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How Many Patients Lost To Follow-Up Is Too Many?
During his fellowship in glaucoma at Duke University, Dr. Williams observed that many glaucoma patients were lost to follow-up, resulting in poorer outcomes compared to those who received consistent care.
He examined an internal data set to determine how patients fared if they lapsed and found that approximately one-third of patients lapsed within 10 years. Of those who returned, two-thirds had disease progression or glaucoma-related complications and required additional surgery and medication.1
With that information in mind, it becomes clear that a significant lapse in care exists, and individuals who experience such lapses tend to fare worse. Dr. Williams applied for grants to examine the IRIS registry, a national ophthalmic database collected by the American Academy of Ophthalmology and Research to Prevent Blindness AAO.
The IRIS registry represents approximately 70% of ophthalmologists, constituting a large cohort of ophthalmic patients.2 This longitudinal cohort study examined patients in the first full year of the data set (2014) and the last full year before the COVID-19 pandemic (2019). And the question Dr. Williams sought to answer was how many patients with primary open-angle glaucoma maintain their care over time?
The answer: about half of the patients lapsed by over a year during the 6-year period. Importantly, the IRIS registry tracks each patient with a unique ID, so even if patients switch practices, their follow-ups remain recorded as long as the new practice participates in the IRIS registry.2
Dr. Williams points out that two-thirds of those patients who lapsed in care simply never returned.2 It is essential to note that if a patient has been absent for several years, they're unlikely to return.
There are a few categories of patients who are at a higher risk of being lost to follow-up, including:2
- Patients without insurance
- Patients with advanced disease
- Patients who were visually impaired or blind
For patients who had a gap in care and returned, based on blindness as measured by the Snellen VA, approximately 5% of them developed blindness in one or both eyes over that time period, as the IRIS registry does not report visual field data. Those who had lapsed in care for 3 or 4 years were more than twice as likely to go blind as those who maintained care.3
These findings highlight the critical role of follow-ups in patient care, underscoring the common occurrence and severe consequences of patients being lost to follow-up.
Treatment and Compliance
These results reinforce the need to select therapies that reduce or eliminate the patient compliance factor. Patients who received intervention, including glaucoma surgery or laser trabeculoplasty, were less likely to be lost to care.2
Early intervention not only helps keep patients engaged in their disease management but may also prevent blindness in those who lapse in care. For instance, the LiGHT trial compared medications to laser trabeculoplasty and found that while intraocular pressure (IOP) was similar, visual field preservation was superior in the laser group.4
This is because laser treatment offers built-in compliance, working continuously, unlike medications that rely on daily patient adherence. These data have helped Dr. Williams’ patient conversations when discussing treatments with patients.
He leads the conversation with a recommendation for laser treatment first, followed by an ophthalmic drop. The same line of reasoning applies to extended-release prostaglandins in various forms. It is essential to inform the patient that they will benefit from an intervention that is effective all the time, as this is better for long-term vision preservation.
Dr. Gupta notes that practitioners sometimes overlook other contributing issues that can affect patient compliance, such as:
- Potential side effects
- Difficulties with manual dexterity
- Challenges in mental capacity, especially in our aging population
- Financial assumptions
These treatment options are excellent for patients. When they have concerns about effectiveness or if they fail, more choices are available to help select the best approach. An extended prostaglandin treatment might be better suited for one patient, while SLT could be more appropriate for another. For patients with both cataracts and glaucoma, it offers an additional opportunity for intervention to reduce reliance on eye drops.
It's helpful to present these options without committing to a filtering procedure, tube, or trabeculectomy, while still allowing for enhancement of the natural outflow process and early intervention in mild-to-moderate stage disease. This approach helps preserve patients' vision.
Addressing Missed Follow-Ups
The question that ophthalmologists need to ask is “What can we do to address these lapses in care and loss to follow-up?”
The first step is to identify why patients might be lost to follow-up. There are several reasons why patients may miss follow-up appointments including:5
- Forgetfulness
- Appointment scheduling conflicts
- Lack of transportation
Consider sending a reminder message and phone calls. If patients no-show for an appointment, it’s best to call or send them a reminder to inform them that they missed their appointment and reinforce the importance of care.
It's essential to ask patients if they need help, but there are also health-related social resources that can provide benefits, such as transportation, which is a major barrier. A patient navigator is a valuable resource for connecting patients to services that can help them maintain their care.
They can help patients find transportation resources, such as local transit, ridesharing services, or community programs, and assist in scheduling appointments during off-peak hours or when services are available.5
Final Thoughts
Glaucoma is a complex condition to manage. Over a 6-year period, about 50% of patients are lost to follow-up. Practitioners should take all necessary steps to prevent patient loss. Phone calls, reminder messages, and social needs screenings, along with early intervention, help maintain care and ensure long-term IOP reduction continues effectively.
PM-US-3561
Dr. Andrew Williams was compensated by Glaukos for his time.
