Bringing advances in global eye care locally

THE WORLD HEALTH Organization reports that of the 2.2 billion people globally with vision impairment, more than half could have been prevented or could still be addressed, with cataracts and refractive error topping the list of most common vision-related ailments. In an effort to reduce the number of people suffering from cataracts around the world, Geoffrey Tabin, MD, Fairweather Foundation professor of ophthalmology and global medicine, has perfected the delivery of high-quality, low-cost cataract surgeries abroad through his work with the nonprofit foundation CureBlindness, which he co-founded as the Himalayan Cataract Project (HCP) with Sanduk Ruit, MD, in 1995. With Tabin joining the Stanford faculty over five years ago, Stanford became the academic home for the foundation, with faculty, fellows, and now residents joining Tabin on his global vision-restoring missions. This work has dramatically reversed the incidence of cataract-related blindness in countries across Asia, and is now making progress in Africa.

Learning from their global experience, Tabin and his Stanford collaborators are now working to introduce lower-cost eye care in the U.S. by replicating some of the same cost-effective patient practices used abroad. While most patients receive excellent eye care in the United States, certain low-income populations, including Medicaid-eligible, uninsured and undocumented adults and children, do not have adequate access to routine eye exams or follow-up care to prevent or reverse needless low vision and blindness.

“With HCP, we harnessed Ruit’s method of small incision cataract surgery to start reversing cataract blindness in Asia and Africa,” Tabin said. “The procedure takes less than 10 minutes and costs just $25 in materials. Now we want to see how we can transfer approaches to U.S. patients in need of access to low-cost, high-quality care.”

Discovering cost-saving methods

A generous gift from a donor made possible a joint study between Tabin and the Stanford Clinical Excellence Research Center (CERC), including Arnold Milstein, MD, MPH, professor of medicine and CERC director; Kevin Schulman, MD, MBA professor of medicine and CERC director of industry partnerships and education; and Mary-Grace Reeves, MD, MBA, a former Stanford student.

The group studied the transferability of international surgical efficiencies amid U.S. regulatory, cultural, and economic factors, with their initial analyses and findings published in the New England Journal of Medicine Catalyst.

Tabin noted that part of the additional costs in the U.S. are unavoidable. Supplies and medications tend to cost more in the U.S. than those used in less industrialized parts of the world. Staffing costs are also higher in the U.S., with nurses and doctors earning a larger salary than their counterparts in other countries.

Other differences between U.S. costs and those abroad are attributable to differences in regulations—whether federal, state, or local. For example, whether nurses or other staff can give medications or patient instructions differs state to state, and federal HIPAA regulations in the U.S. require separate operating rooms for patients, rather than operating on two patients per room.

“We want to implement efficient and effective care,” Tabin said, “yet we experience a higher level of waste in the states. For example, we use a new bottle of medication for each patient and throw it away when only a tenth of it may be used. That bottle could be used for multiple patients. If permitted, we could also add in more cases per hour to utilize our staff’s time more effectively.”

Mobile care for Northern California

The joint studies with CERC have served as the foundation to optimize delivery of care in the U.S., leveraging such learnings from comparisons of costs and regulations. One approach the team has mapped out is to launch a mobile clinic to serve low-income and remote populations where they live, for example directly in Northern California communities. The planned mobile clinic will provide cataract surgeries and other medical care, including screenings for glasses and for treatable eye diseases like diabetic retinopathy. With philanthropic support, the group aims to establish the first preventable blindness-free zone in Northern California.

“We identified an unmet need for patients in Northern California who live in more rural areas or are part of an unhoused population, who may have a harder time traveling to receive care,” Tabin said. “Our mobile clinic goes directly to those communities in need.”

Stanford’s global ophthalmology fellow, Kanwal Matharu, MD, will help launch the program, together with support from Jude Alawa and Cyrus Buckman, Stanford medical students who are collaborating on the project through the Medical Scholars Research Program (MSRP). The MSRP funds medical student research efforts in a variety of settings including those in the local community.

“Once we have a proof of concept in Northern California, we aspire to expand our mobile model to other geographic locations with the greatest need, potentially partnering with other academic medical centers and organizations,” Tabin said. “Ultimately, we envision creating a model that can be replicated across the U.S.”

Using telemedicine tools to improve diagnosis

In addition to improving access to cataract care in the U.S., Tabin is also collaborating with colleagues in the ophthalmic innovation program to use technology to deliver improved care for other eye conditions. For example, David Myung, MD, PhD, associate professor of ophthalmology, developed a special camera that allows patients to be remotely screened for eye diseases. An assessment can then be made as to whether the patient needs to be referred to an ophthalmologist for treatment.

“The heart behind all of these projects is to ensure that patients can receive the same level of care locally, no matter their insurance coverage or ability to pay,” Tabin said. “If patients don’t have access to care, they may not know they even have visual problems until it’s too late.”

Tabin’s goals are to move the above efforts into implementation as soon as possible to alleviate the suffering of those with eye disease who are currently not receiving adequate care.  “Collaborating with Stanford colleagues across the campus, in medicine, business and engineering,” Tabin said, “will allow us to lead in delivering low-cost, high-quality eye care globally, and in transferring those learnings to improve eye care for people locally.”

By KATHRYN SILL

Kathryn Sill is the former web and communications specialist for the Byers Eye Institute in the Department of Ophthalmology, at Stanford University School of Medicine.