Download Evaluating strategies to address eye health inequalities

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
[Logo of De Montfort University]
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
v1.1
Page 1 of 91
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 agerelated macular
degeneration
(AMD), cataract,
diabetic retinopathy
(DR) and glaucoma
at two points in
time, 2010 and
2020
A ‘System
Dynamics’ model to
simulate the
dynamics of eye
disorders in large
populations
n/a
Estimates of the
numbers of the
prevalence of agerelated macular
disease, cataract,
diabetic retinopathy
and glaucoma
AMD: in 2010,
223,224 people
partially sighted or
blind. In 2020,
figure is 291,982
Authors observed
that a more robust
information base is
required
Fit for purpose.
Estimated costs to
society of the
resources used in
health and social
service and in
providing informal
care in that time
frame
The ‘system’
comprises the given
population and the
health care and
related resources
therein
The baseline and
cumulative costs to
society of the
prevailing health
and social care
provision
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
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
Glaucoma: in 2010,
75,157 people
partially sighted or
blind. In 2020,
figure is 75,157
v1.1
Page 2 of 91
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 agerelated 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
Age, location and
type of the choroidal
neovascularisation
were statistically
significantly
associated with VA
at presentation
Age, location and
type of choroidal
neovascularisation,
but not socioeconomic
deprivation, were
associated with VA
at presentation in
exudative AMD
Fit for purpose
Demographics;
duration of
symptoms; and
patient home
address, to
determine the
Scottish Index of
Multiple Deprivation
(SIMD) score
v1.1
SIMD scores, area
and VA in the fellow
eye were not
associated with
presenting vision
Page 3 of 91
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 highdose 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
Versus placebo,
statistically
significant odds
reduction for the
development of
advanced AMD with
antioxidants plus
zinc
Persons older than
55 years should
have dilated eye
examinations to
determine their risk
of developing
advanced AMD
Strong
Moderate visual
acuity loss from
baseline (> or =15
letters)
Estimates of odds
ratios (ORs) for
specified outcomes
v1.1
Both zinc and
antioxidants plus
zinc significantly
reduced the odds of
developing
advanced AMD in
the higher-risk
group
Those with
extensive
intermediate size
drusen, at least 1
large druse, or
advanced AMD
should consider
taking a supplement
of antioxidants plus
zinc
Page 4 of 91
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 AfricanCaribbean
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
Initiatives to
overcome attitudinal
barriers to the
uptake of PECS are
necessary from the
service user and the
provider perspective
Fair/weak
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%)
v1.1
Page 5 of 91
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
An interview on
local radio and an
advertisement in
the local
newspaper
A questionnaire
administered pre
and post
intervention
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
Media work
differently for
different groups /
locations
Fit for purpose
Participants were
approached in the
high street and
local temples in
Southall, London
and in the town
centre of Newport,
Isle of Wight
Questionnaire in
Hindi for residents
of Southall, London
and in English for
residents of Isle of
Wight
Statistical analysis
of survey data
Further research is
required to
determine the best
method of reaching
target populations
through radio.
Other media may
need to be
considered
Newspaper advert
was effective in
both areas but
radio interview only
affected residents
of Southall, London
v1.1
Page 6 of 91
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 helpseeking 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
v1.1
UK study
Page 7 of 91
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%+)
Intervention group:
Enhanced care
including additional
time with practice
nurse and support
from a link worker
and diabetesspecialist nurse
Changes in blood
pressure, total
cholesterol, and
glycaemic control
(haemoglobin A1c)
after 2 years.
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 healthcare delivery in
general practice
and to improve
motivation is
needed to reduce
health-care
inequalities
Strong
Statistical analysis
Control group:
Standard care
Nine of the
practices received
the intervention (n=
868) while 12 were
included in the
control group
(n=618)
v1.1
UK study
Page 8 of 91
Burr JM, Mowatt G, Hernández R, Siddiqui MAR, Cook J, Lourenco T, Ramsay C, Vale L, Fraser C, AzuaraBlanco 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
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)
Insufficient
evidence to
estimate risks in
other ethnic groups
(non-African
descent)
v1.1
UK study
Page 9 of 91
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, patientcentred 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
NHS needs to
develop primary
care ophthalmic
services to meet
increased need,
particularly from
demographic
change
Fit for purpose
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
v1.1
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
Page 10 of 91
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
n/a
Direct evidence on
screening and the
accuracy of
diagnostic tests
Screening for VI in
older adults in
primary care
settings is not
associated with
improved visual or
clinical outcomes
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
Participants from
studies that directly
evaluated screening
for impaired visual
acuity in older
adults from 1996 to
July 2008
Benefits and harms
of treatment.
Quantitative
estimates for
treatment effects
and relative risks
using a randomeffects model
Effective treatment
is available for
refractive error,
cataracts, and AMD
Non-UK study so
may not be totally
transferable
Visual acuity test is
standardr screening
for vision
impairment in
primary care, but
diagnostic accuracy
is uncertain
v1.1
Page 11 of 91
Claydon BE, Efron N, Woods C (1998) Non-compliance in optometric practice. Ophthal Physiol Opt, 18(2): 187190.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Review of noncompliance in
contact lens
behaviour in relation
to organisation of
optometric practice
n/a – mainly selfcitation
n/a
n/a
n/a
Optometric
profession should
pay attention to
compliance issues
weak
v1.1
Page 12 of 91
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
Worldwide
prevalence of
POAG and PCAG
will continue to
increase
Fit for purpose
Dependent upon
original study
included in the
review
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
v1.1
Page 13 of 91
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
Various
Various
Fit for purpose
Mainly dietary
supplementation,
and vascular
endothelial growth
factor (VEGF)
inhibitors
Development of
AMD
Dependent upon
original study
included in the
review
AMD is leading
cause of blindness
in elderly people of
western descent
Modifiable risk
factors
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
v1.1
Page 14 of 91
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 figures
by 2020
Dependent upon
original study: Black,
white and Hispanic
persons with cataract
or pseudophakia/
aphakia
n/a
Estimates of
cataract and of
pseudophakia/
aphakia, measured
in 5-year age
intervals starting at
40 years old
Pooled age-specific
prevalence figures for
cataract increased
with age for both
black and white
persons (P< 0.001)
The number of
Americans
affected by
cataract and
undergoing
cataract surgery
will dramatically
increase over the
next 20 years as
the US population
ages
Fair but major
problems of
heterogeneity
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
Covariates: age and
race/ethnicity
Odds ratios (ORs)
calculated for
relevant variables
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
v1.1
Non-UK study
Existing data are
very poor even in
majority groups:
more and better
research and data
collection needed
Page 15 of 91
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.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Randomized trial to
ascertain whether
motivational
interviewing (MI) for
patients with
glaucoma is
feasible in a busy
ophthalmology
practice
51 patients with
primary or
secondary openangle glaucoma
prescribed
monotherapy
topical glaucoma
medication from
glaucoma clinic at
Rocky Mountain
Lions Eye Institute,
Denver, CO. (USA)
Intervention group
(n=8) received
standard care with
MI while control
group (n=4)
received standard
care
MI training and
instruction manual
for MI educator,
documentation of
MI training
(education
evaluation tools,
session records)
and state of
change rating to
measure patient
enactment after MI
Glaucoma
educators’
knowledge and
delivery of MI
improved after
training
MI training is
feasible in a busy
ophthalmology
practice and can be
implemented with a
standardised
training approach
Fit for purpose
Statistical analysis
using SPSS
Patients assigned
to the intervention
group improved
over time in both
motivation and
adherence to
medication
37 participants
excluded from the
study (less than
80% adherence to
treatment)
Twelve patients
agreed to take part
in RCT
v1.1
Non-UK study
50% of participants
in intervention
group completed all
MI training
sessions
Page 16 of 91
Cross V, Cragg R, Shah P (2009) Attitudes to patient partnership in the management of African-Caribbean
glaucoma. Final Report for the Guide Dogs for the Blind Association (Project Reference 2006-02b).
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
Study of attitudes of
users and
professionals to
patients
participation and
self-care, and
implications for
African-Caribbean
people living with
Glaucoma
32 informants (11
patients, 4 nurses, 5
surgeons, 6
optometrists) and
use of Q-sort
technique
To enhance selfmanagement
strategies
Qualitative sets of
typical views, and
some health related
quality of life
estimates
Practitioners had
low expectations of
patient abilities;
patients were
perhaps overconfident but willing
to engage
Need for more vocal
and effective use of
community
champions and
informal
dissemination:
young A/C patients
are at high risk
Fit for purpose
v1.1
UK study
Page 17 of 91
Cross V, Shah P, Bativala R, Spurgeon P (2005) Glaucoma Awareness and Perceptions of Risk among AfricanCaribbeans in Birmingham UK. Diversity in Health and Social Care, 2(2): 81-90.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
Qualitative study to
explore issues
related to glaucoma
awareness and
perceptions of risk
among the AfricanCaribbean
population
African– Caribbean
participants who
were not receiving
treatment from a
hospital eye service
(n = 48)
n/a
Knowledge of
glaucoma;
glaucoma risk
perception and
protection
motivation; images
of blindness; health
accounts; cultural
context and
individual
differences
Positive attitude to
health promotion
does not include
eye health
Study will help
practitioners to
understand the
health beliefs of
African–Caribbean
patients
Fit for purpose
Family history
helping individuals
to understand how
glaucoma might
affect them
UK study
Attitudes to
blindness reflect
notion of blind
person as victim
Preventative action
depends on
credibility of both
source and nature
of information
v1.1
Page 18 of 91
Cross V, Shah P, Bativala R, Spurgeon P (2007) ReGAE 2: Primary Eye Care Service Utilisation and
Glaucoma: some viewpoints from African-Caribbeans in Birmingham UK. Eye, 21: 912-920.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A qualitative
investigation to
identify issues
related to utilisation
of Primary Eye Care
Services (PECS) by
African-Caribbean
people and consider
the implications for
enhancing the role
of the PECS in
glaucoma detection
and management
Face-to-face
interviews and
focus group
discussions with
members of the
African Caribbean
community outside
the hospital eyeservice (n = 48)
n/a
PECS utilisation
focused on three
key areas: access
route to the
optometrist, causal
stimulus for an
optometric visit, and
experiential
accounts of the
optometric
encounter
Positive attitudes to
health promotion
existed, but ‘eye
health’ was not
integral to
individuals’ health
schemas
Enhancing
reciprocal
understanding
between service
users and
ophthalmic
practitioners in
primary care is
central to
developing flexible,
responsive local
eye-care services
Fit for purpose
The capacity for
primary eye care to
enhance glaucoma
knowledge
appeared under
utilised and
inconsistent
UK study
Service delivery
undermined by
perceived conflicts
of interest
v1.1
Page 19 of 91
Das BN, Thompson JR, Patel R, Rosenthal AR. (1990) The prevalence of age related cataract in the Asian
community in Leicester: a community based study. Eye, 4(5): 723-6.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A community based
ophthalmic survey to
report on the
prevalence of the
age-related cataract
in an Asian
Community in the
UK and to
investigate possible
risk factors
associated with the
disease
Asians and
Caucasians (white)
aged 40 years and
over registered with
four inner-city
general practitioners
in the City of
Leicester, England
(n = 115 Asians, 119
Caucasians and 6
African Caribbeans)
n/a
Ophthalmic:
presence of age
related cataract
Prevalence of agerelated cataract
significantly higher
in Asians when
compared to (white)
Caucasians
This populationbased study
indicates that
there is a
significantly higher
prevalence of
age-related cataract
in the Asians living
in Britain
Fit for purpose
All cataracts that
could be ascribed to
congenital or
secondary causes
were excluded
Covariates: age;
gender; ethnic
origin; racial
subgroup; history of
smoking; alcohol
consumption; diet
medication &
medical history; and
episodes of severe
diarrhoea
v1.1
Age-related cataract
was found to
develop earlier in
the Asians
A strict vegetarian
diet found to be a
significant risk factor
for age-related
cataract in Asian
community in
Leicester
UK study
The findings
suggest an earlier
onset of the disease
in Asians
Repeat analysis will
be considered when
a larger sample size
is available
Page 20 of 91
Das BN, Thompson JR, Patel R, Rosenthal AR (1994) The prevalence of eye disease in Leicester: a comparison
of adults of Asian and European descent. J R Soc Med, 87(4): 219-22.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Ophthalmic survey
to report on
the prevalence of
eye disease among
adults of Asian and
European descent in
the UK
People aged 40
years and over
registered with
two neighbouring
inner-city general
practices: one
predominantly with
Asian patients (n =
173) and the other
predominantly
with European
patients (n = 204)
n/a
Ophthalmic: visual
acuity for near and
distance; diagnosis
of age related
cataract, age related
macula
degeneration, open
angle glaucoma and
diabetic retinopathy
Asians had a
significantly higher
prevalence of agerelated cataract
It is important to
both the health
services and to
scientific research
that we continue to
monitor eye disease
in the British Asian
Community to see if
the patterns of
disease change with
time
Fit for purpose
Covariates: age
band; gender;
diabetes
v1.1
The age of onset of
cataract seems
earlier in Asians
After adjustment for
age, no statistically
significant ethnic
differences in the
prevalence of openangle glaucoma,
macular
degeneration or
diabetic retinopathy
UK study
Page 21 of 91
Day F, Buchan JC, Cassells-Brown A, Fear J, Dixon R, Wood F (2010) A glaucoma equity profile: correlating
disease distribution with service provision and uptake in a population in Northern England, UK. Eye, 24(9): 147885.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Equity profile to
examine the scale of
health inequalities in
a population in
Northern England,
UK
The equity profile
was conducted in
Leeds, a city in the
north of England,
with a population of
794,777 in April
2008
n/a
Location of general
ophthalmic services
(GOS) and hospital
eye Services
A mismatch
between areas of
deprivation and
location of
optometry
Increasing access
involves
collaboration with
optometrists,
ophthalmologists,
public health, and
commissioners
Fit for purpose
Distribution of
glaucoma, known
risk factors for
glaucoma, and
deprivation
Electronic patient
record (EPR) data;
primary care
prescribing data;
certifications for
visual impairment
(CVI); hospital
episode statistics;
GP with special
interest audit data;
GOS data; and
qualitative data on
barriers to uptake
v1.1
Significant
association between
‘late presentation’
and older age
Late presentation
associated with
living in area of high
deprivation
Ethnicity data was
poorly recorded
Qualitative data
provided invaluable
insights
UK study
Not acceptable to
rely on private high
street optometry to
provide primary eye
care services in
areas of high need
Outreach services
must be developed
and evaluated in
areas of relative
deprivation if world
class eye services
are to be achieved
Page 22 of 91
Demakakos P, Nazroo J Y, Breeze E, Marmot M (2008) Socioeconomic status and health: the role of subjective
social status. Social Science and Medicine, 67(2): 330-340.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Cross-sectional data
from the second
wave (2004–2005)
of the English
Longitudinal Study
of Ageing to
examine the link
between subjective
social status (SSS)
and health in old
age and investigate
whether SSS
mediated the
associations
between objective
indicators of
socioeconomic
status and health
People included in
the second wave
(2004–2005) oft the
English Longitudinal
Study of Ageing who
reported their SSS
(n = 3368 men;
4065 women)
n/a
Self-rated health,
long-standing
illness, depression,
hypertension,
diabetes, central
obesity, high-density
lipoprotein
cholesterol,
triglycerides,
fibrinogen, and Creactive protein.
Subjective social
status
In age-adjusted
analyses SSS was
related positively to
almost all health
outcomes.
Many of
relationships
remained significant
after adjustment for
covariates.
SSS mediated fully
or partially the
associations
between education,
occupational class
and self-reported
and clinical health
measures
SSS is an important
correlate of health in
old age, possibly
because of its ability
to epitomize life-time
achievement and
socioeconomic
status
Fit for purpose
Covariates: wealth;
education;
occupational class;
age; gender and
marital status
v1.1
UK study
Page 23 of 91
Desai P. (1993) The National Cataract Surgery Survey: III. Process features. Eye, 7(5): 667–671.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Prospective crosssectional survey to
examine the
process of how
medical care is
provided for cataract
patients within the
National Health
Service
Patients of 50 years
of age and over who
had surgery for agerelated cataract in
the UK during the
period of the 1990
National Cataract
Surgery Survey (n =
975)
n/a
Waiting time and
level of visual
impairment: on
presentation at the
first out-patient
assessment, on
listing for surgery
and on admission
for surgery
The majority of
patients have
considerable levels
of visual impairment
by the time they
present to the
hospital eye service
The survey
represents the
experience of a
sample of all
patients undergoing
surgery for agerelated cataract in
the UK in 1990
Fit for purpose
Visual acuities;
length of stay in
hospital, duration of
post-operative
medication, number
of post-op outpatient visits and
final refraction
Age-standardised
operation rates by
region
v1.1
A difference of
almost twofold was
observed between
the lowest and
highest regional
operation rates,
although it must be
interpreted with
caution
UK study
Repeating the
survey at regular
intervals would
provide a practical
method of
evaluating and
auditing surgical
practice for national
trends in the
management of
age-related cataract
Page 24 of 91
Duke SAS, Colagiuri S, Colagiuri R. Individual patient education for people with type 2 diabetes mellitus.
Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD005268. DOI:
10.1002/14651858.CD005268.pub2.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Systematic review
to evaluate the
effectiveness of
individual patient
education on
metabolic control,
diabetes knowledge
and psychosocial
outcomes
Dependent upon
original study
included in the
review
Individual face-toface patient
education verses
usual care, routine
treatment or group
education
Primary outcomes:
metabolic control;
diabetes
complications;
health service
utilisation and
health care costs
Individual face-toface education did
not significantly
improve glycaemic
control compared
with usual care
Benefit exists of
individual education
on glycaemic
control when
compared with
usual care in those
with a baseline
HbA1c greater than
8%
Strong
Nine randomised
controlled or
controlled clinical
studies (n = 1359
participants)
Participants were
adults diagnosed
with type 2 diabetes
over the age of 18
years
Six studies
compared individual
education to usual
care and three
compared individual
education to group
education
Only studies that
assessed outcome
measures at least
six months from
baseline were
included
Secondary
outcomes:
psychosocial
outcomes; diabetes
knowledge; patient
self-care
behaviours;
physical measures
and metabolic
measures
v1.1
Individual education
had a significant
benefit on
glycaemic control in
patients with a
higher mean
baseline HbA1c
(greater than 8%)
No significant
difference in
glycaemic control
between individual
and group
education
Overall, there did
not appear to be a
significant
difference between
individual education
and usual care
In the small number
of studies
comparing group
and individual
education, the
impact was equal
on HbA1c at 12 to
18 months
Page 25 of 91
Eke T, Reddy MA, Karwatowski WS. (1999). Glaucoma awareness and screening uptake in relatives of people
with glaucoma. Eye. Vol. 13, pt. 5.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
To assess
glaucoma
awareness and
screening uptake in
relatives of people
with glaucoma
52 patients with
primary open angle
glaucoma attending
Leicester Royal
Infirmary and their
relatives (n=90)
n/a
Questionnaires for
patients and their
relatives measuring
awareness of
glaucoma and
available screening
services
53% of relatives felt
they were at
increased lifetime
risk of developing
glaucoma, 81% of
relatives had been
screened but this
was infrequently
Relatives of people
with glaucoma
should be made
more aware of the
need for glaucoma
screening and
encouraged to use
the free screening
service
Fit for purpose
Analysis of
questionnaires
returned by
relatives of patients
(n=70)
v1.1
Siblings of patients
with glaucoma had
lower awareness of
screening services
than their offspring
UK study
Older relatives
should be
particularly
targeted
Page 26 of 91
Evans J. (2008). ‘Antioxidant supplements to prevent or slow down the progression of AMD: a systematic review
and meta-analysis’. Eye. Vol. 22, pt. 6, pp.751-60.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A systematic review
examining the
evidence as to
whether antioxidant
vitamin or mineral
supplements
prevent the
development of AgeRelated Macular
Degeneration (AMD)
or slow down its
progression
Dependent upon
original studies
included in review
Antioxidant vitamin
and/or mineral
supplementation
(alone or in
combination) to
control groups
Ophthalmic:
development and
progression of agerelated maculopathy
(ARM ), AMD and
loss of vision
There was no
evidence that
antioxidant (vitamin
E or β-carotene)
supplementation
prevented AMD
Current evidence
does not support the
use of antioxidant
vitamin supplements
to prevent AMD
Strong
Information on
adverse events
There was evidence
that antioxidant (βcarotene, vitamin C,
and vitamin E) and
zinc
supplementation
slowed down the
progression to
advanced AMD and
visual acuity loss in
people with signs of
the disease
A total of 23,099
people were
randomised in three
trials with treatment
duration of 4–12
years for antioxidant
supplementation
A total of 4,165
people were
randomised in eight
trials for antioxidant
and zinc
supplementation
v1.1
Page 27 of 91
Evans JR, Fletcher AE, Wormald RPL, Siu-Woon Ng E, Stirling S, Smeeth L, Breeze E, Bulpitt CJ, Nunes M,
Jones D, Tulloch A (2002) Prevalence of visual impairment in people aged 75 years and older in Britain: results
from the MRC Trial of Assessment and Management of Older People in the Community. British Journal of
Ophthalmology, 86: 795-800.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Cluster randomised
trial to measure the
prevalence of visual
impairment in a
large representative
sample of people
aged 75 years and
over in the UK
community
Patients aged 75
years or over at 53
practices in the
Medical Research
Council general
practice research
framework (n =
14,600)
n/a
Prevalence of visual
impairment
(binocular visual
acuity <6/18),
categorised
separately into low
vision (binocular
visual acuity <6/18–
3/60) or blindness
(binocular visual
acuity of <3/60)
Age 75–79, 6.2%
visually impaired
(5.1% to 7.3%);
36.9% at age 90+
(32.5% to 41.3%)
Visual impairment is
common in the older
population and this
risk increases
rapidly with
advancing age,
especially for
women
Strong
The prevalence of
binocular acuity
<6/12
Women had excess
risk of visual
impairment (OR
1.43, 95%
confidence interval
1.29 to 1.58)
All patients aged 75
years or over on the
general practitioner
list were invited to
participate, unless
they were in long
stay hospital or
nursing homes, or
were terminally ill
At age 75–79, 0.6%
(0.4% to 0.8%)
blind, with 6.9%
(4.8% to 9.0%) at
age 90+
If visual impairment
had been defined as
visual acuity of
<6/12 (American
definition of visual
impairment), the age
specific prevalence
estimates would
have increased by
60%
19.9% participants
had a binocular
acuity of < 6/12
(17.8% to 22.0%)
v1.1
Page 28 of 91
Fraser S, Bunce C, Wormald R, (1999) Risk factors for late attendance of chronic glaucoma. Invest Ophthalmol
Vis Sci, 40: 2251-7
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Case– control study
to identify the risk
factors for having
advanced
glaucomatous
visual field loss on
the first visit at
hospital eye
services
Patients newly
diagnosed with
glaucoma at first
visit to one of three
ophthalmic
departments in the
United Kingdom (n
= 220; 110 cases,
110 controls).
n/a
Demographic: age
when first
assessed, sex,
ethnic origin, and
Standard
Occupational
Classification
Occupational group,
initial IOP, family
history of glaucoma,
method
of referral to
hospital, and the
number of years
since the last visit to
an optometrist were
found to be
independently
associated with late
presentation
Certain subgroups
of people with
glaucoma are at
greater risk of
having advanced
and irremediable
field loss on first
visiting the eye
services studied
Strong
Patients with a
previous history of
ocular hypertension
or any documented
suspicion of
glaucoma (within
the hospital eye
service) were
excluded
Ophthalmic:
coexisting ocular or
medical disease,
intraocular pressure
(IOP) at initial
examination, and
frequency of sight
testing
UK study
Estimates of the
odds ratios (ORs) of
late attendance
computed by
logistic regression
v1.1
Page 29 of 91
Fraser S, Bunce C, Wormald R & Brunner, E. (2001). Deprivation and late presentation of glaucoma: casecontrol study. BMJ. Vol. 322, pt. 7287.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
To identify
socioeconomic risk
factors for first
presentation
advanced
glaucomatous
visual field loss
220 consecutive
patients newly
diagnosed with
glaucoma at three
independent eye
hospital
departments in
England
(Moorfields Eye
Hospital, London;
Sunderland Eye
Infirmary,
Sunderland; Harold
Wood Hospital,
Essex)
Hospital based
case-control study
with prospective
identification of
patients using
Jarman's
underprivileged
area score to
classify deprivation
and identify
socioeconomic
factors that
influence health
seeking behaviours
Unconditional
logistic regression
was used to
measure the effect
of each
socioeconomic
factor on
presenting with
advanced
glaucomatous field
damage
Patients who
presented with
more advanced
field loss had
higher
underprivileged
area scores, lower
occupational
status, and lower
education level and
were less likely to
have access to a
car and more likely
to be tenants
Glaucoma should
be included among
conditions targeted
in policy aimed at
reducing social
inequalities in
health
Fit for purpose
Case-controlled
study
UK study
Presentation with
advanced
glaucoma is
associated with a
poor prognosis
110 participants
were late
presenters and 110
participants had
early onset
glaucoma (control
group)
v1.1
Page 30 of 91
Friedman DS, Hahn SR, Gelb L, Tan MS, Shah SN, Kim EE, Zimmerman TJ, Quigley HA. (2008). Doctor-patient
communication, health-related beliefs and adherence in glaucoma. Results from the Glaucoma Adherence and
Persistence Study. Ophthalmology. Vol. 115, pp. 1320-7.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Retrospective
database and chart
reviews in
combination with
prospective patient
surveys to
determine drivers
of patient
adherence to
topical ocular
hypotensive
therapy
300 patients with a
new claim
diagnosis for openangle glaucoma
who initially were
prescribed one of
three
prostaglandins and
103 physicians
participating in the
same medical plan
n/a
Self-reported
adherence;
experiences with
medication;
communication
with the physician;
and health-related
beliefs
Doctor-patient
relationship, nonbelief in the effects
of medication,
financial issues,
transport
difficulties, ethnic
minority origin, not
receiving reminders
from primary care
practices were
variables
associated with
lower medication
possession ratio
Increased
educational efforts
by primary care
practices may
increase glaucoma
medication
adherence
Fit for purpose
Phone interviews
conducted with
participating
ophthalmologists
Medication
possession ratio for
adherence
v1.1
Page 31 of 91
Friedman DS, Nordstrom B, Mozaffari E, Quigley HA (2005) Glaucoma management among individuals enrolled
in a single comprehensive insurance plan. Ophthalmology, 112(9): 1500-4.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Retrospective
cohort study to
determine the
management
patterns for
glaucoma and
suspect glaucoma in
newly treated
persons
People enrolled in a
commercial health
plan in the United
Sates between 1995
and 2001 (n = 1712
diagnosed suspects;
3623 diagnosed
glaucoma)
n/a
Probability of
monitoring (return
visits, visual fields
(VF), and optic
nerve head imaging
or photography)
Median follow-up
was 440 days
Large proportion of
individuals requiring
treatment are falling
out of care and are
being monitored at
rates lower than
expected from
recommendations or
published guidelines
Fit for purpose
Inclusion: 365 days
of enrolment before
diagnosis; >30
years old when
diagnosed; no claim
for glaucoma in the
365 days before
diagnosis; and no
claims for a VF test,
fundus photography,
or nerve fiber layer
imaging in the 12- 2
months before
diagnosis
Probability of
treatment (argon
laser
trabeculoplasty
(ALT) and surgery)
for newly treated
persons with
suspect and
glaucoma
diagnoses
Among diagnosed
suspects, 83% had
a follow- visit to
either an optometrist
or ophthalmologist.
Among diagnosed
glaucoma, 84%
attended a follow-up
visit
Surgery was
performed in 1.4%
of suspects and
2.1% with
diagnosed
glaucoma
Non-UK study
More research is
needed to confirm
the findings and to
determine the
reasons for loss to
follow-up and low
monitoring rates
ALT performed in
6% with diagnosed
glaucoma and 2% of
diagnosed suspects
v1.1
Page 32 of 91
Friedman DS, Wolfs RCW, O'Colmain BJ, Klein BE, Taylor HR, West S, Leske C, Mitchell P, Congdon N,
Kempen J, Tielsch J for the EDPRG (2004), 'Prevalence of open angle glaucoma among adults in the United
States'. Archives of Ophthalmology, 122: 532-538.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
To estimate the
prevalence and
distribution of openangle glaucoma
(OAG) in the United
States by age,
race/ethnicity, and
gender
Dependent upon
original study included
in the review
n/a
Estimates OAG for
Black, white and
Hispanic persons,
measured in 5-year
age intervals
starting at 40 years
old
Pooled data for
European-derived
studies found a
strong increase in the
prevalence of OAG
with age (P<0.001)
Open-angle
glaucoma affects
more than 2
million individuals
in the United
States
Fit for purpose but
heterogeneity in
original studies
Data for black
subjects derived from
a single study. The
prevalence of OAG
increased with age,
and OAG consistently
more prevalent than
in white subjects
Owing to the rapid
aging of the US
population, this
number will
increase to more
than 3 million by
2020
Black, white and
Hispanic persons with
OAG
Eight studies (n =
37,229), Barbados
Eye Study; Beaver
Dam Eye Study; Blue
Mountains Eye Study;
Kongwa Eye Project;
Melbourne Vision
Impairment Project;
Proyecto Vision
Evaluation Research;
Rotterdam Study,
Salisbury Eye
Evaluation
Covariates: age and
race/ethnicity
Odds ratios (ORs)
calculated for
relevant variables
Age-adjusted
prevalence in Black
subjects almost 3
times that of white
subjects
v1.1
Non-UK study
More research
and better data
needed
Page 33 of 91
Gehlbach P, Li T, Hatef E. Statins for age-related macular degeneration. Cochrane Database of Systematic
Reviews 2009, Issue 3. Art. No.: CD006927. DOI: 10.1002/14651858.CD006927.pub2.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Systematic review
to examine the
effectiveness of
statins compared
with other
treatments, no
treatment, or
placebo in delaying
the onset and/or
progression
of age-related
macular
degeneration
(AMD)
Dependent upon
original study
included in the
review
Study one:
simvastatin, 20
mg/day) versus
placebo for 3
months
Study one: serum
cholesterol levels;
visual acuity;
microscopic eye
exam; fluorescein
angiography; ERG,
and VEP.
Measures obtained
at baseline, 3
months and 4.5
months
Two studies
There is insufficient
evidence from
RCTs to suggest
that taking statins
may delay the
onset and
progression of
AMD
Strong
People diagnosed
as having early
stages of AMD with
no signs of
choroidal
neovascularization
(CNV)
Two randomised,
placebo-controlled
trial studies: study
one completed (n =
30); study two
ongoing (n = 85
participants
enrolled; follow-up
at six, 12 and 18
months = 60, 42 &
15, respectively)
Study two: Two
tablets of
simvastatin, 20 mg
each, daily,
compared to a
placebo with an
identical
appearance for 3
years
Study two:
progression of high
risk early AMD to
late AMD,
evaluated every 6
months. Secondary
outcomes colour
sensitivity; flicker
sensitivity; bleach
recovery, and
kinetics of dark
adaptation
v1.1
Study one: no
statistically
significant
difference between
the simvastatin and
placebo arm in
visual acuity. Visual
acuity was similar
at 45 days after the
completion of
treatment
Study two: no
statistically
significant
difference between
control and
treatment groups in
visual acuity,
drusen score or
visual function at
12 months followup
Page 34 of 91
Goyal R, Shankar and J, Sullivan S (2004) Referrals for cataract surgery: variations between different geographic
areas within a Welsh Health Authority. Eye, 18: 773–777
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Prospective study to
identify variations in
cataract
presentation across
the same health
authority and to
identify any
correlation between
cataract
presentation and
social deprivation
indices
Patients aged 50
years plus
presenting to
cataract preassessment clinics
over a 2-month
period at three
hospitals in Wales
(n = 112)
n/a
Ophthalmic: Visual
acuity, AMD,
glaucoma, diabetic
retinopathy, corneal
opacity; Visual
Function Index (VF14)
Demographics were
similar to National
Cataract Audi
Variations in
cataract
presentation
correlate well with
social deprivation
indices and poor
use of optometric
services
Fit for purpose
Inclusion criteria
included senile
cataract on the first
eye
Demographic: Age,
Sex, diabetes
mellitus,
hypertension, heart
disease, and Social
deprivation statistics
Waiting time for
outpatient
appointment, and
surgery, and
frequency of
optometrist visit
v1.1
The hospital with
the lowest visual
acuity in both listed
and fellow eye, and
the lowest VF-index
had the longest
outpatient and
surgery waiting
times. The
population also
visited their optician
least frequently
UK study
Local policies are
needed to redress
these inequalities
and raise public and
professional of
causes of poor sight
in the elderly
population
Page 35 of 91
Gray TA, Harper RE, Orton LC, Henson DB, et al (2009). Interventions for improving adherence to ocular
hypotensive therapy. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A systematic
review to
summarise the
effects of
interventions for
improving
adherence to
ocular hypotensive
therapy in people
with ocular
hypertension
(OHT) or glaucoma
Dependent of
original studies
included in review
Randomised
controlled trials
(RCTs) and quasi
RCTs that
compared
interventions to
improve adherence
to ocular
hypotensive
therapy for patients
with OHT or
glaucoma
Primary outcomes:
persistence with
therapy measured
by repeat
prescription or
dispensing counts,
or both
Eight trials met
inclusion criteria
Interventions
involving simplified
dosing regimes,
reminder devices,
education and
individualised care
planning, did show
improvements in
adherence rates
Strong
Patients with a
clinical diagnosis of
glaucoma or OHT
who were
prescribed ocular
hypotensive
therapy, no limits
were set for age
and gender
Secondary:
intraocular
pressure reduction;
progression of optic
nerve head
damage;
progressive visual
field loss; adverse
events; and quality
of life measures
v1.1
Three of five drug
comparison studies
suggest reducing
the frequency of
OHT drops
improves
adherence
A small study found
a reminder device
beneficial to
adherence yet only
one of two studies
involving
individualised care
planning was found
to be successful
Inadequate
methodological
quality and
heterogeneity of
study design so no
particular
intervention can be
advocated
Page 36 of 91
Green J, Siddall H, Murdoch I (2002) Learning to live with glaucoma: a qualitative study of diagnosis and the
impact of sight loss. Social Science and Medicine, 55: 257-267.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions/
Quality
Qualitative study
aimed to identify
triggers to selfreferral for
glaucoma
symptoms in a
sample from Britain,
and to explore the
meaning of
symptoms for
people living with
moderate to severe
glaucoma
Patients (n = 28)
sampled from two
hospitals; one
specialist urban eye
hospital and one
District General
Hospital
n/a
How participants
first noticed
problems with their
eyesight; the
process of referral
to hospital; the
impact of symptoms
and treatment
regimes on their
everyday lives;
hopes for the future
Participants
reported low levels
of awareness of
glaucoma prior to
diagnosis
Health promotion is
a priority to increase
public awareness of
the existence and
symptoms of
glaucoma
Fit for purpose
Visual function
deficits from severe
or moderately
severe open angle
glaucoma with no
other significant
ocular pathology
Gradual onset
meant participants
had learnt to cope
with diminishing
sight
Managing in a
'sighted world'
caused problems
with everyday living,
work and family life.
Problems shaped
primarily by social
factors
Twenty in-depth
one-to-one
interviews. Two
group interviews (n
= 4 each group)
v1.1
UK study
More attention
could be given to
reducing the
environmental and
social causes of
disability
Page 37 of 91
Gulliford MC, Dodhia H, Chamley M, McCormick K, Mohamed M, Naithani S, Sivaprasad S (2010a) Socioeconomic and ethnic inequalities in diabetes retinal screening. Diabetic Medicine, 27: 282-288.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
To quantify socioeconomic and
ethnic inequalities in
diabetes retinal
screening
Data from the
retinal screening
programme for
three South London
boroughs for the 18month period to
February 2009 (n =
59,495 records from
31,484 subjects)
n/a
Ophthalmic: sight
threatening diabetic
retinopathy (STDR)
Non-attendance
was highest in
young adults aged
18-34 years and in
those aged 85
years or greater
Socio-economic
inequality in
diabetes retinal
screening may be
smaller than
reported in earlier
studies
Fit for purpose
Demographics: age
group, duration and
type of diabetes,
self-reported
ethnicity and
deprivation quintile
by participant postal
code
Odds ratio adjusted
for specific outcome
measure
v1.1
Non-attendance
was significantly
higher in the most
deprived quintile
compared with the
least deprived
quintile
UK study
The study
suggested an
increased frequency
of diabetic
maculopathy among
participants of
African origins
Compared with
white Europeans,
STDR was higher in
Africans and African
Caribbeans
Page 38 of 91
Gulliford MC, Dodhia H, Sivaprasad S, Ashworth M (2010) Family Practices’ Achievement of Diabetes Quality of
Care Targets and Risk of Screen-Detected Diabetic Retinopathy. PLoS ONE 5(4): e10424.
doi:10.1371/journal.pone.0010424
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Determine whether
family practices’
achievement of
diabetes quality of
care targets is
associated with
diabetic retinal
disease in
registered patients
Patients at 144
family practices
located in three
London boroughs
that contributed
data to NHS Quality
and Outcome
Framework (QOF)
for the years 2004/5
to 2007/8 (n =
24,458)
n/a
Ophthalmic:
diabetic retinopathy
(DR) and sight
threatening diabetic
retinopathy (STDR)
9,332 (38%) patients
had DR and 2,819
(11.5%) had STDR
The risk of diabetic
retinopathy might
be lower at family
practices that
consistently achieve
highly on diabetes
quality of care
targets for HbA1c
Strong
QOF targets:
proportion of
patients with HBA1c
 7%, by quartile
Covariates: age
group, gender, type
of diabetes,
duration of diabetes
and Indices of
Multiple Deprivation
(IMD)
Odds ratio adjusted
for relevant
outcome measures
v1.1
Relative odds of
diabetic retinopathy
were 0.78 (0.69-0.88;
Sig.) among
participants
registered at
practices in the
highest quartile for
achievement of the
HbA1c target,
compared to relative
odds of 1.16 (1.031.30; Sig.) for
practices consistently
in the lowest quartile
UK study
In the highest
achieving practices,
the relative odds of
STDR were 0.77
(0.65 to 0.92; Sig.)
Page 39 of 91
Hawthorne K, Robles Y, Cannings-John R, Edwards AG. (2008). Culturally appropriate health education for
Type 2 diabetes in ethnic minority groups: a systematic and narrative review of randomized controlled trials.
Diabet Med, 27(6): 613-23.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
Systematic review
assessing the
effectiveness of
culturally
appropriate
diabetes health
education on
important outcome
measures in type 2
diabetes
Dependent upon
original studies
included in review
Dependent upon
studies
Primary outcomes:
biomedical
measures (blood
pressure), patient
centred measures
(quality of life
scales)
Glycaemic control
(HbA1c), improved
after culturally
appropriate health
education but effect
not significant 12
months later
Strong
Secondary
outcomes: (BMI,
lipid levels, acute
hospital
admissions),
patient centred
measures (attitude
scales, patient
satisfaction scores,
patient
empowerment and
self efficacy)
Knowledge scores
improved in the
intervention groups
at all stages after
intervention
A need for longterm, standardised
multi-centre RCTs
to compare
different types of
culturally
appropriate health
education within
defined ethnic
minority groups
People with type 2
diabetes mellitus(
any duration, with
or without
complications, from
an ethnic minority
group living in
middle to high
income countries
Eleven trials
involving 1,603
people included in
the review
v1.1
Other outcomes no
significant
difference between
groups
No evidence of
clinical outcome
improvement over
time despite
improvement in
intermediate issues
Page 40 of 91
Janghorbani M, Jones R, Allison S (2000) Incidence of and risk factors for cataract among diabetes clinic
attendees. Ophthalmic Epidemiology, 77(1): 13 – 25.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
Study to estimate
the incidence of and
risk factors for
proliferative diabetic
retinopathy (PDR)
among insulin- and
non-insulindependent diabetics
Patients with
insulin- and noninsulin-dependent
diabetes attending
three outpatient
clinics at a hospital
in Nottingham,
England (n = 3482)
n/a
Ophthalmic:
diagnosis of PDR
and nonproliferative diabetic
retinopathy (NPDR).
Incidence of PDR
nearly three times
higher in patients
with (NPDR) as in
those without any
retinopathy (42.1 vs.
15.0 per 1000
person-years)
The risk of
blindness was
greater among
those with PDR
than those with
NPDR in all three
types of diabetes,
but was substantial
even for those
without retinopathy
Fit for purpose
Covariates: Gender;
age; smoking
history; glycosylated
haemoglobin
(HbA1); systolic
blood pressure;
duration of
diabetes; creatinine
and proteinuria
Duration of diabetes
only independent
predictor of PDR for
patients without
PDR or any
retinopathy
Gender, age, BMI,
creatinine,
proteinuria and
smoking, had no
significant
association with
PDR
v1.1
Page 41 of 91
Jones HL, Walker EA, Schechter CB, Blanco E (2010) Vision is precious: a successful behavioural intervention
to increase the rate of screening for diabetic retinopathy for inner-city adults. Diabetes Educator, 36(1): 118-126.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
Part of a
randomized
controlled study
(Vision is Precious
stuffy ) to examine
the impact of a
telephone
intervention to
increase the rate of
diabetic retinopathy
screening among
implementation with
English and
Spanish speakers
Adults with diabetes
living in New York
(n = 305; telephone
interview group)
Telephone
intervention from
trained health
educators who were
ethnically diverse
and representative
of the community
Documented receipt
of a dilated fundus
examination (DFE)
within the 6-month
study window
Nearly all
participants who
obtained a DFE did
so after 4 or fewer
calls. All did by the
fifth call.
The telephone
intervention was
highly successful
compared with the
print intervention
Strong
Participants were
part of the Vision is
Precious study
Participants in the
intervention group
who did not receive
a DFE had
significantly more
steps in the
behavioural process
A negative
association
between the time
spent building
rapport and receipt
of DFE
Non-UK
The study
demonstrates the
difficulties and
challenges of
conducting a
tailored telephone
intervention to
improve rates of
screening in an
underserved,
diverse urban
community
As time spent in
educational
activities increased,
so did likelihood of
receiving a DFE
v1.1
Page 42 of 91
Khunti K, Kumar S, Brodie J (2009) Diabetes UK and South Asian Health Foundation recommendations on
diabetes research priorities for British South Asians. Diabetes UK, 2009.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Review report to
highlight the gaps in
the understanding
of diabetes in the
UK-based South
Asian population as
well as to identify
recommendations
and priorities for
future research
areas
Dependent upon
original study
included in the
review
n/a
Various, including
epidemiology,
genetics, cultural
aspects, screening
and prevention,
self-management
and education,
treatment and care,
diabetic
nephropathy, and
diabetic retinopathy
Type 2 diabetes is
up to six times more
common in people
of South Asian
descent.
Various
Fit for purpose
South Asian
population
Priority areas for
future research
identified
Prevalence of
retinopathy is
greater among
South Asians
compared to white
Europeans.
Differential risk of
retinopathy between
South Asians and
white Europeans is
largely observed in
those with diabetes
duration of less than
10 years
v1.1
Page 43 of 91
Kirkwood BJ, Pesudovs K, Latimer P, and Coster DJ. (2006) The efficacy of a nurse-led preoperative cataract
assessment and postoperative care clinic. Medical Journal of Australia, 184: 278–281.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Prospective study to
describe the
implementation of a
nurse-led
preoperative
cataract
assessment and
postoperative care
clinic and to assess
the safety, efficacy
and outcomes
Patients referred to
the Department of
Ophthalmology at
an Australian
hospital for cataract
surgery between
February 2003 and
August 2004 (n =
185; 221 eyes)
Nurse-led
preoperative
assessment clinic
and nurse managed
postoperative care
Concordance
between nurse
practitioner and
ophthalmologist
assessments;
waiting times for
first clinic
appointment and
surgery; visual
acuity and degree
of visual disability;
patient satisfaction
Median waiting
times fell from 115
days to 21 days for
initial clinic
appointment, and
from 44 days to 29
days for surgery
A nurse-led cataract
assessment clinic
can improve access
to care for public
patients with
cataracts.
Fit for purpose
v1.1
All patients had
improved visual
ability and high
levels of
satisfaction.
Quality assurance
evaluations
demonstrated full
concordance
between nurse and
ophthalmologist
assessments
The safety and
efficacy of the
program and its
excellent visual and
patient-centred
outcomes commend
its adaptation and
implementation to
other
ophthalmology
departments
Page 44 of 91
Klein, BE (2007) Overview of Epidemiologic Studies of Diabetic Retinopathy. Ophthalmic Epidemiol, 14: 179 183.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A review of recent
advances in
diagnosis,
treatment, temporal
trends, and health
care for diabetic
retinopathy (DR)
Dependent upon
original study
included in the
review
n/a
Dependent upon
original study
included in the
review
Dependent upon
original study included
in the review
Studies of the
variability of diabetic
retinopathy have
demonstrated the
high prevalences
and incidences of
this condition
Fit for purpose
Mainly prevalence of
diabetic retinopathy
Observational
studies and clinical
trials have
documented the
importance of
glycemic and blood
pressure control in
the development
and progression of
diabetic retinopathy
v1.1
Page 45 of 91
Klein R, Klein BE, Knudtson MD, Wong TY, Cotch MF, Liu K, Burke G, Saad MF, Jacobs DR Jr. (2006)
Prevalence of age-related macular degeneration in 4 racial/ethnic groups in the multi-ethnic study of
atherosclerosis. Ophthalmology, 113(3): 373-80.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Prospective cohort
study to examine
the prevalence of
age-related macular
degeneration (AMD)
in 4 racial/ethnic
groups
Participants aged
45 to 85 years old
from 4 racial/ethnic
groups (white,
black, Hispanic, and
Chinese) that
participated in the
second examination
of the Multi-ethnic
Study of
Atherosclerosis
(MESA; n = 6176)
n/a
Ophthalmic:
presence of AMD
Prevalence of AMD
were 2.4% (black),
4.2% (Hispanic),
4.6% (Chinese), to
5.4% (white);
significant
difference between
all groups
Low prevalences of
AMD were found in
the MESA cohort in
all groups
Strong
Covariates: age,
pupil size, presence
of hypertension,
presence of
diabetes, alcohol
intake, current
smoking status, and
body mass index
Participants drawn
from 6 United
States Communities
The highest
prevalence of any
AMD occurred in
those 75 to 84
years old
Non-UK study
A lower prevalence
of AMD was found
in blacks compared
with whites. The
higher prevalence
of exudative AMD in
Chinese needs
further study
Age, gender, pupil
size, body mass
index, smoking,
alcohol intake,
diabetes, and
hypertension status
did not explain the
variability in the 4
groups
v1.1
Page 46 of 91
Lacey J, Cate H, Broadway DC. (2009). Barriers to adherence with glaucoma medications: a qualitative research
study. Eye. Vol. 23, pt. 4.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Better
understanding of
obstacles to, and
the motivations for,
adherence with
glaucoma
medication and
potential methods
to improve
adherence
24 participants with
moderate to severe
glaucoma who
attended NHS
ophthalmic
departments at
Norfolk and
Norwich University
Hospital and
Cromer and District
Hospital
Qualitative
measures (focus
groups,
questionnaires) to
investigate various
aspects of
adherence to
glaucoma
medications
Framework
analysis and
NVIVO software to
check data
reliability
Multiple obstacles
to adherence were
identified, including
poor education,
lack of motivation,
forgetfulness, drop
application, and
other practical
issues, together
with specific
individual and age
differences.
Motivation for
adherence was
determined by fear
of blindness and a
faith in drop
efficacy
Specific obstacles
to adherence with
anti-glaucomatous
therapy should be
identified early after
diagnosis. Tailored
education about
consequences may
improve patients
motivations for
adherence
Fit for purpose: no
intervention,
reasonable
inferences
7 participants were
included in two
focus groups (one
at each hospital,
total participants =
14) and 10
participants
completed a
questionnaire
v1.1
UK Study
More research
needed on how to
deliver education
about glaucoma
management
Page 47 of 91
Leese GP, Ahmed S, Newton RW, Jung RT, Ellingford A, Baines P, Roxburgh S, Coleiro J (1993) Use of
mobile screening unit for diabetic retinopathy in rural and urban areas British Medical Journal, 306: 187–189.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
Prospective study to
examine the
effectiveness of a
mobile screening
unit in detecting
diabetic retinopathy
(DR) in rural and
urban areas
Patients in the
Tayside region of
Scotland presenting
for diabetic
retinopathy
screening over a
two year period (n =
2186)
n/a
Ophthalmic:
presence of diabetic
Retinopathy; and
need for laser
photocoagulation
Patients in rural
areas less likely to
attend a hospital
based diabetic clinic
(p <0.001)
Fit for purpose
Covariates: age;
duration of
diabetes; and
diabetic treatment
Correcting for age,
patients in rural areas
more likely to have
advanced DR (p <
0001) and require
laser
photocoagulation for
previously
unrecognised
retinopathy (p < 0.02)
Mobile diabetic eye
screening detected
a greater
prevalence of
advanced
retinopathy in
diabetic patients
living in rural areas
Screening cost £10
per patient and
£1000 per patient
requiring treatment
v1.1
Patients in rural
areas were more
likely to need urgent
laser
photocoagulation
Rural patients may
benefit more from
mobile screening
units than urban
patients
Page 48 of 91
Leese GP, Boyle P, Feng Z, Emslie-Smith A, Ellis JD. (2008). Screening uptake in a well-established diabetic
retinopathy screening program: the role of geographical access and deprivation. Diabetes Care. Vol. 31, pt. 11.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
To identify criteria
that affect uptake of
diabetes retinal
screening in a
community
screening program
using mobile retinal
digital photography
units
16, 258 (average
age 63+ years)
patients with
diabetes in 69
general practices in
Tayside, Scotland.
Eye screening data
from 15, 150
patients was
included in the
study
Patients assigned
anonymously to
census based
geographical areas
based on
residential
postcodes and
comparisons made
regarding uptake of
screening services
(static and mobile)
Geographical
information
systems were used
to measure
geographical data
and ‘Carstairs’
deprivation scale to
measure
deprivation
Highest proportion
of non-attendees
came from urban
and deprived areas
(with the exception
of Dundee) even
though these
patients had the
shortest distance to
travel
Static screening
centres are more
effective than
mobile centres
Strong
Random effects
logit models were
used to model the
propensity of
missing eye
screenings
v1.1
Younger people
and patients with a
long history of
diabetes were also
likely to miss the
screening
Social deprivation
is strongly
associated with non
attendance but
geographical
distance seems to
have no effect
Further
improvement is
needed to reach
those in socially
deprived areas
Page 49 of 91
McLaughlan B, Edwards A (2010) Understanding of the Purpose of an Eye Test Among People Aged 60 and
Over in the UK. Optometry in Practice; 11:4 179–188.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Cross sectional
study to examine
the barriers to eye
examinations
among older people
Members of the
50plusview panel
aged 60+ (n =
3848)
n/a
General perceptions
about the frequency
and purpose of eye
tests
Nearly half of
respondent attend for
an eye exam every
year
People fear being
blind to a greater
extent than other
disabilities
Fit for purpose
Personal
experience and
attitudes towards
eye tests
Top three reasons
given for an eye exam:
check prescriptions;
check health of the
eyes; and early
detection of eye
disease. ‘Most
important reason’,
detection of eye
disease
The overwhelming
majority of
respondents cited
checking
prescriptions as a
reason for
having an eye test
Self reported
questionnaire
administered across
the UK
Top three reasons for
non attendance: not
had an eyesight
problem; expense of
glasses; not
considered it
necessary
v1.1
The most frequently
given reason for not
having had an eye
test is not having
had any
eyesight problems
Page 50 of 91
McLaughlan B, Winyard S (2007) Don’t blame the patient! A call for action to eliminate unnecessary sight loss
from glaucoma. RNIB campaign report 27.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
RNIB Campaign
Report –
consensus report
from series of
expert meetings
and literature
review to
summarise
evidence on
compliance in
Glaucoma
treatment
n/a
n/a
Based on
registrations and
summarises
findings from other
studies
Highlights key risk
factors and
importance of
adherence to
treatment plans as
well as early
detection
Need of a
concerted strategy
including better
pathways and
attitude to
compliance in
design
Weak but fit for
purpose
v1.1
Page 51 of 91
McNeil, JJ Robman, L Tikellis, G Sinclair, MI McCarty, CA Taylor, HR (2004). Vitamin E supplementation and
cataract: randomized controlled trial. Ophthalmology. Vol. 111, pt. 1.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A prospective,
randomized,
double-masked,
placebo-controlled
clinical trial to
determine whether
treatment with
vitamin E (500 IU
daily) reduces
either the incidence
or rate of
progression of agerelated cataracts
1, 193 volunteers
with early or no
cataract aged 5580 years in a
screening program
in Melbourne,
Australia were
randomly assigned
to the intervention
or control group
Participants were
assigned randomly
to receive either
500 IU of natural
vitamin E in
soybean oil
encapsulated in
gelatin or a placebo
with an identical
appearance
The incidence and
progression rates
of age-related
cataract were
assessed annually
for four years with
both clinical lens
opacity gradings
and computerized
analysis of
Scheimpflug and
retroillumination
digital lens images
obtained with a
Nidek EAS-1000
lens camera
87% (74% =
intervention, 76% =
control) of
participants
competed the four
years cycle.
Vitamin E has no
effect on the
incidence and
progression of all
types of cataract
Strong
v1.1
Vitamin E did not
reduce the
incidence or
progression of any
type of cataract
Page 52 of 91
Mikelberg FS, Schulzer M, Drance SM, Lau W (1986) The rate of progression of scotomas in glaucoma. Am J
Ophthalmol., 101(1): 1-6.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Retrospective study
to evaluate the rate
of progression of
scotomas
Patients with
glaucoma for whom
demographic data
were stored on
computerised
records in an
ophthalmology clinic
in Canada (n = 45)
n/a
Ophthalmic:
scotoma mass,
calculated and
regressed on time
to obtain the rate of
visual field change
Twenty-two eyes
(49%) showed a
linear type of
progression, nine
(20%) showed a
curvilinear
progression, three
(7%) showed
episodic
progression, and 11
(24%) showed no
significant
progression
Nerves may be lost
in the optic nerve
with minimal
changes to visual
field
Fit for purpose
Only patients with
routine open angle
chronic glaucoma
included. Patients
with low tension
glaucoma were
excluded
After a certain point,
loss of visual field is
more linear and
rapid as little
functional nerve
remains intact
A progressive study
is required on
progression of field
loss in glaucoma as
well as the factors
that may influence
progression of the
disease
v1.1
Page 53 of 91
Muir KW, Santiago-Turla C, Stinnett SS et al. (2009). Glaucoma patients' trust in the physician. Journal of
Ophthalmology.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusiosn
Quality
A cross-sectional
patient survey to
describe glaucoma
patients' trust in the
physician and to
test the hypothesis
that increased
interpersonal trust
is associated with
increased
medication
adherence
195 participants
with open-angle
glaucoma seen by
multiple glaucoma
subspecialists at
Glaucoma Service
of Duke University
Eye Center, NC
n/a
Survey including
demographic data,
the Mini-mental
State Exam
(MMSE), a word
recognition test and
the trust in
physician scale
(TPS)
Patients from
ethnic minorities
had slightly less
trust in their
physician than
white patients
A better
understanding of
the patient –
physician
relationship
between “races” is
needed
Strong
Each participant
was seen by one of
four glaucoma
subspecialists
Descriptive
statistics for initial
results, relationship
between
demographic data
and TPS was
assessed using
analysis of variance
or linear regression
v1.1
Non-UK study
Trust in physician
was not associated
with glaucoma
medication
adherence in this
sample population
Page 54 of 91
Nazroo J Y (2005) The social determination of ethnic/racial inequalities in health. In Social Determinants of
Health (Second Edition), ed. M. Marmot and R.G. Wilkinson, 238-266.Oxford: Oxford University Press, 2005.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Review of previous
studies examining
the social
determination of
ethnic/racial
inequalities in health
Dependent upon
original study
included in the review
n/a
Ethnic./racial
disadvantage
Various
There remain ongoing
problems with the data
to available to explore
ethnic inequalities in
health
Fit for purpose
Ethnic patterning of
health
Socio-economic
patterning of health
Age
Impact of racial
harassment and
discrimination
Social support
networks and
participation
v1.1
A large body of
evidence now supports
the possibility that
ethnic inequalities in
health are largely the
consequence of socioeconomic differentials
but does not explain
the relationship
between ethnicity and
socio-economic
inequality
Page 55 of 91
Ng, WS, Agarwal PK, Sidiki S, McKay L, Townend J, Azuara-Blanco A (2010) The effect of socio-economic
deprivation on severity of glaucoma at presentation. Br J Ophthalmol, 94: 85-87.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Cross sectional
study to evaluate
the influence of
socio-economic
factors on severity
of glaucoma at
presentation
All newly diagnosed
glaucoma patients
at two hospitals in
Scotland, in 2006 (n
= 126; 48 severe
glaucoma; 74 nonsevere glaucoma; 4
not determined)
n/a
Ophthalmic:
severity of
glaucoma at
presentation
Severity of
glaucoma at
presentation was
significantly
associated with
SIMD rank, being
most severe in
patients from areas
with the lowest
ranks
Age and socioeconomic
deprivation were
associated with
severity of
glaucoma at
presentation, with
patients from areas
of higher socioeconomic
deprivation
presenting with
more advanced
glaucoma
Fit for purpose
Demographics: age
and gender
Socio-economic:
Scottish Index of
Multiple Deprivation
Age was a
significant factor
with severe
glaucoma being
more common in
elderly patients
v1.1
Page 56 of 91
Nordmann J-P, Baudouin C, Renard J-P, Denis P, Lafuma A, Laurendeau C, Jeanbat V, Berdeaux G (2010a)
Measurement of treatment compliance using a medical device for glaucoma patients associated with intraocular
pressure control: A survey. Clinical Ophthalmology, 4: 731–739.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome Measures
Results
Conclusions
Quality
Observational
survey to identify
and characterize
treatment
compliance profiles
of glaucoma
patients
and evaluate the
association with
intraocular pressure
(IOP)
Patients attending
specialised
glaucoma treatment
in 17 centres in
France (n = 140)
n/a
Compliance rates for
weekdays and
weekends, over 8
consecutive weeks
IOP was 23.9
mmHg at baseline
and 16.1 mmHg at 8
weeks; 17.7 mmHg
in low compliance
group
AHC identified 3
compliance groups:
‘high’ (56.6%,
approx. 80%
compliance),
‘medium’ (21.2%,
approx. 50%
compliance), and
‘low’ (22.1%,
approx. 20%
compliance)
Compliance
measurement by a
medical device
showed compliance
rates <80% by 50%
(approx.) of
patients,
significantly
impacting IOP
control
Fit for purpose
Demographics:
inclusion and
exclusion findings,
socio-demography,
POAG/OHT history,
current treatment,
IOP and visual acuity
Principal components
analysis (PCA) and
ascendant
hierarchical
classification (AHC)
to identify compliance
groups
v1.1
No demographic or
glaucoma variable
was associated with
low compliance
Demographics and
glaucoma
parameters did not
predict low
compliance
Page 57 of 91
Nordmann JP, Baudouin C, Renard JP et al (2010b) Identification of noncompliant glaucoma patients using
Bayesian networks and the Eye-Drop Satisfaction Questionnaire. Clinical Ophthalmology, 4: 1489-1496.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Observational
cross-sectional
study To identify
poorly compliant
glaucoma patients,
using the Eye-Drop
Satisfaction
Questionnaire
(EDSQ)
Patients with
primary open-angle
glaucoma (POAG)
or ocular
hypertension
attending
specialised
treatment at 17 sites
in France (n = 169)
n/a
Eye-Drop
Satisfaction
Questionnaire
Low compliance
associated with age
<77.5 years plus
poor patient–
physician
relationship
The patient–
physician
relationship plays a
central role in the
compliance process
Fit for purpose
Inclusion: used
Travalert device 
eight weeks;  18
years of age; and
either POAG or high
IOP
Compliance profile
derived from
Travalert® data
A Bayesian network
(BN) was applied to
explore compliance
associations with
EDSQ
Patients aged >77.5
years with a poor
patient–physician
relationship and
declared good
compliance
High compliance
associated with
patients < 77.5
years old with good
patient-physician
relationship
Secondary
glaucoma excluded
v1.1
Age, self-declared
compliance, and
patient satisfaction
with the patient–
physician
relationship are all
dimensions worth
exploring before
glaucoma
medication is
switched or
proceeding to laser
treatment or surgery
Page 58 of 91
Nordstrom BL, Friedman DS, Mozaffari E, Quigley HA, Walker AM (2005) Persistence and adherence with
topical glaucoma therapy. Am J Ophthalmology. 140(4): 598-606.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A retrospective
cohort study to
examine the
patterns and
predictors of
treatment
persistence and
adherence among
patients who are
diagnosed with
glaucoma or as
glaucoma suspects
Newly treated
individuals with
diagnosed
glaucoma (n =
3623) and suspect
glaucoma (n =
1677).
Four drug classes
were included in the
study: betablockers, alphaagonists, carbonic
anhydrase
inhibitors, and
prostaglandin
analogs
Duration of
continuous
treatment with the
prescribed
medication
(persistence)
Nearly one half of
individuals had
discontinued all
topical ocular
hypotensive therapy
within six months
Patients with
diagnosed openangle glaucoma
were more likely to
adhere to treatment
than suspected
glaucoma
Fit for purpose
Prevalence of use of
the initial medication
at various time
points (adherence)
37% of these
individuals had
refilled their initial
medication at three
years after first
dispensing
Patient records
obtained from
healthcare claims
data in the Ingenix
Research Database
Relative risk (RR)
for outcome
measures: patients
diagnosed with
glaucoma vs.
glaucoma suspects
v1.1
Persistence and
adherence were
substantially better
with prostaglandins
than with other drug
classes
Patients with
diagnosed
glaucoma more
likely to adhere to
therapy than with
suspect glaucoma
(RR = 1.11; 95% CI,
1.05-1.18)
Page 59 of 91
Norregaard JC, Bernth-Petersen P, Alonso J, Dunn E, Black C, Andersen TF, Bernth-Petersen P, Bellan L,
Espallargues M (1997) International variation in ophthalmologic management of patients with cataracts. Results
from the International Cataract Surgery Outcomes Study. Arch Ophthalmol, 115(3): 399–403.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Cross-sectional
study to describe
international
variation in the
management of
patients with
cataracts in 4 health
care systems and to
discuss the potential
implications for cost
and utilisation of
services
Ophthalmologists in
the United States (n
= 526), Canada (n =
276), Spain (n =
89), and Denmark
(n = 82)
n/a
Most surgeons
reported that they
performed Ascanning, fundus
examination, and
refraction routinely
before surgery
Both within and
across sites,
considerable
variation in number
of follow-up visits
and postoperative
tests was observed
Significant
international
variation in the
management of
healthy patients with
cataracts has been
observed
Fit for propose
Significant crossnational variation
was observed in
preoperative
ophthalmic and
medical testing
A significantly
higher proportion of
surgeons in the
United States and
Spain reported less
than 100 extractions
per year compared
with surgeons in
Canada and
Denmark (P < .001)
If less intensive care
is not associated
with poorer
outcomes, there is
the potential for less
costly care of
patients with
cataracts
v1.1
Page 60 of 91
O’Donnell K. (2009) Eye care in the UK: Epidemiology, intervention and Ethnicity. PHAST report
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Literature review
produced for NHS
Tower Hamlets in
September 2009 as
part of the ‘Care
Needs
Assessment: Eye
Health’ project
commissioned by
NHS Tower
Hamlets
Dependent upon
original study
included in the
review
n/a
Epidemiology and
clinical appearance
of the four main
causes of visual
impairment in the
UK: glaucoma,
cataract, diabetic
retinopathy and
age-related
macular
degeneration
Various
A number of key
points emerge from
the literature which
may be useful
when formulating
interventions: 1)
the importance of
family; 2) age is a
major risk factor; 3)
ethnicity is a
determinant of risk:
4) the need for
targeted screening
and holistic
assessment; and 5)
investment should
be made in low
vision services
Fit for purpose
Interventions and
treatments,
together with
available data on
cost analysis or
effectiveness.
Dependent on the
cause of visual
impairment and
group included in
the review
The needs of
special groups
v1.1
Page 61 of 91
O'Hare JP, Raymond NT, Mughal S, Dodd L, Hanif W, Ahmad Y, Mishra K, Jones A, Kumar S, Szczepura A,
Hillhouse EW, Barnett AH (2004) Evaluation of delivery of enhanced diabetes care to patients of South Asian
ethnicity: the United Kingdom Asian Diabetes Study (UKADS). Diabet Med., 21(12): 1357-65.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Cluster randomized
controlled trial to
test the hypothesis
that enhanced care
for diabetes,
tailored to the
needs of the South
Asian community
with Type 2
diabetes, would
improve risk factors
for diabetic vascular
complications and
ultimately reduce
morbidity and
mortality
Patients at six
General Practices in
the UK West
Midlands, with a
high population of
South Asians (n =
361; n = 325 ad 12month follow-up)
Intervention:
'enhanced care'
using Asian link
workers, an
additional practice
nurse session per
week and
community diabetes
specialist nurse
input
Blood pressure,
HbA1c and lipid
control after oneyear follow-up
At one-year follow-up
a significant
difference in reduction
of systolic and
diastolic blood
pressure, and total
cholesterol, in the
intervention groups
Small reductions in
blood pressure and
cholesterol were
achieved, but
improvement in
glycaemic control
may require longer
different strategies
Strong
Adjusting for baseline
and age, only
differential reduction
in diastolic blood
pressure was
significant
Using link workers
and extra community
diabetes specialist
nurse input might
prove a useful
strategy in working
towards NSF targets
Eligible patients
were of South Asian
ethnicity with Type
2 diabetes and
either elevated
blood pressure,
elevated glycated
haemoglobin
(HbA1c) or raised
total cholesterol
Control: continued
standard practice
care
There was no
significant change in
HbA1c and no
difference between
groups
v1.1
UK study
Further research is
required to evaluate
effectiveness
Page 62 of 91
Okeke CO, Quigley, Jampel HD, Ying G, Plyer RJ, Jiang Y, Friedman DS (2009). Interventions Improve Poor
Adherence with Once Daily Glaucoma Medications in Electronically Monitored Patients. Ophthalmology. Vol.
116, pp. 2286-2293.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A randomised
controlled trial to
investigate the
impact of an
intervention
program to improve
adherence with
topical, once daily
therapy for
glaucoma
66 patients aged
18+ years with
open angle
glaucoma, angleclosure glaucoma,
glaucoma suspect,
or ocular
hypertension
attending the
Glaucoma Services
of the Wilmer Eye
Institute and the
Scheie Eye
Institute in
Philadelphia, PA
USA
Intervention group:
educational video,
structured
discussion,
reminder telephone
calls
Change in drop
usage adherence
as determined by
the DA device
Patients in the
intervention group
mean of scheduled
doses increased in
the three months
after intervention.
The control mean
adherence rate at
baseline was
statistically
unchanged during
the follow up
A multifaceted
intervention
significantly
increased
adherence with
glaucoma
medications,
further research is
needed to
determine which
components of this
intervention were
most effective
Fit for purpose
Statistical analysis
of results
Control group:
standard care
v1.1
Page 63 of 91
Pappa C, Hyphantis T, Pappa S, Aspiotis M, Stefaniotou M, Kitsos G, Psilas K, Mavreas V. (2006) Psychiatric
manifestations and personality traits associated with compliance with glaucoma treatment. J Psychosom Res,
61(5): 609-17.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Cross-sectional
study to assess the
impact of
psychological
distress and
personality traits on
self-rated
compliance with
glaucoma treatment
Patients with
primary open angel
glaucoma ((POAG
(n = 100)
n/a
Compliance with
treatment: via
qualitative
interviews
Forty-two percent of
patients were noncompliers (omitted
more than two
doses per week).
Non-compliers
presented more
severe symptoms of
glaucoma.
Depression
associated with
poor compliance.
Adoption of
immature defensive
style further
increased the risk
for non-compliance
Depression is
associated with selfreported noncompliance with
glaucoma
treatment, whereas
certain personality
traits are involved in
the increased risk
for non-compliance
Fit for purpose
Eligible for entry
were patients with
either previously
diagnosed POAG or
exfoliation
glaucoma and who
had already
received ocular
hypotensive agents
Other types of
glaucoma and other
ophthalmic
conditions were
excluded
Psychometric
outcomes: General
Health
Questionnaire;
Symptom Distress
Checklist;
Centre for
Epidemiological
Studies Depression
Scale;
Defence Style
Questionnaire;
Hostility and
Direction of
Hostility
Questionnaire
v1.1
Non-UK study
Page 64 of 91
Pardhan S, Gilchrist J, Mahomed I (2004) Impact of age and duration on sight-threatening retinopathy in South
Asians and Caucasians attending a diabetic clinic. Eye, 18(3): 233-40.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
Prospective study to
examine diabetic
retinopathy in
Asians and
Caucasians
attending a hospital
diabetic clinic
Diabetic patients
who attended an
outpatient diabetic
clinic in Bradford
between March
1996 and
December 1997 (n
= 500; 268 Asians,
232 Caucasians)
n/a
Ophthalmic:
existence of sightthreatening
Retinopathy (STR)
Significant
association of STR
with race, age and
duration of
diabetes, with no
significant
interaction effect
between variables
After adjusting for
age and duration of
diabetes, the
probability of STR in
Asian diabetic
patients in Bradford
is significantly
higher than that in
(white) Caucasians
Fit for purpose
Patients were
included if they
were over 40 years
of age, were
diagnosed as
diabetic, and had
not been treated for
any other eye
diseases such as
glaucoma
Covariates: age of
the patient; duration
of diabetes; gender;
insulin-requiring
status; and HbA1
levels
v1.1
Logistic regression
predicted
Caucasians are
approximately 12.5
years older and/or
have had diabetes
for 12.5 years more
to have the same
STR levels
compared to Asians
UK study
The impact of age
and duration was
significantly higher
in patients of South
Asian origin
compared to (white)
Caucasians
Page 65 of 91
Patel D, Baker H & Murdoch I. (2006). Barriers to uptake of eye care services by the Indian population living in
Ealing, west London. Health Education Journal. Vol. 65, pt. 3.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
This study in
Ealing, London was
aimed at
determining the
reasons for poor
utilization of eye
care services by
the Indian
population
44 participants
male and female
from three different
stakeholder
perspectives of
community,
patients and health
in Ealing took part
in the study in
community centres,
temples and GP
practices around
the borough
n/a
Various data
collection methods
The study found
two distinct types of
barriers that
affected the Indian
population of
Ealing those that
are due to
misconceptions
about eye diseases
and those that
come from
experience of
health and social
care services
Relationships
between GPs and
their Indian patients
in Ealing need to
be examined
further
Fit for purpose
Analysis used a
thematic framework
involving five
distinct steps:
(1) Familiarization
(2) Identifying a
thematic framework
(3) Indexing
(4) Charting
(5) Mapping and
interpretation
v1.1
Strategies for
overcoming
identified barriers
need to be created
Page 66 of 91
Quigley H, & Broman, S (2006) The number of people with glaucoma worldwide in 2010 and 2020. Br J
Ophthalmology, 90(3): 262-7.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A review of
published data to
estimate the
number of people
with open angle
(OAG) and angle
closure glaucoma
(ACG) in 2010 and
2020 using
prevalence models
constructed by age,
sex, and ethnicity
Dependent upon
original study
included in the
review
n/a
Prevalence models
for OAG and ACG
by age, sex, and
ethnicity, weighting
data proportional to
sample size of each
study
60.5 million people
with OAG and ACG
in 2010
Glaucoma is the
second leading
cause of blindness
worldwide,
disproportionately
affecting women
and Asians
Fit for purpose
Data from
population based
studies of age
specific prevalence
of OAG and ACG
that satisfied
standard definitions
79.6 million people
with OAG and ACG
by 2020. Of these,
74% will have OAG
Models were
combined with UN
world population
projections for 2010
and 2020 to derive
the estimated
number with
glaucoma
v1.1
Page 67 of 91
Racette L, Wilson MR, Zangwill LM, Weinreb RN, Sample PA. (2003). Primary open-angle glaucoma in blacks: a
review. Surv Ophthalmol. May-Jun; 48(3): 295-313.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Review of published
literature to inform
ongoing ADAGES
African Descent and
Glaucoma
Evaluation Study
(USA)
n/a
n/a
Various depending
on publications
POAG prevalence
is estimated six
times as high in
Black Americans in
certain age groups
compared to whites.
POAG more likely
to result in
irreversible
blindness, appears
approximately 10
years earlier and
progresses more
rapidly in blacks
than in whites.
Blacks have larger
optic disks than
whites. Racial
differences in
intraocular pressure
remain unclear
There is evidence
that blacks are less
responsive to both
drug and surgical
treatment for
POAG. They often
have reduced
accessibility to
treatment and are
less aware of the
risks of having
POAG
Fit for purpose
v1.1
Non-UK study
Page 68 of 91
Reidy A, Minassian DC, Vafidis G, Joseph J, Farrow S, Wu J, Desai P, Connolly A (1998). Prevalence of serious
eye disease and visual impairment in a north London population: population based, cross sectional study. BMJ.
30; 316(7145): 1643–1646.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Cross sectional
survey to estimate
the magnitude of
serious eye
disorders and of
visual impairment in
a defined elderly
population of a
typical metropolitan
area in England
Random sample of
people aged 65 and
older, drawn from a
defined population
of elderly people
registered with 17
general practice
groups (n = 1547)
n/a
Proportions and
population
prevalence
estimates for visual
acuity
The population
prevalence of
bilateral visual
impairment was
30%; 72% was
potentially
remediable
Untreated visual
impairment and eye
disorders affect a
substantial
proportion of people
aged 65 years and
older
Strong
Classified into four
categories:
prevalence of
cataract, age
related macular
degeneration, and
refractive error
causing visual
impairment and of
definite primary
open angle
glaucoma
Status of contact
with eye services
v1.1
88% of people with
cataracts not in
touch with the eye
services
Prevalence of AMD
was 8% and of
glaucoma 3%
Three quarters of
people with definite
glaucoma were not
known to the eye
services
Page 69 of 91
Rose K, Waterman H, Toon L, Mcleod D, Tullo A (1999) Management of day surgery patients with cataract
attending a peripheral ophthalmic clinic. Eye, 13: 71-75
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
To compare two
organisational
models of
management for
patients with
cataract referred to
a peripheral
ophthalmic
clinic who
underwent daysurgery at a main
eye hospital
Patients with
cataract attending a
peripheral
ophthalmic clinic
Experimental group
received preoperative
assessment by a
trained ophthalmic
nurse at the
peripheral clinic
immediately
following diagnosis
of cataract and
diary-booking for
surgery
Ophthalmic: visual
acuity, subjective
visual function (VF14)
No significant
differences between
the experimental
and control groups
with respect to
visual acuity,
subjective visual
function or anxiety
and depression
Nurse-led preoperative
assessment of
patients with
cataract at a
peripheral
ophthalmic clinic is
safe, cost-effective
and is preferred by
patients
Strong
Patients were
randomly drawn to
receive either an
experimental (group
A; n = 25) or control
(group B; n = 24)
model of care
Anxiety and
depression
Patient satisfaction
Cost-benefit
analysis
The control group
received a separate
appointment for preoperative
assessment at the
main hospital
The experimental
model was a more
cost-effective
means of care
delivery
Overall, patients
preferred the
experimental model
v1.1
Page 70 of 91
Rudnicka AR, Mt-Isa S, Owen CG, Cook DG, Ashby D (2006) Variations in Primary Open-Angle Glaucoma
Prevalence by Age, Gender, and Race: A Bayesian Meta-Analysis. Investigative Ophthalmology & Visual
Science. 47:4254–4261.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome Measures
Results
Conclusions
Quality
A systematic review
to quantify the
variation in primary
open-angle
glaucoma (OAG)
prevalence with
age, gender, race,
year of publication,
and survey
methodology
Dependent upon
original study included
in the review
n/a
Number of people
and cases of OAG by
age, race, and gender
Black populations
had the highest OAG
prevalence at all
ages, but proportional
increase with age
was highest in white
populations
Although black
populations had
the highest
prevalence of
OAG at all ages,
white populations
showed the
steepest increase
in OAG
prevalence with
age
Strong
Very sophisticated
statistical approach
NB ‘Asian’ may not
compare to UK
usage of term.
Only ‘Asian’ study
based on
Japanese cases,
and classifies
Chinese, Eskimo
(Inuit) and Thai as
‘Asian’
Forty-six published
observational studies
of OAG prevalence
were included (n =
103,567 participants;
2509 cases of OAG)
Population-based
surveys were included
that examined an
entire town/ village/
geographic region or
used clearly defined
random or clustered
sampling
Information on
whether the definition
of glaucoma relied on
raised intraocular
pressure (IOP) and
whether visual field
examination
Bayesian model
associations between
log odds of OAG and
age, race, gender,
year of publication,
method of visual field
testing, and reliance
on IOP
v1.1
Prevalence in those
older than 70 was 6%
in whites, 16% in
blacks, and 3% in
Asians
Prevalence of OAG
was one third lower in
studies in which
visual fields were not
assessed and IOP
was used in the
definition of
glaucoma
Men were more
likely than women
to have OAG
Page 71 of 91
Salisbury C, Wallace M, Montgomery AA (2010) Patients’ experience and satisfaction in primary care: secondary
analysis using multilevel modelling. BMJ, 341:c5004
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Secondary analysis
of data from a study
of access to general
practice, to explore
whether responses
to questions of
patients that purport
to assess the
performance of
general practices or
doctors, reflect
differences between
practices, doctors,
or the patients
themselves
Secondary analysis
of data obtained
from a survey of
patients’ satisfaction
done in 47 practices
in 9 primary care
trusts in England,
in 2005-6 (n = 4573
patients who
consulted 150
different doctors in
27 practices)
n/a
Overall satisfaction;
experience of wait
for an appointment;
reported access to
care; satisfaction
with communication
skills
Wait for an
appointment more
discriminating than
overall satisfaction
Measures related to
patients’ experience
discriminate more
effectively than do
measures of general
satisfaction
Fit for purpose
79% of the variance
occurred at the
patient level
Patients' age, sex,
ethnicity, and
housing and
employment status
explained some
variation
Adjustment for
patients’
characteristics
made very little
difference to
practices or the
individual ranking
v1.1
Surveys of patients
satisfaction fail to
distinguish between
individual doctors
because most
variation in doctors’
performance is due to
differences between
patients and random
error rather than
differences between
doctors
Page 72 of 91
Saxena S, Misra T, Carr J, Netuveli G, et al. (2007). Systematic review of primary healthcare interventions to
improve diabetes outcomes in minority ethnic groups. Journal of Ambulatory Care Management. Vol. 30, pt. 3,
pp. 218-30.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
To systematically
review the
effectiveness of
primary care
interventions on
glycaemic control
and cardiovascular
risk factors in
minority ethnic
groups with
diabetes
Dependent upon
original studies
included in review
Dependent upon
study
Statistical analysis
Two main models
of care were
identified: (1) case
management, with
specialist diabetes
nurses and
community health
workers and (2) the
use of the services
of link workers from
minority ethnic
groups to guide
people with
diabetes
Case management
in minority ethnic
groups with
diabetes, improves
glycaemic control
and cardiovascular
risk factors
Strong
2, 565 participants
form 9 separate
studies based in
primary care
practices
v1.1
Link workers
improve control of
cardiovascular risk
factors
Relative
effectiveness, cost,
and sustainability
over time warrant
further evaluation
Page 73 of 91
Scanlon PH, Carter SC, Foy C, Husband RFA, Abbas J and Bachmann MO (2008) Diabetic retinopathy and
socioeconomic deprivation in Gloucestershire. J Med Screen 2008;15:118–121
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A cross-sectional
study to investigate
socioeconomic
variations in
diabetes
prevalence, uptake
of screening for
diabetic
retinopathy, and
prevalence of
diabetic retinopathy
(DR)
Individual level
records from the
Gloucestershire
Diabetic Eye
Screening Service
(GDESS) database
n/a
Diabetes
prevalence with
odds ratios, uptake
of screening,
prevalence of any
retinopathy and
prevalence of sightthreatening
retinopathy (STDR)
at screening
compared for
different area
deprivation
quintiles
With each quintile
of deprivation,
diabetes
prevalence
increased,
probability of being
screened for DR
decreased, and
prevalence of
STDR in screened
patients increased
The National
Screening
Programme needs
to attract
socioeconomic
deprived groups to
attend, as these
people are at the
most risk of STDR
Strong
Data from 85 GP
practices
Dataset 1 — all
patients on the
GDESS database
at December 2002.
Dataset 2 —
patients who had
been screened for
diabetic retinopathy
up to February
2003
Logistic regression
was used to adjust
for confounding
v1.1
Prevalence of nonsight-threatening
diabetic retinopathy
was unchanged
with each
increasing quintile
of deprivation
Page 74 of 91
Scully ND, Chu L, Siriwardena D, Wormald R, Kotecha A (2009) The quality of optometrists’ referral letters for
glaucoma. Ophthalmic and Physiological Optics, 29(2): 26-31.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Prospective study to
evaluate the quality
of content of
optometrist-initiated
glaucoma referral
letters arriving at
the appointment
booking centre of a
London based eye
hospital
All new glaucoma
referral arriving at
the appointment
booking centre of a
London based eye
hospital over a 4month period
commencing in
December 2006 (n
= 121)
n/a
Quality of the
referral letter
Forty-nine per cent
of referral letters
found of acceptable
quality, 7% ideal
and the remainder
classed as fail
There is a need to
improve the quality
of optometrists'
glaucoma referral
letters, particularly
with respect to
completion of all the
items set out on the
GOS 18 referral
form
Fit for purpose
Referrals for
patients with
previously
diagnosed or
previously
suspected
glaucoma were
omitted
Acceptable: all
information on
General Ophthalmic
Services (GOS) 18
referral form
Ideal: as above plus
risk factors, visual
field assessment,
optometrist's
diagnosis and
referral speed
Fail: letters not
satisfying all criteria
v1.1
Main reason for
failure was an
omission of nonclinical information
Two-thirds of
acceptable letters
lacked discussion of
risk factors, visual
field analysis or
recommendations
for referral speed
Page 75 of 91
Seddon JM, George S, Rosner B (2006) Cigarette Smoking, Fish Consumption, Omega-3 Fatty Acid Intake, and
Associations With Age-Related Macular Degeneration. The US Twin Study of Age-Related Macular
Degeneration. Arch Ophthalmol. 124:995-1001
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
To evaluate
modifiable risk and
protective factors
for age-related
macular
degeneration (AMD)
among elderly twins
Male twins from the
National Academy
of Sciences–
National Research
Council World War
II Veteran Twin
Registry
n/a
Ophthalmic: signs
of AMD using
slitlamp
Biomicroscopy.
Retinal photography
Current smokers
had a 1.9-fold
increased risk of
AMD
Cigarette smoking
increases the risk
of AMD while fish
consumption and
omega-3 fatty acid
intake reduce risk of
AMD
Strong
Cohort includes n =
681 twins: 222 twins
with AMD
(intermediate or late
stages) and 459
twins with no
maculopathy or
early signs
Dietary: food
frequency
questionnaires
Risk factors:
demographic
characteristics,
cigarette smoking,
alcohol intake, and
physical activity
Past smokers had
about a 1.7-fold
increased risk
Non-UK study
Increased intake of
fish reduced risk of
AMD, particularly
for 2 or more
servings per week
Odds ratio for
specific outcome
measure
v1.1
Page 76 of 91
Smeeth L, Fletcher AE, Hanciles S, Evans J, Wormald R (2003) Screening older people for impaired vision in
primary care: cluster randomised trial. BMJ, 327: 1027-1032.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
Cluster randomised
trial to determine
the effectiveness of
screening for visual
impairment in
people aged 75 or
over as
part of a
multidimensional
screening
programme
People aged 75
years or over
randomly sampled
from 20 general
practices (n = 4340)
Visual acuity testing
and referral to eye
services for people
with visual
impairment
Proportion of people
with visual acuity
less than 6/18 in
either eye
Universal screening
(assessment and
visual acuity testing)
was compared with
targeted screening,
in which only
participants with a
range of health
related problems
were offered an
assessment that
included acuity
screening
Including a vision
screening
component by a
practice nurse in a
pragmatic trial of
multidimensional
screening for older
people did not lead
to improved visual
outcomes
Strong
People resident in
hospitals or nursing
homes were
excluded
3-5 years after
screening, the
relative risk of visual
acuity < 6/18 in
either eye,
(universal vs.
targeted screening),
was 1.07 (95% CI
0.84 to 1.36; NS)
Mean composite
score of 25 item
version of the
National Eye
Institute visual
function
questionnaire
v1.1
Mean composite
score of visual
function
questionnaire 85.6
in targeted
screening group
and 86.0 in the
universal group
(difference 0.4, 95%
CI 1.7 to 2.5, NS)
Page 77 of 91
Smith W, Assink J, Klein R, Mitchell P, Klaver CC, Klein BE, Hofman A, Jensen S, Wang JJ, de Jong PT. (2001)
Risk factors for age-related macular degeneration: Pooled findings from three continents. Ophthalmology,
108(4): 697-704.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Combined analysis
of population-based
eye disease
prevalence data to
assess the
prevalence and
potential risk factors
for late age-related
macular
degeneration (AMD)
in three racially
similar populations
from North America,
Europe, and
Australia
Participants with
gradable
photographs from
the Beaver Dam
Eye Study (n =
4756), Rotterdam
Study (n = 6411),
and Blue Mountains
Eye Study (n =
3585)
n/a
Ophthalmic:
presence of AMD
(geographic atrophy
(GA) and
neovascular NV)
AMD present in
0.2% of the
combined
population aged 55
to 64 years, rising to
13% of population
older than 85 years
The study provides
strong and
consistent evidence
that tobacco
smoking is the
principal known
preventable
exposure
associated with any
form of AMD
Strong
Covariates: age,
gender, tobacco
smoking, body
mass index,
presence of
hypertension,
cholesterol, iris
colour, age at
menopause, and
hormone
replacement
therapy
v1.1
No significant
gender differences
in the prevalence of
AMD (either NV or
GA)
Age and smoking
the only risk factors
associated with any
form of AMD in sites
separately and in
pooled analyses
Page 78 of 91
Stryker JE, Beck AD, Primo SA, Echt KV, Bundy L, Pretorius GC, Glanz K (2010) An exploratory study of factors
influencing glaucoma treatment adherence with medication taking, prescription refills and appointment keeping
to develop an intervention for a specific population. Journal of Glaucoma 19(1): 66-72.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Qualitative study to
understand the
factors that
influence glaucoma
treatment
adherence with
medication
taking, prescription
refills, and
appointment
keeping
Patients attending
two eye clinics
located in hospitals
in the Southeast
United States, aged
between 18 and 80
(n = 80)
n/a
Participant’s eye
condition,
prescription
medication usage,
facilitators and
barriers to
medication
adherence, refill
and clinic visit
behaviour,
medication
knowledge and
health literacy,
psychosocial factors
such as selfefficacy, attitudes,
and social support
Non-adherent
participants less
likely to believe their
eye doctors spent
sufficient time with
them; ask if they
had any questions;
know the benefits of
medication; and
have someone help
them take their
medications
Non-adherent
glaucoma patients
struggle with a
variety of issues
related to consistent
use of glaucoma
medicine and
routine eye care
Fit for purpose
Patients diagnosed
with open angle
glaucoma,
glaucoma suspect
or ocular
hypertension
Patients were taking
daily doses of
topical glaucoma
treatments for at
least the past year
v1.1
Non-adherent
participants more
likely to have
difficulty
remembering to
take medications
and to believe
glaucoma would
affect their eye sight
in the future
Non UK study
Interventions are
needed to address
these modifiable
factors related to
glaucoma treatment
adherence
Page 79 of 91
Sukumar S, Spencer F, Fenerty C & Harper R. (2009). The influence of socioeconomic and clinical factors upon
the presenting visual field status of patients with glaucoma. Eye. Vol. 23, pt. 5.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A cohort review
investigating the
relationship
between
socioeconomic
status and the
extent of visual field
loss in POAG and
treated OHT
patients at their first
presentation
113 glaucoma
patients seen
between 1995 and
2005 at Manchester
Royal Eye Hospital
n/a.
ACORN index was
used to measure
socioeconomic
status
Patients in the
socioeconomically
deprived group
presented with
more advanced field
loss, lower
educational
attainment (18 vs
98% with no or
unknown
qualification), and
were less aware of
glaucoma in the
family (27 vs 17%)
The extent of visual
field loss in
glaucoma patients
at first presentation
is related to a
combination of
clinical and
socioeconomic
factors including the
patient's postcode:
these findings could
be used to target
future case-finding
resources
Fit for purpose
49 patients were
included in affluent
group and 64
patients included in
socioeconomically
deprived group
v1.1
Page 80 of 91
Swamy B, Cumming RG, Ivers R, Clemson L, Cullen J, Hayes MF, Tanzer M, Mitchell P. (2009). Vision
screening for frail older people: a randomised trial. British Journal of Ophthalmology, 93(6): 736-741.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
A randomised trial
assessing the
effects of vision
screening, and
subsequent
management of
visual impairment,
on visual acuity
and vision-related
quality of life
among frail older
people
616 men and
women from a
community in
Sydney, Australia
aged 70+ years
recruited from
outpatient aged
care services
Comprehensive
vision and eye
examinations
conducted by an
optometrist
Distance and near
visual acuity
(logMAR) and
composite scores
on the 25-item
version of the
National Eye
Institute Visual
Function
Questionnaire, both
assessed at a 12month follow-up
home visit
There was no
significant
difference between
the intervention
and control group
Vision screening by
optometrist for frail
older people living
in the community
does not lead to
improvements in
vision or visionrelated quality of
life after 1 year
Strong
300 participants
received visual
assessment while
316 participants
formed the control
group which
received no vision
assessment
v1.1
Page 81 of 91
Swenor BK, Bressler S, Caulfield L, West SK (2010) The Impact of Fish and Shellfish Consumption on AgeRelated Macular Degeneration. Opthalmology, 13.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusion
Quality
A cross-sectional
study of dietary and
ophthalmologic
data to determine
the relationship
between fish and
shellfish
consumption and
age-related
macular
degeneration
(AMD) status
A random sample
participants in the
Salisbury Eye
Evaluation Study (n
= 2520)
n/a
Ophthalmic: status
of AMD
Weekly
fish/shellfish
consumption not
different between
specific AMD
categories
compared with
controls
These data support
a protective effect
of fish/shellfish
intake against
advanced AMD
Fit for purpose
Dietary: selfreported
fish/shellfish
consumption based
on completion a
food frequency
questionnaire
Association
between weekly
fish/shellfish intake
and risk of AMD
adjusting for risk
factors and
correlation between
eyes
v1.1
Those with
advanced AMD
significantly less
likely to consume
fish/shellfish high in
omega-3 fatty acids
(OR 0.4; CI 0.20.8)
No relationship of
AMD with intake of
crab and oysters
combined
Page 82 of 91
Tan JSL, Wang JJ, Flood V, Mitchell P (2009) Dietary Fatty Acids and the 10-Year Incidence of Age-Related
Macular Degeneration The Blue Mountains Eye Study. Arch Ophthalmol. 2009;127(5):656-665.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Population-based
cohort study to
assess the
relationship
between baseline
dietary fatty acids
and 10-year
incident age-related
macular
degeneration (AMD)
Patients aged 39
years of older living
in a Australian town,
diagnosed with
AMD (n = 3654 at
baseline; n = 2454
examined at 5
and/or 10 years
later)
n/a
145-item, semiquantitative food
frequency
questionnaire (FFQ)
Adjusting for age,
sex, and smoking, 1
serving of fish per
week was
associated with
reduced risk of
incident early AMD
Regularly eating
fish, greater
consumption of -3
polyunsaturated
fatty acids, and low
intakes of foods rich
in linoleic acid
appear to protect
against early AMD
Strong
Grading of AMD
Intervieweradministered
questionnaire on
demographic
information, family
history, medication
history, history of
smoking and
alcohol use
Relative risk for
specific outcomes
v1.1
Two servings of
nuts per week was
associated with
reduced risk of
incident early AMD
Regular
consumption of nuts
may also reduce
AMD risk
Joint effects from
multiple factors are
suggested
Page 83 of 91
Taylor HR, Vu HTV, McCarty CA, Keefe, JE (2004) The Need for Routine Eye Examinations. Investigative
Ophthalmology & Visual Science, 45(8).
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Prospective study to
determine the
incidence and
causes of vision
loss to assist in the
objective
determination of the
preferred frequency
of routine screening
for those with
normal vision
People aged 40
years or more, living
six months in
Melbourne (n =
3271 eligible at
baseline study;
2594 at five-year
follow-up)
n/a
Ophthalmic
assessment:
presenting and best
corrected visual
acuity, visual field
testing;
comprehensive eye
examination with
dilation
The 5-year
incidence of vision
loss was 2.39%
Frequent routine
eye examinations of
those with normal
results will have a
low yield and may
not be cost effective
Strong
Socioeconomic
indicators:
sociodemographic
characteristics;
history and current
symptoms of eye
disease; medical
history; and
medication use
v1.1
Overall, 24 of those
38 people with
vision loss had
noticed a change in
their vision, and 18
of 24 had attended
an eye examination
Only 14 people who
had normal baseline
examination results
developed
asymptomatic vision
loss over the 5-year
period
Non-UK study
Health promotion
messages should
target those who
notice a change in
vision and those at
higher risk
Page 84 of 91
Thornton J, Edwards R, Mitchell P, Harrison RA, Buchan I, Kelly SP. (2005) Smoking and age-related macular
degeneration: a review of association. Eye, 19(9): 935-44.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Systematic review
of the
epidemiological
evidence
associating
smoking with agerelated macular
degeneration
(AMD)
Dependent upon
original study
included in the
review
n/a
Relationship
between tobacco
smoking and AMD
or age-related
maculopathy
(ARM). Included an
estimate of the
degree of
association (odds
ratio or relative
risk)
Thirteen studies
found a statistically
significant
association
between smoking
and AMD
Cigarette smoking
is likely to have
toxic effects on the
retina
Strong
Total of 17 studies:
seven crosssectional studies (n
= 23,081); four
prospective cohort
studies (n =
approx. 59,000;
approx. numbers
due to one study
which reported
results from two
time points); six
case–control
studies (n = 6703)
The outcome
measure was the
presence of ARM
or AMD as defined
by the investigators
of each study
v1.1
Increased risk of
AMD of two- to
three-fold in
current-smokers
compared with
never-smokers
Five studies found
no association
between smoking
and AMD
In spite of the
evidence, there
appears to be a
lack of awareness
about the risks of
developing eye
disease from
smoking among
both healthcare
professionals and
the general public
Page 85 of 91
Tsai T, Robin AL, Smith 3rd JP (2007) An evaluation of how glaucoma patients use topical medications: a pilot
study. Trans Am Ophthalmol Soc, 105:29-35.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Pilot study to
evaluate how
glaucoma patients
use topical
medications
Patients attending
regularly scheduled
clinical visits with
one of two
geographically
distinct glaucoma
specialists (n = 253)
n/a
Questionnaire:
current use of eye
drops and
administration
techniques
Approx 17% of
participants relied
on others for the
administration of
drops
Fit for purpose
Demographics: age,
gender, selfreported ethnicity
Inadequate vision
and manual
dexterity were
leading causes of
dependency
Although most
individuals may
have little difficulty
with the use,
storage, and
handling of eye
drops, a broad
variation in reported
practices exists
Only 16.3% of selfadministering used
a mirror
This finding
suggests a need for
better instruction in
eye drop
administration
The most common
location for
administration was
bedroom (46.8%),
or bathroom
(23.4%)
v1.1
Page 86 of 91
Walker EA, Schechter CB, Caban A, Basch CE. (2008). Telephone intervention to promote diabetic retinopathy
screening among the urban poor . Journal of Preventive Medicine. Vol. 34, pt. 3, pp. 185-91
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
A randomised
controlled trial
testing the
hypothesis that a
tailored telephone
intervention in
urban minority
diabetes
populations, offered
in English or
Spanish, would
result in greater
screening for
retinopathy than a
standard print
intervention
598 diabetic
patients (40% male,
mean age = 57
years) of three
healthcare centres
in the Bronx, NY.
A tailored
telephone
intervention to
promote
retinopathy
screening
(intervention group)
compared to a
standard print
intervention (control
group) over a 6month period
Documentation of a
dilated fundus
examination (DFE)
within 6 months
was the main
outcome
There was a 74%
increase in
retinopathy
screening in the
telephone
(intervention group)
versus print
(control) group, with
no differences by
intervention
language or by
gender
A limited telephone
intervention can
improve
significantly
participation in
retinopathy
screening in a
minority, lowincome population
Strong
45% of participants
were African
American and 42%
of Hispanic ethnic
origin with 23%
choosing to receive
the intervention in
Spanish
Data on risk
perceptions using
the Risk Perception
Survey for Diabetes
were collected preand postintervention
Electronic
databases were
used to obtain
hemoglobin A1c
information
v1.1
Subjects who had
poor diabetes
control responded
with greater
success to
telephone
interventions
Non-UK study
Further research is
needed to develop
effective risk
communications to
prevent the
complications of
diabetes
Page 87 of 91
Wilson R, Walker A, Dueker DK, Pitts-Crick R. (1982) Risk factors for rate of progression of glaucomatous visual
field loss. Archives of Ophthalmology 100: 737-742.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Study to examine
factors affecting the
progression of
visual field loss
caused by
Glaucoma
Patients with bilateral
open angle glaucoma
(n = 57)
n/a
Visual field loss at
initial examination
Patients with marked
visual field loss at
initial examination
deteriorated 11.7
times faster than
patients without initial
field loss
Visual field loss at
follow-up
Conclusions
Quality
Fit for purpose (but
now rather dated:
however, widely
cited and not
contradicted)
Family history of
glaucoma, gender,
and initial registration
intraocular pressure
important prognostic
factors for
progressive visual
field loss
Age and systemic
blood pressure not
found to affect rate of
visual field loss
v1.1
Page 88 of 91
Wolfs RC, Klaver CC, Ramrattan RS, van Duijn CM, Hofman A, de Jong PT (1998) Genetic risk of primary openangle glaucoma: Population-based familial aggregation study. Arch Ophthalmol, 116(12): 1640-5.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Population based
study to examine
familial aggregation
of primary open
angle glaucoma in a
general population
and to determine
the absolute and
relative risks for
first-degree relatives
First-degree
relatives of patients
with glaucoma
(n = 48) and control
subjects (n = 155)
from the
population-based
Rotterdam Study
n/a
Ophthalmic:
intraocular pressure;
vertical cup-disc
ratio; and the
presence of
glaucoma
Prevalence of
glaucoma 10.4% in
siblings of patients,
1.1% in offspring of
patients, 0.7% in
siblings of controls,
0% in offspring of
controls
Relatives of patients
with glaucoma have
a strongly increased
risk of glaucoma
Strong
Other risk factors:
presence of
diabetes mellitus or
hypertension
Covariates: age and
gender
Risk ratio for
glaucoma in
relatives of patients
vs. controls was 9.2
(95% CI = 1.2-73.9)
Populationattributable risk of
glaucoma 16.4%
v1.1
Non -UK study
Enlarged cup-disc
ratio, not intraocular
pressure, the
earliest and most
prominent feature of
familial aggregation
Further studies
needed to
disentangle genetic
components of
increased familial
risk
Page 89 of 91
Wormald RP, Basauri E, Wright LA, Evans JR (1994) The African Caribbean Eye Survey: risk factors for
glaucoma in a sample of African Caribbean people living in London. Eye, 8(3): 315-20.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Cross-sectional
study to estimate
the prevalence of
and risk factors for
chronic glaucoma in
a sample of African
Caribbean people
over 35 years
African and
Caribbean people
living in the London
borough of
Haringey (n = 873)
n/a
Socio-economic:
personal and family
medical and ocular
history, migration
history; and
demographic data
32 definite cases of
glaucoma were
identified, a
prevalence of 3.9%
Study provides
strong evidence that
the 4 times greater
risk of glaucoma
estimated for
American blacks
compared with
whites applies
equally to the
United Kingdom
population
Fit for purpose
Community-based
survey clinics at six
different sites in
Haringey
Blood pressure and
blood sugar
Ophthalmologic:
binocular and
uniocular visual
acuity;
suprathreshold
visual fields,
applanation
tonometry, lens
opacity; vertical
cup-to-disc ratio;
and fundus
photography
v1.1
Comparison with a
previous study
revealed a relative
risk for glaucoma
for Haringey blacks
compared with Irish
whites of 3.7
Significant risk
factors for
glaucoma included
age, African
birthplace and
darker skin colour
UK study
Community-based
facilities are
required to raise
awareness of the
risk among this
ethnic minority in
this country and
case finding
resources should be
provided
Page 90 of 91
Zhang X, Norris SL, Saadine J, Chowdhury FM, Horsley T, Kanjilal S, et al. (2007) Effectiveness of interventions
to promote screening for diabetic retinopathy. American Journal of Preventive Medicine, 33(4): 318-35.
Study Purpose &
Type
Sample
Characteristics
Intervention
Outcome
Measures
Results
Conclusions
Quality
Systematic review
to assess the
effectiveness of
interventions aimed
to increase retinal
screening among
people with
diabetes
Dependent upon
original study
included in the
review
Patient focused:
awareness of DR;
adherence to
recommendations
Flexibility of
providers and
practices
System-focused:
access to health
care; availability of
a delivery system;
better records;
creation of a
screening system;
improved services
in a resource-poor
agency
Primary measure:
relative risk (RR)
Four of five RCTs
focusing on patients
demonstrated
interventions
significantly
increased screening
Provider focused:
adherence to
recommendations
reduced negligence
of practices.
Increasing patient
knowledge of
diabetic retinopathy,
improving provider
and practice
performance, and
improving
healthcare system
infrastructure and
processes, can
significantly
increase screening
for diabetic
retinopathy
Strong
Interventions used
to promote
screening for
diabetic retinopathy
(DR) in any
language and with
any study design
12 randomized
controlled trials
(RCT); four
nonrandomized
studies; 32 pre–post
studies (n =
162,157)
Five RCTs with a
focus on the system
all demonstrated
significant increases
in screening
Non-RCTs, which
included also
generally
demonstrated
positive effects
v1.1
Page 91 of 91