Predictors of Clinic Attendance After Community-Based Vision Screening

Abstract

Purpose: The purpose of this study was to analyze appointment attendance rates and patient characteristics associated with follow-up adherence after referral from a community vision screening event.

Methods: A retrospective chart review of patients who attended a 2021 or 2022 community vision screening event and were referred to the university clinic for further care. Appointments were offered without charge and scheduled at the event. Associations between patients’ clinical and demographic characteristics and appointment attendance were assessed by binary logistical regression.

Results: A total of 935 patients attended the annual community vision screening events held in 2021 and 2022. Of these patients, 117 (13%) were referred to the clinic for follow-up, of whom 56 (48%) attended their scheduled follow-up appointment. The most common reasons for clinic referral included cataract (12, 10%), diabetic retinopathy (11, 9%), glaucoma (9, 8%), and challenging refractive error (9, 8%). Health insurance and male gender were predictors of follow-up (odds ratio [OR] = 3.08, 95% confidence interval [CI] = 1.19–7.99, P = 0.021 and OR = 2.72, 95% CI = 1.10–6.61, P = 0.035, respectively).

Conclusions: Half of the referred patients followed up after vision screening. Providing appointment scheduling at the point of care and offering follow-up care at no cost may help to promote clinic follow-up, but further assessment of barriers to regular eye care is warranted. Health insurance most strongly predicted successful clinic attendance.

Translational Relevance: This study emphasizes the enduring impact of health insurance status as a barrier to accessing comprehensive vision care.

Introduction

Underserved populations face barriers to regular eye care and are burdened by avoidable visual impairment.¹ In order to enhance eye care for underserved communities, it is important to provide access to both initial eye examinations and follow-up appointments to ensure continuity of care.² Community outreach events have emerged as a valuable approach in facilitating vision screenings and addressing the healthcare needs of disadvantaged populations.³ In a recent survey, three-quarters of patients attending a free community vision screening event reported at least one barrier to regular eye care, most commonly medical costs and insurance.⁴ 

The University of Pittsburgh Medical Center (UPMC) Vision Institute organizes an annual community event that provides free vision screening, manifest refraction, and spectacles at no cost. Those with suspicion for pathology beyond refractive error are offered follow-up appointments without charge and scheduled on-site. The goal of this study is to analyze the attendance rates for follow-up appointments and to identify the patient characteristics associated with follow-up. 

Methods

This retrospective study received approval from the University of Pittsburgh Institutional Review Board and adhered to the principles of the Declaration of Helsinki. 

Mission of Mercy Vision Screening Event

Since 2021, the Department of Ophthalmology at the University of Pittsburgh has collaborated with the Mission of Mercy (MoM) to sponsor a 2-day vision screening event in downtown Pittsburgh.⁴ This event provides free vision services to underserved patients, including patient education, vision screening, and referrals for treatment to promote vision health. Vision screening for all patients included measurement of visual acuity, manifest refraction, and optical fitting. For a smaller subset of patients with suspected ocular pathology, on-site further examination included dilated fundoscopic examinations and optical coherence tomography imaging. Patients who required prescription eyeglasses received them free of charge by mail to their home or at a scheduled pick-up time at our hospital. Patients with ocular pathology requiring follow-up care and those with a known history of eye disease received a scheduled appointment at the university eye clinic, where additional care would be provided at no cost. Follow-up appointments were arranged on-site at the time of screening, during which patients were registered into our electronic health record and scheduled for clinic visits. Patients received personalized appointment cards and were informed that follow-up care would be provided at no cost. 

Data Collection and Statistical Analysis

A retrospective chart review was conducted for patients who attended an MoM vision screening event on October 22 and 23, 2021, or August 5 and 6, 2022. Demographic information, clinical data, and successful clinic attendance were assessed for patients who were recommended to follow-up at our university-based clinic. 

All patients ages 18 years and older were included in this study, and there were no exclusion criteria. Demographic and clinical data were extracted from electronic health records. The demographic variables collected included age, gender, race, ethnicity, language, employment, and insurance status. Patient-specific ZIP code data were collected and used to calculate travel distance to the university eye clinic using the shortest driving route on Google Maps. Clinical data included best-corrected visual acuity (BCVA), reason for referral, clinic diagnosis, and treatment. Successful follow-up was defined as an attended scheduled follow-up appointment at the university eye clinic within 3 months of the vision screening event, or at a later date if indicated during scheduling by the referring provider. 

Data were entered into an electronic spreadsheet, and statistical analysis was performed using IBM SPSS statistical software, version 28 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to summarize continuous variables as mean ± standard deviation, and categorical variables were presented as percentages. Binary logistic regression analysis was conducted to identify predictors of follow-up. Odds ratios (ORs) were calculated, and a P value of less than 0.05 was considered statistically significant. 

Results

A total of 935 patients were seen at the 2021 and 2022 vision screening events, of whom 117 (13%) had a follow-up appointment scheduled at UPMC Vision Institute for suspected ocular pathology. Of 117 referred patients, 56 (48%) attended their scheduled follow-up appointment. 

Patient Characteristics

Table 1 provides descriptive statistics for all patients scheduled for a follow-up appointment. The average age was 55 ± 16 years, slightly more were women (65, 56%), and most patients identified as either Black (48, 41%) or White (47, 40%). One-third of the patients were employed (37, 32%), whereas one-fifth of the patients were unemployed (24, 21%). Employment information was not available for one-third of the patients (41, 35%). Forty-nine patients were uninsured (42%). Of insured patients, most had Medicare (25, 21%) or Medicaid (22, 18%). The majority of patients were English speakers (95, 81%) and nine (8%) spoke Spanish. The mean logMAR BCVA was 0.35 ± 0.61 (Snellen equivalent 20/43) for the right eye and 0.32 ± 0.51 (Snellen equivalent 20/42) for the left eye. 

Table 1.

 

Characteristics of 117 Patients Scheduled for Follow-Up From the 2021 or 2022 Mission of Mercy Vision Screening Event to UPMC Vision Institute

 

Reasons for Referral

Patients were most commonly referred for cataract (12, 10%), diabetic retinopathy (11, 9%), glaucoma or glaucoma suspect (9, 8%), and challenging refractive error (9, 8%; Table 2). Follow-up rates were highest for glaucoma (6/9, 67%) and refractive error (5/9, 56%) but lower for diabetic retinopathy (4/11, 36%) and cataract (3/12, 25%). Six patients were referred for more urgent retinal pathologies, including retinal detachment, retinal vein occlusion, neovascular age-related macular degeneration, and macular edema. All patients who were urgently referred attended the scheduled follow-up appointments. 

Table 2.

 

Reasons for Referral and Attendance Rates (n = 117)

 

Clinic Diagnosis and Treatment

Clinic diagnoses and treatments divided by subspecialty clinic are presented in Table 3. Of 56 patients who attended their scheduled follow-up appointments, 9 (16%) required surgery or an in-office procedure. Surgical treatments were provided for retinal detachment, cataract, ptosis, and strabismus. Additionally, three patients required intravitreal injections and one patient required panretinal photocoagulation. Three patients were diagnosed with primary open-angle glaucoma, all of whom were started on treatment. Of four patients with corneal pathologies, one patient had a corneal foreign body removed at the vision screening event and was followed up in our department's comprehensive service. Three patients were followed by the neuro-ophthalmology service for optic neuropathy. Clinic diagnoses for which observation was recommended included lamellar hole, solar retinopathy, choroidal nevus, narrow angles, and ocular hypertension. 

Table 3.

 

Clinic Diagnosis and Treatment for all Patients who Followed Up (n = 56)

 

Predictors of Follow-Up

In a binary logistic regression, we found that health insurance and male gender were predictive of follow-up (OR = 3.08, 95% confidence interval [CI] = 1.19–7.99, P = 0.021 and OR = 2.72, 95% CI = 1.10–6.61, P = 0.035, respectively; Table 4). In contrast, age, race, spoken language, and employment status were not significant predictors of follow-up. Similarly, successful follow-up was not associated with a presenting visual acuity of less than a logMAR BCVA of 0.3 (Snellen equivalent of 20/40, OR = 0.75, 95% CI = 0.25–2.24, P = 0.603). In analyzing the travel distance from the patient's home to the eye clinic, no association was observed between successful follow-up and residence within 10 miles of the clinic (OR = 1.38, 95% CI = 0.66–2.86, P = 0.389). 

Table 4.

 

Binary Logistic Regression to Assess Predictors of Follow-Up

 

Discussion

During 2 annual vision screening visits, we evaluated 935 patients, of whom 117 were referred to our academic department for further care. Those who were referred were scheduled on-site and offered a follow-up visit at no cost. Of the 117 referred to clinic, 56 (48%) attended their scheduled visit. Health insurance and male gender were associated with greater odds of follow-up. 

Our follow-up rate of 48% is consistent with the wide range of clinic follow-up rates in the existing literature from free ophthalmology screening programs.⁵ An analysis from a vision screening program similarly revealed that half of the patients referred did not attend their follow-up visit.⁶ Another study revealed that 19% of patients successfully attended follow-up at a local county hospital subsequent to attending a student-managed free eye clinic.⁷ Interestingly, we found higher follow-through rates from our department's collaboration with a university-affiliated free clinic, from which 72% of patients referred successfully presented to the eye clinic for further care.⁸ Barriers to follow-up may be more pervasive in larger community-based events. 

The most common reasons for clinic referrals in our study were cataract, diabetic retinopathy, glaucoma, and challenging refraction. Follow-up rates for refractive error and glaucoma surpassed those of cataract and diabetic retinopathy. These diseases have been similarly identified as the most common eye-related issues among patients who sought follow-up care after participating in a vision screening event.⁵ Uncorrected refractive error is a leading cause of correctable visual impairment and has been previously identified as the most common problem among patients who followed-up after a vision screening event.^5,9 Encouragingly, our study also showed higher follow-up rates among patients referred due to challenging refractions that necessitated further clinic-based evaluation. 

Regarding glaucoma, follow-up in our study sample was high when compared to a previous glaucoma specific community outreach program.¹⁰ In another vison screening program for glaucoma, vision loss, namely poor presenting vision and abnormal macular findings on fundus photography were associated with increased clinic follow-up.¹¹ Appointment adherence is especially important for patients with glaucoma due to the asymptomatic nature of the disease which often reduces disease awareness and prevents patients from seeking early diagnosis and treatment. 

Diabetic retinopathy follow-up rates of 36% align with previously reported follow-up rates from diabetic retinopathy screening programs, and further efforts are warranted to improve follow-up for this vulnerable group.^12,13 In fact, among the five patients who attended a clinic follow-up visit for diabetic retinopathy or macular edema, three received treatment with laser or intravitreal injection, which suggests a high burden of severe-stage disease in underserved communities. 

All six patients diagnosed with urgent pathologies attended their follow-up appointments. This underscores the role of vision screening events in identifying and providing timely intervention for acute ophthalmic conditions and may also suggest the need for more frequent implementation of such community health initiatives. Sixteen percent of patients who attended follow-up received surgical intervention or an in-office procedure. The range of diagnoses and treatments spanned multiple ophthalmic subspecialties, including retina, glaucoma, cornea, and neuro-ophthalmology. Among four patients who required intravitreal injections, one patient, despite lacking insurance, was successfully enrolled in a clinical trial to receive ongoing care. These study findings illustrate the broad-spectrum utility of community-based vision screening as an important introduction of ophthalmic care and its role in establishing more subspecialized continuity of care. 

Despite offering free follow-up care, we found that health insurance strongly predicted follow-up in our study population. The reasons behind this are not entirely clear, however, the underutilization of complimentary health services has been reported and may particularly affect low socioeconomic populations.¹⁴ Kacker et al. recently investigated the effect of vouchers on follow-up rates and found that providing patients with an estimated retail value of their follow-up appointment increased patient attendance.¹⁵ Another strategy to enhance follow-up rates in community outreach programs could involve conducting the screening initiative in the same location that provides follow-up care. The familiarity with the follow-up clinics could promote improved adherence to follow-up protocols. Further exploration of behaviorally informed interventions to increase utilization of free health services may be helpful in increasing follow-up for community vision screening events. Our analysis also revealed male gender as predictive of follow-up in our study population. This finding lies in contrast to previous literature in which women have had higher rates of eye care when compared to men, or no difference between the genders was found.^16–19 Further investigation into gender disparities and their effect on follow-up rates at community vision screening events could be informative. 

Although this study provides valuable insights into follow-up adherence after community vision screenings, it is important to acknowledge its limitations. First, the results from a single-center community vision screening event may not apply broadly to other geographic regions or socioeconomic contexts. Second, our study did not evaluate the reasons for missed appointments. Understanding the motivations and barriers that influence patients’ decisions to attend or miss their scheduled follow-ups could yield valuable insights for enhancing appointment adherence. Furthermore, we focused on follow-up attendance at our university clinic, potentially underestimating actual follow-up rates if patients sought care elsewhere. Despite these limitations, the study still holds valuable implications for improving adherence to follow-up care after vision screening, such as providing resources for health insurance enrollment. 

Our study demonstrates that, despite the provision of free appointments and on-site scheduling, only half of the referred patients attended clinic follow-up appointments. All patients with urgent referrals attended follow-up visits, highlighting the role of vision screening events in providing timely intervention for ophthalmic emergencies and laying the foundation for the potential benefit of conducting these events with greater regularity. Health insurance was predictive of follow-up, emphasizing the enduring impact of health insurance on follow-up attendance rates. To enhance patient attendance, future initiatives could incorporate on-site insurance connectivity and screenings for social determinants of health. This approach could help address a broader range of barriers and connect patients to resources that aid in prolonged and effective engagement with healthcare systems. 

Acknowledgments

Supported by the Henry L. Hillman Foundation, NIH CORE Grant P30 EY08098, the Eye and Ear Foundation of Pittsburgh, and from an unrestricted grant from Research to Prevent Blindness to the Department of Ophthalmology at the University of Pittsburgh. 

Disclosure: L.M. Wasser, None; J. Cassidy, None; K. Cecconi, None; D. McGinnis-Thomas, None; A. Ayalon, None; H.A. Zaheer, None; E.L. Waxman, None; J.-A. Sahel, None; A.M. Williams, None