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«Census of Alabama Eye Care Providers Prepared for By Paul A. MacLennan, MPH, PhD Cynthia Owsley, PhD, MSPH Karen Searcey, MPSH Gerald McGwin, Jr., ...»

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Census of Alabama

Eye Care Providers

Prepared for

By

Paul A. MacLennan, MPH, PhD

Cynthia Owsley, PhD, MSPH

Karen Searcey, MPSH

Gerald McGwin, Jr., MS, PhD

June 2012

Author Information:

Paul MacLennan PhD

Assistant Professor

Department of Surgery

School of Medicine

University of Alabama at Birmingham

Cynthia Owsley PhD, MSPH

Nathan E. Miles Chair of Ophthalmology

Vice Chair for Clinical Research

Department of Ophthalmology

School of Medicine

University of Alabama at Birmingham Karen Searcey, MSPH Clinical Research Unit Manager Department of Ophthalmology School of Medicine University of Alabama at Birmingham Gerald McGwin Jr. MS, PhD Professor of Epidemiology, Ophthalmology, and Surgery Vice Chair of Epidemiology School of Public Health University of Alabama at Birmingham

FUNDING SUPPORT

This work was funded by the EyeSight Foundation of Alabama, with supplementary support from UAB’s Comprehensive Diabetes Center; Department of Ophthalmology, School of Medicine; Minority Health and Disparities Research Center; School of Public Health; and Vision Science Research Center.

ACKNOWLEDGMENTS

We appreciate the guidance of Torrey V.A. DeKeyser, Executive Director, and Shirley Hamilton, Director of Grants and Communications; Stephen A. Yoder, JD, Chairman, Board of Trustees; and N. Carlton Baker Jr., Immediate Past Chairman, Board of Trustees, all of The EyeSight Foundation of Alabama.

We thank the following individuals for facilitating our efforts in surveying eye care providers in Alabama: Amanda Buttenshaw, CAE, Executive Director, Alabama Optometric Association;

Mike Merrill, JD, Executive Director, Alabama Academy of Ophthalmology; Fred Wallace, OD, Executive Director, Alabama Board of Optometry; Dawn DeCarlo, OD, Associate Professor of Ophthalmology, UAB; Jennifer Elgin OTR/L, CDRS, Occupational Therapist, Department of Ophthalmology, UAB and Tammy Than OD, Associate Professor of Optometry, UAB.

In addition, we thank Melissa Braswell, Research Specialist, Clinical Research Unit, UAB Department of Ophthalmology, for assistance with data collection.

TABLE OF CONTENTS

EXECUTIVE SUMMARY

BACKGROUND

METHODS

RESULTS

Provider characteristics Ophthalmologists

Optometrists

Rehabilitation providers

Practice characteristics Ophthalmologists

Optometrists

Rehabilitation providers

Patient characteristics Ophthalmologists

Optometrists

Rehabilitation providers

Provider opinions Ophthalmologists

Optometrists

Rehabilitation providers

DISCUSSION

REFERENCES

APPENDICES Appendix A. Eligible and participating providers by county........57 Appendix B. Provider surveys

Appendix C. Domains and subcategories for written responses....81 Executive Summary In 2010 the EyeSight Foundation of Alabama commissioned a survey of eye care providers in Alabama as part of a needs assessment for eye health and eye care issues in Alabama. The survey’s specific purpose was to obtain information about the characteristics of providers (ophthalmologists, optometrists, visual rehabilitation specialists), and their practices and patients.

In addition, providers’ opinions were solicited on major unmet eye care needs in Alabama. This report is a summary of the survey methodology and its results. A survey with similar although not identical content was previously conducted in 1999 shortly after the Foundation was created.

The current survey, carried out about ten years after the original survey, was conducted in order to get an up-to-date picture on the topic. The results of this survey will provide guidance to the Foundation for potential areas of need. It is also hoped that this report will serve as a resource to clinicians, researchers and policy-makers in Alabama.

Surveys specific to each provider group were developed and administered. These surveys requested information regarding four domains: provider characteristics, practice characteristics, patient characteristics and provider opinions as elicited by two opened-ended questions. Survey participants were identified from August 2010 to October 2010 through information obtained from professional associations, licensing boards, and internet searches. The final group of eligible participants consisted of 1,033 vision care providers: 217 ophthalmologists, 638 optometrists and 178 rehabilitation providers. Survey participants were contacted over a tenmonth period from November 2010 through August 2011. Overall, 438 of eligible vision health providers participated in the survey. Participation varied by provider group with ophthalmologists having the highest participation rate (51.2%), followed by rehabilitation providers (45.5%) and optometrists (38.6%).

The survey found that many Alabama communities are geographically isolated from eye care services. Due to long travel distances, people who live in rural areas have increased barriers to receive basic and specialized eye care, and vision rehabilitation services. Among survey participants, Jefferson County had the highest number of participants, followed by Madison, Mobile, Shelby and Montgomery. The majority of participating vision care providers was located in urban counties. All rehabilitation providers located in rural areas were in northern rural counties but none were located in southern counties.





The majority of participating ophthalmologists, optometrists and rehabilitation providers identified themselves as white of non-Hispanic origin. According to 2010 US Census estimates, over one-quarter of Alabama’s population is African American. Previous research indicates that rates of vision impairment and eye disease among African Americans are two times higher than those of whites, especially uncorrected refractive error, cataract, glaucoma, and diabetic retinopathy. Research suggests that provider-patient communication and the use of preventive services can be facilitated when there is racial/ethnic concordance between providers and patients. Thus, it is possible that an increase in the number of African American ophthalmologists and optometrists in Alabama would have positive benefits on eye health in the state.

The growing prevalence of diabetes in Alabama is likely to result in more people, and at younger ages, at risk for diabetic eye diseases. Diabetic retinopathy is the leading cause of blindness among working age adults in the United States. Those with diabetes are also at increased risk for glaucoma and cataracts. Based on Centers for Disease Control & Prevention estimates, Alabama has a higher prevalence of diabetes than any other state. In the current survey, ophthalmologists and optometrists estimated that 27% and 22%, respectively, of their patients had diabetes;

however, providers estimated that the proportion that adhered to eye care guidelines was 61% among ophthalmology patients and 53% among optometry patients. Programs that enhance the likelihood of early detection and monitoring with timely treatment could stop or slow disease progression.

A frequently expressed opinion among participating ophthalmologists, optometrists and vision rehabilitation providers was the need for more providers. A recent analysis concluded that due to changing patient demographics, retirement, and a fixed number of ophthalmology residency slots nationwide, ophthalmology will face substantial challenges in manpower by year 2020.

Four priority focus areas were identified that can potentially deliver significant benefit to the eye health of Alabamians. They are: 1) Identify strategies to increase the number of eye care providers, including more African American providers; 2) Develop and implement strategies in the eye care system for improved detection and follow-up management of the ocular complications of diabetes; and 3) Develop and implement strategies to improve access to eye care, satellite eye care practices, telemedicine approaches and possibly transportation systems.

(4) Scientifically evaluate these and any other public eye health interventions to improve the quality of and access to eye care in Alabama, in terms of their impact on both health outcomes and cost, so that eye health strategies in the state are evidence-based.

BACKGROUND

Vision health is an important public health concern that affects Alabama’s children, adults and the elderly. Even though research has shown that early detection and treatment are effective in preventing many vision problems, adequate vision care remains an unmet need for many Americans.1 Compared to many other chronic diseases, the personal and economic burden associated with eye disease is high.2,3 Those with vision impairment have difficulties with communication, mobility and performance of everyday tasks, and among older adults visual deficits can result in increased isolation, depression, disability and premature death.4,5 Among infants and children, the most prevalent and disabling problems include amblyopia, strabismus, and uncorrected refractive error.6 For adults younger than 40, problems related to refractive error are common but eye injury is also prevalent.7 Other eye diseases that can be detected and treated early among at risk adults include glaucoma and diabetic eye conditions. For people 40 and older, the most common eye diseases are age-related macular degeneration, cataract, diabetic retinopathy, and glaucoma.1 With increasing age the prevalence of blindness and vision impairment increase dramatically and is greatest for those older than 75; as the population ages, the number at risk also increases.8 Moreover, the prevalence of diabetes in the United States has more than doubled over the past 20 years,9 a trend that is expected to continue,10 increasing the numbers at risk for diabetic retinopathy.

Inadequate access to eye care results in delayed diagnosis, causing unnecessary increases in burden of disease, disability and costs.2,3 For some eye diseases such as cataract, glaucoma, agerelated macular degeneration, and diabetic eye conditions and retinopathy, by the time symptoms are apparent, damage is permanent that could have been avoided or delayed. A recent Centers for Disease Control and Prevention (CDC) Vision Impairment Task Force reported that the primary barriers related to individuals’ decisions not to seek vision care (i.e., screening, diagnosis, treatment and rehabilitation) were related to behavior, costs, and accessibility.11 Many people are unaware of the importance of eye care and often cite the reason for not seeking care as “did not feel a need.”12 However, barriers to eye care are not equivalent for all groups. For example, a recent investigation of perceptions and beliefs of vision care among older African Americans who resided in Birmingham and Montgomery reported that the most frequently cited barrier to care was transportation, followed by trusting the doctor, communicating with the doctor, and costs.13 A similar investigation of eye care beliefs among elderly African Americans in Maryland reported that cost was the most important barrier.14 Prohibitively high cost is frequently identified as a barrier to eye care.12 As an example, researchers utilizing the CDC’s Behavioral Risk Factor Surveillance System reported that among women 40 and older diagnosed with diabetic retinopathy, glaucoma and age-related macular degeneration, those without eye care insurance less frequently followed recommended guidelines for visiting an eye-care provider.15 The proportion of Alabama’s population without health insurance is relatively large and has increased in a short time from a low of 12.5% in 2005 to approximately 16% in 2011.16 Medicaid is a state run health insurance program for certain, qualifying low income populations; however, not all people with low incomes or those without insurance qualify for Medicaid. For those who do qualify, coverage may not be accepted by providers because it fails to cover their costs. Among Medicare patients, routine eye examinations for those without eye conditions are not covered. The costs for spectacles and contact lenses are not covered (except for spectacles following cataract surgery). For those with health care insurance, coverage may be insufficient for purchasing spectacles and prescription medications, or high co-pays may act as disincentives to seeking care. Among adults with selfreported severe vision impairment, eye care utilization in the preceding 12 months was no greater than 61% for those with vision care insurance and 34% for those with no insurance.



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