New Research: Medicaid Recipients with Glaucoma Receive Substantially Less Testing Than Persons with Commercial Health Insurance

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Cover of the journal Ophthalmology

Glaucoma often is called "the sneak thief of sight" for good reason: Many people are unaware that glaucoma has few symptoms or warning signs in its early stages. Early treatment for glaucoma can usually (but not always) slow the progression of the disease. However, as of yet, there is no cure for glaucoma.

Because glaucoma has no obvious initial symptoms and is a chronic condition that must be managed for life, regular comprehensive dilated eye exams, consistent monitoring, and compliance with recommended treatments are all critical components of effective, responsible glaucoma care.

However, new research from the University of Michigan has determined that "Irrespective of race/ethnicity, Medicaid recipients with open-angle glaucoma are receiving substantially less glaucoma testing compared with persons with commercial health insurance. Compared with those with commercial health insurance, Medicaid recipients were 234% more likely to not receive any glaucoma testing in the 15 months after initial diagnosis."

Medicaid is a social health care program for families and individuals with limited resources. Medicaid provides health coverage to low-income adults, children, pregnant women, older adults, and people with disabilities. Medicaid is funded jointly by states and the United States federal government.

The research team further concludes that "Disparities in testing are observed across all races/ethnicities, but were most notable for blacks. These findings are particularly disconcerting because blacks are more likely than whites to go blind from open-angle glaucoma and there are disproportionately more blacks in Medicaid. Efforts are needed to improve the quality of glaucoma care for Medicaid recipients, especially racial minorities."

From the Journal Ophthalmology

This new glaucoma/Medicaid research, titled Large Disparities in Receipt of Glaucoma Care between Enrollees in Medicaid and Those with Commercial Health Insurance, has been published online ahead of print in the July 2017 edition of Ophthalmology, the official journal of the American Academy of Ophthalmology. The authors are Angela R. Elam, MD; Chris Andrews, PhD; David C. Musch, PhD, MPH; Paul P. Lee, MD, JD; and Joshua D. Stein, MD, MS, all from the University of Michigan, Ann Arbor.

Ophthalmology publishes original, peer-reviewed research in ophthalmology, including new diagnostic and surgical techniques, the latest drug findings, and results of clinical trials.

About the Glaucoma and Medicaid Research

Excerpted from Medicaid recipients with open-angle glaucoma receive less glaucoma testing, via Healio (registration required):

A total of 21,766 patients aged 40 years old or younger with newly diagnosed open-angle glaucoma were included in a retrospective longitudinal study. The researchers determined the proportion of patients with Medicaid or commercial health insurance who underwent typical glaucoma testing, such as fundus photography and visual field testing, within the first 15 months of their diagnosis.

[Editor's note: A longitudinal study follows, and gathers information about, the same individuals or group of people over an extended period of time – often many decades. A retrospective study examines data and records that were collected in the past. A retrospective study has limitations because it collects data from past records and does not follow up with patients in the present.]

In the study, 18,372 patients were commercial health insurance recipients and 3,394 patients were Medicaid recipients.

A statistically significant lower proportion of Medicaid recipients underwent visual field testing and other ocular imaging testing within 15 months of their diagnosis than those with commercial health insurance; 48.6% of Medicaid recipients did not have any of these … glaucoma tests within 15 months of initial diagnosis compared with 21.5% of commercial health insurance recipients.

What Is Glaucoma?

Glaucoma is a group of eye diseases that can lead to blindness by damaging the optic nerve, which transmits information from the eye to the brain, where it is processed and interpreted. The eye continuously produces a fluid, called the aqueous, that must drain from the eye to maintain healthy eye pressure. Glaucoma is particularly dangerous to your vision because there are usually no noticeable initial symptoms or early warning signs.

The Different Types of Glaucoma

Primary Open Angle Glaucoma

The most common type of glaucoma is Primary Open Angle Glaucoma (POAG). In POAG, the eye's drainage canals become blocked, and the fluid accumulation causes pressure to build within the eye. This pressure can cause damage to the optic nerve, which transmits information from the eye to the brain.

Vision loss is with this type of glaucoma is usually gradual, and often there are no early warning signs. There is a strong genetic predisposition for this type of glaucoma.

Angle Closure Glaucoma

Angle Closure Glaucoma is much less common than POAG in the United States. In this type of glaucoma, the aqueous cannot drain properly because the entrance to the drainage canal is either too narrow or is closed completely. In this case, eye pressure can rise very quickly and can be triggered by pupil dilation.

Symptoms can include sudden eye pain, nausea, headaches, and blurred vision. If you experience these symptoms, you should seek immediate medical treatment.

Normal Tension Glaucoma

In this type of glaucoma, also called low-pressure glaucoma, there is damage to the optic nerve, even though the eye pressure is not elevated excessively. A family history of any type of glaucoma, cardiovascular disease, and Japanese ancestry are a few of the risk factors for this type of glaucoma.

This type of glaucoma is treated much like POAG, but the eye pressure needs to be kept even lower to prevent progression of vision loss.

Secondary Glaucomas

Secondary glaucomas are those that develop as secondary to, or as complications of, other conditions, including eye trauma, cataracts, diabetes, eye surgery, or tumors.

Series of four photos demonstrating typical progression of vision loss due to glaucoma. Source: National Eye Institute

The typical progression of vision loss from glaucoma
Source: National Eye Institute

How Is Glaucoma Detected?

Because glaucoma can begin to develop without noticeable symptoms, the best way to protect your sight is to schedule regular comprehensive dilated eye examinations, which should include all of the following components:

  • A health and medication history
  • A vision history
  • Visual acuity testing
  • Basic visual field testing

You can read more about each of these eye examination components at What Is a Comprehensive Dilated Eye Examination?

Additional Tests for Glaucoma

If your eye doctor suspects that you may have glaucoma, you will need to undergo additional testing that can help your doctor make a more definitive glaucoma diagnosis:

Pachymetry

  • This test uses a probe that emits an ultrasonic wave to measure the thickness of your cornea. Thicker than normal corneas can give eye pressure readings that are inaccurately high, while thinner than normal corneas can give readings that are inaccurately low.
  • To measure your corneal thickness, the doctor will touch the tip of the pachymeter probe to the surface of your cornea. The probe emits a painless ultrasound wave that measures your corneal thickness. The doctor will numb the surface of your eye with an anesthetic drop for this test.

Perimetry

  • This test measures and maps your visual fields. Perimetry testing can draw a map of your visual fields and show you where you may have lost vision, especially your peripheral (or side) vision, which is the vision usually affected by early damage to the optic nerve from glaucoma.
the Humphrey Field Analyzer
  • The most commonly used test for perimetry is the Humphrey Field Analyzer (pictured at left). The machine resembles a large bowl.
  • One eye is covered with a patch and the other eye remains stationary and focused straight ahead. Small white lights of varying sizes and intensities will flash at different locations around the bowl. You will be instructed to press a button whenever you see a flashing light.
  • By recording which lights you see and which ones you do not, it creates a map of your visual field.

Gonioscopy

  • This test assesses the angle, or drainage canal, that is formed between your cornea and iris. Because angle-closure glaucoma requires immediate medical attention, it is important to examine the drainage canals, or angles, to ensure that they are functioning properly.
  • Because the drainage angle is located around a "corner" of your cornea, the doctor can't see whether your angle is open by looking directly into your eye.
  • Gonioscopy uses a lens with a mirror to view the angle. During the exam, the doctor places this lens, called a gonioscope, on the surface of your eye like a large contact lens. The doctor will numb the surface of your eye with an anesthetic drop for this test.

For more detailed and patient-centered information about ophthalmoscopy, tonometry, pachymetry, perimetry, and gonioscopy, see Discovering the Sneak Thief: Diagnosing Glaucoma in VisionAware's Patient's Guide to Living with Glaucoma and El descubrimiento del ladrón silencioso: El diagnóstico de glaucoma in Guía del Paciente: Vivir con Glaucoma.

What Is the Treatment for Glaucoma?

Glaucoma is a chronic condition that must be monitored for life. With proper monitoring and compliance with treatment, glaucoma can be managed – but not cured. Current treatments include eye medications, laser treatment, surgery, and several newer surgical alternatives.

Eye Medications

For tips, adaptations, and assistive devices to help you take your glaucoma medications, see Tips for Taking Glaucoma (and Other) Eye Drops by Ira Marc Price, O.D.

Laser Treatment

If eye drop medications do not adequately control your glaucoma, the next step is a treatment called a laser trabeculoplasty. In this procedure, laser energy is directed at the trabecular meshwork, which is the drainage system of the eye. The laser treatment lowers pressure by increasing the drainage of the fluid from the eye. The procedure is relatively short, painless, and usually performed in the doctor's office.

Three types of lasers can be used for the procedure:

  • Argon laser trabeculoplasty (ALT) has been used for more than two decades.
  • Selective laser trabeculoplasty (SLT)
  • Micropulse laser trabeculoplasty (MLT)
  • SLT and MLT are two newer laser treatments now available.
  • Side effects from all types of lasers include mild inflammation in the eye and a possible temporary pressure rise. A short course of a mild steroid or non-steroidal anti-inflammatory eye drop is used to treat any resulting inflammation.
  • Other lasers are available, but these are reserved for people with particular types of glaucoma that narrow or completely close the drainage system of the eye.

Surgery

Surgery to treat glaucoma is usually undertaken only as a final step for people who have not achieved adequate pressure control with either eye drop medications or laser treatment.

Depending on the type of glaucoma and associated risk factors, two types of surgeries are available:

  • Filtering Surgery: Trabeculectomy: In a trabeculectomy, a small incision is made in the sclera (the white of the eye). Fluid slowly leaks from this incision into a "bleb," which is a covered space made in the conjunctiva (the thin, transparent tissue that covers the outer surface of the eye). The fluid in the bleb is slowly reabsorbed by the eye. This surgery provides a "natural" alternate drainage for aqueous to flow out of the eye.
  • Drainage Device Surgery: Drainage device surgery partially inserts an artificial tube implant into the eye. Fluid drains through the tube and out to a reservoir. This surgery provides an "artificial" alternate drainage for aqueous to flow out of the eye.

Both types of surgeries have been proven effective in lowering eye pressure. Some people may still need to use post-surgery eye drop medications to maintain healthy eye pressure.

You can read more about glaucoma treatment at Surgical Alternatives and Alternative Treatments, Clinical Trials, and Research.

More About the Research from Ophthalmology

Excerpted from the article abstract:

Purpose: To determine whether the type of health insurance a patient possesses and a patient's race/ethnicity affect the receipt of common tests to monitor open-angle glaucoma.

Participants: A total of 21,766 persons aged 40 years or older with newly diagnosed OAG between 2007 and 2011 enrolled in Medicaid or a large United States managed care network.

Methods: We determined the proportion of patients with newly diagnosed open-angle glaucoma who underwent visual field testing, fundus photography, other ocular imaging, or none of these tests within the first 15 months after initial open-angle glaucoma diagnosis.

Results A total of 18,372 persons with commercial health insurance and 3,394 Medicaid recipients met the study inclusion criteria.

The proportions of persons with commercial health insurance with newly diagnosed open-angle glaucoma who underwent visual field testing, fundus photography, and other ocular imaging were 63%, 22%, and 54%, respectively, whereas the proportions were 35%, 19%, and 30%, respectively, for Medicaid recipients.

Compared with those with commercial health insurance, Medicaid recipients were 234% more likely to not receive any glaucoma testing in the 15 months after initial diagnosis. Whites with open-angle glaucoma enrolled in Medicaid had 198% higher odds of receiving no glaucoma testing compared with whites possessing commercial health insurance. Blacks with Medicaid insurance demonstrated 291% higher odds of not receiving any glaucoma testing compared with blacks with commercial health insurance.

Conclusions: Irrespective of race/ethnicity, Medicaid recipients with open-angle glaucoma are receiving substantially less glaucoma testing compared with persons with commercial health insurance. Disparities in testing are observed across all races/ethnicities but were most notable for blacks. These findings are particularly disconcerting because blacks are more likely than whites to go blind from open-angle glaucoma and there are disproportionately more blacks in Medicaid. Efforts are needed to improve the quality of glaucoma care for Medicaid recipients, especially racial minorities.

Additional Information


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