with poor SDH and a glaucoma prevalence of 12%, the PPV is 71% and the FDR is 29%; population prevalence of glaucoma hugely impacts FDR

Genetic risk for glaucoma: glaucoma is a complex inherited disease; patients with an elevated genetic risk for glaucoma may be screened; glaucoma was identified in 40% of individuals (50-60 yr of age) with top 10% PRS in a genome-wide association study; PRS for glaucoma should be derived from a cohort of similar ancestry (eg, for a patient of African descent, PRS should be compared with a cohort of African ancestry); Verma et al (2024) showed that risk scoring performed better when PRS was matched to the appropriate ancestry

Disparities in glaucoma: glaucoma (3-fold), unilateral blindness (5-fold), and bilateral blindness (2-fold) are more likely in people who identify as Black compared with people who identify as White; after adjusting for race, education, and comorbidities, people with household net worth of >$100,000 had a 12% reduced odds of developing glaucoma compared with people with household net worth of <$25,000; factors impacting the risk for glaucoma include household income, access to resources, and neighborhood; income of White persons is more than that of Hispanic or Black persons, leading to racial and ethnic differences in utilization of eye care services and identification of eye diseases

Identifying populations at high risk: insurance coverage for PRS may be available in the future; FQHCs — 80% of people receiving care through FQHCs are covered by Medicaid and 20% are uninsured; Lee et al (2018) found that individuals with Medicaid were 60% less likely to receive an appointment ≤2 mo compared with those with other insurance types; reimbursement is less with Medicaid vs Medicare and private insurance, impacting access to care

Federally qualified health centers: the flat fee payment structure of FQHCs is more favorable compared with Medicaid (but not Medicare or private insurance); FQHCs are approved only in places of medical necessity; in 2021, 44% of people served by FQHCs were insured by Medicaid, 22% had no insurance, and 63% were below the poverty line; by contrast, 19% of the US population were insured by Medicaid, 8% had no insurance, and 12% were below the poverty line; only 27% of FQHCs provide eye care (mostly limited to screening for diabetic retinopathy); 50% of optometrists in FQHCs work in Massachusetts, New York, and California; despite having a robust infrastructure including community health workers, social workers, transportation, and interpreter services, only 2.3% of patients visiting FQHCs receive eye care

The Climate and Economic Justice Screening Tool: identifies areas of deprivation and need; measures neighborhood-level deprivation based on the census tract under different categories, eg, climate change, energy, health, housing, legacy pollution, transportation, water and wastewater, and workforce development (all may impact one’s susceptibility to glaucoma); exposure to particulate matter 2.5 increases the prevalence of glaucoma

Area Deprivation Index (ADI): a measure of socioeconomic disadvantage in a neighborhood combining categories including income, employment, housing quality, and education; the higher the percentile of national ADI, the worse the deprivation in the neighborhood

Neighborhood characteristics of FQHCs: FQHCs serve neighborhoods in the 66th percentile of ADI, overall; 31% of people are covered by Medicaid

Targeting high-risk populations: the network of FQHCs can be leveraged to target people at high risk for glaucoma and underutilization of eye care; an affordable, easily accessible, and reimbursable PRS for glaucoma can enable further risk stratification within the FQHC setting

Engaging high-risk populations: electronic communication may not be effective in high-risk populations with low socioeconomic status; Screening to Prevent Glaucoma program — funded by the Centers for Disease Control and Prevention; Zhao et al (2017) screened individuals around Baltimore and identified glaucoma in 6.7% of individuals screened; Philadelphia Glaucoma Detection and Treatment Project — partnered with community organizations who served African American, Latino, and low-income communities; a project that conducted direct screenings in low-income senior housing buildings and community clinics diagnosed glaucoma in 40% of screened individuals (ophthalmology referral, 66%), implying underutilization of eye care; glaucoma screening in Alabama — a screening program was conducted in Alabama through FQHCs; glaucoma was found in 25% of the screened population, which consisted of individuals with high levels of poverty, underutilization, and a high percentage of African American persons

Trust in providers: Muir et al (2012) found that decreased trust is a barrier to eye care among minority populations; Black patients with glaucoma-related blindness had less trust in their providers compared with White patients; FQHCs are integrated in a community and strive to employ community health workers and providers trusted by the people, which helps overcome barriers to care

Community-engaged research: Agency for Healthcare Research and Quality states that community-engaged research creates greater participation rates, increased external validity, decreased loss to follow-up, and increased individual and community capacity

University of Michigan: a Community Advisory Board (CAB) was established to identify ways to sustain the program; key stakeholders were interviewed to understand and overcome barriers; all participants were invited to be part of the CAB; the program should be housed in the community clinic, and community outreach should include flyers and posters in public places; community outreach was successful, and patients felt part of the program, which is modeled on the Veterans Affairs ocular telehealth programs; the program assists patients in selecting eyeglasses; glaucoma was identified in 5% of screened individuals; most patients had not visited an eye care provider in 2 yr; the program identified high rates of disease (visual impairment, 11.5% [national average (NA), 5.3%]; cataract, 22% [NA, 17%]; glaucoma, 22.5% [NA, 6%-13%]; diabetic retinopathy, 4.7% [NA, 3.4%]); vision-related quality of life improved; Healthcare Effectiveness Data and Information Set improved from 18% to 27%

Policy changes needed to expand screening: reimbursement of Medicaid is less than Medicare; optometrists and ophthalmologists are not eligible for National Health Service Corps Loan Repayment Program; flat fee per patient for FQHCs does not account for ancillary testing costs; telemedicine is reimbursable only for diabetic retinopathy

Readings

Craig JE, Han X, Qassim A, et al. Multitrait analysis of glaucoma identifies new risk loci and enables polygenic prediction of disease susceptibility and progression. Nat Genet. 2020;52(2):160-166. doi:10.1038/s41588-019-0556-y; Hamid S, Desai P, Hysi P, et al. Population screening for glaucoma in UK: current recommendations and future directions. Eye (Lond). 2022;36(3):504-509. doi:10.1038/s41433-021-01687-8; Lee YH, Chen AX, Varadaraj V, et al. Comparison of Access to Eye Care Appointments Between Patients With Medicaid and Those With Private Health Care Insurance. JAMA Ophthalmol. 2018;136(6):622-629. doi:10.1001/jamaophthalmol.2018.0813; Muir KW, Alder B, Thomas A, et al. Trust in the provider and glaucoma-related blindness. ISRN Ophthalmol. 2012;2012:393917. doi:10.5402/2012/393917; Newman-Casey PA, Hark LA, Rhodes LA. It is time to rethink adult glaucoma screening recommendations. J Glaucoma. 2023;32(2):69-71. doi:10.1097/IJG.0000000000002146; Newman-Casey PA, Talwar N, Nan B, et al. The relationship between components of metabolic syndrome and open-angle glaucoma. Ophthalmology. 2011;118(7):1318-1326. doi:10.1016/j.ophtha.2010.11.022; Verma SS, Gudiseva HV, Chavali VRM, et al. A multi-cohort genome-wide association study in African ancestry individuals reveals risk loci for primary open-angle glaucoma. Cell. 2024;187(2):464-480.e10. doi:10.1016/j.cell.2023.12.006; Waisbourd M, Pruzan NL, Johnson D, et al. The Philadelphia Glaucoma Detection and Treatment Project: Detection Rates and Initial Management. Ophthalmology. 2016;123(8):1667-1674. doi:10.1016/j.ophtha.2016.04.031; Woodward MA, Hicks PM, Harris-Nwanyanwu K, et al. Eye Care in Federally Qualified Health Centers. Ophthalmology. 2024;131(10):1225-1233. doi:10.1016/j.ophtha.2024.04.019; Zhao D, Guallar E, Gajwani P, et al. Optimizing Glaucoma Screening in High-Risk Population: Design and 1-Year Findings of the Screening to Prevent (SToP) Glaucoma Study. Am J Ophthalmol. 2017;180:18-28. doi:10.1016/j.ajo.2017.05.017.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Newman-Casey was recorded at the 23rd Annual Downeast Ophthalmology Symposium, held September 27-29, 2024, in Bar Harbor, ME, and presented by The Maine Society of Eye Physicians and Surgeons, Manchester, ME. For more information about upcoming CME activities from this presenter, please visit https://maineeyemds.com. Audio Digest thanks Dr. Newman-Casey and The Maine Society of Eye Physicians and Surgeons, Manchester, ME, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

OP630101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.