Barriers and facilitators in the referral pathways to low vision services from the perspective of patients and professionals: a qualitative study

Low-Vision Rehabilitation Services in Saudi Arabia: A Nationwide Survey of Optometrists on Current Status and Future Directions

Background

Low vision (LV) is a significant public health challenge with profound effects on patients and their families. In Saudi Arabia, studies indicate a high prevalence of LV, yet low vision services (LVS) remain limited, with gaps in optometrist knowledge, training, and service accessibility. This study evaluates the current state of LV services, documents optometrist involvement, and identifies barriers to delivering LVS.

Methods

A nationwide, cross-sectional study surveyed 275 optometrists using a validated, self-administered electronic questionnaire. Awareness, clinical practices, referral patterns, and perceived barriers were assessed. Multivariate logistic regression analyzed awareness levels and barriers, with statistical significance set at p<0.05.

Results

Moderate awareness of the WHO definition of LV was observed (70.1%), significantly higher among those with formal training (90.1%, p<0.001). Only 36.4% provided LV services, primarily in the central region. Low vision cases constituted 1% of patient loads for most participants (44.4%). Key barriers included device unavailability (68.4%), insufficient training (65.8%), and high costs (50.9%). Diabetic retinopathy (70.9%), glaucoma (63.3%), and hereditary conditions (46.5%) were leading causes of LV.

Conclusion

Critical gaps in LV care include insufficient awareness, uneven service distribution, and financial/training-related barriers. Enhancing education, improving affordability, and fostering multidisciplinary care are essential. Region-specific interventions are urgently needed to ensure equitable access to LVS across Saudi Arabia.

Interventions to improve referrals from primary care to outpatient specialist services for chronic conditions: a systematic review and framework synthesis update

BACKGROUND

Prior systematic reviews highlight that accessing specialist healthcare to treat chronic conditions can be obstructed by variations in referral rates, inappropriate referrals, and poor communication. Structured referral proformas, peer feedback, and educational interventions involving specialists have been identified as successful strategies for improving referral rates and appropriateness. However, the success of such interventions is often dependent on specific clinical contexts, and little is known about the practicalities of implementation. Additionally, with advancements in healthcare delivery, such as e-referral systems, there is a need to explore new interventions and how they address barriers to referral.

METHODS

This systematic review evaluated the updated evidence exploring interventions aiming to improve rates and/or appropriateness of referral from primary care to specialist services in patients with chronic conditions.Five academic databases were searched (CINAHL, MEDLINE, Embase, British Nursing Index, and Public Health Database), and studies published in English between 2013 and 2023 were included. The Joanna Briggs Institute's appraisal tool was used to assess the quality of studies, and a narrative synthesis was conducted using the TiDiER framework (template for intervention description and replication).

RESULTS

Eighteen full-text publications and five abstracts were included. A behavioral theory or framework for intervention development was used in seven studies. All interventions were based on primary care, and thirteen studies evaluated a multi-component intervention. Process and system changes were most commonly used to improve referral, including electronic health systems, referral algorithms, collaborative working, and patient direct access. Interventions targeted at patients were the least common. Staff education was often used in addition to process and system changes. When used alone, referral algorithms and staff education were less effective at improving referral rates or appropriateness. Implementation barriers included time constraints, logistical issues, and patients/staff preconceived perceptions of referral necessity.

CONCLUSION

Unsurprisingly, the success of interventions aimed at improving referral practices is based on contextual circumstances, and as with previous reviews, there is no one-size-fits-all approach.Given the challenges highlighted in this review, multi-component interventions addressing referral barriers in both primary and secondary care appear to be a successful way to improve referral practices.

REVIEW REGISTRATION

PROSPERO CRD42023480493.

Low Vision Rehabilitation Referral Characteristics for Patients with Neovascular Age-Related Macular Degeneration

Background: Despite evidence that low vision rehabilitation (LVR) services can improve visual function in patients with neovascular age-related macular degeneration (nAMD), many patients are not directed to access these resources. This study was conducted to determine factors associated with LVR referral and to assess the visual outcomes from completed evaluations. Methods: The study comprised a retrospective, cross-sectional analysis of patients with nAMD. Referrals for LVR services were extracted from the electronic health record (EHR). The effectiveness of each evaluation was determined by assessing the change in best corrected visual acuity (BCVA) achieved after distance refraction. Costs, quality-adjusted life years (QALYs), and incremental costs per-QALY-gained were calculated based upon the better-seeing eye by using a willingness-to-pay threshold of $50,000/QALY. Results: Out of 560 eligible patients with nAMD, 110 were referred for LVR (19.6%). Referral was more common for individuals who qualified as having low vision, based upon the visual acuity of the better-seeing eye (adjusted odds ratio [aOR], 3.214; 95% confidence interval [CI], 1.920-5.380, p < 0.001), had bilateral nAMD (aOR, 1.592; 95% CI, 1.017-2.492, p = 0.042), or had commercial health insurance compared to those who had Medicare (aOR, 2.887; 95% CI, 1.041-8.009, p = 0.042). Most patients referred completed LVR appointments (86%). More than half of the patients achieved improved BCVA for their better-seeing eye (53%) yielding an average gain of 0.04 QALYs/patient at a cost of $3504/QALY. The estimated net monetary benefit was $1704 per evaluation completed. Conclusions: Most patients with nAMD achieved improvements in visual function after low vision evaluation, yielding improvements in vision-related quality of life at a reasonable cost.

Referral to Vision Rehabilitation Services for Uveitis Patients: Referral Criteria and Barriers

PURPOSE

Despite the benefits of vision rehabilitation services (VRS) for uveitis patients, limited literature has examined issues in VRS access within uveitis. We surveyed American Uveitis Society members regarding VRS referral practices, criteria, and barriers.

METHODS

Survey responses were collected from November 2022 to January 2023. Analysis summarized responses and compared response patterns of frequently-referring and infrequently-referring providers through Fisher's exact tests and logistic regression.

RESULTS

Most of the 33 respondents completed 1 to 5 monthly referrals using criteria of visual acuity loss, visual field loss, and difficulty performing vision-related activities. Key referral barriers included cost of services and insufficient patient-provider communication regarding vision loss. The practice of speaking to patients about vision loss during clinic visits was correlated with higher VRS referral rates (P = 0.047).

CONCLUSIONS

Greater patient-provider communication about vision loss may represent an opportunity to increase access to VRS.

Perspectives on Referral Pathways for Timely Head and Neck Cancer Care

Importance

Timely diagnosis and treatment are of paramount importance for patients with head and neck cancer (HNC) because delays are associated with reduced survival rates and increased recurrence risk. Prompt referral to HNC specialists is crucial for the timeliness of care, yet the factors that affect the referral and triage pathway remain relatively unexplored. Therefore, to identify barriers and facilitators of timely care, it is important to understand the complex journey that patients undertake from the onset of HNC symptoms to referral for diagnosis and treatment.

Objective

To investigate the referral and triage process for patients with HNC and identify barriers to and facilitators of care from the perspectives of patients and health care workers.

Design, Participants, and Setting

This was a qualitative study using semistructured interviews of patients with HNC and health care workers who care for them. Participants were recruited from June 2022 to July 2023 from HNC clinics at 2 tertiary care academic medical centers in Boston, Massachusetts. Data were analyzed from July 2022 to December 2023.

Main Outcomes and Measures

Themes identified from the perspectives of both patients and health care workers on factors that hinder or facilitate the HNC referral and triage process.

Results

In total, 72 participants were interviewed including 42 patients with HNC (median [range] age, 60.5 [19.0-81.0] years; 27 [64%] females) and 30 health care workers (median [range] age, 38.5 [20.0-68.0] years; 23 [77%] females). Using thematic analysis, 4 major themes were identified: the HNC referral and triage pathway is fragmented; primary and dental care are critical for timely referrals; efficient interclinician coordination expedites care; and consistent patient-practitioner engagement alleviates patient fear.

Conclusions and Relevance

These findings describe the complex HNC referral and triage pathway, emphasizing the critical role of initial symptom recognition, primary and dental care, patient information flow, and interclinician and patient-practitioner communication, all of which facilitate prompt HNC referrals.

Big data study using health insurance claims to predict multidisciplinary low vision service uptake

SIGNIFICANCE

There is a lack of research from high-income countries with various health care and funding systems regarding barriers and facilitators in low vision services (LVS) access. Furthermore, very few studies on LVS provision have used claims data.

PURPOSE

This study aimed to investigate which patient characteristics predict receiving multidisciplinary LVS (MLVS) in the Netherlands, a high-income country, based on health care claims data.

METHODS

Data from a Dutch national health insurance claims database (2015 to 2018) of patients with eye diseases causing potentially severe visual impairment were retrieved. Patients received MLVS (n = 8766) and/or ophthalmic treatment in 2018 (reference, n = 565,496). MLVS is provided by professionals from various clinical backgrounds, including nonprofit low vision optometry. Patient characteristics (sociodemographic, clinical, contextual, general health care utilization) were assessed as potential predictors using a multivariable logistic regression model, which was internally validated with bootstrapping.

RESULTS

Predictors for receiving MLVS included prescription of low vision aids (odds ratio [OR], 8.76; 95% confidence interval [CI], 7.99 to 9.61), having multiple ophthalmic diagnoses (OR, 3.49; 95% CI, 3.30 to 3.70), receiving occupational therapy (OR, 2.32; 95% CI, 2.15 to 2.51), mental comorbidity (OR, 1.17; 95% CI, 1.10 to 1.23), comorbid hearing disorder (OR, 1.98; 95% CI, 1.86 to 2.11), and receiving treatment in both a general hospital and a specialized ophthalmic center (OR, 1.23; 95% CI, 1.10 to 1.37), or by a general practitioner (OR, 1.23; 95% CI, 1.18 to 1.29). Characteristics associated with lower odds included older age (OR, 0.30; 95% CI, 0.28 to 0.32), having a low social economic status (OR, 0.91; 95% CI, 0.86 to 0.97), physical comorbidity (OR, 0.87; 95% CI, 0.82 to 0.92), and greater distance to an MLVS (OR, 0.95; 95% CI, 0.92 to 0.98). The area under the curve of the model was 0.75 (95% CI, 0.75 to 0.76; optimism = 0.0008).

CONCLUSIONS

Various sociodemographic, clinical, and contextual patient characteristics, as well as factors related to patients' general health care utilization, were found to influence MLVS receipt as barriers or facilitators. Eye care practitioners should have attention for socioeconomically disadvantaged older patients when considering MLVS referral.

The socioeconomic epidemiology of inherited retinal diseases in Portugal

BACKGROUND

Inherited retinal diseases (IRDs) are a group of rare degenerative disorders of the retina that can lead to blindness from birth to late middle age. Knowing the target population and its resources is essential to better plan support measures. The aim of this study was to evaluate the socioeconomic characteristics of regions in Portugal where IRD patients reside to inform the planning of vision aid and rehabilitation intervention measures.

RESULTS

This study included 1082 patients from 973 families, aged 3 to 92 years, with a mean age of 44.8 ± 18.1 years. Patients living with an IRD were identified in 190 of the 308 municipalities. According to this study, the estimated IRD prevalence in Portugal was 10.4 per 100,000 inhabitants, and by municipalities, it ranged from 0 to 131.2 per 100,000 inhabitants. Overall, regions with a higher prevalence of IRD have a lower population density (r=-0.371, p < 0.001), a higher illiteracy rate (r = 0.404, p < 0.001) and an overall older population (r = 0.475, p < 0.001). Additionally, there is a lower proportion of doctor per capita (r = 0.350, p < 0.001), higher social security pensions beneficiaries (r = 0.439, p < 0.001), worse water quality for human consumption (r=-0.194, p = 0.008), fewer audiences at the cinema (r=-0.315, p < 0.001) and lower proportion of foreign guests in tourist accommodations (r=-0.287, p < 0.001).

CONCLUSION

The number of identified patients with IRD varied between regions. Using data from national statistics (PORDATA), we observed differences in socioeconomic characteristics between regions. Multiple targeted aid strategies can be developed to ensure that all IRD patients are granted full clinical and socioeconomic support.

Pancreatic Cancer Health Disparity: Pharmacologic Anthropology

Pancreatic cancer (PCa) remains a formidable global health challenge, with high mortality rates and limited treatment options. While advancements in pharmacology have led to improved outcomes for various cancers, PCa continues to exhibit significant health disparities, disproportionately affecting certain populations. This paper explores the intersection of pharmacology and anthropology in understanding the health disparities associated with PCa. By considering the socio-cultural, economic, and behavioral factors that influence the development, diagnosis, treatment, and outcomes of PCa, pharmacologic anthropology provides a comprehensive framework to address these disparities and improve patient care.