Study suggests that frail Medicare patients with glaucoma may receive less disease monitoring and fewer interventions for their disease management. Photo: Getty Images.

Not much is known about the prevalence of frailty among older adults with glaucoma. To determine if it’s an important factor among this population, researchers recently investigated differences in eyecare usage by frailty levels among Medicare beneficiaries with glaucoma.

A total of 76,260 Medicare beneficiaries with glaucoma over the age of 65 were included. Female beneficiaries constituted 60.5%, and 78.7% self-identified as non-Hispanic white. Based on a claims-based frailty index, 79.5% of beneficiaries were non-prefrail, 17.1% were mildly frail and 3.4% were moderately-to-severely frail.

The study showed that frail beneficiaries were less likely than non-prefrail beneficiaries to undergo outpatient eye exams and consultations, visual field and retinal nerve fiber layer OCT testing, selective laser trabeculoplasty and glaucoma surgeries and to have fewer days of glaucoma medications dispensed. “Conversely, frail beneficiaries were more likely to receive eye examinations in inpatient, emergency department, nursing facilities and home-visit settings,” the study authors wrote in their paper. “These findings persisted among both white and Black frail beneficiaries, with further stratified analyses demonstrating that differences in utilization among frail patients could not be explained by race alone.”

It should be noted that 20.5% of beneficiaries with glaucoma were frail, similar to the overall frailty prevalence of 20.8% among the Medicare population, suggesting that frailty is an important factor in the care of older beneficiaries with glaucoma.

A lower rate of usage of eyecare services in the outpatient setting was found among frail beneficiaries, but a higher rate of eye-related encounters was found in more acute settings.

“This is particularly significant given that glaucoma progression is primarily detected through ambulatory testing in outpatient clinics, and thus frail individuals with glaucoma may not be receiving sufficient monitoring and subsequent intervention to prevent further vision loss,” the authors noted.

A possible explanation for this is that older adults with frailty may have greater comorbidity scores, as was observed in this study. This is because increased comorbidities may lead to more frequent hospitalizations and admissions to rehabilitation facilities, limiting the ability of frail patients to prioritize eyecare visits, according to the authors.

“Additionally, frail individuals may have lower referral rates for outpatient glaucoma testing and interventions given provider perceptions of lower life expectancy or suboptimal risk-benefit for quality of life,” they wrote. “However, while frailty and comorbidity are closely related, our sensitivity analysis showed that differences in eye care utilization among moderate-severely frail beneficiaries persisted after controlling for comorbidity scores, suggesting that frailty is independently associated with eye care utilization.

They concluded that their findings “have important implications for disease monitoring and treatment in frail older adults with glaucoma, as inadequate monitoring and prevention of vision loss in this population may have severe consequences for morbidity and mortality.”

Halawa OA, Kang J, Parikh AA. Relationship between claims-based frailty index and eye care utilization among Medicare beneficiaries with glaucoma. Ophthalmology. January 23, 2023. [Epub ahead of print].