Census of Alabama Eye Care Providers

Census of Alabama Eye Care Providers

Prepared for

By

Paul A. MacLennan, MPH, PhD Cynthia Owsley, PhD, MSPH Karen Searcey, MPSH Gerald McGwin, Jr., MS, PhD June 2012

Author Information: Paul MacLennan PhD Assistant Professor Department of Surgery School of Medicine University of Alabama at Birmingham Cynthia Owsley PhD, MSPH Nathan E. Miles Chair of Ophthalmology Vice Chair for Clinical Research Department of Ophthalmology School of Medicine University of Alabama at Birmingham Karen Searcey, MSPH Clinical Research Unit Manager Department of Ophthalmology School of Medicine University of Alabama at Birmingham Gerald McGwin Jr. MS, PhD Professor of Epidemiology, Ophthalmology, and Surgery Vice Chair of Epidemiology School of Public Health University of Alabama at Birmingham

2

FUNDING SUPPORT This work was funded by the EyeSight Foundation of Alabama, with supplementary support from UAB’s Comprehensive Diabetes Center; Department of Ophthalmology, School of Medicine; Minority Health and Disparities Research Center; School of Public Health; and Vision Science Research Center.

3

ACKNOWLEDGMENTS We appreciate the guidance of Torrey V.A. DeKeyser, Executive Director, and Shirley Hamilton, Director of Grants and Communications; Stephen A. Yoder, JD, Chairman, Board of Trustees; and N. Carlton Baker Jr., Immediate Past Chairman, Board of Trustees, all of The EyeSight Foundation of Alabama.

We thank the following individuals for facilitating our efforts in surveying eye care providers in Alabama: Amanda Buttenshaw, CAE, Executive Director, Alabama Optometric Association; Mike Merrill, JD, Executive Director, Alabama Academy of Ophthalmology; Fred Wallace, OD, Executive Director, Alabama Board of Optometry; Dawn DeCarlo, OD, Associate Professor of Ophthalmology, UAB; Jennifer Elgin OTR/L, CDRS, Occupational Therapist, Department of Ophthalmology, UAB and Tammy Than OD, Associate Professor of Optometry, UAB. In addition, we thank Melissa Braswell, Research Specialist, Clinical Research Unit, UAB Department of Ophthalmology, for assistance with data collection.

4

TABLE OF CONTENTS EXECUTIVE SUMMARY .........................................................................6 BACKGROUND .........................................................................................8 METHODS ................................................................................................10 RESULTS ..................................................................................................15 Provider characteristics Ophthalmologists ...........................................................................19 Optometrists ...................................................................................20 Rehabilitation providers .................................................................21 Practice characteristics Ophthalmologists ...........................................................................22 Optometrists ...................................................................................25 Rehabilitation providers .................................................................28 Patient characteristics Ophthalmologists ...........................................................................31 Optometrists ...................................................................................33 Rehabilitation providers .................................................................35 Provider opinions Ophthalmologists ...........................................................................37 Optometrists ..................................................................................40 Rehabilitation providers .................................................................43 DISCUSSION ............................................................................................46 REFERENCES ..........................................................................................51 APPENDICES Appendix A. Eligible and participating providers by county ........57 Appendix B. Provider surveys .......................................................60 Appendix C. Domains and subcategories for written responses....81

5

Executive Summary In 2010 the EyeSight Foundation of Alabama commissioned a survey of eye care providers in Alabama as part of a needs assessment for eye health and eye care issues in Alabama. The survey’s specific purpose was to obtain information about the characteristics of providers (ophthalmologists, optometrists, visual rehabilitation specialists), and their practices and patients.

In addition, providers’ opinions were solicited on major unmet eye care needs in Alabama. This report is a summary of the survey methodology and its results. A survey with similar although not identical content was previously conducted in 1999 shortly after the Foundation was created.

The current survey, carried out about ten years after the original survey, was conducted in order to get an up-to-date picture on the topic. The results of this survey will provide guidance to the Foundation for potential areas of need. It is also hoped that this report will serve as a resource to clinicians, researchers and policy-makers in Alabama.

Surveys specific to each provider group were developed and administered. These surveys requested information regarding four domains: provider characteristics, practice characteristics, patient characteristics and provider opinions as elicited by two opened-ended questions. Survey participants were identified from August 2010 to October 2010 through information obtained from professional associations, licensing boards, and internet searches. The final group of eligible participants consisted of 1,033 vision care providers: 217 ophthalmologists, 638 optometrists and 178 rehabilitation providers. Survey participants were contacted over a tenmonth period from November 2010 through August 2011. Overall, 438 of eligible vision health providers participated in the survey. Participation varied by provider group with ophthalmologists having the highest participation rate (51.2%), followed by rehabilitation providers (45.5%) and optometrists (38.6%).

The survey found that many Alabama communities are geographically isolated from eye care services. Due to long travel distances, people who live in rural areas have increased barriers to receive basic and specialized eye care, and vision rehabilitation services. Among survey participants, Jefferson County had the highest number of participants, followed by Madison, Mobile, Shelby and Montgomery. The majority of participating vision care providers was located in urban counties. All rehabilitation providers located in rural areas were in northern rural counties but none were located in southern counties.

The majority of participating ophthalmologists, optometrists and rehabilitation providers identified themselves as white of non-Hispanic origin. According to 2010 US Census estimates, over one-quarter of Alabama’s population is African American. Previous research indicates that rates of vision impairment and eye disease among African Americans are two times higher than those of whites, especially uncorrected refractive error, cataract, glaucoma, and diabetic retinopathy. Research suggests that provider-patient communication and the use of preventive services can be facilitated when there is racial/ethnic concordance between providers and patients. Thus, it is possible that an increase in the number of African American ophthalmologists and optometrists in Alabama would have positive benefits on eye health in the state.

6

The growing prevalence of diabetes in Alabama is likely to result in more people, and at younger ages, at risk for diabetic eye diseases. Diabetic retinopathy is the leading cause of blindness among working age adults in the United States. Those with diabetes are also at increased risk for glaucoma and cataracts. Based on Centers for Disease Control & Prevention estimates, Alabama has a higher prevalence of diabetes than any other state. In the current survey, ophthalmologists and optometrists estimated that 27% and 22%, respectively, of their patients had diabetes; however, providers estimated that the proportion that adhered to eye care guidelines was 61% among ophthalmology patients and 53% among optometry patients. Programs that enhance the likelihood of early detection and monitoring with timely treatment could stop or slow disease progression.

A frequently expressed opinion among participating ophthalmologists, optometrists and vision rehabilitation providers was the need for more providers. A recent analysis concluded that due to changing patient demographics, retirement, and a fixed number of ophthalmology residency slots nationwide, ophthalmology will face substantial challenges in manpower by year 2020.

Four priority focus areas were identified that can potentially deliver significant benefit to the eye health of Alabamians. They are: 1) Identify strategies to increase the number of eye care providers, including more African American providers; 2) Develop and implement strategies in the eye care system for improved detection and follow-up management of the ocular complications of diabetes; and 3) Develop and implement strategies to improve access to eye care, satellite eye care practices, telemedicine approaches and possibly transportation systems.

(4) Scientifically evaluate these and any other public eye health interventions to improve the quality of and access to eye care in Alabama, in terms of their impact on both health outcomes and cost, so that eye health strategies in the state are evidence-based.

7

BACKGROUND Vision health is an important public health concern that affects Alabama’s children, adults and the elderly. Even though research has shown that early detection and treatment are effective in preventing many vision problems, adequate vision care remains an unmet need for many Americans.1 Compared to many other chronic diseases, the personal and economic burden associated with eye disease is high.2,3 Those with vision impairment have difficulties with communication, mobility and performance of everyday tasks, and among older adults visual deficits can result in increased isolation, depression, disability and premature death.4,5 Among infants and children, the most prevalent and disabling problems include amblyopia, strabismus, and uncorrected refractive error.6 For adults younger than 40, problems related to refractive error are common but eye injury is also prevalent.7 Other eye diseases that can be detected and treated early among at risk adults include glaucoma and diabetic eye conditions. For people 40 and older, the most common eye diseases are age-related macular degeneration, cataract, diabetic retinopathy, and glaucoma.1 With increasing age the prevalence of blindness and vision impairment increase dramatically and is greatest for those older than 75; as the population ages, the number at risk also increases.8 Moreover, the prevalence of diabetes in the United States has more than doubled over the past 20 years,9 a trend that is expected to continue,10 increasing the numbers at risk for diabetic retinopathy.

Inadequate access to eye care results in delayed diagnosis, causing unnecessary increases in burden of disease, disability and costs.2,3 For some eye diseases such as cataract, glaucoma, agerelated macular degeneration, and diabetic eye conditions and retinopathy, by the time symptoms are apparent, damage is permanent that could have been avoided or delayed. A recent Centers for Disease Control and Prevention (CDC) Vision Impairment Task Force reported that the primary barriers related to individuals’ decisions not to seek vision care (i.e., screening, diagnosis, treatment and rehabilitation) were related to behavior, costs, and accessibility.11 Many people are unaware of the importance of eye care and often cite the reason for not seeking care as “did not feel a need.”12 However, barriers to eye care are not equivalent for all groups. For example, a recent investigation of perceptions and beliefs of vision care among older African Americans who resided in Birmingham and Montgomery reported that the most frequently cited barrier to care was transportation, followed by trusting the doctor, communicating with the doctor, and costs.13 A similar investigation of eye care beliefs among elderly African Americans in Maryland reported that cost was the most important barrier.14 Prohibitively high cost is frequently identified as a barrier to eye care.12 As an example, researchers utilizing the CDC’s Behavioral Risk Factor Surveillance System reported that among women 40 and older diagnosed with diabetic retinopathy, glaucoma and age-related macular degeneration, those without eye care insurance less frequently followed recommended guidelines for visiting an eye-care provider.15 The proportion of Alabama’s population without health insurance is relatively large and has increased in a short time from a low of 12.5% in 2005 to approximately 16% in 2011.16 Medicaid is a state run health insurance program for certain, qualifying low income populations; however, not all people with low incomes or those without insurance qualify for Medicaid. For those who do qualify, coverage may not be accepted by providers because it fails to cover their costs. Among Medicare patients, routine eye examinations for those without eye conditions are not covered. The costs for spectacles and 8

contact lenses are not covered (except for spectacles following cataract surgery). For those with health care insurance, coverage may be insufficient for purchasing spectacles and prescription medications, or high co-pays may act as disincentives to seeking care. Among adults with selfreported severe vision impairment, eye care utilization in the preceding 12 months was no greater than 61% for those with vision care insurance and 34% for those with no insurance.

Overall, those with vision care insurance are more than twice as likely to have an annual eye examination. Other factors associated with increased likelihood of eye care utilization include higher income, and greater educational attainment.17 Accessibility is also an important barrier to eye care and is related to patients’ geographic location and the lack of general and specialized providers in some geographic areas.12 Research has reported that rural populations are at increased risk for vision problems relative to urban populations.18 Owsley et al. (2006) reported that transportation was the most frequently perceived barrier among older African Americans.13 Interestingly, study participants were drawn from Birmingham and Montgomery, two of the largest cities in Alabama where, compared to other locations in the state, the prevalence of providers is high and transportation options greater.13 Previous research has advocated an integrated approach to reduce the burden of vision impairment through multilevel interventions of a number of identified modifiable factors (system, provider and patient) associated with increased disease incidence.11 Information about the prevalence of these risk factors can be used to inform policy makers and stakeholders to identify and understand gaps in care. Ultimately, information can be used for targeted multilevel interventions, directed at those in greatest need and ensuring that scarce public health care dollars are focused on areas identified through scientific evidence.11 A survey carried out by the Alabama Eye Institute (former name of the EyeSight Foundation of Alabama) in 1999 identified eye care providers working in Alabama, the services available to address vision problems, and services provided by ophthalmologists and optometrists, and reported participating eye care providers’ perceptions of what the major eye care needs were in their communities.19 The researchers summarized the major gaps in service availability for eye health and vision problems as needs for: (1) public education concerning the importance of routine screening and preventative eye care; (2) financial support for eye health services; (3) greater availability of rehabilitation and adaptive aids and services; and (4) improved geographic access to specialty services.19 Over ten years has passed since the previous survey and although informative, the current survey aims to provide up to date information on many of the topics included in the previous survey. It also aims to increase the numbers of participants, and to enquire more deeply into the characteristics of providers, their practices, and patients. The current assessment of Alabama’s eye care providers, their patients, and available services will help to identify gaps in services by aligning known resources to population needs.

9

METHODS This is a survey of eye care providers delivering eye care in the State of Alabama. The Institutional Review Board of the University of Alabama at Birmingham reviewed and approved the survey’s protocol.

Study Population The survey population consisted of three provider groups: (1) Ophthalmologists, defined as physicians (MD or DO) who have a medical license in Alabama per the Alabama State Board of Medical Examiners, have completed residency training in ophthalmology, and practice at least part time in Alabama; (2) Optometrists, defined as those who have a Doctor of Optometry degree, are licensed by the Alabama Board of Optometry to practice optometry in Alabama, and practice at least part time in Alabama; and (3) Vision rehabilitation providers, defined as those who provide vision rehabilitation services and practice at least part time in Alabama.

Ophthalmologists or optometrists who provide vision rehabilitation services were categorized with their respective profession (ophthalmologist or optometrist), not in the vision rehabilitation provider category.

Survey participants were identified from August 2010 through October 2010. Identification and contact information was initially obtained from professional associations, licensing boards, and internet searches. Attempts were made to contact all potential participants via telephone to verify that providers still worked in Alabama and that their contact information was correct. When incorrect, contact information was updated; however, participants who met the exclusion criteria, e.g., retired and no longer practicing, deceased, or relocated outside of Alabama, were deemed ineligible.

Overall, 1,337 potential participants were identified: 378 ophthalmologists, 759 optometrists, and 200 rehabilitation providers (Table 1). Of these, 42.6% of ophthalmologists (161 of 378), 15.9% of optometrists (121 of 759), and 11.0% of rehabilitation providers (22 of 200) were deemed ineligible of whom, 88.2%, 92.6%, and 72.7%, respectively, were excluded because they no longer worked in Alabama. In addition, 8.1% and 1.7% of the ineligible ophthalmologists and optometrists, respectively, were excluded because they were still in training. The final group of eligible participants consisted of 1,033 vision care providers: 217 ophthalmologists (21.0%), 638 optometrists (61.8%) and 178 rehabilitation providers (17.2%).

Jefferson County had the greatest number of eligible providers overall and in each provider group; 36.4% of ophthalmologists, 27.4% of optometrists, and 39.9% of rehabilitation providers (Table 2). The majority of vision care providers (94.0% of ophthalmologist, 79.6% of optometrists, and 85.4% of rehabilitation providers) were located in urban counties. There were ten counties for which no eligible providers were identified: Bullock, Clay, Coosa, Hale, Lawrence, Lowndes, Monroe, Randolph, Washington, and Wilcox. A detailed list of county level eligibility and participation by provider type is found in Appendix A.

10

Table 1. Determination of eligibility status among study subjects by provider group Ophthalmologists Optometrists Rehabilitation Potential participants 378 759 200 Eligibility (%) Eligible 217 (57.4) 638 (84.1) 178 (89.0) Ineligible 161 (42.6) 121 (15.9) 22 (11.0) Ineligible reason (%) Not practicing in Alabama 142 (88.2) 112 (92.6) 16 (72.7) Medical leave/disability 2 ( 1.2) 0 ( -- ) 0 ( -- ) Residency 13 ( 8.1) 2 ( 1.7) 0 ( -- ) Duplicate entry 1 ( 0.6) 4 ( 3.3) 1 ( 4.6) Other 3 ( 1.9) 3 ( 2.5) 5 (22.7)

Table 2. County and region location of eligible participants by provider group Ophthalmologists Optometrists Rehabilitation 217 638 178 Top ten counties by numbers of eligible participants, N (%) Jefferson 79 (36.4) 175 (27.4) 71 (39.9) Madison 19 ( 8.8) 53 ( 8.3) 9 ( 5.1) Mobile 26 (12.0) 33 ( 5.2) 12 ( 6.7) Shelby 5 ( 2.3) 49 ( 7.7) 9 ( 5.1) Montgomery 20 ( 9.2) 31 ( 4.9) 9 ( 5.1) Houston 19 ( 8.8) 18 ( 2.8) 3 ( 1.7) Tuscaloosa 6 ( 2.8) 18 ( 2.8) 9 ( 5.1) Baldwin 5 ( 2.3) 23 ( 3.6) 1 ( 0.6) Talladega 3 ( 1.4) 5 ( 0.8) 16 ( 9.0) Calhoun 4 ( 1.8) 16 ( 2.5) 3 ( 1.7) Eligibility by regiona (%) Urban 204 (94.0) 508 (79.6) 152 (85.4) North rural 7 ( 3.2) 68 (10.7) 22 (12.4) South rural 3 ( 1.4) 53 ( 8.3) 2 ( 1.1) Black Belt 3 ( 1.4) 9 ( 1.4) 2 ( 1.1) a 20 Based on regional classification defined by the Alabama Department of Public Health

Survey Instrument Surveys specific to each provider group were developed by the authors of this report with input from providers in the fields of ophthalmology, optometry, and vision rehabilitation. For all provider types, survey structure was similar and requested information regarding four areas of interest: provider characteristics, practice characteristics, patient characteristics and provider opinions as elicited by two opened-ended questions. In general, the length of all three surveys was similar, for example, ophthalmologists were asked 31 questions while optometrists and rehabilitation providers were asked 30 questions. Many of the questions were similar, but a moderate proportion of survey questions were unique to each provider type (see Appendix B).

11

Provider characteristics questions inquired about demographics (i.e., race/ethnicity, age and gender) and training. With respect to training, information was requested from ophthalmologists regarding the year of residency completion, whether residency was followed by a fellowship, and if yes, the field of training; from optometrists, the year of receiving optometry degree, whether specialty training was completed, and if yes, the field of specialty training; and from rehabilitation providers, the year of receiving highest degree and vision rehabilitation specialty.

Practice characteristics questions inquired about practice types, other settings where services were provided, practice organization and function, types of insurance accepted, and available patient services. Practice type information included whether respondents worked in group practice with another ophthalmologist or optometrist, and whether their practice was based at a university, Department of Veterans Affairs facility, rehabilitation hospital, general hospital, outpatient rehabilitation clinic, independent service for the visually impaired, State agency, optical retail shop, or other type. Those who selected other were asked to be specific. In addition, information was requested about other settings where participants provided services. Other settings included: day programs in public or private schools, residential schools, general hospitals, in-patient psychiatric hospitals, nursing homes, State or Federal prisons or local jails, and other. Those who selected other were asked to be specific.

Requested practice organization and function information included whether services were provided in group practice, whether an optical shop was located at the practice, if services were provided in Spanish, the typical amount of time from patients’ seeking an appointment to seeing the provider, if walk in appointments were accepted, the average number of patients personally seen per week, and sources of patient referral. We also asked whether insurance was accepted and if yes, the types of insurance.

The final practice characteristics questions were specific to each provider type and solicited information about types of services provided. Both ophthalmologists and optometrists were asked whether services provided included: comprehensive eye care for adults, comprehensive eye care for infants and children, and contact lens fitting and dispensing. Ophthalmologists were asked whether they provided any of the following services: cataract surgery, refractive surgery, retinal – vitreal surgery, glaucoma surgery, corneal surgery, oculo-plastic surgery, visual rehabilitation services, neuro-ophthalmological services and other. Optometrists were asked whether they provided vision therapy and/or low vision rehabilitation services. Those who selected other were asked to be specific. Rehabilitation providers were asked whether they provided in-home services, and the following training services: the use of assistive devices (e.g., optical, non-optical), orientation and mobility, eccentric viewing or preferred retinal loci, scanning strategy, strategies to perform everyday visual tasks (e.g., household activities, managing money, preparing meals), and the use of computers and software. Rehabilitation providers were also asked if they offered any of the following services: psychological or counseling, support groups (for clients and/or families), social work, driving rehabilitation, home-based visits for education or training, vocational rehabilitation or career counseling, and other. Those who selected other were asked to be specific.

Patient characteristics questions inquired about the providers’ patient or client base, specifically demographics, i.e., the estimated proportions of patients by age group, race, and 12

gender; and the estimated proportions of patients by insurance type (e.g., Medicare, Medicaid, and private insurance).

All providers were asked to estimate the prevalence of each of the following eye conditions among their patients: refractive error, amblyopia, strabismus, dry eye, age-related macular degeneration, glaucoma, diabetic eye conditions including retinopathy, cataract, vision loss from brain injury including stroke, juvenile or young adult onset retinal degenerations, optic neuritis or other optic nerve disorders, retinopathy of prematurity, corneal problems, complications from contact lens wear, conjunctivitis, ocular trauma, and refractive error. Participants were asked to estimate the prevalences of diabetes and low-vision among their patients; ophthalmologists and optometrists were asked to estimate the proportion of diabetic patients that adhere to eye care guidelines. In addition ophthalmologists and optometrists were asked where low-vision patients in need of rehabilitative services were referred. Finally, rehabilitation providers were asked to estimate the proportion of their patients with the following specific difficulties or problems: reading, writing, financial management, other detailed near tasks, independent living, mobility, driving, identification of objects/ people/ events from a distance, self care/domestic activity, and emotional or psychological adjustment.

Provider opinions were sought for two open ended questions: 1) “What are the greatest unmet eye care needs in your community?” and 2) “What single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community?” Responses were reviewed by two researchers with experience in health care research, and general domains were defined and within those domains, specific subcategories were delineated. For the first question regarding unmet community needs, five general domains were defined: clinical care, education, accessibility, eye care organization, and policy. For the clinical care domain, subcategories included eye care, glaucoma screening, diabetic retinopathy screening, pediatric in general, pediatric screening, pediatric comprehensive eye exams, and Hispanic care. For the education domain, subcategories included education to the public and provider education. For the accessibility domain, subcategories included transportation to appointments, satellite clinics, and nursing homes. For the eye care organization domain, subcategories included more providers, new eye hospital, dyslexia services, disparities, blind services, VA services, handicapped children, dual sensory impairment screening, sports related, and support groups. For the policy domain, subcategories included financial assistance with prescriptions, lower co-pays for office visits, higher reimbursements, spectacles for Medicare, state funds for disability services, pedestrian mobility paths, school screenings, funding for school spectacles, assistance to indigent patients, and vision rehabilitation funding.

General domains and subcategories for the second question regarding what single action by a private foundation would make the greatest improvement in community’s eye care included: fund research, education (public and provider), accessibility (transportation to appointments), policy, clinical care and screening, and building relationships.

Text responses were reviewed by two members of the research team, and each independent statement (many participants gave several) was classified according to its corresponding general domain and subcategory. For example, a response that stated that glaucoma screening was an unmet eye care need would fall into the clinical care domain and the specific category of 13

glaucoma screening. A thorough description of the general domains and specific categories within them is available in Appendix C.

Survey Conduct Study participants were contacted over a ten-month period from November 2010 through August 2011. Eligible subjects (N=1,033) were first contacted via mail informing them of the study goals and requesting their participation. Included in the mail contact was a survey specific to subject provider type and a pre-paid return envelope. Additional steps were taken to encourage participation among non-responders; these included: telephone calls to practices to remind the provider about the opportunity to participate, faxes and emails by study personnel to the provider, attendance at several professional seminars and conferences where surveys were made available, two announcements of the survey in the Alabama Optometric Association monthly newsletter, a mass email to members of the Alabama Optometric Association, and the option of completing the survey online.

Analysis Results are presented for each survey domain (provider characteristics, practice characteristics, patient characteristics and provider opinions) by provider group. Calculated percentages are based on the numbers of providers who responded to the question. For example, although 111 ophthalmologists participated in the survey, only 109 responded to the race/ethnic group question and 107 responded to the gender question; thus, for those questions, denominators for calculating percentages were 109 and 107, respectively.

14

RESULTS Overall, 438 (42.4%) of 1,033 eligible vision health providers participated in the survey (Table 3). Participation varied by provider group with ophthalmologists having the highest participation (51.2%), followed by rehabilitation providers (45.5%) and optometrists (38.6%).

Table 3. Region and county of participants by provider group Ophthalmologists Optometrists Participants 111 246 Top ten counties by numbers of participants, N (%) Jefferson 46 (41.4) 80 (32.5) Madison 10 ( 9.0) 23 ( 9.4) Mobile 11 ( 9.9) 15 ( 6.1) Shelby 2 ( 1.8) 22 ( 8.9) Montgomery 10 ( 9.0) 15 ( 6.1) Houston 9 ( 8.1) 6 ( 2.4) Tuscaloosa 4 ( 3.6) 8 ( 3.3) Baldwin 2 ( 1.8) 4 ( 1.6) Talladega 3 ( 2.7) 1 ( 0.4) Calhoun 1 ( 0.9) 4 ( 1.6) Participants by region (%) Urban 105 (94.6) 200 (81.3) North rural 6 ( 5.4) 23 ( 9.4) South rural 0 ( -- ) 21 ( 8.5) Black Belt 0 ( -- ) 2 ( 0.8)

Rehabilitation 81

27 (33.3) 7 ( 8.6) 7 ( 8.6) 5 ( 6.2) 5 ( 6.2) 0 ( -- ) 3 ( 3.7) 1 ( 1.2) 11 (13.6) 0 ( -- ) 67 (82.7) 14 (17.3) 0 ( -- ) 0 ( -- )

By county of location, Jefferson County had the highest number of participants, followed by Madison, Mobile, Shelby and Montgomery. The majority of participating vision care providers was located in urban counties. However, relative to ophthalmologists (5.4%), a greater number of optometrists (18.7%) and rehabilitation providers (17.3%) were located in rural areas. All rehabilitation providers located in rural areas were in northern rural counties but none were located in southern counties. Only two survey participants were from Black Belt counties; both were optometrists.

Figures 1 – 3 provide information on the numbers of ophthalmologists and optometrists per 10,000 county residents eligible for the survey, regardless of whether they participated or not, organized by county location. Figures 2 and 3 provide additional information regarding the number of ophthalmologists and optometrists per county.

15

Figure 1. County Location of Ophthalmologists and Optometrists for every 10,000 County Residents, Alabama (2010)

16

Figure 2. County Location of Alabama Ophthalmologists (2010)

17

Figure 3. County Location Alabama Optometrists (2010) 18

PROVIDER CHARACTERISTICS Ophthalmologists The majority of participating ophthalmologists identified themselves as non-Hispanic White (94.5%), with only one or two reporting for each of the other race/ethnicity groups (Table 4).

Respondents’ average age was 53 years and most (88.8%) were male.

Table 4. Demographic characteristics of ophthalmologists Race/ethnicity group (%) White, non-Hispanic African-American Hispanic Asian Native American Other Average age (SD) Gender (%) Male Female

103 (94.5) 1 ( 0.9) 1 ( 0.9) 2 ( 1.8) 1 ( 0.9) 1 ( 0.9) 53.0 (11.8) 95 (88.8) 12 (11.2)

Among ophthalmologists, 25.2% completed their residency training in 2000 or after, 19.8% in the 1990s, 19.8% in the 1980s, and 35.2% before 1980 (Table 5). Approximately 50% of ophthalmologists had completed a fellowship, and among those, the most common areas of specialty were retina (20.4%), cornea (18.5%), glaucoma (16.7%), pediatric ophthalmology (13.0) and oculoplastics (13%). Other specialties specified by respondents included: anterior segment, aviation ophthalmology, cataract, general ophthalmology, nuclear ophthalmology, ocular trauma, and refractive surgery.

Table 5. Training characteristics of ophthalmologists Year residency training completed 2000 and after 1990 – 1999 1980 – 1989 Before 1980 Fellowship post residency?

Yes Fellowship field Retina Glaucoma Cornea Pediatric Ophthalmology & Strabismus Neuro-Ophthalmology Oculoplastics Visual Rehabilitation Ophthalmic Pathology Ocular Inflammatory Disease Other

N (%) 28 (25.2) 22 (19.8) 22 (19.8) 39 (35.2) 53 (49.5) 11 (20.4) 9 (16.7) 10 (18.5) 7 (13.0) 4 ( 7.4) 7 (13.0) 0 ( -- ) 1 ( 1.9) 1 ( 1.9) 7 (13.0)

19

Optometrists Among participating optometrists, most (89.6%) identified themselves as non-Hispanic White (Table 6). On average they were 45 years of age and though most (55.7%) were male, a large proportion (44.3%) was female.

Table 6. Demographic characteristics of optometrists Race/ethnicity group (%) White, non-Hispanic African-American Hispanic Asian Native American Other Average age (SD) Gender (%) Male Female

216 (89.6) 16 ( 6.6) 4 ( 1.7) 2 ( 0.8) 2 ( 0.8) 1 ( 0.4) 45.7 (12.0) 136 (55.7) 108 (44.3)

Among optometrists, 31.7% received their optometry degree in 2000 or after, 27.2% in the 1990s, 24.4% in the 1980s, and 16.7% before 1980 (Table 7). Among those who reported completing a residency (21.3%), the most frequently areas of specialty training were family practice (26.9%), geriatric optometry (26.9%), low vision rehabilitation (23.1%) and primary eye care (21.1%). Less frequently listed areas of specialty included cornea and contact lenses (9.6%), pediatric optometry (7.7%), vision therapy (3.8%), and refractive and ocular surgery (1.9%).

Other areas of specialty training specified by participants included hospital based and ocular diseases.

Table 7. Training characteristics of optometrists Year O.D. degree received 2000 and after 1990 – 1999 1980 – 1989 Before 1980 Following O.D., residency in specialty?

Yes Residency specialty (%) Community Health Optometry Cornea and Contact Lenses Family Practice Optometry Geriatric Optometry Low Vision Rehabilitation Pediatric Optometry Primary Eye Care Refractive and Ocular Surgery Vision Therapy Other. Specify

N (%) 78 (31.7) 67 (27.2) 60 (24.4) 41 (16.7) 52 (21.3) 0 ( -- ) 5 ( 9.6) 14 (26.9) 14 (26.9) 12 (23.1) 4 ( 7.7) 11 (21.1) 1 ( 1.9) 2 ( 3.8) 16 (30.8)

20

Vision Rehabilitation Providers Among participating rehabilitation providers, 84.0% were non-Hispanic White and 13.6% were African Americans (Table 8). On average participants were 47 years of age and most (80.3%) were female.

Table 8. Demographic characteristics of rehabilitation providers Race/ethnicity group (%) White, non-Hispanic African-American Hispanic Asian Native American Other Average age (SD) Gender (%) Male Female

68 (84.0) 11 (13.6) 1 ( 1.2) 0 ( -- ) 1 ( 1.2) 0 ( -- ) 47.8 (11.1) 16 (19.8) 65 (80.2)

Among rehabilitation providers, 33.3% received their highest degree in 2000 or after, 25.9% in the 1990s, 16.1% in the 1980s, and 24.7% before 1980 (Table 9). Rehabilitation providers’ specialties included educator (30.7%), vision rehabilitation therapist (20.0%) and rehabilitation counselor (16.0%), and vocational rehabilitation counselor (9.3%). It should be noted that these categories are not mutually exclusive and that some of the participants selected more than one answer. Very few participants identified themselves as low vision therapists (5.3%); however, many participants specified another specialty (30.7%) outside of the ones offered in the survey.

Other specialties specified included administration, assistive technology, case manager, and consultant.

Table 9. Rehabilitation providers’ year of highest degree and specialties Year degree received N (%) 2000 and after 27 (33.3) 1990 – 1999 21 (25.9) 1980 – 1989 13 (16.1) Before 1980 20 (24.7) Specialty Occupational therapist 7 ( 9.3) Occupational therapist assistant 0 ( -- ) Vision rehabilitation therapist 15 (20.0) Certified low vision therapist 4 ( 5.3) Social worker 2 ( 2.7) Rehabilitation counselor 12 (16.0) Vocational rehabilitation counselor 7 ( 9.3) Psychologist 2 ( 2.7) Educator 23 (30.7) Other 23 (30.7)

21

PRACTICE CHARACTERISTICS

Ophthalmologists Most ophthalmologists (82.0%) worked in a private practice with one or more ophthalmologists; a lower proportion (24.3%) reported working in a practice with at least one optometrist and 11.7% worked at a university-based practice (Table 10). Very few ophthalmologists reported working in a Department of Veterans Affairs clinic or medical center (2.7%) or in a general hospital (3.6%). No participants reported working in a rehabilitation hospital, outpatient rehabilitation center, independent service for the visually impaired, or state agency. Few ophthalmologists (7.2%) worked in a practice identified as an optical retail store. Other practice types specified by ophthalmologists included a practice based at a hospital, a multi-specialty group, and a common management group of multi-sole practitioners.

Table 10. Practice types of ophthalmologists Private practice with at least one Ophthalmologist Private practice with at least one Optometrist Practice based in a university Department of Veterans Affairs clinic or medical center Rehabilitation hospital General hospital Outpatient rehabilitation center Independent service for the visually impaired State agency Optical retail store Other

N (%) 91 (82.0) 27 (24.3) 13 (11.7) 3 ( 2.7) 0( 4( 0( 0( 0( 8( 4(

-- ) 3.6) -- ) -- ) -- ) 7.2) 3.6)

Relatively few ophthalmologists reported that they provided services in other settings (Table 11). Other settings ophthalmologists offered services included general hospitals (18.2%), inpatient psychiatric hospitals (1.8%) and nursing homes (2.7%).

Table 11. Other settings where ophthalmologists provide services Public or private schools (day programs) Residential schools (e.g., Alabama Institute for the Deaf & Blind, residential schools for the developmentally delayed) General hospitals In-patient psychiatric hospitals Nursing homes State or Federal prisons or local jails Other

N (%) 0 ( -- ) 1 ( 0.9)

20 (18.2) 2 ( 1.8) 3 ( 2.7) 0 ( -- ) 1 ( 0.9)

22

A large proportion of ophthalmologists reported providing comprehensive eye care for adults (78.2%) and children (52.7%), as well as dispensing and fitting of contact lenses (41.8%) (Table 12). Approximately 80% (N=89) of ophthalmologists reported that they performed any type of surgery; 61% of ophthalmologists reported that they performed cataract surgery but fewer performed surgeries that were refractive (20.0%), retinal (13.5%), glaucoma (31.8%), corneal (18.2%) and oculoplastic (33.6%). Few ophthalmologists reported that they provided visual rehabilitation services (2.7%). A greater proportion (13.6%) provided neuro-ophthalmological services. Other services respondents specified included: diagnostic testing, adult strabismus, ocular inflammatory and other immune diseases, and ocular trauma.

Table 12. Services provided by ophthalmologists Comprehensive eye care for adults Comprehensive eye care for infants and children Contact lens fitting and dispensing Cataract surgery Refractive surgery Retinal – vitreal surgery Glaucoma surgery Corneal surgery Oculo-plastic surgery Visual rehabilitation services Neuro-ophthalmological services Other

N (%) 86 (78.2) 58 (52.7) 46 (41.8) 67 (60.9) 22 (20.0) 15 (13.5) 35 (31.8) 20 (18.2) 37 (33.6) 3 ( 2.7) 15 (13.6) 9 ( 8.2)

A large number of ophthalmologists reported that they provided services in a group practice (72.2%) (Table 13). Although very few had previously answered that their practice was an optical shop (Table 10), a greater number (50.0%) reported that an optical shop was located within their practice. Nearly one third (32.7%) provided services in Spanish.

Most ophthalmologists (77.0%) estimated that patients would be seen within two weeks of seeking an appointment but 9.6% estimated that patients could expect to wait for a month or more. Most accepted walk-in appointments (67.0%); 31.1% accepted walk-in appointments only from established patients in an emergency. The median number of patients seen per week was 120, and ranged from 15 to 240. The most common source of referrals was patients’ family and friends (33.5%), followed by patients themselves (24.8%), a physician (17.4%), another ophthalmologist (17.2%), and an optometrist (16.1%). Respondents estimated that very few of their patients were referred by hospitals or emergency rooms (3.9%) and school or pre-school vision screening programs (2.5%).

Most ophthalmologists accepted Blue Cross Blue Shield (93.6%), Medicare (86.4%), Medicaid (85.5%), Tricare/Champus (84.6%), United Healthcare (83.6%), and Medicare Complete (83.6%) (Table 14). Acceptance of other types of insurance plans varied by type, for example, many providers accepted Aetna (79.1%), and Cigna (74.6%); but fewer accepted Viva (61.8%) and Viva Medicare Plus (52.7%); and less than half accepted GEHA (41.8%), Veterans Administration coverage (38.2%), CHIP (38.1%), and Multiplan (30.9%).

23

Table 13. Practice characteristics of ophthalmologists Provide services in group practice Optical shop at practice/agency Services provided in Spanish Time for appointment: < 1 week 1 – 2 weeks 3 – 4 weeks > 1 month Do not know Walk in appointments accepted?

Yes Only in an emergency w/ est. patient No Average number of patients seen per week (SD) Median Range Sources of patient referral (%): Themselves Family or friends An ophthalmologist An optometrist Physician, e.g., a family physician Hospital emergency room School or pre-school vision screening program Other

N (%) 78 (72.2) 52 (50.0) 34 (32.7) 48 (46.2) 32 (30.8) 12 (11.5) 10 ( 9.6) 2 ( 1.9) 69 (67.0) 32 (31.1) 2 ( 1.9) 119.8 (47.5) 120 15-240 24.8 33.5 17.2 16.1 17.4 3.9 2.5 2.1

Table 14. Patient health insurance plans accepted by ophthalmologists Insurance plans N (%) Medicare 95 (86.4) Medicare Complete 92 (83.6) Medicaid 94 (85.5) Blue Cross Blue Shield 103 (93.6) Viva 68 (61.8) Viva Medicare Plus 58 (52.7) United Healthcare 92 (83.6) Cigna 82 (74.6) Aetna 87 (79.1) Multiplan 34 (30.9) GEHA 46 (41.8) Tricare/Champus 93 (84.6) Veterans Administration coverage 42 (38.2) CHIP (Children’s Health Insurance Program) 42 (38.2) Others 9 ( 8.2) Do not accept health insurance 0 ( -- )

24

Optometrists About 2/3 of optometrists (61.0%) worked in a private practice with one or more other optometrists; a low proportion (10.2%) reported working in a practice with at least one ophthalmologist and 8.5% worked at a university-based practice (Table 15). Very few optometrists practiced in a clinic or medical center associated with the Department of Veterans Affairs (4.1%) or in a general hospital (1.2%). A few participants reported working in a rehabilitation hospital (0.4%), general hospital (1.2%), outpatient rehabilitation center (0.4%), independent service for the visually impaired (0.4%), or state agency (0.8%). Few optometrists (18.7%) worked in a practice identified as an optical retail store. Other practice areas reported by optometrists included a non-profit agency, an educational facility, a federally qualified health center, a corporate optometric office, an independent practice within a Wal-Mart, a Lasik center, an Indian reservation, a referral center and a health care center.

Table 15. Practice types of optometrists Private practice with at least one Ophthalmologist Private practice with at least one Optometrist Practice based in a university Department of Veterans Affairs clinic or medical center Rehabilitation hospital General hospital Outpatient rehabilitation center Independent service for the visually impaired State agency Optical retail store Other

N (%) 25 (10.2) 150 (61.0) 21 ( 8.5) 10 ( 4.1) 1 ( 0.4) 3 ( 1.2) 1 ( 0.4) 1( 0.4) 2 ( 0.8) 46 (18.7) 18 ( 7.3)

Few optometrists reported that they provided services in other settings (Table 16). Other settings where providers offered services included public or private schools (4.9%), residential schools (1.6%), general hospitals (3.7%), in-patient psychiatric hospitals (1.6%), nursing homes (11.4%), state or federal prisons and local jails (2.9%). Other settings written that were outside of the choices offered in the survey, included National Guard, community free clinics, and homeless shelters.

Table 16. Other settings where optometrists provide services Public or private schools (day programs) Residential schools (e.g., Alabama Institute for the Deaf & Blind, residential schools for the developmentally delayed) General hospitals In-patient psychiatric hospitals Nursing homes State or Federal prisons or local jails Other

N (%) 12 ( 4.9) 4 ( 1.6)

9 ( 3.7) 4 ( 1.6) 28 (11.4) 7 ( 2.9) 25 (10.2)

25

A large proportion of optometrists reported providing comprehensive eye care for adults (95.1%) and children (81.3%), as well as fitting and dispensing contact lenses (86.2%) (Table 17).

Optometrists reported that 12.6% provided vision therapy and 15.0% provided low vision rehabilitation services. Optometrists also offered other services not listed in the survey, including: occupational and environmental services, and pre- and post- surgery care and management.

Table 17. Services provided by optometrists Comprehensive eye care for adults Comprehensive eye care for infants and children Contact lens fitting and dispensing Vision therapy Low vision rehabilitation services Other

N (%) 234 (95.1) 200 (81.3) 212 (86.2) 31 (12.6) 37 (15.0) 20 ( 8.1)

Approximately half of optometrists reported that they provided services in a group practice (48.8%) (Table 18). Although very few had previously reported that their practice was an optical shop (Table 15), most (92.5%) reported that an optical shop was located within their practice.

Over one quarter (27.3) provided services in Spanish.

Most optometrists (90.5%) estimated that patients would be seen within two weeks of seeking an appointment and only 3.0% estimated that patients would not be seen for a month or more. Most accepted walk-in appointments (75.2%), 22.5% accepted only walk-in appointments from established patients in an emergency. The median number of patients seen per week was 60, and ranged from four to 200. The most common estimated source of referrals was patientsâ&#x20AC;&#x2122; family and friends (38.1%), followed by patients themselves (34.3%), and a physician (12.3%). Less common sources of referrals were from school or pre-school vision screening programs (8.2%), an ophthalmologist (5.1%), another optometrist (4.2%), and hospitals or emergency rooms (2.0%).

Many optometrists accepted Blue Cross Blue Shield (85.0%), Medicare (78.5%), United Healthcare (65.5%), Tricare/Champus (58.9%), Medicare Complete (56.9%), and Medicaid (61.8%) (Table 19). Acceptance of other types of insurance plans varied by type, for example, many providers accepted Cigna (48.4%), Aetna (47.2%), Viva (45.5%) and Viva Medicare Plus (41.5%); but few accepted CHIP (23.6%), Veterans Administration coverage (12.2%), GEHA (10.2%), and Multiplan (6.5%). Optometrists also reported accepting reimbursement from various health plans including: All Kids, VSP, Humana Vision Care/VCP, and Eye Med.

26

Table 18. Practice characteristics of optometrists Provide services in group practice Optical shop at practice/agency Services provided in Spanish Time for appointment (%) < 1 week 1 – 2 weeks 3 – 4 weeks > 1 month Do not know Walk in appointments accepted?

Yes Only in an emergency w/ est. patient No Average number of patients seen per week (SD) Median Range Sources of patient referral: Themselves Family or friends An ophthalmologist An optometrist Physician, e.g., a family physician Hospital emergency room School or pre-school vision screening program Other

Table 19. Patient health insurance plans accepted by optometrists Insurance plans Medicare Medicare Complete Medicaid Blue Cross Blue Shield Viva Viva Medicare Plus United Healthcare Cigna Aetna Multiplan GEHA Tricare/Champus Veterans Administration coverage CHIP (Children’s Health Insurance Program) Others Do not accept health insurance

N (%) 117 (48.8) 211 (92.5) 63 (27.3) 151 (65.4) 58 (25.1) 12 ( 5.2) 7 ( 3.0) 3 ( 1.3) 170 (75.2) 51 (22.6) 5 ( 2.2) 64.3 (36.3) 60 4-200

34.3 38.1 5.1 4.2 12.3 2.0 8.2 5.0

N (%) 193 (78.5) 140 (56.9) 152 (61.8) 209 (85.0) 112 (45.5) 102 (41.5) 161 (65.5) 119 (48.4) 116 (47.2) 16 ( 6.5) 25 (10.2) 145 (58.9) 30 (12.2) 58 (23.6) 35 (14.2) 1 ( 0.4)

27

Vision Rehabilitation Providers No rehabilitation providers listed their practice type as private practice with one or more ophthalmologists or optometrists. Most worked in a state agency (54.3%) and a large proportion practiced at a Department of Veterans Affairs clinic (13.6%) or independent service for visually impaired (13.6%) (Table 20). A few listed practices based in a university (4.9%) and one each worked in a rehabilitation hospital or outpatient rehabilitation center. Among other practice types specified, responses included: ADRS, Alabama Institute for Deaf and Blind (AIDB), public school system, private non-profit rehabilitation center, and home-private office.

Table 20. Practice types for rehabilitation providers Private practice with at least one Ophthalmologist Private practice with at least one Optometrist Practice based in a university Department of Veterans Affairs clinic or medical center Rehabilitation hospital General hospital Outpatient rehabilitation center Independent service for the visually impaired State agency Optical retail store Other

N (%) 0 ( -- ) 0 ( -- ) 4 ( 4.9) 11 (13.6) 1 ( 1.2) 0 ( -- ) 1 ( 1.2) 11 (13.6) 44 (54.3) 0 ( -- ) 21 (25.9)

Other settings where rehabilitation providers offered services included public and private school day programs (25.9%) and residential schools such as the AIDB (22.2%) (Table 21). No participants provided services in a general hospital or an in-patient psychiatric hospital but approximately 10% provided services to nursing homes. Other setting specified included, homes as requested, colleges or universities, and ADRS. Approximately 40% of responding rehabilitation providers worked in a group practice and over one-third provided services in Spanish (Table 22). Patients were able to be seen within twoweeks of seeking an appointment for approximately 60.9% of providers, 11.1% accepted only walk-in appointments from established patients in an emergency. The median number of patients seen per week was 10, and ranged from one to 40. The most common source for referrals was ophthalmologists (15.2%), followed by schools (13.4%), family (13.3%), optometrists (11.1%), vision screening programs (7.0%) and non-ophthalmologist physician (5.6%). Few patients (0.3%) were estimated referred by hospitals or emergency rooms. Other sources specified included ADRS, Vocational Rehabilitation, and VA Services.

28

Table 21. Other settings where rehabilitation participants provide services N (%) Public or private schools (day programs) 21 (25.9) Residential schools (e.g., Alabama Institute 18 (22.2) for the Deaf & Blind, residential schools for the developmentally delayed) General hospitals 0 (----) In-patient psychiatric hospitals 0 (----) Nursing homes 8 (9.9) State or Federal prisons or local jails 3 (3.7) Other 17 (21.0)

Table 22. Practice characteristics of rehabilitation providers Provide services in group practice?

Optical shop at practice/agency?

Services provided in Spanish?

Time for appointment? < 1 week 1 â&#x20AC;&#x201C; 2 weeks 3 â&#x20AC;&#x201C; 4 weeks > 1 month Do not know Do you take walk in appointments?

Yes Only in an emergency w/ est. patient No Average number of patients seen per week Median Range Sources of patient referral Themselves Family or friends Ophthalmologist Optometrist Another physician including a family physician Hospital emergency room Schools Vision screening program Other

N (%) 30 (40.5) 5 ( 6.7) 25 (34.7) 17 (24.6) 25 (36.2) 9 (13.0) 6 ( 8.7) 12 (17.4) 27 (42.9) 7 (11.1) 29 (46.0) 12.9 10 1-40 11.2 13.3 15.2 11.1 5.6 0.3 13.4 7.0 25.8

Few rehabilitation providers accepted health insurance plans for payment (Table 23). For example, the most commonly accepted was Medicaid (14.8%), followed by Medicare (11.1%) and Blue Cross Blue Shield (11.1%). Of those responding, 49.4% did not accept health insurance.

29

Table 23. Patient health insurance plans accepted by rehabilitation providers Insurance plans N (%) Medicare 9 (11.1) Medicare Complete 5 (6.2) Medicaid 12 (14.8) Blue Cross Blue Shield 9 (11.1) Viva 2 ( 2.5) Viva Medicare Plus 2 ( 2.5) United Healthcare 4 ( 4.9) Cigna 3 ( 3.7) Aetna 3 ( 3.7) Multiplan 0 ( -- ) GEHA 0 ( -- ) Tricare/Champus 4 ( 4.9) Veterans Administration coverage 4 ( 4.9) CHIP (Childrenâ&#x20AC;&#x2122;s Health Insurance 1 ( 1.2) Program) Others 8 ( 9.9) Do not accept health insurance 40 (49.4)

Approximately 50% of rehabilitation participants provided in-home services (Table 24). The most frequent service provided was training in the use of assisted devices (63.3%), training in strategies to perform everyday tasks (55.7%), orientation and mobility training (43.0%), homebased education or training (40.5%), computer and software training (39.2), vocational rehabilitation and career counseling services (36.7), and support groups for clients and families (32.9%). Other services specified by respondents included administrative, awareness and outreach, teaching Braille, and cognitive testing.

Table 24. Service characteristics of rehabilitation providers Provide in-home services Services provided: Training in the use of assistive devices (e.g., optical, non-optical) Orientation and mobility training Eccentric viewing training or training in preferred retinal loci Scanning strategy training Training in strategies to perform everyday visual tasks (e.g., household activities, managing money, preparing meals) Psychological or counseling services Support groups (for clients and/or families) Social work services Driving rehabilitation Home-based visits for education or training Vocational rehabilitation or career counseling services Training in the use of computers and software Other

40 (49.4) 50 (63.3) 34 (43.0) 15 (19.0) 20 (25.3) 43 (55.7) 10 (15.2) 26 (32.9) 6 ( 7.6) 3 ( 3.8) 32 (40.5) 29 (36.7) 31 (39.2) 18 (22.2)

30

PATIENT CHARACTERISTICS

Ophthalmologists Ophthalmologists reported that a large proportion of their patients were 60 years and older (57.4%), followed by patients aged 20-59 (26.8%), and younger than 20 (15.3%) (Table 25). The majority of patients were white (57.1%), followed by African American (32.6%). Relatively few patients were estimated to be Hispanic (5.1%) and from other racial/ethnic groups (3.4%). About half of patients were female (54.4%). A large proportion of patients were covered by Medicare (50.2%) and private insurance (36.7%). Smaller proportions of patients had Medicaid (16.2%) and no insurance (4.1%).

Table 25. Ophthalmologistsâ&#x20AC;&#x2122; patient characteristics Patient age (%) <5 5-19 20-59 60-79 80+ Patient race/ethnic groups (%) White African American Hispanic Asian Native American Other Patient gender (%) Male Female Patient insurance plans (%) Medicare Medicaid Private insurance No insurance Others

6.3 9.0 26.8 42.1 15.3 57.1 32.6 5.1 2.5 0.4 0.5 45.6 54.4 50.2 16.2 36.7 4.1 2.5

Ophthalmologists were asked to estimate the proportion of their patients with specific eye conditions and eye diseases (Table 26). Large proportions of patients had problems with refractive error (66.8%), dry eye (39.6%), cataract (36.9%), glaucoma (25.7%), diabetic eye conditions including retinopathy (20.3%) and age-related macular degeneration (19.7%). Fewer patients suffered from corneal problems (12.6%), conjunctivitis (8.2%), strabismus (7.0%), and amblyopia (6.4%). Providers estimated that low numbers of patients had ocular trauma (5.4%), vision loss from brain injury (4.7%), complications from contact lens wear (4.7%), optic neuritis (3.7%), juvenile or young adult onset retinal degenerations (1.9%), or retinopathy of prematurity (1.2%).

31

Ophthalmologists estimated that approximately 27% of their patients had diabetes and of those, 61.4% adhered to eye care guidelines (Table 26). Patients with low vision made up 14.4% of all patients. For low vision patients in need of rehabilitation services, 13.1% of ophthalmologists provided those services, 61.6% referred patients to the UAB Center for Low Vision Rehabilitation, and 29.3% referred to the UAB School of Optometry Low Vision Clinic. Other places low vision patients were referred to included ADRS (47.5%), state, county and city educational services (13.1%), St. Vincent’s East (6.1%), and other (27.3%). Other rehabilitation service providers specified included AIDB, Community Services for Vision Rehabilitation (CSVR) in Mobile, and VA low vision rehabilitation.

Table 26. Ophthalmologists’ patient eye conditions, and those with diabetes and low vision Patient eye conditions (%) Refractive error 66.8 Amblyopia 6.4 Strabismus 7.0 Dry eye 39.6 Age-related macular degeneration 19.7 Glaucoma 25.7 Diabetic eye conditions including 20.3 retinopathy Cataract 36.9 Vision loss from brain injury including 4.7 stroke Juvenile or young adult onset retinal 1.9 degenerations Optic neuritis or other optic nerve 3.7 disorders Retinopathy of prematurity 1.2 Corneal problems 12.6 Complications from contact lens wear 4.7 Conjunctivitis 8.2 Ocular trauma 5.4 Other 4.2 Diabetic patients (%) 27.3 % who adhere to guidelines 61.4 Low vision patients (%) 14.4 Where low vision patients in need of rehabilitation services referred (%) Practice provides 13.1 ADRS 47.5 State, county, or city/town educational 13.1 services UAB School of Optometry Low Vision 29.3 Clinic UAB Center for Low Vision 61.6 Rehabilitation St. Vincent’s East 6.1 Other 27.3

32

Optometrists Optometrists reported that the largest proportion of their patients were aged 20-59 years (41.7%), followed by patients aged 60 and older (33.5%) and younger than 20 (23.8%) (Table 27). The majority of patients were white (59.2%), followed by African American (30.3%). Relatively few patients were Hispanic (6.3%) and other racial/ethnic groups (4.0%). Patients were more often female (52.6%). A large proportion of patients were covered by private insurance (41.6%); however, smaller proportions of patients had Medicare (26.6%) and Medicaid (15.2%) and 18.1% had no insurance.

Table 27. Optometristsâ&#x20AC;&#x2122; patient characteristics Patient age (%) <5 5-19 20-59 60-79 80+ Patient race/ethnic groups (%) White African American Hispanic Asian Native American Other Patient gender (%) Male Female Patient insurance plans (%) Medicare Medicaid Private insurance No insurance Others

4.5 19.3 41.7 25.9 7.6 59.2 30.3 6.3 3.0 0.6 0.4 47.2 52.6 26.6 15.2 41.6 18.1 3.4

Optometrists were asked to estimate the proportion of their patients with specific eye conditions and eye diseases (Table 28). Large proportions of patients had problems with refractive error (86.3%), dry eye (36.8%), cataract (25.9%), glaucoma (13.8%), diabetic eye conditions including retinopathy (13.7%), conjunctivitis (11.7%), complications from contact lens wear (11.4%), corneal problems (11.0%), and age-related macular degeneration (10.9%). Providers estimated that fewer numbers of patients had amblyopia (6.0%), strabismus (5.0%), ocular trauma (4.3%), vision loss from brain injury (3.0%), optic neuritis (2.6%), juvenile or young adult onset retinal degenerations (1.4%), or retinopathy of prematurity (0.8%).

Optometrists estimated that approximately 22.3% of their patients had diabetes and that 52.9% adhered to eye care guidelines (Table 28). Patients with low vision made up 6.6% of all patients.

For low vision patients in need of rehabilitation services, 17.5% of optometrists provided those 33

services, 68.2% referred patients to the UAB School of Optometry Low Vision Clinic, and 40.8% referred patients to the UAB Center for Low Vision Rehabilitation. Other places low vision patients were referred to included ADRS (32.7%), state, county and city educational services (13.1%), St. Vincent’s East (0.9%), and other (20.5%). Other rehabilitation service providers specified included AIDB, CSVR, and VA low vision rehabilitation.

Table 28. Optometrists’ patient eye conditions, and those with diabetes and low vision Patient eye conditions (%) Refractive error 86.3 Amblyopia 6.0 Strabismus 5.0 Dry eye 36.8 Age-related macular degeneration 10.9 Glaucoma 13.8 Diabetic eye conditions including 13.7 retinopathy Cataract 25.9 Vision loss from brain injury including 3.0 stroke Juvenile or young adult onset retinal 1.4 degenerations Optic neuritis or other optic nerve 2.6 disorders Retinopathy of prematurity 0.8 Corneal problems 11.0 Complications from contact lens wear 11.4 Conjunctivitis 11.7 Ocular trauma 4.3 Other 1.4 Diabetic patients (%) 22.3 % who adhere to guidelines 52.9 Low vision patients 6.6 Where low vision patients in need of rehabilitation services referred (%) Practice provides 17.5 ADRS 32.7 State, county, or city/town educational 13.1 services UAB School of Optometry Low Vision 68.2 Clinic UAB Center for Low Vision 40.8 Rehabilitation St. Vincent’s East 0.9 Other 20.5

34

Vision Rehabilitation providers Rehabilitation providers reported that the largest proportion of their patients were aged 20-59 years (39.9%), followed by patients aged 60 and older (37.7%), and younger than 20 (19.3%) (Table 29). The majority of patients were white (61.3%), followed by African American (33.3%). Relatively few patients were Hispanic (2.3%) and other racial/ethnic groups (1.4%).

Patients were more often male (54.6%). A large proportion of patients were covered by Medicare (46.9%); however, smaller proportions of patients had Medicaid (30.1%) and private insurance (19.4%), and 23.3% had no insurance.

Table 29. Rehabilitation providersâ&#x20AC;&#x2122; patient/client characteristics Age group (%) <5 5-19 20-59 60-79 80+ Race/ethnic group (%) White African American Hispanic Asian Native American Other Gender (%) Male Female Insurance plan (%) Medicare Medicaid Private insurance No insurance Others

2.8 16.5 39.9 25.0 12.7 61.3 33.3 2.3 0.7 0.1 0.6 54.6 45.4 46.9 30.1 19.4 23.3 --

Rehabilitation providers were asked to estimate the proportion of their patients with specific eye conditions and eye diseases (Table 30). Large proportions of patients had age-related macular degeneration (24.9%), diabetic eye conditions including retinopathy (20.8%), glaucoma (18.0%), cataract (15.2%), problems with refractive error (15.1%), juvenile or young adult onset retinal degenerations (11.4%), vision loss from brain injury (10.8%). Fewer patients had optic neuritis (7.9%), retinopathy of prematurity (7.1%), dry eye (6.7%), ocular trauma (4.8%), strabismus (3.5%), corneal problems (3.3%), amblyopia (2.4%), conjunctivitis (0.8%), and complications from contact lens wear (0.2%). Rehabilitation providers estimated that approximately 28% of their patients had diabetes and that patients with low vision made up 67% of all patients.

35

Table 30. Rehabilitation providersâ&#x20AC;&#x2122; patient eye conditions, those with diabetes and low vision Patients with eye condition (%) Refractive error 15.1 Amblyopia 2.4 Strabismus 3.5 Dry eye 6.7 Age-related macular degeneration 24.9 Glaucoma 18.0 Diabetic eye conditions including 20.8 retinopathy Cataract 15.2 Vision loss from brain injury including 10.8 stroke Juvenile or young adult onset retinal 11.4 degenerations Optic neuritis or other optic nerve 7.9 disorders Retinopathy of prematurity 7.1 Corneal problems 3.3 Complications from contact lens wear 0.2 Conjunctivitis 0.8 Ocular trauma 4.8 Other 3.4 Diabetic patients 27.9 Patients with Low Vision

66.7

Rehabilitation providers estimated the proportion of their patients who experienced specific problems (Table 31). The majority of patients had difficulties reading (63.8%) and driving a car (55.2%), and large proportions had problems with mobility (50.1%), identifying objects, people or events from a distance (48.8%), writing (48.3%), independent living (40.8%), and other detailed near tasks (37.3%). Many patients also had difficulty with emotional or psychological adjustment (35.4%), self care and domestic activity (32.8%), and financial management (31.1%).

Table 31. Rehabilitation providersâ&#x20AC;&#x2122; patients with specific difficulties or problems (%) Reading 63.8 Writing 48.3 Financial management 31.1 Other detail near tasks 37.3 Independent living 40.8 Mobility 50.1 Driving 55.2 Identification of objects, people, events from a 48.8 distance Self care/domestic activity 32.8 Emotional or psychological adjustment 35.4

36

PROVIDER OPINIONS

Ophthalmologists Overall, 71.2% (N=79) of the 111 participating ophthalmologists responded to the question regarding their community’s greatest unmet eye care needs (Table 32). The most common comments were about clinical care (41.8%), policy (34.2%), and eye care organization (25.3%).

Less frequent (7.6%) were comments regarding eye health education for patients and the public, and accessibility (6.3%). A small portion of ophthalmologists reported that their community had no unmet needs (3.8%) or that they did not know (2.5%).

Table 32. Ophthalmologists’ responses to “greatest unmet community eye care needs” question Participants responding, N (%) 79 (71.2) General domains (%) Clinical care 41.8 Education 7.6 Accessibility 6.3 Eye care organization 25.3 Policy 34.2 No needs Do not know

3.8 2.5

Approximately 42% of ophthalmologists made comments that the greatest unmet need involved clinical care (Table 33). Of those, 60.6% fell into the eye care subcategory. A typical answer was, “caring for and covering the uninsured; helping low income patients without Medicaid to pay for glasses.” Of those who felt that clinical care was the greatest unmet need, 15.2% specifically mentioned glaucoma screening and 6.1% mentioned screening for diabetic retinopathy. Approximately 12% favored pediatric screening. A small proportion of ophthalmologists thought Hispanic eye care (3.6%) was the greatest unmet need.

Table 33. Ophthalmologists’ subcategories for clinical care responses to “greatest unmet community eye care needs” question Participants responding, N (%) 33 (41.8) Clinical care subcategories (%) Eye care 60.6 Glaucoma screening 15.2 Diabetic retinopathy screening 6.1 Pediatric in general 3.0 Pediatric screening 12.1 Pediatric comprehensive eye exams 0.0 Hispanic care 3.0 Dry eye 3.0 Refractive error 9.1

37

Only six responses (7.6%) from ophthalmologists were related to education (Table 34). Of those, all concerned eye health education for the public.

Table 34. Ophthalmologists’ subcategories of education responses to “greatest unmet community eye care needs” question Participants responding, N (%) 6 (7.6) Education subcategories (%) Public education 100 Provider education --

Comments from five ophthalmologists (6.3%) were related to accessibility, and of those, 100% were about the need to provide patients with transportation to appointments (Table 35).

Table 35. Ophthalmologists’ subcategories of accessibility responses to “greatest unmet community eye care needs” question Participants responding, N (%) 5 (6.3) Accessibility subcategories (%) Transportation to appointments 100 Satellite clinics -Nursing homes --

Approximately 25% of ophthalmologist made comments related to eye care organization. Most (75%) were about the need for more providers (Table 36). For example, several ophthalmologists stated there was a need for more neuro-ophthalmologists, pediatric ophthalmologist, and low vision specialists. Others were concerned about the need for a new eye hospital (10.0%), dyslexia services (5.0%), disparities (5.0%), and services for the blind (5.0%).

Table 36. Ophthalmologists’ subcategories of eye care organization responses to “greatest unmet community eye care needs” question Participants responding, N (%) 20 (25.3) Eye care organization subcategories (%) More providers 75.0 New eye hospital 10.0 Dyslexia services 5.0 Disparities 5.0 Blind services 5.0 VA services 0.0 Handicapped children 0.0 Dual sensory impairment screening 0.0 Sports related 0.0 Support groups 0.0

A large proportion (34.2%) of ophthalmologists made comments that were related to policy (Table 37). The majority (59.3%) of responses fell into the financial assistance to patients for prescriptions subcategory, frequently regarding glaucoma medications. A smaller proportion (29.6%) said that the greatest need was for assistance to indigent patients. One ophthalmologist 38

wrote “services for uninsured patients, financial aid for glaucoma medications,” while another answered “patients unable to afford eye meds.”

Table 37. Ophthalmologists’ subcategories of policy responses to “greatest unmet community eye care needs” question Participants responding, N (%) 27 (34.2) Policy subcategories (%) Financial assistance with prescriptions 59.3 Lower co-pays for office visits 3.7 Higher reimbursements 3.7 Spectacles for Medicare 3.7 State funds for disability services 0.0 Pedestrian mobility paths 0.0 School screenings 0.0 Fund school spectacles 0.0 Assistance to indigent patients 29.6 Vision rehabilitation funding 0.0

Ophthalmologists were asked “what single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community?”

(Table 38). Of those ophthalmologists who answered the question (60.4%), most responses (59.2%) fell into the clinical care and screening subcategory. For example, responses from ophthalmologists included: “free vision screening clinics,” and “preschool screening programs expanded,” and “program for financial assistance for the uninsured.” Several participants believed that the role of a private foundation should be with building relationships. One ophthalmologist answered, “support the development of regional/national eye trauma care at UAB. UAB and EFH already have many well developed resources in ocular trauma and the development of such a center benefits virtually all eye care practitioners and eye care facilities in the state.” Another ophthalmologist answered, “make it easier and faster for patients to get the assistance needed.”

Table 38. Ophthalmologists’ responses to “What single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community?”

Participants responding, N (%) 67 (60.4) Domains specified (%) Fund research 1.5 Education (%) 20.9 Public education 100 Provider education 14.3 Accessibility (%) 6.0 Transportation to appointments 75.0 Policy 14.9 Clinical care and screening 52.2 Build relationships 6.0 Not sure 3.0 None 1.5

39

Optometrists Overall, 63.4% (N=156) of the 246 participating optometrists responded to the question regarding their community’s greatest unmet eye care needs (Table 39). The most common comments were about clinical care (53.9%), education (21.2%), policy (12.2%), and eye care organization (10.9%). Less frequent were comments regarding accessibility (5.1%). Of responding optometrists, 9.0% reported that their community had no unmet needs or that they did not know (1.9%).

Table 39. Optometrists’ responses to “greatest unmet community eye care needs” question Participants responding, N (%) 156 (63.4) General domains (%) Clinical care 53.9 Education 21.2 Accessibility 5.1 Eye care organization 10.9 Policy 12.2 No needs Do not know

9.0 1.9

Approximately 54% of optometrists made comments that the greatest unmet need involved clinical care (Table 40). Most responses (61.0%) were categorized as being related to eye care.

For example, one optometrist wrote, “patients who have too much income to receive government assistance, but cannot afford routine or medical eye care due to lack of insurance.” Of those who felt that clinical care was the greatest unmet need, none specifically mentioned glaucoma screening and diabetic retinopathy. Approximately 10% favored pediatric comprehensive eye exams and pediatric screening was mentioned by 3.6%. Comments regarding refractive error were mentioned by 14.3% of responding optometrists. Approximately 10% of responses mentioned Hispanic eye care (3.6%) as the greatest unmet need.

Table 40. Optometrists’ subcategories for clinical care responses to “greatest unmet community eye care needs” question Participants responding, N (%) 84 (53.9) Clinical care subcategories (%) Eye care 61.9 Glaucoma screening 0.0 Diabetic retinopathy screening 0.0 Pediatric in general 9.5 Pediatric screening 3.6 Pediatric comprehensive eye exams 9.5 Hispanic care 9.5 Dry eye 0.0 Refractive error 14.3

40

Approximately 21% of responses from optometrists were related to education (Table 41). Of those, 90.9% concerned public education. A typical response from an optometrist was, “diabetic patients who do not know or understand why they need comprehensive eye care on a yearly basis.” Provider education was mentioned by 9.1%. For example, one optometrist responded, “primary care physicians and pediatricians not referring patients to optometrist due to their lack of medical training education & understanding optometrists’ scope of practice.”

Table 41. Optometrists’ subcategories of education responses to “greatest unmet community eye care needs” question Participants responding, N (%) 33 (21.2) Education subcategories (%) Public education 90.9 Provider education 9.1

Comments from eight responding optometrists (5.1%) were related to accessibility, and of those, 50% were related to nursing home accessibility, and 37.5% were about the need to for transportation to appointments (Table 42).

Table 42. Optometrists’ subcategories of accessibility responses to “greatest unmet community eye care needs” question Participants responding, N (%) 8 (5.1) Accessibility subcategories (%) Transportation to appointments 37.5 Satellite clinics 0.0 Nursing homes 50.0

Approximately 11% of responding optometrists made comments related to eye care organization (Table 43). Most (70.6%) were about the need for more providers. Others were concerned about the need for dyslexia services (5.9%), VA services (5.9%), handicapped children (5.9%), and sports related (5.9%).

Table 43. Optometrists subcategories of eye care organization responses to “greatest unmet community eye care needs” question Participants responding, N (%) 17 (10.9) Eye care organization subcategories (%) More providers 70.6 New eye hospital 0.0 Dyslexia services 5.9 Disparities 0.0 Blind services 0.0 VA services 5.9 Handicapped children 5.9 Dual sensory impairment screening 0.0 Sports related 5.9 Support groups 0.0

41

A small proportion (12.2%) of optometrists made comments that were related to policy (Table 44). A large proportion of those responses were related to the need to provide financial assistance to patients for prescriptions (26.3%). Smaller proportions mentioned spectacles for Medicare patients (10.5%), lower co-pays for office visits (5.3%), higher reimbursements (5.3%), school screenings (5.3%) and assistance to indigent patients (5.3%).

Table 44. Optometrists’ subcategories of policy responses to “greatest unmet community eye care needs” question Participants responding, N (%) 19 (12.2) Policy subcategories (%) Financial assistance with prescriptions 26.3 Lower co-pays for office visits 5.3 Higher reimbursements 5.3 Spectacles for Medicare 10.5 State funds for disability services 0.0 Pedestrian mobility paths 0.0 School screenings 5.3 Fund school spectacles 0.0 Assistance to indigent patients 5.3 Vision rehabilitation funding 0.0

Optometrists were asked “what single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community?”

Of those optometrists who answered the question (52.4%), most responses (59.2%) fell into the education category, and of those, 86% were about public education (Table 45). For example, one optometrist answered, “provide education about the need for regular eye and other medical care and coordinate agencies and sources to help with funding and transportation for the underserved, non insured population.” Many of the responses (35.7%) fell into the clinical care category. One optometrist answered, “assist patients in getting their prescription medication filled (those who cannot afford to) or provide a central source that can refer.” Few respondents listed funding research (3.9%) or accessibility (7.0%). Slightly more responses were related to policy (10.1%) and to building relationships (10.9%).

Table 45. Optometrists’ responses to “What single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community?”

Participants responding, N (%) 129 (52.4) Domains specified (%) Fund research 3.9 Education (%) 38.8 Public education 86.0 Provider education 14.0 Accessibility (%) 7.0 Transportation to appointments 88.9 Policy 10.1 Clinical care and screening 35.7 Build relationships 10.9 Not sure 8.5 None 0.8

42

Vision rehabilitation providers Overall, 67.9% (N=55) of the 81 participating rehabilitation providers responded to the question regarding their community’s greatest unmet eye care needs (Table 46). The most frequent comments were about clinical care (30.9%), education (30.9%), and accessibility (25.5%). Less frequent were comments regarding eye care organization (16.4%) and policy (10.9%). A few participants responded that their community had no needs (3.6%) or that they did not know (3.6%).

Table 46. Rehabilitation providers’ responses to “greatest unmet community eye care needs” question Participants responding, N (%) 55 (67.9) General domains (%) Clinical care 30.9 Education 30.9 Accessibility 25.5 Eye care organization 16.4 Policy 10.9 No needs Do not know

3.6 3.6

Approximately 31% of rehabilitation provider made comments that the greatest unmet need involved clinical care (Table 47). Most responses (52.9%) fell into the eye care subcategory. For example, one rehabilitation providers wrote, “affordable eye care and drug costs.” Refractive error was mentioned by 17.7%, pediatric in general by 11.8% and glaucoma screening by 5.9%.

Table 47. Rehabilitation providers’ subcategories for clinical care responses to “greatest unmet community eye care needs” question Participants responding, N (%) 17 (30.9%) Clinical care subcategories (%) Eye care 52.9 Glaucoma screening 5.9 Diabetic retinopathy screening 0.0 Pediatric in general 11.8 Pediatric screening 0.0 Pediatric comprehensive eye exams 0.0 Hispanic care 0.0 Dry eye 0.0 Refractive error 17.7

43

Approximately 31% of responses from rehabilitation providers were related to education (Table 48). Of those, 82.5% concerned public education. A large proportion mentioned provider education, for example, a typical response from a rehabilitation provider was, “ensuring that persons who have low vision or vision impairment from brain injury are being referred for low vision rehab services,” and another wrote, “there is a lack of understanding among/training of ophthalmology residents in functional low vision.”

Table 48. Rehabilitation provider’s subcategories of education responses to “greatest unmet community eye care needs” question Participants responding, N (%) 17 (30.9) Education subcategories (%) Public education 82.5 Provider education 29.4

Fourteen comments from responding rehabilitation providers (25.5%) were related to accessibility, and of those, 85.7% were about the need for transportation to appointments, 14.3% for satellite clinics and 7.1% were related to nursing home accessibility (Table 49).

Table 49. Rehabilitation providers’ subcategories of accessibility responses to “greatest unmet community eye care needs” question Participants responding, N (%) 14 (25.5) Accessibility subcategories (%) Transportation to appointments 85.7 Satellite clinics 14.3 Nursing homes 7.1

Approximately 16% of responding rehabilitation providers made comments related to eye care organization (Table 50). Most (55.6%) were about the need for more providers. Other comments were concerned about the need for support groups (22.2%) and dual sensory impairment screening (11.1%).

Table 50. Rehabilitation subcategories of eye care organization responses to “greatest unmet community eye care needs” question Participants responding, N (%) 9 (16.4) Eye care organization subcategories (%) More providers 55.6 New eye hospital 0.0 Dyslexia services 0.0 Disparities 0.0 Blind services 0.0 VA services 0.0 Handicapped children 0.0 Dual sensory impairment screening 11.1 Sports related 0.0 Support groups 22.2

44

A small proportion (10.9%) of rehabilitation providers made comments that were related to policy (Table 51). Of those, most comments had to do with the need to provide financial assistance to patients for prescriptions (50.0%). Smaller proportions mentioned pedestrian mobility paths (16.7%), funding for school spectacles (16.7%) and vision rehabilitation funding (16.7%).

Table 51. Rehabilitation providers’ subcategories of policy responses to “greatest unmet community eye care needs” question Participants responding, N (%) 6 (10.9) Policy subcategories (%) Financial assistance with prescriptions 50.0 Lower co-pays for office visits 0.0 Higher reimbursements 0.0 Spectacles for Medicare 0.0 State funds for disability services 0.0 Pedestrian mobility paths 16.7 School screenings 0.0 Fund school spectacles 16.7 Assistance to indigent patients 0.0 Vision rehabilitation funding 16.7

Rehabilitation providers were asked “what single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community?” A large proportion (67.9%) answered the question (Table 52). Of those rehabilitation providers who answered, 38.2% of comments fell into the clinical care and screening subcategory and 30.9% concerned education (75.5% public and 23.5% provider).

Categories of other responses included 10.9% accessibility (100% transportation to appointments), 9.1% policy, and 7.3% to build relationships. Approximately 7% were not sure.

One rehabilitation provider wrote, “low income kids who receive glasses through agencies and they are broken before they are eligible for new pair; schools deal with this issue,” while another wrote, “continue to support rural eye care and teacher training since we are finally reaching the persons who may move to these areas or go there for education and eye care.”

Table 52. Rehabilitation providers’ responses to “What single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community?”

Participants responding, N (%) 55 (67.9) Domains specified (%) Fund research 0.0 Education (%) 30.9 Public education 76.5 Provider education 23.5 Accessibility (%) 10.9 Transportation to appointments 100 Policy 9.1 Clinical care and screening 38.2 Build relationships 7.3 Not sure 7.3 None 0.0

45

DISCUSSION This report presents details about the numbers of eye care providers in Alabama and their county of location, and among survey participants, descriptive information about provider demographics, training, and experience; practice and patient characteristics, as well as provider opinions. It is our hope that survey results will be utilized and referenced by researchers and policy makers interested in the eye health of Alabamians. Below we discuss some highlights of our survey results in terms of relevance to public eye health in Alabama.

The majority of participating ophthalmologists, optometrists and rehabilitation providers in Alabama identified themselves as white of non-Hispanic origin. Few minorities were represented in any of the provider groups; 0.9% of ophthalmologists, 6.6% of optometrists and 13.6% of rehabilitation providers indicated they were African American. Over one-quarter of Alabamaâ&#x20AC;&#x2122;s population is African American according to the 2010 U.S. Census.21 Research suggests that provider-patient communication and the use of preventive services can be facilitated when there is racial/ethnic concordance between providers and patients.22 Communication problems with eye care providers have been identified by African Americans as a barrier to seeking eye care.13,14 Research also indicates that African American physicians are more likely to care for patients in predominantly African American communities, underinsured patients, underserved patients, and those covered by Medicaid.23,24 Thus, it is possible that an increase in the number of African American ophthalmologists and optometrists in Alabama would have positive benefits on eye health in the state.

Compared to optometrists, ophthalmologists were on average, approximately seven years older and fewer were women (11.2% versus 44.3%). The vast majority (80.3%) of rehabilitation providers were women. These demographic results for all three types of eye care providers in Alabama are consistent with national demographic estimates for these providers in the United States. For example, the Association of Schools and Colleges of Optometry estimates that a small proportion of optometrists graduating in 2009-2010 were African American (2.7%) and that the majority (65%) were women.25 The American Academy of Ophthalmology (AAO), whose membership included 95% of practicing ophthalmologists does not collect race information; however, AAO estimates for year 2012 that approximately 20% of practicing ophthalmologists are women, whereas 42% of ophthalmologists in training (residency and fellowships) are women.26 Ophthalmologists and optometrists reported that on average 32.6% and 30.3% of the patients they treated, respectively, were African American. Previous research indicates that rates of vision impairment and eye disease among African Americans are two times higher than those of whites, especially uncorrected refractive error, cataract, glaucoma, and diabetic retinopathy.27-29 Glaucoma is at least four to five times higher in African Americans as compared to persons of European descent.29,30 In addition, the disease progresses more rapidly and appears about 10 years earlier in African Americans.27,31-36 Older African Americans are less likely to receive routine, comprehensive eye care, when newly emerging eye conditions could be detected and treated in a timely fashion,37-39 which could be contributing to their higher rates of eye disease and vision impairment. When they eventually enter treatment, their eye conditions are often in

46

more advanced forms accompanied by irreversible vision impairment, and thus more difficult to treat, as compared to whites.

The public health challenges to decrease blindness and vision impairment in Alabama are likely to increase, not only due to the aging of the population, but because of the growing prevalence of diabetes. In addition to diabetic retinopathy, those with diabetes are at increased risk for glaucoma,30,41 and cataracts.42,43 Based on CDC estimates, Alabama has a higher prevalence of diabetes than any other state, i.e., 13.2% of those persons over the age of 16.44 In 2008, African American Alabamians had a diabetes mortality rate (52.0/100,000 people) that was 2.5 times greater than White Alabamians (20.6/100,000 people).45 The increased incidence of diabetes nationwide is in large part due to increased obesity, 46 .and it is estimated that over 80 percent of those diagnosed with type 2 diabetes are obese.47 Recently, the CDC estimated that over 32% of Alabama adults were obese (body mass index > 30 km/m2), second to Mississippi (34%), which is first among states in obesity rates.48 Even more troubling is that greater numbers of children are now obese. Nationwide, beginning in the early 1970s, the prevalence of obesity increased from 5.0% to 10.4% among children aged 2-5, from 4.0% to 19.6% among children aged 6-11, and from 6.1% to 18.1% for those aged 12-19. Further, African American girls have the highest obesity rates (29.2%) among all childhood gender-racial groups.49 Since obesity is a risk factor for diabetes and more children are now obese, it is not surprising that more young people are being diagnosed with type 2 diabetes.50,51 Thus, it is expected that more people, including more at younger ages, will be at risk for diabetic eye diseases.

Nearly all people with diabetes will have diabetic retinopathy to some degree.52 Diabetic retinopathy is the leading cause of blindness among working age adults in the United States.

Recent estimates suggest a prevalence rate of 3.4% (approximately 4 million people), of which approximately 20% is vision threatening.53 The 2008 prevalence of diabetic retinopathy in Alabama among those with diabetes 40 years and older and based on self-report is estimated to be 23.6%.54 The natural history of diabetic retinopathy is well characterized and is due to leakage and blockage of small vessels in the retina, resulting in swelling of retinal tissue, angiogenesis, cell death and retinal detachments.52. Those with type 1 or type 2 diabetes are at risk, and duration of diabetes and glycemic control are associated with onset of diabetic retinopathy.

In the current survey, ophthalmologists, optometrists, and rehabilitation providers estimated that 27%, 22% and 28%, respectively, of their patients had diabetes. Providers estimated the proportion of diabetic patients that adhered to eye care guidelines was 61.4% among ophthalmology patients and 53% among optometry patients. In addition, ophthalmologists and optometrists estimated that 20% and 14%, respectively, of their patients had diabetic eye conditions including diabetic retinopathy. Alabamaâ&#x20AC;&#x2122;s prevalence of diabetic retinopathy among those 65 and older is in the top 25% of reporting states.55 Fortunately, early detection and monitoring with timely treatment, e.g., retinal laser photocoagulation, can stop or slow disease progression. Diabetic retinopathy is detected by eye care providers through a comprehensive eye examination that includes pupil dilation and examination of the fundus; however, only about half of all people with diabetes receive recommended annual comprehensive eye examinations.56 Compared to ophthalmologists and optometrists, a greater number of rehabilitation providers stated that accessibility, e.g., transportation to appointments, was the greatest unmet eye care 47

need in their community. This is not surprising since their patient base, by definition, consists of visually impaired persons experiencing difficulties with the visual activities of daily living.

Based on figures within the report, it is apparent that many Alabama communities are geographically isolated from eye care services. Due to long travel distances, people who live in rural areas have increased barriers to receive basic and specialized eye care, and vision rehabilitation services. Those that are geographically isolated with early asymptomatic eye diseases are more likely to delay eye care until their symptoms become apparent. Early detection of eye diseases can help reduce disability through timely intervention, slowing disease progression. Compounding the inherent lack of access due to distance, many rural and Black Belt counties have large African American populations, who are at increased risk for glaucoma, and due to the high prevalence of diabetes, increased risk for diabetic eye conditions. Due to income and geographic disparities, the Black Belt region has long suffered from lack of healthcare services necessary for early detection and treatment of chronic diseases.57 Additional disparities are related to the decreasing numbers of general and specialty ophthalmologists. A frequently expressed opinion among participating ophthalmologists, optometrists and vision rehabilitation providers was the need for more providers. A recent analysis concluded that due to changing patient demographics, retirement, and a fixed number of ophthalmology residency slots nationwide, ophthalmology will face substantial challenges in manpower by year 2020.58 Even with existing numbers of providers, current care patterns often fail to meet AAO Preferred Practice Patterns; for example, studies have reported that open-angle glaucoma patients are likely to have incomplete assessments,59 receive less than recommended testing,60,61 and otherwise receive wide variation in treatment.62 In addition, fewer ophthalmologists are sub-specializing in a number of ophthalmology fields. For example, fewer ophthalmologists are entering the field of neuro-ophthalmology because of poor compensation compared to other subspecialities.63 For similar reasons, other ophthalmology subspecialties experiencing dwindling numbers of practitioners include uveitis, pediatrics, and pathology.64 There are currently no programs that provide encouragement (e.g., financial incentives, tuition coverage) for optometrists to practice in rural areas. Before 2002, optometrists were able to participate in the National Health Service Corps student loan program administered by the Centers for Medicare and Medicaid Services that supports new graduates to work in underserved communities in exchange for educational loan repayment; however, due to a legislative oversight, they were excluded from the program when it was restructured.65 Potentially, new federal legislation, i.e., H.R. 1195 (National Health Service Corps Improvement Act of 2011), introduced in March 2011 and currently before committee, will address this and optometrists will once again be able to participate in the program.66 In addition, the University of Alabamaâ&#x20AC;&#x2122;s College of Community Health Sciencesâ&#x20AC;&#x2122; has had success through their Rural Health Leaders Pipeline in increasing the numbers of rural students who prepare for health and medical careers.

As of 2011, 84 participants of their Rural Medical Scholars Program have graduated from medical school, and of these physicians, 21 practice in rural Alabama counties, the majority in primary care and family medicine.67 By utilizing current technologies, telemedicine has the potential to fill some of the gaps in rural eye care services by removing distance barriers and providing patients remote access to eye care specialists who screen, diagnose, and manage eye diseases. Telemedicine is well suited for vision 48

and eye disease screening services and also monitoring of disease through imaging and other specialized tests because of the low invasiveness of testing, wider spread availability and affordability of imaging technologies, high levels of diagnostic reliability,68 and ease of training of testing personnel.69 Telemedicine has the potential to be used to screen for and monitor diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration, and glaucoma.70 Research has established the effectiveness of using digital fundus imaging with remote image interpretation for screening of diabetic retinopathy in developing nations,71 among a prison population with type 2 diabetes,72 and by the Indian Health Service for screening of Alaskan Natives.73 Acceptance of telemedicine has increased steadily over the years stemming from its proven efficacy and cost-effectiveness, specifically in the areas of screening for diabetic eye conditions through fundus photography.

UAB investigators are currently participating in the Insight Collaborative Network Research Study, a CDC sponsored multi-center study of diabetes eye screening in the community setting.

The UAB site location is the Internal Medicine Clinic at Cooper Green Hospital in Birmingham.

The objective of the study, lead by the UAB Department of Ophthalmology, is to determine the feasibility and effectiveness of using an automated, non-invasive, non-mydriatic (no dilating drops needed) fundus camera to screen and detect diabetic retinopathy and other ocular diseases.

Each of the four sites will recruit 500 adult patients with diabetes. Those who screen positive will be referred for a follow-up comprehensive eye examination. Questions that the study will help answer include: determining the number of patients undergoing retinal image screening at each site; the rates of positive screening for diabetic retinopathy and diabetic macular edema; the rate for follow-up scheduling for comprehensive eye examinations among those who screen positive; and the rate of those who actually receive follow-up care.

To develop a telemedicine eye care program for under-served areas of Alabama would require strong health care organization leadership supported by an organizational framework that includes all stakeholders, e.g., community leaders, eye care providers, and policy makers to secure financing and direct where resources are best used. Similar programs are currently underway in other regions of the US,73-75 but still require rigorous evaluation. In addition to increased access, telemedicine has been shown to be efficient and effective. Relative to other screening programs, telemedicine programs may require high startup costs for infrastructure that are often supported by federal,76 and state initiatives;77 however, successful programs that are accepted by communities, ultimately lead to decreased costs.78,79 Scientific evaluation, e.g., the proportion of those who screen positive who are ultimately seen by an ophthalmologist, would be necessary to judge the effectiveness of any intervention. It is also critical to evaluate the costeffectiveness of the program, as compared to a system that does not rely on telemedicine.

Strengths and Limitations of the Survey The study was strengthened by involving a number of organizations and individuals who assisted in comprehensively identifying eye care providers currently practicing in the state of Alabama.

By survey participation standards, participation was adequate among ophthalmologist (> 50%) but was less than optimal for optometrists (38.6%) and rehabilitation providers (45.5%). The current survey exceeded the previous survey in total number of providers identified and 49

contacted, and in participation rates, i.e., the previous survey reported a 34.0% participation rate (127 of 373) for ophthalmologists (38%) and optometrists (30%).19

Future Considerations Four challenges emerge from this survey that, if addressed by well thought-out strategies in the coming decade, could potentially deliver significant benefit to the eye health of Alabamians.

These topics are not listed in any recommended priority, but rather, are offered for consideration by the Foundation, professionals in this area, and the public.

There is a need for more eye care providers, including more African American providers.

Policies and programs that introduce incentives to eye care providers to provide services in more rural areas of the state could be beneficial to the eye health of the state.

With the high rate of diabetes in Alabama, there is a need to develop and implement an eye care system that improves detection and follow-up management of the ocular complications of diabetes, both medically and in terms of cost.

Many Alabama communities are geographically isolated from eye care services. Improved access to eye care may be achievable by creating satellite eye care practices in underserved communities, introducing telemedicine to eye care organization, and improving transportation services in the state.

Regardless of the types of programs introduced, there will be a need to scientifically evaluate these and any other public eye health interventions to improve the quality of and access to eye care in Alabama, in terms of their impact on both health outcomes and cost, so that eye health strategies in the state are evidence-based.

50

REFERENCES 1.

U.S. Department of Health and Human Services. Healthy People 2020 Vision Objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=42.

Accessed January 10 2012.

2. Vision Problems in the U.S., Available at: http://www.preventblindness.org/sites/default/files/national/documents/visionimpairment-blindness.pdf. Accessed November 15 2011.

3. The economic impact of vision problems. Available at http://www.preventblindnessflorida.org/research/Impact_of_Vision_Problems.pdf.

Accessed Nov 15 2011.

4. Elliott AF, Dreer LE, McGwin G Jr, Scilley K, Owsley C. The personal burden of decreased vision targeted health-related quality of life in nursing home residents. J Aging Health. 2010; ;22:504-21 5. Elliott AF, McGwin G Jr, Owsley C. Health-related quality of life and visual and cognitive impairment among nursing home residents. British Journal of Ophthalmology.

2009;93:240-243.

6. Olitsky SE, Nelson LB. Common ophthalmologic concerns in infants and children.

Pediatr Clin North Am. 1998;45:993-1012.

7. McGwin G, Aiyuan X, Owsley C. Rate of eye injury in the United States. Arch Ophthalmol 2005;123:970-976.

8. US Census Bureau. Population profile of the United States. Available at: http://www.census.gov/population/www/pop-profile/natproj.html. Accessed November 15 2011.

9. Centers of Disease Control and Prevention (CDC). National Diabetes Surveillance System. Atlanta, GA: US Department of Health and Human Services, CDC; 2011.

Available at http://apps.nccd.cdc.gov/ddtstrs/default.aspx. Accessed November 15 2011.

10. Mainous AG, Baker R, Koopman RJ, Saxena A, Diaz VA, Everett CJ, Majeed A. Impact of the population at risk of diabetes on projections of diabetes burden in the United States: an epidemic on the way. Diabetologia. 2007;50:934â&#x20AC;&#x201C;940.

11. Centers of Disease Control and Prevention (CDC). Improving the nation's vision health a coordinated public health approach. Available at: http://www.eyeresearch.org/pdf/improving_nations_vision_health.pdf. Accessed January 2012.

12. Centers for Disease Control and Prevention (CDC). Reasons for not seeking eye care among adults aged â&#x2030;Ľ40 years with moderate-to-severe visual impairment--21 States, 2006-2009. MMWR Morb Mortal Wkly Rep. 2011;60:610-3.

13. Owsley C, McGwin G, Scilley K, Girkin CA, Phillips JM, Searcey K. Perceived barriers to care and attitudes about vision and eye care: focus groups with older African Americans and eye care providers. Investigative Ophthalmology & Visual Science 2006; 47: 2797-2802.

14. Ellish NH, Royak-Schaler R, Passmore SR, Higginbotham EJ. Knowledge, attitudes and beliefs about dilated eye examinations among African-Americans. Investigative Ophthalmology & Visual Science 2007;48:1989-1994.

51

15. Centers of Disease Control and Prevention (CDC). Eye-Care Utilization Among Women Aged ≥40 Years with Eye Diseases ---19 States, 2006—2008. MMWR Weekly.

2010;59:588-591 16. United Health Foundation. America’s Health Ranking. Available at: http://www.americashealthrankings.org/al/healthinsurance/2011. Accessed December 2011 17. Lee DJ, Lam BL, Arora S, et al. Reported eye care utilization and health insurance status among US adults. Arch Ophthalmol. 2009;127:303-10.

18. Odom JV. Vision, Visual Needs, and Quality of Life of Older People in Rural Environments: A Report and Synthesis of a Meeting.” J Rural Health. 2001;17:360-63.

19. Morrisey MA, Bronstein JM. Eye Health Needs Assessment for Alabama, Prepared for The Alabama Eye Institute, April 2000. Available at: http://www.eyesightfoundation.org/uploadedFiles/File/ESFANeedsAssessment.doc.

Accessed January 2012.

20. ALDPH. The Alabama Chartbook of Regional Disparities in Mortality. Available at: http://adph.org/healthstats/assets/Disparities2003.pdf. Accessed December 20 2011 21. US Census Bureau. http://quickfacts.census.gov/qfd/states/01000.html 22. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care. Archives of Internal Medicine 1999; 159: 997-1004.

23. Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, Bindman AB. The role of black and Hispanic physicians in providing health for underserved populations. New England Journal of Medicine 1996; 334: 1305-1310.

24. Xu G, Fields SK, Laine C, Veloski JJ, Barzansky B, Martini CJ. The relationship between the race/ethnicity of generalist physicians and their care for underserved populations. American Journal of Public Health 1997; 87: 817-822.

25. Association of Schools and Colleges of Optometry (ASCO). Student Data Report Highlights. Available at: http://www.opted.org/files/Graduate(1).pdf. Accessed February 22 2012.

26. American Academy of Ophthalmology (AAO). Personal communication. February 24, 2012.

27. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. The New England Journal of Medicine. 1991;325:14121417.

28. West SK, Munoz B, Schein OD, Duncan DD, Rubin GS. Racial differences in lens opacities: The Salisbury eye evaluation (SEE) project. American Journal of Epidemiology. 1998;148:1033-1039.

29. Tielsch JM, Sommer A, Katz J, Royall RM, Quigley HA, Javitt JC. Racial variations in the prevalence of primary open-angle glaucoma. JAMA. 1991;266:369-374.

30. Javitt JC, Bean AM, Nicolson GA, Babish JD, Warren JL, Krakauer H. Undertreatment of glaucoma among black Americans. New England Journal of Medicine.

1991;325:1418-1422.

31. Wilson R, Richardson TM, Hertzmark E, Grant WM. Race as a risk factor for progressive glaucomatous damage. Annals of Ophthalmology. 1985;17:653-659.

52

32. Grant WM, Burke JFJ. Why do some people go blind from glaucoma? Ophthalmology.

1982;89:991-998.

33. Coulehan JL, Helzlsouer KJ, Rogers KD, Brown SI. Racial differences in intraocular tension and glaucoma surgery. American Journal of Epidemiology. 1980;111:759-768.

34. Martin MJ, Sommer A, Gold EB, Diamond EL. Race and primary open-angle glaucoma.

American Journal of Ophthalmology. 1985;99:383-387.

35. David R, Livingston D, Luntz MH. Ocular hypertension: A comparative follow-up of black and white patients. British Journal of Ophthalmology. 1978;62:676-678.

36. Wilensky JT, Gandhi N, Pan T. Racial influences in open-angle glaucoma. Annals of Ophthalmology. 1978;10:1398-1402.

37. Wang F, Javitt JC. Eye care for elderly Americans with diabetes mellitus: Failure to meet current guidelines. Ophthalmology. 1996;103:1744-1750.

38. Orr P, Barron Y, Schein OD, Rubin GS, West SK. Eye care utilization by older Americans: The SEE project. Ophthalmology. 1999;106:904-909.

39. Bazargan M, Baker RS, Bazargan S. Correlates of recency of eye examination among elderly African-Americans. Ophthalmic Epidemiology. 1998;5:91-100.

40. Chopra V, Varma R, Francis BA, Wu J, Torres M, Azen SP; Los Angeles Latino Eye Study Group. Type 2 diabetes mellitus and the risk of open-angle glaucoma the Los Angeles Latino Eye Study. Ophthalmology. 2008;115:227-232.

41. Pasquale LR, Kang JH, Manson JE, Willett WC, Rosner BA, Hankinson SE. Prospective study of type 2 diabetes mellitus and risk of primary open-angle glaucoma in women.

Ophthalmology. 2006;113:1081-6.

42. Hiller R, Sperduto RD, Ederer F. Epidemiologic associations with nuclear, cortical, and posterior subcapsular cataracts. Am J Epidemiol. 1986;124:916â&#x20AC;&#x201C;925.

43. Klein BE, Klein R, Wang Q, Moss SE. Older-onset diabetes and lens opacities. The Beaver Dam Eye Study. Ophthalmic Epidemiol. 1995;2:49-55.

44. Behavioral Risk Factor Surveillance System, 2010; analysis by the National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, available at http://apps.nccd.cdc.gov/brfss/list.asp?cat=DB&yr=2010&qkey=1363&state=All. 45. Centers for Disease Control and Prevention (CDC), National Center for Health Statistics.

Compressed Mortality File 1999-2008. Available at: http://wonder.cdc.gov/ucdicd10.html. Accessed February 15 2012.

46. Geiss LS, Pan L, Cadwell B, Gregg EW, Benjamin SM, Engelgau MM. Changes in incidence of diabetes in U.S. adults, 1997-2003. Am J Prev Med. 2006;30:371-7.

47. Gregg EW, Cheng YJ, Narayan KM, Thompson TJ, Williamson DF. The relative contributions of different levels of overweight and obesity to the increased prevalence of diabetes in the United States: 1976-2004. Prev Med. 2007;45:348-52.

48. Centers for Disease Control and Prevalence (CDC). Prevalence and Trends, Diabetes 2010. Available at: http://apps.nccd.cdc.gov/brfss/list.asp?cat=DB&yr=2010&qkey=1363&state=All. Accessed February 16 2012.

53

49. Centers for Disease Control and Prevalence (CDC). Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963–1965 Through 2007–2008.

Available at: http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.pdf.

Accessed February 2012.

50. Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatrics.

1996;128:608–15.

51. Bloomgarden ZT. Type 2 diabetes in the young: the evolving epidemic. Diabetes Care.

2004;27:998–1010.

52. Aiello LP, Gardner TW, King GL, Blankenship G, Cavallerano JD, Ferris FL 3rd, Klein R. Diabetic retinopathy. Diabetes Care. 1998;21:143-56.

53. The Eye Diseases Prevalence Research Group. The Prevalence of diabetic retinopathy among adults in the United States. Arch Ophthalmol 2004;122:552-63.

54. Centers for Disease Control and Prevalene (CDC). Vision Health Initiative: Data, Trends, and Maps. Available at: http://apps.nccd.cdc.gov/DDT_VHI/VHIHome.aspx. Accessed March 1 2012.

55. Centers for Disease Control and Prevalene (CDC). The State of Vision, Aging and Public Health in America. Available at: http://www.cdc.gov/visionhealth/pdf/vision_brief.pdf.

Accessed February 16 2012.

56. Lee SJ, Sicari C, Harper CA, Livingston PM, McCarty CA, Taylor HR, Keeffe JE. Examination compliance and screening for diabetic retinopathy: a 2-year follow-up study. Clin Experiment Ophthalmol. 2000;28:149-52.

57. Hansen J, Crowder C. Bleak diagnosis for sickly region. The Birmingham News. Nov 17, 2002. Available at: http://www.al.com/specialreport/birminghamnews/index.ssf?blackbelt/blackbelt19.html.

Accessed March 1, 2012.

58. Lee PP, Hoskins HD Jr, Parke DW 3rd. Access to care: eye care provider workforce considerations in 2020. Arch Ophthalmol. 2007;125:406-10.

59. Fremont AM, Lee PP, Mangione CM, Kapur K, Adams JL, Wickstrom SL, Escarce JJ. Patterns of care for open-angle glaucoma in managed care. Arch Ophthalmol.

2003;121:777-83.

60. Friedman DS, Nordstrom B, Mozaffari E, Quigley HA. Glaucoma management among individuals enrolled in a single comprehensive insurance plan. Ophthalmology.

2005;112:1500-4.

61. Coleman AL, Yu F, Rowe S. Visual field testing in glaucoma Medicare beneficiaries before surgery. Ophthalmology. 2005;112:401-6.

62. Friedman DS, Nordstrom B, Mozaffari E, Quigley HA. Variations in treatment among adult-onset open-angle glaucoma patients. Ophthalmology. 2005;112:1494-9.

54

63. Frohman LP. The human resource crisis in neuro-ophthalmology. J Neuroophthalmol.

2008;28:231-234.

64. American Association of Ophthalmology. Saving Ophthalmology's Endangered Subspecialties. EyeNet Magazine. Available at: http://www.aao.org/publications/eyenet/200910/feature1.cfm. Accessed February 15 2012.

65. Unite for Sight. Eye Care Policy in the United States. Accessed February 15 2012 at: http://www.uniteforsight.org/eye-care-policy/module1 66. H.R. 1195: National Health Service Corps Improvement Act of 2011. Available at: http://www.govtrack.us/congress/bill.xpd?bill=h112-1195. Accessed March 1 2012.

67. The University of Alabama College of Community Health Services. Rural Scholars Programs Help Meet Need for More Rural Doctors. Available at: http://cchs.ua.edu/wpcontent/cchsfiles/crm/RuralScholarsPrograms.pdf. Accessed March 1 2012.

68. Whited JD. Accuracy and reliability of teleophthalmology for diagnosing diabetic retinopathy and macular edema: a review of the literature. Diabetes Technol Ther.

2006;8:102-11.

69. Cuadros J, Bresnick G. EyePACS: an adaptable telemedicine system for diabetic retinopathy screening. J Diabetes Sci Technol. 2009;3:509-16.

70. Au A, Gupta O. The economics of telemedicine for vitreoretinal diseases. Curr Opin Ophthalmol. 2011;22:194-8.

71. Bai VT, Murali V, Kim R, Srivatsa SK. Teleophthalmology-based rural eye care in India.

Telemed J E Health. 2007;13:313-21.

72. Aoki N, Dunn K, Fukui T, Beck JR, Schull WJ, Li HK. Cost-effectiveness analysis of telemedicine to evaluate diabetic retinopathy in a prison population. Diabetes Care.

2004;27:1095-101.

73. Indian Health Services, Division of Diabetes Treatment and Prevention. Fact Sheets - The IHSâ&#x20AC;&#x201C;Joslin Vision Network Teleophthalmology Program. Available at: http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=resourcesFactSheets_ JVN. Accesses February 15, 2012.

74. Quade R. Evaluation of the Expanding Access to Diabetic Retinopathy Screening Iniative. California Healthcare Foundation. Available at: http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/E/PDF%20Evaluatio nDiabeticRetinopathyScreening2011.pdf. Accessed February 22 2012.

75. California Telemedicine and eHealth Center (CTEC). Diabetic Retinopathy Screening Practice Guide. Available at: http://www.innovations.ahrq.gov/content.aspx?id=3376.

Accessed February 20 2012.

76. US Department of Health and Human Services. Health Resources and Services Administration (HRSA). Telehealth. Availanle at: http://www.hrsa.gov/ruralhealth/about/telehealth/. Accessed February 15 2012.

77. California Telehealth Network. Available at: http://www.caltelehealth.org/visioncalifornia-telehealth. Accessed February 15 2012.

78. Whited JD, Datta SK, Aiello LM, et al. A modeled economic analysis of a digital teleophthalmology system as used by three federal health care agencies for detecting proliferative diabetic retinopathy. Telemed J E Health. 2005;11:641-51.

55

79. Maberley D, Walker H, Koushik A, Cruess A. Screening for diabetic retinopathy in James Bay, Ontario: a cost-effectiveness analysis. CMAJ. 2003;168:160-4.

56

APPENDIX A

ELIGIBLE AND PARTICIPATING PROVIDERS BY COUNTY

57

Provider counties by eligibility and participations

County Autauga Baldwin Barbour Bibb Blount Butler Calhoun Chambers Cherokee Chilton Choctaw Clarke Cleburne Coffee Colbert Conecuh Covington Crenshaw Cullman Dale Dallas DeKalb Elmore Escambia Etowah Fayette Franklin Geneva Greene Henry Houston Jackson Jefferson Lamar Lauderdale Lee Limestone Macon Madison Marengo Marion Marshall Mobile Montgomery

Ophthalmologist Eligible Participants 0 5 0 0 0 0 4 1 0 0 2 0 0 1 2 0 0 0 0 0 1 0 0 0 5 0 0 0 0 0 19 0 79 0 5 5 1 0 19 0 0 0 26 20

-2 ----1 0 --0 --0 1 -----0 ---3 -----9 -46 -1 2 1 -10 ---11 10

Optometrists Eligible Participants 7 23 4 1 1 3 16 1 1 6 0 2 1 10 6 1 6 1 9 5 1 6 4 5 10 3 5 1 1 2 18 8 175 1 13 12 10 1 53 2 4 17 33 31

1 4 1 0 1 1 4 0 0 4 -1 1 2 4 0 3 1 2 0 1 3 0 2 4 1 2 0 0 1 6 2 80 0 7 2 3 0 23 0 3 6 15 15

Vision rehabilitation Eligible Participants 1 1 0 0 1 0 3 0 0 0 0 0 0 0 1 0 0 0 4 0 0 1 0 0 5 0 0 0 0 0 3 0 71 0 3 4 1 1 9 1 0 1 12 9

0 1 --1 -0 -------0 ---3 --0 --2 -----0 -27 -1 1 1 0 7 0 -0 7 5

58

Provider counties by eligibility and participations

County Morgan Perry Pickens Pike Russell St Clair Shelby Sumter Talladega Tallapoosa Tuscaloosa Walker Winston

Ophthalmologist Eligible Participants 2 0 0 0 1 0 5 0 3 1 6 1 0

1 ---1 -2 -3 0 4 1 --

Optometrists Eligible Participants 13 1 2 5 3 8 49 1 5 5 18 7 1

1 0 0 3 0 0 22 1 1 2 8 2 0

Vision rehabilitation Eligible Participants 5 0 0 2 0 4 9 0 16 0 9 0 0

3 --0 -3 5 -11 -3 ---

No providers were identified in the following counties: Bullock, Clay, Coosa, Hale, Lawrence, Lowndes, Monroe, Randolph, Washington, and Wilcox.

Regional classifications based on ALDPH definitions: Metro (Autauga, Baldwin, Blount, Calhoun, Colbert, Dale, Elmore, Etowah, Houston, Jefferson, Lauderdale, Lawrence, Lee, Limestone, Madison, Mobile, Montgomery, Morgan, Russell, Saint Clair, Shelby, Tuscaloosa); North rural (Cherokee, Clay, Cleburne, Cullman, DeKalb, Fayette, Franklin, Jackson, Lamar, Marion, Marshall, Randolph, Talladega, Walker, Winston); South rural (Barbour, Bibb, Butler, Chambers, Chilton, Clarke, Coffee, Conecuh, Coosa, Covington, Crenshaw, Escambia, Geneva, Henry, Monroe, Pike, Tallapoosa, and Washington); Black belt (Bullock, Choctaw, Dallas, Greene, Hale, Lowndes, Macon, Marengo, Perry, Pickens, Sumter, and Wilcox)

59

APPENDIX B

PROVIDER SPECIFIC SURVEYS FOR:

1. Ophthalmologists 2. Optometrists 3. Vision rehabilitation providers

60

Survey of Alabama Ophthalmologists

Thank you for taking a brief moment out of your day to complete this survey. Youâ&#x20AC;&#x2122;ll notice that it is short and goes quickly. Weâ&#x20AC;&#x2122;d appreciate it if the person this survey is addressed to is the one who actually completes the survey, rather than someone from your staff. Thank you!

What is the name of your business/practice/clinic/agency where you provide eye care services?

City or Town: County: Day/Hours you provide service to patients or clients?

Days: Hours:

If you have a website, please list it.

1. What is the type of clinic/agency where you are primarily based? Please check all that apply.

Private practice with at least one Ophthalmologist Private practice with at least one Optometrist Practice based in a university Department of Veterans Affairs clinic or medical center Rehabilitation hospital General hospital Outpatient rehabilitation center Independent service for the visually impaired State agency Optical retail store Other, specify: ____________________________________ 2. What is your race/ethnicity?

White, non-Hispanic African-American Hispanic Asian Native American Other 3. What is your age? years 4. What is your gender?

Male Female 5. In what year did you complete your Residency Training in Ophthalmology? ______________

61

Survey of Alabama Ophthalmologists 6. Following your Residency, did you complete Fellowship Training in a Subspecialty?

No Yes 7. If Yes, what is your Subspecialty?

Retina Glaucoma Cornea Pediatric Ophthalmology & Strabismus Neuro-Ophthalmology Oculoplastics Visual Rehabilitation Ophthalmic Pathology Ocular Inflammatory Disease Other ___________________________ 8. Please list the city/town of all office locations in Alabama where you yourself provide in-clinic services.

1.___________________________ 2.___________________________ 3.___________________________ 4.___________________________ 5.___________________________ 9. Please list all the hospitals or surgery centers where you yourself provide surgical services along with their town or city.

1. Hospital or surgery center name:__________________________ City/town _____________________ 2. Hospital or surgery center name:__________________________ City/town _____________________ 3. Hospital or surgery center name:__________________________ City/town _____________________ 4. Hospital or surgery center name:__________________________ City/town _____________________ 5. Hospital or surgery center name:__________________________ City/town _____________________ 10. Other than the clinic setting that you answered above, are you currently providing eye care services in any of the following settings? Please check all that apply.

Public or private schools (day programs) Residential schools (e.g., Alabama Institute for the Deaf & Blind, residential schools for the developmentally delayed) General hospitals In-patient psychiatric hospitals Nursing homes State or Federal prisons or local jails Other. Specify: _________________________________________________________

62

Survey of Alabama Ophthalmologists 11. Please place a check by any of the following services you yourself provide: Comprehensive Eye Care for Adults Comprehensive Eye Care for Infants and Children Contact Lens fitting and dispensing Cataract Surgery Refractive Surgery Retinal â&#x20AC;&#x201C; Vitreal Surgery Glaucoma Surgery Corneal Surgery Oculo-plastic Surgery Visual Rehabilitation Services Neuro-Ophthalmological Services Other. Specify: _______________________________________________ 12. Do you provide services in a group practice?

Yes No 13. If Yes, what are the names of the ophthalmologists and/or the other health care providers who practice in your group? Please circle what type of healthcare provider they are.

1. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 2. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 3. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 4. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 5. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 6. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 7. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 14. Do you have an optical service or shop at your practice?

Yes No 15. Does your practice/clinic provide services in Spanish?

Yes No 16. What is your best estimate of the typical time between the call for an appointment and the first available appointment in your clinic/agency/practice?

Less than 1 week 1 to 2 weeks 3 to 4 weeks More than a month Donâ&#x20AC;&#x2122;t know

63

Survey of Alabama Ophthalmologists 17. Do you take â&#x20AC;&#x153;walk-insâ&#x20AC;?, that is, a person who does not have an appointment?

Yes Only if it is an emergency and an established patient No 18. Please estimate the number of patients you see personally (regardless of location) in a typical week.

This includes both clinic patients and surgery patients. We realize this may vary from week to week.

Just estimate for what you would consider a typical week.

Approximate number of patients/week_______ 19. Below is a list of age ranges. Please estimate what percentage (%) of your patients fall within the following age categories. You do not have to know precisely. We are just looking for your best estimate. _______ Under 5 years _______ 5 to 19 years _______ 20 to 59 years _______ 60 to 79 years _______ 80 years and over 20. Below is a list of ethnic/racial groups. Please estimate what percentage (%) of your patients fall into each group. You do not have to know precisely. We are just looking for your best estimate. _______ White, non-Hispanic _______ African-American _______ Hispanic _______ Asian _______ Native American _______ Other 21. Please estimate what percentage (%) of your patients are male and female. You do not have to know precisely. We are just looking for your best estimate. _______ Male _______ Female 22. Below is a list of health insurance types. Please estimate what percentage (%) of your patients have the following kinds of insurance. You do not have to know precisely. We are just looking for your best estimate. (These donâ&#x20AC;&#x2122;t have to add up to 100% because patients may have more than one type of insurance.) _______ Medicare _______ Medicaid _______ Private insurance _______ No insurance _______ Other (Specify: __________________________)

64

Survey of Alabama Ophthalmologists

23. What types of health insurance do you accept toward payment in your practice or clinic? Please place a check by each type you accept. _______ Medicare _______ Medicare Complete _______ Medicaid _______ Blue Cross Blue Shield _______ Viva _______ Viva Medicare Plus _______ United Healthcare _______ Cigna _______ Aetna _______ Multiplan _______ GEHA _______ Tricare/Champus _______ Veterans Administration coverage _______ CHIP (Children’s Health Insurance Program) _______ Others, Specify: ___________________________________________________ _______ I don’t accept health insurance as payment.

24. Below is a list of eye conditions. What percentage (%) of your patients has each of the following eye conditions or diseases? You do not have to know precisely. We are just looking for your best estimate.

(These don’t have to add up to 100% because patients may have multiple problems.) _______ Refractive error _______ Amblyopia _______ Strabismus _______ Dry eye _______ Age-related macular degeneration _______ Glaucoma _______ Diabetic eye conditions including retinopathy _______ Cataract _______ Vision loss from brain injury including stroke _______ Juvenile or young adult onset retinal degenerations (e.g. retinitis pigmentosa, rod-cone dystrophies) _______ Optic neuritis or other optic nerve disorders _______ Retinopathy of prematurity _______ Corneal problems _______ Complications from contact lens wear _______ Dry eye _______ Conjunctivitis _______ Ocular trauma _______ Other. Specify: __________________________________________________

65

Survey of Alabama Ophthalmologists 25. What percentage (%) of your patients are diabetics (either Type 1 or Type 2)? You do not have to know precisely. We are just looking for your best estimate. _________% 26. What percentage (%) of your diabetic patients adhere to guidelines for annual comprehensive eye examination? You do not have to know precisely. We are just looking for your best estimate. _________% 27. We are interested in how your patients “find you”. What percent (%) of your patients are referred from the following sources. You do not have to know precisely. We are just looking for your best estimate. (These don’t have to add up to 100% because a client may be referred by multiple sources.) _______Refer themselves. _______Referred by family or friends _______Referred by an ophthalmologist. _______Referred by an optometrist _______Referred by another physician including a family physician. _______Referred by hospital emergency room. _______Referred by school or pre-school vision screening program. _______Other, specify: ___________________________________________________

28. What percentage (%) of your patients have “low vision”. A commonly used definition for low vision is visual acuity worse than 20/60 in both eyes with best refraction, and/or visual field loss in both eyes of less than 10 degrees from fixation. _________% 29. For your patients with low vision who are in need of visual rehabilitation services, where do you refer them? Please check all that are appropriate. _______ My own practice provides rehabilitation services so they are taken care of in my own practice. _______ Alabama Department of Rehabilitation Services (e.g., OASIS, vocational rehab) _______ State, county, or city/town educational services _______ UAB School of Optometry low vision clinic _______ UAB Center for Low Vision Rehabilitation _______ St. Vincent’s East, Birmingham AL _______ Other, Specify: ___________________________________________________

66

Survey of Alabama Ophthalmologists

30. What are the greatest unmet eye care needs in your community? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ___________________________________________________________________________________ 31. What single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community? Please explain why? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

67

Survey of Alabama Optometrists

Thank you for taking a brief moment out of your day to complete this survey. Youâ&#x20AC;&#x2122;ll notice that it is short and goes quickly. Weâ&#x20AC;&#x2122;d appreciate it if the person this survey is addressed to is the one who actually completes the survey, rather than someone from your staff. Thank you!

What is the name of your business/practice/clinic/agency where you provide eye care services?

City or Town: County: Day/Hours you provide service to patients or clients?

Days: Hours:

If you have a website, please list it.

1. What is the type of clinic/agency where you are primarily based? Please check all that apply.

Private practice with at least one Ophthalmologist Private practice with at least one Optometrist Practice based in a university Department of Veterans Affairs clinic or medical center Rehabilitation hospital General hospital Outpatient rehabilitation center Independent service for the visually impaired State agency Optical retail store Other, specify: ____________________________________ 2. What is your race/ethnicity?

White, non-Hispanic African-American Hispanic Asian Native American Other 3. What is your age? years 4. What is your gender?

Male Female 5. In what year did you receive your O.D. degree? ______________

68

Survey of Alabama Optometrists 6. Following optometry school, did you do a residency in a specialty area of optometry?

No Yes 7. If Yes, what was your specialty training in? Please check all that apply.

Community Health Optometry Cornea and Contact Lenses Family Practice Optometry Geriatric Optometry Low Vision Rehabilitation Pediatric Optometry Primary Eye Care Refractive and Ocular Surgery Vision Therapy Other. Specify: ___________________________________ 8. Please list the city/town of all office locations in Alabama where you yourself provide in-clinic services.

1.___________________________ 2.___________________________ 3.___________________________ 4.___________________________ 5.___________________________ 9. Other than the clinic settings you listed above, are you currently providing eye care services in any of the following settings? Please check all that apply.

Public or private schools (day programs) Residential schools (e.g., Alabama Institute for the Deaf & Blind, residential schools for the developmentally delayed) General hospitals In-patient psychiatric hospitals Nursing homes State or Federal prisons or local jails Other. Specify: _________________________________________________________ 10.

Please place a check by any of the following services you yourself provide: Comprehensive Eye Care for Adults Comprehensive Eye Care of Infants and Children Contact Lens Fitting and Dispensing Vision Therapy Low Vision Rehabilitation Services Other. Specify: ________________________________________________

69

Survey of Alabama Optometrists 11.

Do you provide services in a group practice?

Yes No

12.

If Yes, what are the names of the optometrists, ophthalmologists, and/or the other health care providers who practice in your group? Please circle what type of healthcare provider they are.

1.

2.

3.

4.

5.

6.

7.

13.

_________________________Optometrist/Ophthalmologist/Other: Specify ________________ _________________________Optometrist/Ophthalmologist/Other: Specify ________________ _________________________Optometrist/Ophthalmologist/Other: Specify ________________ _________________________Optometrist/Ophthalmologist/Other: Specify ________________ _________________________Optometrist/Ophthalmologist/Other: Specify ________________ _________________________Optometrist/Ophthalmologist/Other: Specify ________________ _________________________Optometrist/Ophthalmologist/Other: Specify ________________

Do you have an optical service or shop at your practice?

Yes No

14.

Does your practice/clinic provide services in Spanish?

Yes No

15. What is your best estimate of the typical time between the call for an appointment and the first available appointment in your clinic/agency/practice?

Less than 1 week 1 to 2 weeks 3 to 4 weeks More than a month Don’t know 16. Do you take “walk-ins”, that is, a person who does not have an appointment?

Yes Only if it is an emergency and an established patient No 17. Please estimate the number of patients you see personally (regardless of location) in a typical week.

We realize this may vary from week to week. Just estimate for what you would consider a typical week.

Approximate number of patients/week_______ 18. Below is a list of age ranges. Please estimate what percentage (%) of your patients fall within the following age categories. You do not have to know precisely. We are just looking for your best estimate. _______ Under 5 years _______ 5 to 19 years _______ 20 to 59 years

70

Survey of Alabama Optometrists _______ 60 to 79 years _______ 80 years and over 19. Below is a list of ethnic/racial groups. Please estimate what percentage (%) of your patients fall into each group. You do not have to know precisely. We are just looking for your best estimate. _______ White, non-Hispanic _______ African-American _______ Hispanic _______ Asian _______ Native American _______ Other 20. Please estimate what percentage (%) of your patients are male and female. You do not have to know precisely. We are just looking for your best estimate. _______ Male _______ Female 21. Below is a list of health insurance types. Please estimate what percentage (%) of your patients have the following kinds of insurance. You do not have to know precisely. We are just looking for your best estimate. (These donâ&#x20AC;&#x2122;t have to add up to 100% because patients may have more than one type of insurance.) _______ Medicare _______ Medicaid _______ Private insurance _______ No insurance _______ Other (Specify: __________________________) 22. What types of health insurance do you accept toward payment in your practice or clinic? Please place a check by each type you accept.

Medicare Medicare Complete Medicaid Blue Cross Blue Shield Viva Viva Medicare Plus United Healthcare Cigna Aetna Multiplan GEHA Tricare/Champus Veterans Administration coverage CHIP (Childrenâ&#x20AC;&#x2122;s Health Insurance Program)

71

Survey of Alabama Optometrists Others, Specify: ___________________________________________________ I don’t accept health insurance as payment.

23. Below is a list of eye conditions. What percentage (%) of your patients has each of the following eye conditions or diseases? You do not have to know precisely. We are just looking for your best estimate.

(These don’t have to add up to 100% because patients may have multiple problems.) _______ Refractive error _______ Amblyopia _______ Strabismus _______ Dry eye _______ Age-related macular degeneration _______ Glaucoma _______ Diabetic eye conditions including retinopathy and macular edema _______ Cataract _______ Vision loss from brain injury including stroke _______ Juvenile or young adult onset retinal degenerations (e.g. retinitis pigmentosa, rod-cone dystrophies) _______ Optic neuritis or other optic nerve disorders _______ Retinopathy of prematurity _______ Corneal problems _______ Complications from contact lens wear _______ Dry eye _______ Conjunctivitis _______ Ocular trauma _______ Other 24. What percentage (%) of your patients are diabetics (either Type 1 or Type 2)? You do not have to know precisely. We are just looking for your best estimate. _________% 25. What percentage (%) of your diabetic patients adhere to guidelines for annual comprehensive eye examination? You do not have to know precisely. We are just looking for your best estimate. _________% 26. We are interested in how your patients “find you”. What percent (%) of your patients are referred from the following sources. (You do not have to know precisely. We are just looking for your best estimate.) (These don’t have to add up to 100% because a client may be referred by multiple sources.) _______ Refer themselves. _______ Referred by family or friends _______ Referred by an ophthalmologist. _______ Referred by an optometrist. _______ Referred by another physician including a family physician. _______ Referred by hospital emergency room. _______ Referred by school or pre-school vision screening program.

72

Survey of Alabama Optometrists _______ Other, specify: ___________________________________________________ 27. What percentage (%) of your patients have “low vision”. A commonly used definition for low vision is visual acuity worse than 20/60 in both eyes with best refraction, and/or visual field loss in both eyes of less than 10 degrees from fixation. _________% 28.

For your patients with low vision who are in need of visual rehabilitation services, where do you refer them? Please check all that are apply.

My own practice provides rehabilitation Alabama Department of Rehabilitation Services (e.g., OASIS, vocational rehab) State, county, city/town educational services UAB School of Optometry low vision clinic UAB Center for Low Vision Rehabilitation St. Vincent’s East, Birmingham AL Other, Specify: ___________________________________________________ 29. What are the greatest unmet eye care needs in your community? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

30. What single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community? Please explain why. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

73

Survey of Alabama Vision Rehabilitation Providers

Thank you for taking a brief moment out of your day to complete this survey. Youâ&#x20AC;&#x2122;ll notice that it is short and goes quickly. Weâ&#x20AC;&#x2122;d appreciate it if the person this survey is addressed to is the one who actually completes the survey, rather than someone from your staff. Thank you!

What is the name of your business/practice/clinic/agency where you provide eye care services?

City or Town: County: Day/Hours you provide service to patients or clients?

Days: Hours:

If you have a website, please list it.

1. What is the type of clinic/agency where you are primarily based? Please check all that apply.

Private practice with at least one Ophthalmologist Private practice with at least one Optometrist Practice based in a university Department of Veterans Affairs clinic, medical center or rehabilitation center Rehabilitation hospital General hospital Outpatient rehabilitation center Independent service for the visually impaired State agency Optical retail store Other, specify: ____________________________________ 2. What is your race/ethnicity?

White, non-Hispanic African-American Hispanic Asian Native American Other 3. What is your age? years 4. What is your gender?

Male Female

74

Survey of Alabama Vision Rehabilitation Providers

5. In what year did you receive your highest degree that is rehabilitation related? ______________ 6. Which of the following best describes what type of visual rehabilitation professional you are? Please check all that apply.

Occupational Therapist Occupational Therapist Assistant Vision Rehabilitation Teacher Certified Low Vision Therapist (CLVT) Social Worker Orientation and Mobility Specialist Rehabilitation Counselor Vocational Rehabilitation Counselor Psychologist Educator of the Visually Impaired (Professionals with a special education degree) Other: Specify _____________________________________________________ 7. Please list the city/town of all office locations in Alabama where you yourself provide in-clinic services.

1.___________________________ 2.___________________________ 3.___________________________ 4.___________________________ 5.___________________________ 8.

Check this box if you provide in-home services.

9. Other than the clinic settings you listed above, are you currently providing eye care services in any of the following settings? Please check all that apply.

Public or private schools (day programs) Residential schools (e.g., Alabama Institute for the Deaf & Blind, residential schools for the developmentally delayed) General hospitals In-patient psychiatric hospitals Nursing homes State or Federal prisons or local jails Other. Specify: _________________________________________________________ 10. Please place a check by any of the following services you yourself provide. Please check all that apply.

Training in the use of assistive devices (e.g., optical, non-optical) Orientation and mobility training Eccentric viewing training or training in preferred retinal loci Scanning strategy training

75

Survey of Alabama Vision Rehabilitation Providers

Training in strategies to perform everyday visual tasks (e.g., household activities, managing money, preparing meals) Psychological or counseling services Support groups (for clients and/or families) Social work services Driving rehabilitation Home-based visits for education or training Vocational rehabilitation or career counseling services Training in the use of computers and software Other; specify: ____________________________________________________ 11. Do you provide services in a group practice or agency where there are multiple providers?

Yes No 12. If Yes, what are the names of the other eye care, health care, or rehabilitation providers who practice in your group? Please circle what type of healthcare provider they are.

1. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 2. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 3. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 4. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 5. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 6. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 7. _________________________Ophthalmologist/Optometrist/Other: Specify ________________ 13. Do you have an optical service or shop at your practice or agency?

Yes No 14. Does your practice/agency provide services in Spanish?

Yes No 15. What is your best estimate of the typical time between the call for an appointment and the first available appointment in your clinic/agency/practice?

Less than 1 week 1 to 2 weeks 3 to 4 weeks More than a month Don’t know 16. Do you take “walk-ins”, that is, a person who does not have an appointment?

Yes Only if it is an emergency and an established patient

76

Survey of Alabama Vision Rehabilitation Providers

No 17. Please estimate the number of patients/clients you see personally (regardless of location) in a typical week. We realize this may vary from week to week. Just estimate for what you would consider a typical week.

Approximate number of patients/ clients per week_______ 18. Below is a list of age ranges. Please estimate what percentage (%) of your patients/clients fall within the following age categories. You do not have to know precisely. We are just looking for your best estimate. _______ Under 5 years _______ 5 to 19 years _______ 20 to 59 years _______ 60 to 79 years _______ 80 years and over 19. Below is a list of ethnic/racial groups. Please estimate what percentage (%) of your patients fall into each group. You do not have to know precisely. We are just looking for your best estimate. _______White, non-Hispanic _______African-American _______Hispanic _______Asian _______Native American _______Other 20. Please estimate what percentage (%) of your patients are male and female. You do not have to know precisely. We are just looking for your best estimate. _______Male _______Female 21. Below is a list of health insurance types or 3rd party reimbursement programs. Please estimate what percentage (%) of your patients have the following kinds of insurance. You do not have to know precisely. We are just looking for your best estimate. (These don’t have to add up to 100% because patients may have more than one type of insurance.) _______Medicare _______Medicaid _______Private insurance _______Vocational rehab _______CHIP (Children’s Health Insurance Program) _______No insurance _______Other (Specify: __________________________) _______I don’t accept health insurance as payment.

22. What types of health insurance or 3rd party reimbursement programs do you accept toward payment in your practice or clinic? Please place a check by each type you accept.

77

Survey of Alabama Vision Rehabilitation Providers

Medicare Medicare Complete Medicaid Blue Cross Blue Shield Viva Viva Medicare Plus United Healthcare Cigna Aetna Multiplan GEHA Tricare/Champus Veterans Administration coverage Vocational Rehab CHIP (Children’s Health Insurance Program) Others, Specify: ___________________________________________________ I don’t accept health insurance as payment.

23. Do you provide services through Alabama’s OASIS Program? (OASIS stands for Older Alabamians System of Information and Services. It is a federally funded program designed to assist persons 55 years and older and visually impaired in living more independently in their homes.)

Yes No 24. Below is a list of eye conditions. What percentage (%) of your patients has each of the following eye conditions or diseases? You do not have to know precisely. We are just looking for your best estimate.

(These don’t have to add up to 100% because patients may have multiple problems.) _______Refractive error _______Amblyopia _______Strabismus _______Dry eye _______Age-related macular degeneration _______Glaucoma _______Diabetic eye conditions including retinopathy and macular edema _______Cataract _______Vision loss from brain injury including stroke _______Juvenile or young adult onset retinal degenerations (e.g. retinitis pigmentosa, rod-cone dystrophies) _______Optic neuritis or other optic nerve disorders _______Retinopathy of prematurity _______Corneal problems _______Complications from contact lens wear _______Dry eye _______Conjunctivitis

78

Survey of Alabama Vision Rehabilitation Providers

_______Ocular trauma _______Other. Specify: _____________________________________________________ 25. What percentage (%) of your patients/clients are diabetics (either Type 1 or Type 2)? You do not have to know precisely. We are just looking for your best estimate. _________% 26. We are interested in how your patients/clients “find you”. What percent (%) of your patients are referred from the following sources. You do not have to know precisely. We are just looking for your best estimate. (These don’t have to add up to 100% because a patient/client may be referred by multiple sources.) _______Refer themselves. _______Referred by family or friends _______Referred by an ophthalmologist. _______Referred by an optometrist. _______Referred by another physician including a family physician. _______Referred by hospital emergency room. _______Referred by a school system. _______Referred by a vision screening program. _______Other. Specify: ___________________________________________________ 27. What percentage (%) of your patients/clients patients have “low vision”. A commonly used definition for low vision is visual acuity worse than 20/60 in both eyes with best refraction, and/or visual field loss in both eyes of less than 10 degrees from fixation. _________% 28. What percentage of your rehabilitation patients/clients have difficulties or problems in the following areas? You do not have to know precisely. We are just looking for your best estimate. (These don’t have to add up to 100% because clients may have multiple problems.) _____Reading _____Writing _____Financial Management _____Other Detail Near Tasks _____Independent Living _____Mobility _____Driving _____Identification of objects, people, events from a distance _____Self-Care/Domestic Activity _____Emotional or Psychological Adjustment

79

Survey of Alabama Vision Rehabilitation Providers

29. What are the greatest unmet eye care needs in your community? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 30. What single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community? Please explain why. ____________________________________________________________________________________

80

APPENDIX C

DOMAINS AND SUBCATEGORIES FOR WRITTEN RESPONSES TO:

1. What are the greatest unmet eye care needs in your community?

2. What single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community?

81

Table B1. Domains and subcategories for the survey question, â&#x20AC;&#x153;What are the greatest unmet care needs in your community?â&#x20AC;?

Domains/subcategory

Detailed description

CLINICAL CARE

Eye care

Provision of routine comprehensive eye care to high-risk populations High-risk = uninsured, underinsured, poor, ethnic/racial minorities, nursing home population, or institutionalized populations.

Glaucoma screening

Glaucoma screening for high-risk populations High-risk = African Americans, Hispanic/Latinos, uninsured, underinsured

Diabetic retinopathy screening

Diabetic retinopathy screening for high-risk populations High risk = those with diabetes (any type)

Pediatric unspecified

Pediatric ophthalmology or pediatric optometry w/o screening or eye exams specified.

Pediatric screening

Pediatric screening services for pre-K or K children to screen for refractive error, amblyopia or strabismus

Pediatric comprehensive eye exam

Comprehensive eye exams need to be provided for all pre-K or K children

Hispanic eye care

Services for Hispanic/Latino community in AL (most are uninsured) Even the most basic eye care needs such as glasses or contact lenses are not readily accessible for this population

82

Table B1. Domains and subcategories for the survey question, â&#x20AC;&#x153;What are the greatest unmet care needs in your community?â&#x20AC;?

Domains/subcategory

Detailed description

Dry eye

Dry eye treatment

Refractive error

Treatment of refractive error

EDUCATION

Eye health education for the public

Eye health education in general Educating about the importance of early diagnosis and intervention for chronic diseases of adulthood, and importance of routine comprehensive eye care to achieve early diagnosis Educating about compliance with follow-up appointments Educating about medication adherence Educating parents about early vision screening and screening for amblyopia and strabismus in children Educating about low vision rehabilitation services and what they are Educating about importance of getting assessed and treatments for hypertension Educating about how to improve communication with doctor and his staff Educating visually impaired persons and the public about bioptic driving program

Provider education Educating ophthalmologists and optometrists about low vision rehabilitation services and the importance of making referrals for those

83

Table B1. Domains and subcategories for the survey question, “What are the greatest unmet care needs in your community?”

Domains/subcategory

Detailed description

with irreversible vision impairment to low vision rehab specialty clinics.

Educating internists and family physicians about the importance of urging and referring their diabetic patients to annual comprehensive eye care Educating eye care providers about how to improve doctor-patient communication Educating about bioptic driving program Better education of family medicine physicians about how to treat bacterial eye infections.

Better education of ophthalmic assistants

ACCESSIBILITY

Transportation to appointments

Especially appointments at ophthalmology clinics and tertiary care centers that are primarily in the metropolitan areas and not in more rural areas of state

Satellite clinics

Satellite clinics or providers willing to base practices outside the major metropolitan areas

Nursing homes

Eye care providers who provide services in nursing homes

EYE CARE ORGANIZATION/EYE HEALTH SYSTEM

More providers

Shortage of providers – the following were specifically mentioned

84

Table B1. Domains and subcategories for the survey question, “What are the greatest unmet care needs in your community?”

Domains/subcategory

Detailed description

Low vision rehabilitation specialists Ophthalmologists who do LASIK Pediatric Ophthalmologists Oculoplastics specialists Neuro-ophthalmologists Providers willing to work in non-metropolitan areas, more rural regions of state where providers are non-existent or too few Orientation and Mobility Instructors and Rehab Teachers Providers that offer “vision therapy”

New hospital

New eye hospital

Disability services

Clinics that provide services for reading disability and dyslexia

Health disparities

Implement strategies to reduce health disparities in eye care

Blind services

Better services for the blind

VA services

More service availability for eye care at Veterans Administration for veterans (too overbooked)

Handicapped children

Clinics that serve multi-handicapped children (e.g., vision impairment, cognitive and motor disorders)

85

Table B1. Domains and subcategories for the survey question, â&#x20AC;&#x153;What are the greatest unmet care needs in your community?â&#x20AC;?

Domains/subcategory

Detailed description

Dual sensory impairment

Clinics that screen for dual sensory impairment

Sports

Sports vision services

Support group

Support groups for the visually impaired

POLICY CHANGES

Financial prescriptions

Financial assistance for prescription medications for the uninsured or underinsured

Low co-pay

Lower co-pays for office visits and prescription medications

Higher reimbursements

Higher reimbursements to eye care providers so that practice is sustainable and the latest technologies for disease management can be purchased

Medicare spectacles

Medicare coverage for spectacles (not just after cataract surgery) at some periodic time period

State funds

More funds for state services for visually impaired persons

Mobility paths

Mobility friendly pedestrian paths

86

Table B1. Domains and subcategories for the survey question, “What are the greatest unmet care needs in your community?”

Domains/subcategory

Detailed description

School screening

Organize and fund system wide school vision screening

School spectacles

A spectacle fund in schools for those children with uncorrected refractive error whose parents cannot afford spectacles

Vision rehabilitation funding

More funding for vocational rehabilitation programs for visually impaired

NO NEEDS

No unmet care needs in my community

NOT KNOWN

I don’t know

87

Table B2. Domains and subcategories for the survey question, “What single action by a private foundation (such as the EyeSight Foundation of Alabama) would make the greatest improvement in eye care in your community?”

Domains/specific category

Detailed description

Fund Research

Funding research on major blinding conditions (glaucoma, diabetic retinopathy, Age related macular degeneration)

Education

Education

Public education

Eye health education for the public

Provider education

Education of providers

Accessibility Transportation to appointments

Accessibility Transportation to appointments

Policy

Promote policy or program changes

Clinical care and screening

Support clinical care and screening programs

Relationships

Facilitate relationships in professional communities

Not known

I don’t know

None

None

88