This prospective study identified important patient- and system-related barriers to glaucoma follow-up at an urban county hospital, with wait times being the most significant barrier.
Subjects were 152 glaucoma patients treated at San Francisco General Hospital that the investigators determined to have either good (n=72) or poor (n=72) follow-up. All subjects completed an oral questionnaire pertaining to the barriers to follow-up for glaucoma, as well as ethnicity. For all subjects, glaucoma follow-up visits 12 to 18 months before commencement of the study were determined from medical records. Those deemed to have good follow-up were those who attended follow-up visits within the maximum interval between visits advised by their ophthalmologist.
The most significant barriers to follow-up were long wait times in the clinic, appointment scheduling difficulties, other medical or physical conditions, and difficulties related to interpretation, with the first three being the same across all ethnicities.
Although some of these barriers are more challenging in a large county hospital system compared to most general ophthalmology practices, long wait times and other medical and physical conditions are factors that many practices face to some degree. It is noteworthy that, although the patients reported these particular barriers to follow-up, the barriers were not statistically associated with actual poor follow-up. Thus it appears that while all patients have common complaints or excuses, other factors (e.g., ethnicity, poor understanding of glaucoma) are more predictive of inconsistent follow-up. In addition, patients who failed to follow up at all were not included in this study.
The average patient-reported wait time was 2.3 hours (range, 1 to 6 hours). The clinic staff confirmed that this estimate was reasonable.
The investigators write that one contributing factor to long waiting times may have been an overabundance of patients with glaucoma relative to glaucoma physicians, a problem that is widespread across the United States and particularly worse in medically underserved areas and in developing countries. Other factors could include the frequent need to use interpreters for patients lacking English proficiency and that certain patients may need to be evaluated by both a resident and an attending ophthalmologist.
Difficulty with appointment scheduling was the second most commonly cited reason for poor follow-up, with limiting factors ranging from a lack of availability of follow-up appointments at the recommended interval to inability of the patient to communicate with appointment schedulers who lacked proficiency in the language spoken by the patient. Strategies to mitigate the latter might include hiring appointment schedulers with basic proficiency in the most commonly spoken languages among patients in the clinic and using interpreter services for patient scheduling when needed.
The authors conclude that although individual barriers to follow-up did not ultimately predict who did and did not follow up as advised, these barriers certainly have implications in terms of quality and equitability of care provided. This study underscores how different barriers to follow-up may be borne disproportionately by certain ethnic groups.
Future studies are needed to assist in developing interventions that can reduce system-related barriers to follow-up, ensure equitable glaucoma care delivery regardless of language or ethnicity, and ultimately determine whether reducing patient-reported barriers leads to improved clinical follow-up and outcomes.