Representation of Race and Ethnicity in Randomized Clinical Trials of Diabetic Macular Edema and Retinal Vein Occlusion Compared to 2010 US Census Data

Temporal trends and characteristics associated with racial, ethnic, and sex representation in COVID-19 clinical trials: A systematic review and meta-analysis

BACKGROUND

Early in the pandemic, extensive attention was cast on limited inclusion of historically underrepresented patient populations in COVID-19 clinical trials. How diverse representation improved following these initial reports remains unclear.

METHODS

PubMed, Embase and the Cochrane Library were searched (through April 2024) for US-based COVID-19 trials. Utilizing random-effects, we compared expected proportions of trial participants from racial and ethnic groups and of female sex between trials enrolling primarily in 2020 versus primarily 2021-2022. Meta-regression was performed to assess associations between trial characteristics and group representation.

RESULTS

We retrieved 157 studies comprising 198,012 participants. White (2020: 63.1% [95% CI, 60.8%-67.3%]; 2021-2022: 73.8% [95% CI, 71.5%-76.0%]) and female representation (2020: 46.1% [95% CI, 44.7%-47.4%)]; 2021-2022: 51.1% [95% CI, 49.3%-52.8%) increased across enrollment periods. Industry-sponsored trials were associated with higher White (coefficient, 0.10 [95% CI, 0.03-0.18]) and Hispanic or Latinx representation (coefficient, 0.16 [95% CI, 0.08-0.25]) and lower Asian (coefficient, -0.03 [95% CI, -0.06- -0.003]) and female representation (coefficient, -0.03 [95% CI, -0.07- -0.002]). Outpatient trials were associated with higher White (coefficient, 0.20 [95% CI, 0.13-0.26]) and female representation (coefficient, 0.16 [95% CI, 0.13-0.18]), and lower Black representation (coefficient, -0.10 [95% CI, -0.10- -0.08]).

CONCLUSIONS

Despite improved female representation in COVID-19 trials over time, there was no clear increase in non-White representation. Trial characteristics such as primary sponsor, clinical setting, and intervention type correlate with representation of specific demographic groups and should be considered in future efforts to improve participant diversity.

Lack of racial and ethnic diversity in pediatric ophthalmology clinical trials from 2000 to 2022

PURPOSE

To examine the prevalence of and factors associated with racial and ethnic reporting and trends in such reporting and to assess whether categories of race and ethnicity have been under- or over-represented in pediatric ophthalmology randomized control trials (RCTs) in the United States.

METHODS

We systematically searched the literature on pediatric ophthalmology RCTs in high-impact factor ophthalmology journals published between 2000 and 2022. Logistic regression was used to assess parameters linked to race/ethnicity reporting; linear regression, to gauge the relationship between publication year and race/ethnicity reporting. The racial and ethnic composition of RCTs was contrasted with 2010 US census data by calculating percentage difference.

RESULTS

Of 170 eligible articles, 89 (52.4%) included race/ethnicity data. Multivariable analysis showed that academic (OR = 12.19; 95% CI, 3.34-44.44) and government (OR = 3.91; 95% CI, 1.20-12.72) funding was linked to data reporting. During the study period, publication year and race/ethnicity reporting had a nonstatistically significant 1.0% annual increase (r = 0.29, P = 0.18). White participants were over-represented, with a percentage difference of 16.7% (95% CI, 11.8%-21.7%), whereas Hispanic individuals were under-represented, with a percentage difference of -7.6% (95% CI, -11.2% to -4.1%) compared to the 2010 US census data.

CONCLUSIONS

Our results indicate a gradual rise in reported race and/or ethnicity in published pediatric ophthalmology RCTs, though not statistically significant, both in the United States and globally. Notably, under-representation of Hispanic, over-representation of White, and proportional representation of Black and Asian individuals were observed in US-based studies.

Racial, Ethnic, and Gender Diversity in United States Ophthalmology Clinical Trials

Purpose

To investigate the representation of various gender, racial, and ethnic groups in ophthalmology clinical trials conducted in the United States (US) between 1997 and 2022.

Design

Retrospective cross-sectional study.

Participants

We included all participants in completed phase II/III, III, and IV ophthalmology clinical trials reported on the ClincialTrials.gov database.

Methods

The proportional enrollment of each racial/ethnic and gender group in the clinical trials was calculated and compared with the US population. We also investigated the impact of various clinical trial features on the rate of reporting demographic information and enrollment of minorities.

Main Outcome Measures

Proportional enrollment of each gender and race/ethnicity group compared with the US Census.

Results

Of the total clinical trials included in the study, less than half (43.6%) provided information on the racial or ethnic backgrounds of their participants. The majority of the enrollees in trials were female (median: 57.5%, interquartile range [IQR]: 47.2%-65.8%). Among the trials that reported race and/or ethnicity data, White populations were overrepresented (median: 76.6%, IQR: 69.0%-84.0%, P = 0.001), and minorities, including Asian, Hispanic, and "other" groups, were underrepresented compared with the 2010 US Census (P < 0.001). Enrollment of Black individuals was found to be comparable to the US population estimates (median: 12.4%, IQR: 6.2%-20.8%, P = 0.44). The trial phase, the number of study participants, the primary clinical condition, and the year the trial started all affected demographic reporting and minority enrollments.

Conclusions

Our findings highlight the need for increased efforts to promote diversity and inclusivity in ophthalmology clinical trials. Ensuring equitable inclusion of different gender, racial, and ethnic groups in the trials is essential for minimizing disparities and producing unbiased scientific findings generalizable to the entire population.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Racial and Ethnic Distribution in Diabetic Macular Edema Clinical Trials in the United States (2002-2021)

PURPOSE

Diabetic macular edema (DME), the leading cause of vision loss among patients with diabetes mellitus, disproportionately affects Black and Hispanic patients. Currently, non-White racial and ethnic subgroups are frequently underrepresented in clinical trials, limiting the application of results to the most pertinent patient populations. Thus, we aimed to characterize the trajectory of racial reporting as well as changes and disparities in racial and ethnic distribution among participants of DME clinical trials.

DESIGN

This is a cross-sectional retrospective study.

SUBJECTS

Patients enrolled in United States (US)-based clinical trials for DME.

METHODS

We examined the racial and ethnic demographic distribution of participants in clinical trials related to DME across a 20-year period from 2002 to 2021. Clinical trials were screened from ClinicalTrials.gov for DME, US trial location, study completion, and > 50 patient enrollment. Descriptive statistics, proportions, odds ratios (ORs), and chi-square tests were reported and compared with 2021 US Census demographic data and diagnosed patients with diabetes demographic data.

MAIN OUTCOME MEASURES

Change in racial reporting and race/ethnicity across 2 decades and comparison of racial/ethnic distribution with 2021 US Census demographics and diagnosed patients with diabetes.

RESULTS

There was an increase in race reporting from January 2002 to December 2011 (8 trials [40%]) versus January 2012 to December 2021 (20 trials [87%]; OR, 10.00; 95% confidence interval [CI], 2.21-45.16; P = 0.0032). Across the 2 decades, the proportion of Asian patients enrolled increased from 2.4% to 8.0% (OR, 3.47; 95% CI, 2.64-4.56; P < 0.0001). Similarly, the proportion of enrolled Hispanic patients increased from 13.4% to 19.5% (OR, 1.56; 95% CI, 1.37-1.78; P < 0.0001). Compared with diabetes prevalence, many minority groups are underrepresented in the total enrollment of DME clinical trial patients (Black [z = -18.51, P < 0.001]; Asian [z = -5.11, P < 0.0001]; Hispanic [chi-square = 274.7, df = 1, P < 0.0001]).

CONCLUSIONS

In the past 2 decades, there has been a trend of increased racial reporting and minority patient enrollment in DME clinical trials. However, Black, Asian, and Hispanic patients remain significantly underrepresented among the DME clinical trial patient population based on diabetes prevalence.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ophthalmology at the Forefront of Big Data Integration in Medicine: Insights from the IRIS Registry Database

Ophthalmology stands at the vanguard of incorporating big data into medicine, as exemplified by the integration of The Intelligent Research in Sight (IRIS) Registry. This synergy cultivates patient-centered care, demonstrates real world efficacy and safety data for new therapies, and facilitates comprehensive population health insights. By evaluating the creation and utilization of the world's largest specialty clinical data registry, we underscore the transformative capacity of data-driven medical paradigms, current shortcomings, and future directions. We aim to provide a scaffold for other specialties to adopt big data integration into medicine.

Diversity, equity and inclusion in ophthalmology

PURPOSE OF REVIEW

Diversity, equity and inclusion (DEI) initiatives in ophthalmology have received increased attention in recent years. This review will highlight disparities, barriers to workforce diversity, as well as current and future efforts to improve DEI in ophthalmology.

RECENT FINDINGS

Racial, ethnic, socioeconomic and sex disparities exist in vision health and across many ophthalmology subspecialties. The pervasive disparities result from factors such as a lack of access to eye care. In addition, ophthalmology is one of the least diverse specialties at the resident and faculty level. The lack of diversity has also been documented in ophthalmology clinical trials, wherein participant demographics do not reflect the diversity of the U.S. population.

SUMMARY

Addressing social determinants of health including racism and discrimination is necessary to promote equity in vision health. Diversifying the workforce and expanding the representation of marginalized groups in clinical research are also paramount. Supporting existing programmes and creating new ones focusing on improving workforce diversity and reducing eye care disparities are essential to ensure equity in vision health for all Americans.

Demographic and Socioeconomic Factors in Prospective Retina-Focused Clinical Trial Screening and Enrollment

Historically marginalized populations are disproportionately affected by many diseases that commonly affect the retina, yet they have been traditionally underrepresented in prospective clinical trials. This study explores whether this disparity affects the clinical trial enrollment process in the retina field and aims to inform future trial recruitment and enrollment. Age, gender, race, ethnicity, preferred language, insurance status, social security number (SSN) status, and median household income (estimated using street address and zip code) for patients referred to at least one prospective, retina-focused clinical trial at a large, urban, retina-based practice were retrospectively extracted using electronic medical records. Data were collected for the 12-month period from 1 January 2022, through 31 December 2022. Recruitment status was categorized as Enrolled, Declined, Communication (defined as patients who were not contacted, were contacted with no response, were waiting for a follow-up, or were scheduled for screening following a clinical trial referral.), and Did Not Qualify (DNQ). Univariable and multivariable analyses were used to determine significant relationships between the Enrolled and Declined groups. Among the 1477 patients, the mean age was 68.5 years old, 647 (43.9%) were male, 900 (61.7%) were White, 139 (9.5%) were Black, and 275 (18.7%) were Hispanic. The distribution of recruitment status was: 635 (43.0%) Enrolled, 232 (15.7%) Declined, 290 (19.6%) Communication, and 320 (21.7%) DNQ. In comparing socioeconomic factors between the Enrolled and Declined groups, significant odds ratios were observed for age (p < 0.02, odds ratio (OR) = 0.98, 95% confidence interval (CI) [0.97, 1.00]), and between patients who preferred English versus Spanish (p = 0.004, OR = 0.35, 95% CI [0.17, 0.72]. Significant differences between the Enrolled and Declined groups were also observed for age (p < 0.05), ethnicity (p = 0.01), preferred language (p < 0.05), insurance status (p = 0.001), and SSN status (p < 0.001). These factors may contribute to patient participation in retina-focused clinical trials. An awareness of these demographic and socioeconomic disparities may be valuable to consider when attempting to make clinical trial enrollment an equitable process for all patients, and strategies may be useful to help address these challenges.

Racial Disparities in Barriers to Care for Patients With Diabetic Retinopathy in a Nationwide Cohort

Purpose

To ascertain specific barriers of care among patients with diabetic retinopathy (DR) from different racial/ethnic groups.

Methods

In this cross-sectional study, we included adult participants in the National Institutes of Health All of Us Research Program with DR who answered questions in the Healthcare Access & Utilization survey and Social Determinants of Health (SDoH) survey. Logistic regression was used to study the association between barriers to care and race/ethnicity.

Results

Our cohort included 885 DR patients who answered the Healthcare Access & Utilization survey and 385 DR patients who responded to the SDoH survey. After adjusting for confounders, Hispanic individuals were more likely than non-Hispanic White individuals to report delaying getting medical care due to not being able to get child care (odds ratio [OR] = 6.57 [95% confidence interval {CI}, 1.67-27.8]). Furthermore, compared to non-Hispanic White individuals, non-Hispanic Black individuals were significantly more likely to report being treated with less respect (OR = 2.62 [95% CI, 1.15-5.80]), treated with less courtesy (OR = 2.51 [95% CI, 1.01-5.92]), and receive poorer service than other people (OR = 2.85 [95% CI, 1.25-6.34]) when they go to a doctor's office or other healthcare provider.

Conclusions

We found that Hispanic and non-Hispanic Black individuals with DR reported greater delays/barriers to care compared to non-Hispanic White individuals even after controlling for individualized socioeconomic factors.

Translational Relevance

This study highlights the importance of taking steps to promote health equity, such as increasing access to child care resources and reducing implicit bias among eye care providers, to increase access to care and prevent vision loss from DR.