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Mr. Nacinovich:
Welcome to Clinician’s Roundtable on ReachMD. I’m Mario Nacinovich. And joining me today about how socioeconomic factors could impact care for patients with glaucoma is Dr. Sally Baxter, who is an Assistant Professor of Ophthalmology and Biomedical Informatics at the University of California-San Diego.

Dr. Baxter, thanks for joining me today.

Dr. Baxter:
It’s great to be here. Thanks so much for having me.

Mr. Nacinovich:
Diving right in, Dr. Baxter, what are the socioeconomic factors that could affect a patient’s access to eye care, specifically for a patient with glaucoma?

Dr. Baxter:
Well, I think not just in glaucoma but in, you know, health conditions in general, there are a lot of social determinants, including socioeconomic factors that can play a role, and you know, in our particular study, the ones that came out as being particularly significant for being able to access eye care were primarily income and education. But there’s a whole range of other factors that are increasingly being studied in medicine and public health, things like housing security, food security, transportation, and sort of general environmental conditions in addition to those socioeconomic factors so a whole array of contextual and social factors that are becoming increasingly studied in addition to patients’ biological risk factors.

Mr. Nacinovich:
And according to data from the All of Us research program, patients with higher levels of education and income were more likely to see an eye doctor in the past year as opposed to those with lower education and income levels. Why do you think that is?

Dr. Baxter:
I think that there’s a lot of different factors at play. One is that people with higher income levels and higher levels of education tend to have a higher level of health literacy, and what that means is that they may have more awareness of what their condition is and what is needed in terms of treatment. They may have more access and awareness about the health services that might be available to them. I think at face value just having more financial resources from, you know, the income standpoint gives people greater ability to travel longer distances to see eye care providers, for example, if they don’t have somebody locally. So there are a lot of different levels to that, and unfortunately, our goal is not to have a care vary about how much money someone makes or how much education they have had, and so I think a lot of the efforts in the field have focused on how do we make health care, and including eye care, more accessible to everybody. How do we create, you know, patient education materials in different languages or at different literacy levels so that it’s understandable by all? What kind of outreach can we do to sort of level that playing field? And so I think data like this can really emphasize that these disparities still exist, and this is definitely something that we as healthcare providers still need to actively work on.

Mr. Nacinovich:
For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD. I’m Mario Nacinovich, and I’m speaking here with Dr. Sally Baxter about the impact of socioeconomic status on care for patients with glaucoma.

Dr. Baxter, let’s take a look at visit adherence and how could a patient’s socioeconomic status impact this.

Dr. Baxter:
Yeah. So visit adherence is something that has not been as commonly studied as things like medication adherence. And what we mean by visit adherence is that we have certain clinical guidelines in place around the frequency of visits or clinical monitoring that needs to be done for various conditions, and for glaucoma, which is a blinding eye disease that involves progressive damage to the optic nerve, which is the structure that connects your eye to your brain essentially, that really patients with this condition should be seen at least once a year and if not more often depending on the severity of their condition. And so, in this case, you know, we used the All of Us database to look at patients who had a diagnosis of glaucoma and their self-reported data around whether they had seen an eye doctor in the last year or not. And ideally, all of the patients would have seen an eye doctor, but what we found was that a substantial portion of them actually had not seen an eye doctor in the last year and that this varied by some of the socioeconomic factors we were talking about earlier. So, about 16 percent of the cohort, at least in this study, had not seen an eye care provider, and so the metric here that we used was whether they had seen an eye doctor in the last year or not.

Now, I think in the past, there were some conceptions around adherence that weren’t always very positive. Right? It was framed as, well, the patient is not sort of keeping up with their health care, or they’re not doing their part to take their medications or go to their visits, and I think that increasingly, we are taking a more nuanced view of it. Right? I think the awareness around contextual factors of, well, patients are dealing with so many different potential barriers to them getting to see the eye doctor. One is, you know, for a specialty like ophthalmology, there may not be a glaucoma specialist in that particular area that the patient is living in, so they may face hardship to travel a long distance to go see an eye doctor for their glaucoma. You know, obviously, from a lower income level, as we were talking about, if you don’t have financial resources and don’t have great insurance coverage and there’s high copays and other financial barriers to, to being able to do that visit plus time off work. Right? There are people who have the ability to have sick leave or to be able to take paid time off to go to their doctor appointments, but a lot of people don’t have that and that is an issue as well. And certainly, you know, all these other factors like if they have a housing issue or if they have a caregiver burden, there’s all these other factors that impact whether someone can make it to their appointments or not.

So I think instead of, you know, pointing our fingers at patients and saying, ‘Why aren’t you coming to see your eye doctor when we’ve sort of recommended that,’ I think, really, our stance as doctors, as public health practitioners, is how do we make it easier for people to go to those appointments and improve their visit adherence. And so I really think there’s been a real shift in mindset over the last couple of years, especially around this.

Mr. Nacinovich:
No, and I appreciate you making the distinguishing remark between what we typically are aware of in terms of adherence with glaucoma medications, and we know that’s a fundamental problem in about 50 percent of patients, but, you know, rarely, like you said, do we think about this is a chronic disease, and these are patients that are going to need to see and access a specialist as their condition potentially progresses. Lots of barriers in terms of patient compliance and all sorts of administration and communication but rare do we think about visit adherence, so certainly appreciate you illuminating the audience with that.

Now, with all this in mind, are there any strategies we can use to combat these challenges and improve care for these patients and for all patients with glaucoma? Any lessons learned we can share with our audience today?

Dr. Baxter:
Sure. I think that there are a lot of different approaches that have be taken to try to improve access to care, whether that’s health care in general or eye care specifically and then even more specifically for patients with glaucoma. I’d say one is education and awareness and trying to make sure that we communicate with our patients around the importance of coming to visits. One thing for glaucoma that is particularly challenging is that symptoms often don’t present until the disease is very advanced, so the damage to vision often occurs at sort of the edges or the periphery of the visual field, which is, you know, the sort of range of vision that the patients see, and the damage can be very slow and insidious. And so, people don’t realize that they have a problem and it’s only in the very late stages of disease where they might see a change to their central vision. So I think that has traditionally been a real challenge because for the early stages of the disease, it’s symptomless, it’s not painful, it doesn’t cause any discernable vision changes. And so, as patients are weighing the different demands on their lives, they may not necessarily prioritize glaucoma care, and I think that’s something that we need to work on from an education standpoint. And then, you know, with my informatics training, I have interest and expertise in the technology side, and so from a technology standpoint, there are a lot of exciting developments. For example, in telemedicine or how we might be able to incorporate artificial intelligence, or AI, and using these as ways of helping with this issue. Right? So if travel and time are barriers to people accessing care, can we mitigate some of that by having telemedicine approaches to care?

And, you know, there are some challenges in ophthalmology in particular because we use a lot of specialized equipment, specialized imaging, but there are definitely advancements in that space, and I think that’s been very promising for helping to address some of the barriers. There’s also ways that we can do mass outreach on a population scale using automated messaging and bulk orders in the electronic health record system, so, you know, we can order medications or send messages to an entire group of patients all at once without having to do a lot of individual messaging.

And then, of course, you know, I don’t think you can go anywhere today without hearing something about ChatGPT and the potential use for scaling up, you know, health coaching and maybe medication adherence reminders in a way that is perhaps more personal or engaging then prior chatbots, and so I think that’s something that people are going to be exploring in the coming years.

Mr. Nacinovich:
Now, this is certainly a challenging problem for ophthalmologists and any physician who provides services to patients with chronic diseases. And, you know, it’s almost easier to say, well, visit adherence, it’s obvious if they’re not showing up these days, but certainly, like you had said, the technology is allowing for interactions in a different capacity, but certainly, there remains large gaps in, you know, detecting and identifying and addressing a lot of issues in medical nonadherence, and certainly there’s a multifaceted approach that is looking at putting together some of those strategies to employ in that area. And I think you’re on to something in terms of, you know, how do we combat these challenges and improve care for all patients on the visit adherence side.

And certainly, Dr. Baxter, before we close, you know, do you have any final thoughts you’d like to leave with our audience on this topic?

Dr. Baxter:
You know, I just think it’s great that this is being discussed and really appreciate you having me here to talk about, just a small sliver of it. It’s certainly a complex, you know, situation, and I think that if anyone learns about what glaucoma is and if, you know, they have had someone in their family with glaucoma and they haven’t been screened themselves yet, it would have helped someone somewhere with being here. And so I just want to be able to spread that awareness because I do think that it’s not necessarily a disease that is well-known or commonly understood in sort of the general population that’s a large goal of my research is really to help spread awareness about it and, you know, hopefully, develop ways to intervene and make sure that we have, as I said, sort of a level playing field and that everybody has equal access to care and have a lower risk of becoming blind from this condition.

Mr. Nacinovich:
Absolutely. Well, with those key takeaways in mind, I want to thank my guest, Dr. Sally Baxter, for joining me today to share her insights on how we can improve care and address an important health disparity for patients with glaucoma.

Dr. Baxter, it was absolutely great speaking with you today.

Dr. Baxter:
Thank you so much for having me, Mario.

Mr. Nacinovich:
For ReachMD, I’m Mario Nacinovich. To access this and other episodes in our series, I invite to you visit ReachMD.com/CliniciansRoundtable where you can be Part of the Knowledge. Thanks for listening.