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6. Evaluation and implementation of a new scheme of diagnostic testing, visit frequency, and therapy to optimize cost-effective glaucoma treatment outcomes

Drs. Jampel and Friedman

Some doctors see glaucoma patients 4 times a year and other doctors see them once or twice.  Testing frequency varies widely and how the tests are used to make decisions is highly variable. Visits for glaucoma are a huge cost to Medicare and the health system, and new imaging tests are the most rapidly growing feature of health care costs. The GCE proposes to study cost-effectiveness of glaucoma care both through national studies and within the GCE itself in two project areas.

Project 1:  The national study, implemented through the Glaucoma Research Network proposed here, will study new testing centers that are convenient for patients with centralized grading of data. Physicians will assign visit frequency based on risk assessment data. The project will compare present visit/doctor approach to the newer method in the outcomes: patient satisfaction, eye pressure control, glaucoma worsening, and overall cost.

This is new model of care will take up to 2 years initially to implement and to test.  We anticipate more attention will be given to managing the impact of glaucoma on the patient (through social workers, low vision specialists and support personnel), while physicians will have regular access to the best technology for their patients and will spend more time to spend with those patients who require careful monitoring or a change in care. This project will initially need $200,000 to establish a team to develop the care model and to engage the healthcare system, and likely will require additional funding as the program expands.

Project 2: The strategy of visits and testing for glaucoma patients, although endorsed by expert panels, is based on habit not data. Diagnostic tests are probably unnecessarily often for some and too infrequent in others. Actual time of communication between physician and patient is modest, and possibly inadequate. Patients generally have a poor (or untested) understanding of their disease, impeding their ability to fully participate in their care. Both are contributing factors in suboptimal patient adherence with the prescribed therapeutic regimen. The GCE has led the world in both observational and interventional studies of adherence with glaucoma eyedrop taking. Collaboration with Eric Bass, a specialist in public health assessment of medical interventions is important in this work.

To have each member of the health care team perform the functions they do best, the GCE will evaluate a scheme of care for patients to increase cost-effectiveness, improve adherence with eyedrops, and raise patient satisfaction.  All new patients will receive a comprehensive evaluation by the glaucoma specialist with the formulation of a therapeutic plan. In addition, the patients will be asked about visual limitations on their reading, walking, and driving, since these are key functions that matter to glaucoma patients.  Brief tests of reading and ambulation refined at Wilmer will be administered. A baseline evaluation of the patient’s satisfaction with their vision and understanding of the disease will be performed.

Following the visit with the glaucoma specialist the patient will be randomized to either current pattern of care or a new pattern of care. The new method consists of a comprehensive annual doctor visit with quarterly visits including technician testing and a meeting with an ophthalmic nurse, who reviews adherence and medication side effects. Quarterly visit data are reviewed by the glaucoma specialist and discussed with the patient by phone or in person where changes are required.

The program will be formally evaluated annually for 5 years. The primary outcomes will be visual acuity, visual field testing, optic disc imaging, quality of life and patient satisfaction assessment, disease understanding questionnaire results, as well as functional tests of reading and mobility. The direct costs of care for both arms will be also be determined. The program has need for a full-time nurse—educator who will also serve as the research coordinator for data collection, at an annual cost of $100,000.

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