An Initiative to Improve Follow-up of Patients with Glaucoma

Abstract

Purpose: This study describes the implementation of an electronic medical record (EMR)-based initiative aimed at reducing the number of patients with glaucoma-related diagnoses lost to follow-up (LTF) and reviews its short-term outcomes.

Design: Retrospective, comparative case series.

Participants: Patients with glaucoma-related diagnoses seen 1 year prior at the Lahey Medical Center and who had not returned within the 6-month period between January 1, 2020, and June 30, 2020, which spanned the outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic in the United States.

Methods: An EMR-based tool was designed to identify patients suspected of being LTF with glaucoma-related diagnoses. Providers were enlisted to review the EMR for each of these patients and re-engage them, as appropriate. One month later, the initiative was evaluated by means of a retrospective chart review. Binary logistic regression analysis was used to identify demographic, clinical, and sociomedical factors associated with being LTF.

Main outcome measures: Patients who completed a telemedicine or in-person appointment, or had a future scheduled or ordered return appointment, were considered re-engaged.

Results: Of the 3551 patients seen during the study period, 384 patients were identified as LTF (11%), with 60 identifying COVID-19 as the reason for canceling their visit (16%). Patients who lived farther from the eye clinic (P < 0.001) or who had a history of canceling or missing an appointment (P < 0.001) were more likely to be LTF. Patients with open-angle glaucoma (P = 0.042) or who had completed a visual field (P < 0.001) or ophthalmic imaging (P < 0.001) within the past year were less likely to be LTF. One month after the re-engagement initiative, 124 LTF patients (32%) had been re-engaged (40% through telemedicine), 238 patients (62%) had future scheduling orders in place, and 22 patients (6%) had no active plan for future follow-up.

Conclusions: An EMR-based tool is an effective method for identifying patients at risk of being LTF and provides an opportunity for providers to recall and re-engage patients. Use of telemedicine to recontact LTF patients shows promise of improving the management of glaucoma, enhancing clinical productivity, and documenting treatment plans, thereby potentially reducing medicolegal liability.

Keywords: Adherence; CDR, cup-to-disc ratio; CI, confidence interval; COVID-19, Coronavirus Disease 2019; EMR, electronic medical record; Electronic Health Record; Glaucoma; IOP, intraocular pressure; LTF, lost to follow-up; Medical informatics; OR, odds ratio; Open-Angle Glaucoma; POAG, primary open-angle glaucoma; QI, quality improvement; Quality Improvement; RNFL, retinal nerve fiber layer; Taxonomy; VA, visual acuity.

Figure 1

Process for patient identification and re-engagement strategy. An electronic medical record (EMR)-based strategy identified 558 potentially lost to follow-up (LTF) patients, of whom 384 patients were identified as LTF, comprising approximately 11% of all patients in the study period. One month after implementation of the quality improvement (QI) initiative, 124 of these LTF patients (32%) had been re-engaged: 40% through telemedicine, 57% with recall ordered or scheduled, and 4% declined follow-up when contacted. An additional 238 LTF patients (62%) had existing scheduling orders in the EMR; only 22 LTF patients (6%) had no active plan for future follow-up care.