A review of evidence to evaluate effectiveness of intervention strategies to address inequalities in eye health care

Annex A: Summary reference table

Date:

December 2011

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This annex accompanies the report: A review of evidence to evaluate effectiveness of intervention strategies to address inequalities in eye health care, RNIB report: RNIB/CEP/01, 2011.

To accommodate formatting constraints, the font used in this annex may not be fully accessible. A large print version of the annex is available on request.

Atri J, Falshaw M, Gregg R, Robson J, et al. (1997). Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice reception staff to contact non-attenders. British Medical Journal. Vol. 315, pp. 1356-9.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
A controlled trial randomised by general practice to determine whether a two hour training programme for general practice reception staff could improve uptake in patients who had failed to attend for breast screening, and whether women from different ethnic groups benefited equally / 2,064 women aged 50-64 years who came from 26 general practices in the inner London borough of Newham, 31% were white, 17% were Indian, 10% Pakistani, 14% black, 6% Bangladeshi, 1% Chinese, 4% were from other ethnic groups, and in 16% the ethnic group was not reported / Intervention group: Training programme for a member of reception staff at a general practice.
Control group: No training programme for reception staff / Attendance for breast screening in relation to ethnic group in women who had not taken up their original invitation / Attendance in the intervention group was significantly better than in the control group with the best response coming from Indian women / Train front line staff and use telephone calls to remind people called for screening. This intervention could be effective as part of a multifaceted strategy to improve uptake in areas with low rates / Strong but indirect as does not focus on vision

Access Economics (2009) Future sight loss UK (1): The economic impact of partial sight and blindness in the UK adult population. Report prepared for RNIB by Access Economics Pty Limited, July 2009.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
Epidemiological estimates of the numbers of people likely to have age-related macular degeneration (AMD), cataract, diabetic retinopathy (DR) and glaucoma at two points in time, 2010 and 2020
Estimated costs to society of the resources used in health and social service and in providing informal care in that time frame / A ‘System Dynamics’ model to simulate the dynamics of eye disorders in large populations
The ‘system’ comprises the given population and the health care and related resources therein / n/a / Estimates of the numbers of the prevalence of age-related macular disease, cataract, diabetic retinopathy and glaucoma
The baseline and cumulative costs to society of the prevailing health and social care provision / AMD: in 2010, 223,224 people partially sighted or blind. In 2020, figure is 291,982
Cataract: number of operations in 2010 more than 389,000. rising to 473,944 in 2020
DR: in 2010, 65,958 people partially sighted or blind. In 2020, figure is 76,430
Glaucoma: in 2010, 75,157 people partially sighted or blind. In 2020, figure is 75,157 / Authors observed that a more robust information base is required
The serious deficit in reliable information on levels of detection and treatment coverage for eye conditions limits the output of this decade model at present / Fit for purpose.

Acharya N, Lois N, Townend J, Zaher S, Gallagher M, Gavin M (2009) Socio-economic deprivation and visual acuity at presentation in Exudative age-related macular degeneration. Br J Ophthalmol, 93: 627-629.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
Study to evaluate the influence of socio-economic factors on visual acuity (VA) at presentation in exudative age-related macular degeneration (AMD) / All consecutive patients with newly diagnosed exudative AMD examined at the Ophthalmology Departments of two hospitals in Scotland, between July 2004 and June 2005 (n = 240) / n/a / Ophthalmic: VA in study and fellow eye, exudative AMD characteristics; and status of fellow eye
Demographics; duration of symptoms; and patient home address, to determine the Scottish Index of Multiple Deprivation (SIMD) score / Age, location and type of the choroidal neovascularisation were statistically significantly associated with VA at presentation
SIMD scores, area and VA in the fellow eye were not associated with presenting vision / Age, location and type of choroidal neovascularisation, but not socio-economic deprivation, were associated with VA at presentation in exudative AMD / Fit for purpose

AREDS (2001) A Randomized, Placebo-Controlled, Clinical Trial of High-Dose Supplementation With Vitamins C and E, Beta Carotene, and Zinc for Age-Related Macular Degeneration and Vision Loss: AREDS Report No. 8’ (Age-Related Eye Disease Study Research Group). Arch Ophthalmol, 119: 1417-1436.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
A randomized, placebo-controlled study to evaluate the effect of high-dose vitamins C and E, beta carotene, and zinc supplements on AMD progression and visual acuity / Participants aged 55 to 80 enrolled into 11 retinal specialty clinics between the years 1992 and 1998 (n = 3640) / Participants were randomly assigned to receive daily oral tablets containing: (1) antioxidants (vitamin C, 500 mg; vitamin E, 400 IU; and beta carotene, 15 mg); (2) zinc, 80 mg, as zinc oxide and copper, 2 mg; (3) antioxidants plus zinc; or (4) placebo / Photographic assessment of progression to or treatment for advanced AMD
Moderate visual acuity loss from baseline (> or =15 letters)
Estimates of odds ratios (ORs) for specified outcomes / Versus placebo, statistically significant odds reduction for the development of advanced AMD with antioxidants plus zinc
Both zinc and antioxidants plus zinc significantly reduced the odds of developing advanced AMD in the higher-risk group / Persons older than 55 years should have dilated eye examinations to determine their risk of developing advanced AMD
Those with extensive intermediate size drusen, at least 1 large druse, or advanced AMD should consider taking a supplement of antioxidants plus zinc / Strong

Awobem JF, Cassels-Brown A, Buchan JC, Hughes KA (2009) Exploring glaucoma awareness and the utilization of primary eye care services: community perceived barriers among elderly African Caribbeans in Chapeltown, Leeds. Eye, 23(1): 243.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
Community-based qualitative study conducted in fulfilment of a Masters in Public Health Dissertation to explore knowledge and attitudes concerning glaucoma and investigate the utilisation and barriers to uptake of primary eye care / Members of the Black African-Caribbean community living in a large city in Northern England (n = 16) / n/a / Knowledge and attitudes concerning access to primary eye care services (PECS) / Utilisation of PECS was largely symptom driven
Once attendance is established, optometrist letters a substantial incentive for attendance (50% of respondents)
Family members most important source of info about glaucoma (87%)
Barriers to PECS include perceived cost of eye tests (37%); mistrust (31%); pressure to buy expensive glasses (37%) / Initiatives to overcome attitudinal barriers to the uptake of PECS are necessary from the service user and the provider perspective / Fair/weak

Baker H, Murdoch IE. (2004). Can a public health package on glaucoma reach its target population? Eye. Vol. 18, pp. 478-82.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
A pilot study to assess how successful a newspaper advertisement and a radio interview about glaucoma are at reaching their target population / A convenience method of sampling used for residents aged 45+ years living in either Southall, London or on the Isle of Wight
Participants were approached in the high street and local temples in Southall, London and in the town centre of Newport, Isle of Wight / An interview on local radio and an advertisement in the local newspaper / A questionnaire administered pre and post intervention
Questionnaire in Hindi for residents of Southall, London and in English for residents of Isle of Wight
Statistical analysis of survey data / Participants who had heard of glaucoma increased from 54% before the intervention to 60% after. Those who had heard of the disease increased by 13% in Southall (SA sample) from lower baseline and by 8% on the Isle of White
Newspaper advert was effective in both areas but radio interview only affected residents of Southall, London / Media work differently for different groups / locations
Further research is required to determine the best method of reaching target populations through radio. Other media may need to be considered / Fit for purpose

Baker H, Murdoch IE. (2008). Can a public health intervention improve awareness and health-seeking behaviour for glaucoma? British Journal of Ophthalmology. Vol. 92, pt. 12.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
To investigate whether a public education campaign can increase awareness and change help-seeking behaviour with respect to ocular health in an Indian population / Indian population aged 60+ years living in Southall, Ealing / Health knowledge questionnaire and a health campaign consisting of television advertising, local press, local radio and places of worship / Sight test data collected by local optometric patients 6 months before and after the intervention / After the intervention the majority of participants (69%) heard about glaucoma from local radio rather than from their GP though the study did not show a change in health seeking behaviours / Radio appeared to be the most effective method of reaching target group (Indians aged 60+ years) but had little effect on behaviour / Fit for purpose
UK study

Bellary S, O'Hare JP, Raymond NT, Gumber A, et al (2008). Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study): a cluster randomised controlled trial. Lancet. 24;371(9626), pp. 1769-76.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
Cluster randomised trial investigating the effectiveness of a culturally sensitive, enhanced care package in UK general practices for improvement of cardiovascular risk factors in patients of south Asian origin with type 2 diabetes / 1,486 patients at 21 general practices, seven in Coventry (patients = 500) and 14 in Birmingham (patients = 986). General practices were chosen for the high number of south Asian patients they have (80%+)
Nine of the practices received the intervention (n= 868) while 12 were included in the control group (n=618) / Intervention group: Enhanced care including additional time with practice nurse and support from a link worker and diabetes-specialist nurse
Control group: Standard care / Changes in blood pressure, total cholesterol, and glycaemic control (haemoglobin A1c) after 2 years.
Statistical analysis / A comparison of intervention and control groups after 2 years showed significant differences for diastolic blood pressure and mean arterial pressure after adjustment for confounding and clustering / Small but sustained improvements in blood pressure in SA patients can be achieved through a culturally sensitive, enhanced care package. Improvement in glycaemic control remains a major challenge. Further work on health-care delivery in general practice and to improve motivation is needed to reduce health-care inequalities / Strong
UK study

Burr JM, Mowatt G, Hernández R, Siddiqui MAR, Cook J, Lourenco T, Ramsay C, Vale L, Fraser C, Azuara-Blanco A, Deeks J, Cairns J, Wormald R, McPherson S, Rabindranath K, Grant A (2007) The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation Health Technology Assessment 11,41

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
Systematic review to determine if OAC screening meets national criteria for inclusion in NHS national screening programmes / All relevant papers in major electronic databases up to 2005 / Screening / Evidence of benefit (years of added quality life etc) / No RCTs found nor any consistent evidence of effectiveness although some support that early treatment is desirable
Insufficient evidence to estimate risks in other ethnic groups (non-African descent) / Screening for high risk groups (defined as ‘Black’ ethnic groups and older age groups might be justifiable but at present best practice would be to improve opportunistic case finding through regular attendance at eye health checks / Strong (Systematic review with health economics assessments)
UK study

Busby D (2004) First Report of the National Eye Care Steering Group London: Department of Health.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
First report of the Eye Care Services Steering Group set up in 2002 to develop proposals for modernisation of NHS eyecare, maintaining and developing an integrated, patient-centred service, and improving access, choice, waiting times and quality / Dependent upon original study included in the review / n/a / n/a / Incidence of visual impairment will rise by approx. 35% by 2020
By age 75, a quarter of all people will have developed a cataract
Prevalence of glaucoma rises from 1-2% >40s, to 5% of >75s
ARMD is the most common cause of irremediable serious visual lossin people over 65 years of age / NHS needs to develop primary care ophthalmic services to meet increased need, particularly from demographic change
Developing partnerships between primary, secondary care and patient will increase access and choice
With training and protocols, primary care could take an enhanced role to benefit of patients and professional development / Fit for purpose

Chou R, Dana T, Bougatos C (2009) Screening older adults for impaired visual acuity: a review of the evidence for the US Preventive Services Task force (Cochrane review). Annals Internal Medicine, 151: 37-43 and 44-58.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
Review of randomized trials and controlled observational studies to update the 1996 U.S. Preventive Services Task Force evidence review on benefits and harms of screening for impaired visual acuity in primary care settings in adults age 65 years or older / Dependent upon original study included in the review
Participants from studies that directly evaluated screening for impaired visual acuity in older adults from 1996 to July 2008 / n/a / Direct evidence on screening and the accuracy of diagnostic tests
Benefits and harms of treatment. Quantitative estimates for treatment effects and relative risks using a random-effects model / Screening for VI in older adults in primary care settings is not associated with improved visual or clinical outcomes
Effective treatment is available for refractive error, cataracts, and AMD
Visual acuity test is standardr screening for vision impairment in primary care, but diagnostic accuracy is uncertain / More research is needed to understand why direct evidence shows no benefits of screening, even though impaired visual acuity is common and effective treatments are available / Strong
Non-UK study so may not be totally transferable

Claydon BE, Efron N, Woods C (1998) Non-compliance in optometric practice. Ophthal Physiol Opt, 18(2): 187-190.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
Review of non-compliance in contact lens behaviour in relation to organisation of optometric practice / n/a – mainly self-citation / n/a / n/a / n/a / Optometric profession should pay attention to compliance issues / weak

Coleman HR, Chan CC, Ferris FL 3rd, Chew EY. (2008) Coleman, A. L. (1999) Glaucoma. Lancet 354 (9192), 1803-1810.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
Review of the knowledge related to the diagnosis, screening, aetiology and risk factors, and management of glaucoma / Dependent upon original study included in the review / n/a / Dependent upon original study included in the review / Various
Dependent upon original study included in the review / Worldwide prevalence of POAG and PCAG will continue to increase
Glaucoma detection should be more aggressive
Burden of POAG and PCAG falls on patients, but also on society
Information might highlight need for periodic eye examinations among individuals with family history / Fit for purpose

Coleman HR, Chan CC, Ferris FL 3rd, Chew EY. (2008) Age-related macular degeneration. Lancet, 22, 372 (9652): 1835-45.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
Review of the literature related to the epidemiology, risk factors, pathophysiology, and management of age-related macular degeneration (AMD) / Dependent upon original study included in the review / Various
Mainly dietary supplementation, and vascular endothelial growth factor (VEGF) inhibitors / Various
Development of AMD
Modifiable risk factors / Various
Dependent upon original study included in the review / AMD is leading cause of blindness in elderly people of western descent
Most common risk factors are age and cigarette smoking
Treatment with antioxidant vitamins and zinc can reduce the risk of developing AMD by a quarter in those at least at moderate risk
Intravitreal ranibizumab can stabilise vision loss and may improve vision / Fit for purpose

Congdon N, Vingerling JR, Klein BE, West S, Friedman DS, Kempen J, O'Colmain B, Wu SY, Taylor HR; Eye Diseases Prevalence Research Group (2004). Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Archives of Ophthalmology, 122(4): 487-94.

Study Purpose & Type / Sample Characteristics / Intervention / Outcome Measures / Results / Conclusions / Quality
To determine the prevalence of cataract and prior cataract surgery (pseudophakia/ aphakia) in the United States and to project the expected change in these prevalence figuresby 2020 / Dependent upon original study: Black, white and Hispanic persons with cataract or pseudophakia/ aphakia
Seven studies (n = approx 50,000), Barbados Eye Study; Beaver Dam Eye Study; Blue Mountains Eye Study; Melbourne Vision Impairment Project; Proyecto Vision Evaluation Research; Rotterdam Study, Salisbury Eye Evaluation / n/a / Estimates of cataract and of pseudophakia/ aphakia, measured in 5-year age intervals starting at 40 years old
Covariates: age and race/ethnicity
Odds ratios (ORs) calculated for relevant variables / Pooled age-specific prevalence figures for cataract increased with age for both black and white persons (P< 0.001)
Women have a significantly (odds ratio=1.37; 95% confidence interval, 1.26-1.50) higher age-adjusted prevalence of cataract
Prevalence of cataract in US did not systematically differ from Australia and Europe / The number of Americans affected by cataract and undergoing cataract surgery will dramatically increase over the next 20 years as the US population ages
Existing data are very poor even in majority groups: more and better research and data collection needed / Fair but major problems of heterogeneity
Non-UK study

Cook PF, Bremer RW, Ayala A, Kahook MY. (2010). Feasibility of motivational interviewing delivered by a glaucoma educator to improve medication adherence. Clinical Ophthalmology. Vol. 4, pp. 1091–1101.