A new systematic review analyzed the existing literature on eye and vision health services provided at Federally Qualified Health Centers in the United States and identified key barriers and potential strategies to improve access to care. Among an initial 423 articles, 43 met inclusion criteria for the review.
Findings from this research indicated that just 18.3% to 29% of Federally Qualified Health Centers (FQHCs) offered on-site vision services. Diabetic retinopathy was the most commonly evaluated eye condition (26 studies), followed by general eye health (11 studies) and glaucoma (6 studies). Investigators also found that telehealth initiatives played a crucial role in expanding access to vision care.
Because FQHCs often lack dedicated ophthalmologists or optometrists, some centers rely on visiting eye care professionals, but these arrangements are inconsistent and may not provide adequate follow-up care, the investigators—led by Patricia Bai, MD, of the Department of Ophthalmology and Visual Sciences at the Illinois Eye and Ear Infirmary at the University of Illinois Chicago—described in JAMA Ophthalmology. The integration of comprehensive vision services remains an unmet need within many FQHC settings, despite their role in primary health care.
Barriers to vision services at FQHCs were categorized into systemic and patient-related challenges. Systemic barriers included a shortage of eye care professionals, limited financial resources, and inadequate reimbursement structures, which may have made implementing and sustaining vision screening programs difficult. Patient barriers involved financial constraints, a lack of awareness about the importance of routine eye exams, transportation difficulties, and challenges navigating the health care and insurance systems.
Additionally, cultural and language barriers often limited patient engagement in vision care. The studies included in the review showed that many patients treated at FQHCs did not seek eye exams as a result of misconceptions about vision loss prevention, or because they prioritized more immediate health care needs.
Telehealth initiatives may offer benefits to these patients. For example, teleretinal screening programs have been shown to enhance early detection of diabetic retinopathy and other ocular conditions, and telemedicine consultations with ophthalmologists have reduced wait times for referrals and improved the continuity of care. Some programs have successfully implemented remote refraction and vision testing and can offer prescription eyeglasses through FQHCs in collaboration with nonprofit organizations.
By integrating fundus photography into primary care visits, FQHCs were able to improve screening rates for diabetic eye disease. One study in the review demonstrated that incorporating retinal imaging into diabetes care visits increased the annual screening rate from 12% to 20%.
Despite the potential benefits, implementing telehealth vision screening programs may present its own challenges. Issues such as inadequate training for medical staff, poor image quality, and long wait times for specialist referrals hindered program effectiveness, though a study in Chicago demonstrated that these problems could be addressed: the rate of ungradable fundus images decreased from 44% to 0% following targeted staff training and workflow improvements.
Nonetheless, limited broadband access in rural areas also affected the feasibility of teleophthalmology services. Infrastructure investment is needed to support the integration of telemedicine into primary care workflows at FQHCs.
The review also highlighted the need for policy changes to include vision care as a core FQHC service, similar to dental care. Current Medicaid reimbursement rates for vision services at FQHCs are approximately 36% lower compared with rates for private ophthalmology offices, the investigators noted. Expanding federal and state funding for vision services at FQHCs could allow for hiring full-time eye care professionals and purchasing necessary diagnostic equipment. Policymakers may also consider revising Medicare and Medicaid reimbursement policies to improve financial incentives for offering vision care at FQHCs.
Echoing studies analyzed for the review, the investigators offered additional suggestions to expand vision services at FQHCs, particularly partnerships among eye care providers, ophthalmology and optometry residencies, and FQHCs. Such partnerships, they wrote, “provide more exposure to working within an FQHC system during training and beyond to increase awareness among the vision specialist workforce regarding opportunities to improve vision health for underserved populations. Additionally, these partnerships can consider initiative to increase health literacy surrounding the importance of routine eye examinations.”
Articles that included FQHCs without explicitly labeling them as such may have been excluded from the review. Other limitations included potential gaps in reported programs, underrepresentation of diseases other than diabetic retinopathy, lack of pediatric data, and variability of the types of studies included in the review.
Disclosures are included in the published research.