A new study addressed the current challenges and missed opportunities in glaucoma screening across health care systems, critically examining the effectiveness of programs in high-income countries and low- and middle-income countries and explored the potential for improvement.
Significant variability in glaucoma care practices, even in well-off areas, was found. Despite existing guidelines, there is both underuse and overuse of diagnostic technologies and treatments. Many glaucoma patients may be undiagnosed or may not be found early enough to prevent vision loss, and a similar proportion might be treated without manifest disease, leading to unsustainable health care costs. The situation is even more challenging in low- and middle-income countries, where 80% of the global population and 90% of people with visual disabilities reside.
“How can we create and maintain a sustainable balance between finding and treating underserved high-risk patients without burdening the broader patient population and societies with over-diagnostics and treatments?” the researchers asked in their review, published in The Journal of Glaucoma. “There is a need to train all physicians to think like public health professionals.”
Challenging the 'At Least We Are Doing Something' Approach in High-Income Countries
There is insufficient evidence to recommend systematic screening for primary open-angle glaucoma in Europe, Finland, the United States, and the United Kingdom because of concerns about the balance of benefits versus harms of screening, as well as a lack of consensus on whether conducting more research on glaucoma screening would be cost-effective. Some experts suggest that a well-conducted major screening trial could be less costly than unplanned, low-quality screening initiatives. There is also debate on the ethics of pursuing more diagnoses when resources may be insufficient to care for already-diagnosed patients. Further, training clinicians to improve diagnosis rates may increase health care costs without also improving outcomes.
Tele-glaucoma screening has shown promise in detecting more cases than in-person examinations, particularly in underserved areas. However, AI-based glaucoma screening may introduce biases, such as the “healthy screenee effect”, where healthier individuals are more likely to participate in screening, leading to skewed results that could affect screening in less healthy patients.
“If professionals and organizations continue adopting interventions that are not cost-effective, they not only increase the demand, needs, and expenditures of the services but also enhance the perception of increasing underfunding,” the researchers wrote.
Focuses for Low- and Middle-Income Countries
The American Academy of Ophthalmology recommends targeted glaucoma screening for high-risk populations, such as African Americans, Hispanics, older adults, and those with a family history of glaucoma.
Glaucoma screening is suggested to be cost-effective in low-income countries like Nigeria and rural India, where the risk of blindness is higher. However, challenges such as low screening attendance and lack of resources, including trained personnel, hinder effective screening efforts.
Obtaining research funding for glaucoma screening in low-income settings is difficult because of lack of financial incentives for stakeholders. Simulations suggest that glaucoma screening could be cost-effective in both urban and rural China, but further research is needed to improve screening attendance rates.
Missed Opportunities in Screening
“We need to understand how the cumulative effect of small changes in clinical practice (eg, adding a new diagnostic test) have massive impacts on health care budgets,” the investigators concluded. “Advanced, fast and seemingly easily interpretable diagnostic technologies as well as more frequent testing lead to a situation where findings of a ‘disease’ become so subtle that even experts disagree who has the diagnosis. This phenomenon applies extremely well to glaucoma.”
In exploring alternatives, they recommended a systems approach in addition to individual-level evaluation and treatment. They suggested prioritizing patients who have “the biggest risk for visual disability, implementing different technologies appropriately both in screening/case finding and follow-up protocols, and educating and collaborating with trained non-physician staff.”
A full list of author disclosures can be found in the published research