The mean total number of visits for each patient was compared with the visit rate based on the follow-up recommendations at each visit. Statistical significance was calculated using paired t tests. Error bars indicate standard deviation.
aP < .001.
bP < .05.
cNot significant compared with actual number of visits.
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Kanu LN, Jang I, Oh DJ, et al. Glaucoma Care of Prison Inmates at an Academic Hospital. JAMA Ophthalmol. 2020;138(4):358–364. doi:10.1001/jamaophthalmol.2020.0001
What is the glaucoma profile of prison inmates referred to an academic center, and how is the treatment of those patients managed?
In this cohort study of 82 prison inmates, suspected and primary open-angle glaucoma were the most common diagnoses, with advanced disease present in 53.2% of patients with confirmed glaucoma. Most patients self-reported medication nonadherence, and follow-up visits often were delayed, with approximately one-quarter of visits during the recommended time frame and one-third delayed by more than 1 month.
These findings suggest that glaucoma management of prison inmates requires careful consideration of barriers to care, and close communication with the referring facility may be advised.
Glaucoma care for prison inmates is underrepresented in the literature even though managing the treatment of such patients may provide unique challenges.
To evaluate the glaucoma profile of prison inmates treated at an academic ophthalmology center and to report on the medical and surgical management and follow-up metrics.
Design, Setting, and Participants
This retrospective cohort study assessed data from 82 incarcerated patients treated at the glaucoma clinic, an academic referral center at the University of Illinois at Chicago, between January 2013 and December 2017.
Main Outcomes and Measures
Diagnosis, glaucoma severity, medical and surgical interventions, and patient-reported medication adherence were recorded for each visit. Recommended and actual follow-up times were recorded and compared. Data analyses were conducted from January 2013 to December 2018.
In total, 82 patients (161 eyes) had 375 visits during the study period. All patients were male and ranged from 20 to 75 years of age (mean [SD] age, 50.8 [11.9] years). Most participants were black patients (65 [79.3%]). The most common diagnoses were primary open-angle glaucoma (POAG; 53 eyes [32.9%]) and POAG suspect (52 eyes [32.3%]). Glaucoma severity ranged from mild (25 of 77 eyes [32.5%]) to advanced (41 of 77 eyes [53.2%]). Overall, 59 patients (73.2%) were treated medically with up to 4 topical agents (40.0%). Of those treated, 70.0% of patients (95% CI, 57.7%-81.2%) reported medication nonadherence during at least 1 visit. Medication nonadherence was more common among those taking 4 different topical medications (21 of 24 [87.5%]) compared with others taking fewer medications (20 of 35 [57.1%]), for a difference of 30.4% (95% CI, 7.0%-53.6%; P = .02), and among those with advanced disease (22 of 26 [84.6%]) compared with glaucoma suspect (6 of 13 [46.2%]), for a difference of 38.4% (95% CI, 9.3%-67.5%; P = .02). Nineteen office procedures, including laser peripheral iridotomy and laser trabeculoplasty, were performed on 14 eyes. Seventeen incisional glaucoma procedures were performed on 15 eyes, including glaucoma drainage device implant (11 procedures [64.7%]) and trabeculectomy (3 procedures [17.6%]). Only 26.6% of return office visits (95% CI, 21.3%-32.3%) occurred within the recommended follow-up time frame. Furthermore, 93 patients (34.8%; 95% CI, 28.2%-40.0%) were seen more than 1 month after the recommended follow-up.
Conclusions and Relevance
Despite incarceration in prison, where medication administration and appointment attendance are theoretically controlled, the results of this study suggested that substantial medication and follow-up nonadherence exists among inmates.
The medical care of incarcerated patients is an important and growing problem. In the United States, the total imprisoned population and the per capita imprisonment rates are the highest worldwide,1 with substantial increases during the last several decades.2 However, medical care in this population is lacking.3-5 Chronic conditions, such as cancer, infectious disease, and cardiovascular disease, tend to be overrepresented in the prison inmate population.6,7 In addition, the high prevalence of psychiatric conditions,8 the high rate of illicit drug use,9 and the low socioeconomic and educational status10,11 among prison inmates present challenges to the provision of high-quality medical care.
In many cases, a correctional facility may employ health care workers or a contracted health care service to provide basic medical care for inmates. For specialized care, patients may be referred to outside medical facilities in academic centers. Although such arrangements provide access to specialty clinicians, they also produce several barriers. For example, for security purposes, prison inmates are not told of follow-up recommendations or arrangements. Instead, the physician-patient relationship is bypassed, and a third party—a prison official—ultimately controls follow-up scheduling. This setup adds a layer of complexity to medical practice and may increase the potential for errors in communication. Specific barriers to care have been discussed in the context of medical care for psychiatric conditions8,12,13 and infectious disease,14-16 but there is a paucity of literature on this subject in fields such as ophthalmology or surgical subspecialties. Given the highly specialized nature of ophthalmologic examinations and surgical management, barriers may have profound consequences.
The importance of medication and follow-up adherence in the management of glaucoma is well established,17-21 but, to our knowledge, the treatment of incarcerated patients with glaucoma has not yet been studied. In the context of the potential challenges of ophthalmologic care in an imprisoned population, understanding the patient population and current treatment management is important to guide clinicians as well as to inform improvements in the system. The purpose of the present study was to identify the glaucoma disease and treatment profile of incarcerated patients referred to an academic ophthalmology center for glaucoma management.
This was a retrospective, noncomparative cohort study of incarcerated patients seen at the University of Illinois at Chicago glaucoma clinic from January 2013 to December 2017. The study followed the research agreement put forth by the Illinois Department of Corrections and received approval from the Institutional Review Board at the University of Illinois at Chicago, which waived the requirement for patient informed consent for this retrospective, noninterventional study because there was minimal risk to study participants. No one received compensation or was offered any incentive for participating in this study. The research was conducted according to the tenets of the Declaration of Helsinki22 and in compliance with the Health Insurance Portability and Accountability Act.
On entry, inmates in local Illinois Department of Corrections facilities or federal prisons undergo screening eye examinations, which include Snellen distance visual acuity testing. Those with abnormal screening results or those with self-expressed ocular concerns are evaluated by an optometrist, who may refer the patient for evaluation at the University of Illinois at Chicago if deemed to require ophthalmologist evaluation. Follow-up recommendations are communicated to and scheduled by prison officials. Patients who miss a follow-up appointment are rescheduled by prison officials. When treated, medications belonging to inmates may be secured and administered by the facility or may be kept in possession of the inmate for self-administration at the discretion of prison officials.
Data from all visits from all prison inmates at the glaucoma clinic during the study period are included in the present study. For each patient, initial presentation to the glaucoma clinic was recorded regardless of whether this appointment occurred during the study period. After the study end date, follow-up was reviewed until December 2018 to assess the follow-up interval for the final study visit.
Initial visits were reviewed for demographic information and medical and ocular history. Custody date was obtained for each patient through publicly accessible resources23 to determine time from incarceration to initial clinic visits. A primary glaucoma diagnosis was determined on the basis of physical examination and ancillary testing results. Glaucoma staging was based on the American Academy of Ophthalmology Preferred Practice Pattern.24 Each visit within the study period was reviewed for physical examination, treatment, and ancillary testing information. Patients were asked about medication adherence at each visit, and a patient was considered adherent if he had reported consistent use of therapy up to at most 1 week prior to a scheduled visit.
Follow-up recommendations generally followed current preferred practice patterns24 for standard follow-up visits. The actual follow-up rate was compared with a calculated recommended follow-up rate. For example, if a patient was seen twice during 2 years but the recommended follow-up after the first visit was 3 months, the actual follow-up rate would be 1 visit per year, whereas the recommended follow-up rate would be 4 visits per year. Loss to follow-up was defined as at least 1 year lapsing between the latest follow-up and the end of the study.
Statistical analyses included the performance of the t test, 1-way analysis of variance, the Kruskal-Wallis rank sum test, the Fisher exact test, or the χ2 test, as appropriate. Data were confirmed to be normal in distribution prior to use of parametric tests. A 2-sided value of P < .05 was considered statistically significant. All statistical tests were conducted using R, version 3.5.3 (R Core Team) from January 2013 to December 2018.
Eighty-two prison inmates (161 eyes) had 375 visits in the glaucoma clinic during the study. Sixty-five new patients were seen during the study, whereas the remaining 17 patients were already established in the clinic prior to the start of the study. Although the institution provides care for female inmates, all patients meeting inclusion criteria were male. Ages ranged from 20 to 75 years old (mean [SD], 50.8 [11.9] years). A majority (65) were black patients (79.3%). Eight patients (9.8%) were legally blind (visual acuity of 20/200 or worse in the better-seeing eye). Most patients had a diagnosis of glaucoma prior to their initial visit and had already received medical (53 patients) or surgical (8 patients) glaucoma therapy (Table 1).
Prison inmates came from 9 different Illinois Department of Corrections facilities and local federal prisons. The current cumulative inmate population of the referring facilities from this study was approximately 12 200 inmates,25 and the facilities were located between 8 and 371 km from the University of Illinois at Chicago. The current prison inmate population in the state of Illinois is approximately 39 300.26
Prison inmates were first seen in an ophthalmology clinic at a mean (SD) of 11.39 (8.85) years (range, 4 months to 37 years) following admission into custody. Most patients (48 [58.5%]) were referred directly to the glaucoma clinic. The remaining patients were initially seen in another ophthalmology clinic—most commonly the general eye clinic (24 patients [70.6%])—prior to being referred to the glaucoma clinic. There was a mean (SD) of 3.23 (4.45) years (range, 1 month to 21 years) between initial general eye clinic visit and initial glaucoma visit. The time difference between incarceration and initial ophthalmology visit was not associated with disease severity (mean [SD] years: advanced, 10.4 [9.5]; moderate, 15.7 [13.6]; and mild: 8.0 [7.9]; P = .42).
The most common glaucoma diagnoses were primary open-angle glaucoma (POAG) (53 eyes [32.9%]), POAG suspect (52 eyes [32.3%]), and traumatic glaucoma (10 eyes [6.2%]) (Table 2). Approximately half of those with confirmed glaucoma (77 eyes excluding indeterminate and suspect) had advanced disease (41 eyes [53.2%]), whereas 25 eyes (32.5%) had mild disease.
Of the 138 eyes with glaucoma, 105 (76.1%) were treated medically during the study period, including with oral medications or up to 4 topical medications (42 of 105 eyes [40.7%]) (Table 3). Nineteen office procedures were performed on 14 eyes (9 patients), and 15 eyes (12 patients) underwent 17 incisional interventions, including glaucoma drainage device implant (11 procedures [64.7%]) and trabeculectomy (3 procedures [17.6%]). Patients undergoing incisional glaucoma surgery were older than those undergoing other office procedures (mean [SD] age, 58.3 [13.5] vs 49.9 [9.9] years; P = .04), and 16 patients with advanced disease (38.4%) underwent incisional glaucoma surgery. Complications included 1 trabeculectomy bleb leak and 1 corneal incision wound leak.
Ancillary testing included optical coherence tomography for 31 patients (37.8%) and visual field testing for 68 patients (82.9%). However, only 5 patients had more than 1 optical coherence tomography examination during the study period. Similarly, although 19 patients had multiple visual field tests, only 2 patients had more than 3 examinations. The paucity of testing results over time precluded analysis of progression based on these metrics.
From the first visit within the study period to the end of the study period, patients attended a mean (SD) of 1.75 (1.73) visits per year. The number of visits was correlated with disease severity, and those with advanced (mean [SD], 2.33 [1.57] visits per year) or moderate (mean [SD], 2.32 [2.12] visits per year) disease were seen more frequently than those with mild (mean [SD], 1.95 [1.84] visits per year) or suspect (mean [SD], 1.02 [1.20] visits per year) disease severity (P = .01). However, these visit rates were less than expected based on recommended follow-up times. Those with advanced disease had a mean (SD) recommended follow-up time of 51.34 (44.28) days compared with 80.31 (46.45) days for moderate disease, 105.13 (51.77) days for mild disease, and 171.02 (107.46) days for glaucoma suspect (P < .001). There was a significant difference between the recommended and actual visit rates among those with mild or advanced disease and among those with glaucoma suspect (Figure).
There was a significant difference between recommended and actual follow-up times throughout the 5-year study period. Fewer than one-third (71 of 267 visits[26.6%]) of all visits occurred within the recommended time frame (95% CI, 21.3%-32.3%), whereas fewer than half of all visits were scheduled (by the prison system) to within 1 week of the recommended follow-up time (126 visits [47.2%]), and more than one-third of visits occurred more than 1 month after the recommended follow-up time (93 visits [34.8%]; 95% CI, 28.2%-40.0%). Initial postoperative visits (first visit following an incisional procedure) occurred at a mean (SD) of 1.4 (1.2) postoperative days. The second postoperative visit (typically recommended for 1 week after surgery) occurred a mean (SD) of 26.5 (59.4) days later. Only 37.5% of second postoperative visits took place within the recommended time frame. In 1 case, the second postoperative visit was delayed by more than 1 month; in 1 case, it was delayed nearly 1 year; and 1 case, it was lost to follow-up after the first postoperative visit.
In total, 70.0% (95% CI, 57.7%-81.2%) of patients reported not taking their glaucoma medications during at least 1 visit in the study period. When all clinic visits were evaluated individually, patients reported medication nonadherence at more than one-quarter of visits (Table 4). Patients taking 4 different topical medications had significantly higher self-reported nonadherence rates than those taking fewer topical medications (21of 24 [87.5%] vs 20 of 35 [57.1%]), for a difference of 30.4% (95% CI, 7.0%-53.6%; P = .02). Similarly, self-reported nonadherence was more common among those with advanced disease compared with those with glaucoma suspect (22 of 26 [84.6%] vs 6 of 13 [46.2%]), for a difference of 38.4% (95% CI, 9.3%-67.5%; P = .02). There was no significant mean (SD) age difference between patients who were medication adherent (53.0 [10.6] years) and nonadherent patients (48.4 [15.1] years; P = .19). Race/ethnicity (odds ratio, 3.7; 95% CI, 0.78-17.5; P = .18), history of trauma (odds ratio, 1.2; 95% CI, 0.37-4.0; P = .77), and psychiatric history (odds ratio, 0.86; 95% CI, 0.19-3.9; P = .99) were not associated with differences in self-reported nonadherence (Table 4).
Ultimately, 50 patients (61.0%) were lost to follow-up (defined as a lapse of more than 1 year between the last visit and the end of the study period). It is not known whether these patients established care elsewhere or were released from prison.
Chronic diseases are common among prison inmates, and medical care is often lacking,3 but the characteristics of ophthalmic conditions, including glaucoma, are understudied. Our study is the first, to our knowledge, to characterize the glaucoma profile observed in a prison inmate population evaluated at an academic center. The referring facilities included a large population of state and federal prisons covering a large geographic area and serving a substantial proportion of the Illinois inmate population; therefore, the studied population may function as a reasonable representative sampling of male prison inmates.
Mirroring the general population in some ways, POAG and POAG suspect were the most common glaucoma conditions encountered. However, trauma and secondary traumatic glaucoma—including angle-recession glaucoma—were seen more frequently than is reported in the general population,27,28 perhaps reflecting the relatively higher level of violent behavior encountered among prison inmates compared with the general population.29-31 The glaucoma profile of the inmates in our study was skewed toward the advanced stages compared with nonincarcerated patients.32 This finding may be associated with delayed glaucoma presentation; prison inmates are more likely to come from lower socioeconomic and educational backgrounds compared with general population,33,34 and these factors are associated with the presence and delayed presentation of glaucoma.35-37 More advanced disease may also have been associated with referral bias. Some cases of glaucoma may be managed by the optometrist employed within the prison, and the present study population may generally represent more severe cases. Similarly, some patients with glaucoma were referred and their treatment managed by the general eye clinic of our institution. Those patients initially treated by the general eye clinic but later requiring glaucoma surgery were referred internally to the glaucoma clinic, which may also have increased selection bias.
In most cases, the time between the incarceration date and the initial visit to the ophthalmology clinic was several years. The screening eye examination on entry to prison is minimal and includes Snellen visual acuity; therefore, most referrals occur when patients are symptomatic. Given that visual acuity testing tends to be given later in the disease course of glaucoma, this practice has the potential to delay detection. However, we did not observe an association between disease severity and time to presentation after incarceration. It may be beneficial to expand the screening examination on admission to a correctional facility.
The most commonly performed surgical intervention was glaucoma drainage implant, with relatively few trabeculectomy procedures. This distribution aligns with current common practices38,39 and is generally associated with a higher success rate and a lower rate of complications with tube surgery than with trabeculectomy.40
This study found relatively high rates of medication nonadherence19 and loss to follow-up41 compared with those reported for the general population. Comparison with prison inmate studies from some specialties, including psychiatry, infectious disease, and endocrinology, is problematic owing to the variable-defined metrics of medication and follow-up adherence, but estimates for nonadherence range from below 30% to upward of 70%.42-45 Nonadherence in the general population is multifactorial and is associated with such factors as poor education, long waiting times, and travel distance to the clinic.46 Some of these factors should be controlled for the institutionalized patient given that medications are scheduled and transportation to office visits are provided. However, psychosocial factors, such as competence and perceived benefits,21,47 may still be associated with adherence among prison inmates who self-administer medication. In addition, inmate-specific risk factors for nonadherence may include logistical and communication issues. For example, for security purposes, follow-up information is not shared with the prison inmate at each visit. Instead, the physician fills out a form indicating a recommended follow-up time that is then processed at the correctional facility. Establishing follow-up visits while the patient is still in the clinic may help resolve some of these issues. Our study did not distinguish between medication nonadherence that was volitional (ie, patient refusing to take medications) and medication nonadherence that was nonvolitional (eg, the prison failed to provide the medication). However, refusal of medication is a common problem among prison inmates,48 and it is plausible that this issue could account for some of the nonadherence found in our study. In prisons, medications may be either provided to the patient for self-administration or directly administered by the prison staff. There is debate as to whether self-administration improves adherence rates,43,49,50 and further study of this question in the context of glaucoma is warranted. Polypharmacy may play a role in medication adherence because patients in the present study were found to have worse adherence when using 4 topical medications compared with those taking fewer medications. Other studies have also shown a higher number of medications as a barrier to medication adherence.51 However, although our study found higher medication nonadherence rates among those with advanced disease, the causality is not known; those with advanced disease may be more nonadherent because of polypharmacy, or patients may have advanced disease as a result of being nonadherent.
Our study found that follow-up nonadherence was mostly associated with suspected glaucoma and with advanced disease. Individuals with suspected glaucoma in the general population also demonstrate poor follow-up adherence, perhaps because of a lower perception of the seriousness of the disease.41 Advanced glaucoma is associated with poor follow-up adherence in the general population.46 This association may occur because poor adherence results in worsening disease, or it may be that those with advanced disease tend to be less able or willing to follow up at the recommended intervals. In the present patient population, the association may be logistical because those with advanced disease require more frequent visits, which may be more difficult for the prison staff to arrange. This issue was highlighted by postoperative visits; although the first follow-up visit after incisional surgery, scheduled prior to surgery, typically occurred within a reasonable time frame, the second visit was sometimes delayed by weeks or months. The sample size of surgical patients was insufficient to assess whether follow-up delay led to increased complication rates. Given potential issues with scheduling delays, patients may benefit from having the first several postoperative follow-up visits scheduled at the time of surgical scheduling rather than sequentially at each follow-up visit, as is the current practice.
In addition to the aforementioned selection bias, there were several other limitations to our study. Although many patients were lost to follow-up, medical management following final visits was unknown. Given the known issues with general transition of medical care after release from prison,4 further study into this issue is necessary. Assessment of medication adherence was subjective and dependent on self-report by the prison inmate, which may tend to overestimate true adherence.52 Because this study was retrospective, certain potentially useful information was not available, such as patient-reported reasons for medication nonadherence. Perhaps as a result of poor follow-up adherence, there was insufficient ancillary testing (visual field testing and optical coherence tomography) to perform progression analysis based on current recommendations.53 The sample size limited our analysis of surgical outcomes. Finally, our study included only the state of Illinois, and the results may not be generalizable to other states.
Given the results of this study, we recommend that more care be taken not only in educating the incarcerated patient with glaucoma but also in ensuring clear communication with the prison staff regarding the recommended treatment management and follow-up for inmates. We encourage the prison system to work to reduce logistical barriers to specialty medical follow-up. The ophthalmologist should be prepared to seek direct communication with the correctional facility staff in cases in which timely treatment management is important, such as postoperatively.
Accepted for Publication: December 23, 2019.
Corresponding Author: Levi N. Kanu, MD, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, 1855 W Taylor St, Ste 1.145 (MC 648), Chicago, IL 60612 (email@example.com).
Published Online: February 20, 2020. doi:10.1001/jamaophthalmol.2020.0001
Author Contributions: Dr Kanu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Kanu, Oh, Mehta, Dikopf, Aref, Edward.
Acquisition, analysis, or interpretation of data: Kanu, Jang, Oh, Tiwana, Dikopf, Vajaranant, Aref, Edward.
Drafting of the manuscript: Kanu, Jang, Oh, Tiwana.
Critical revision of the manuscript for important intellectual content: Kanu, Tiwana, Mehta, Dikopf, Vajaranant, Aref, Edward.
Statistical analysis: Kanu, Tiwana, Edward.
Administrative, technical, or material support: Oh, Dikopf, Aref, Edward.
Supervision: Mehta, Dikopf, Vajaranant, Aref, Edward.
Conflict of Interest Disclosures: Dr Aref reported personal fees from Aerie Pharmaceuticals and from New World Medical outside the submitted work. No other disclosures were reported.
Funding/Support: General salary support was provided by the Core Grant for Vision Research P30 EY001792 from the National Eye Institute.
Role of the Funder/Sponsor: The National Eye Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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