Addressing Social Determinants of Vision Health

Health disparities in ocular oncology

Social determinants of health (SDH) play a crucial role in shaping health outcomes, including those in ophthalmology. Only a few studies have explored the impact of SDH in ocular oncology, looking at differences in disease presentation, treatment choices, and outcomes based on race, ethnicity, socioeconomic status (SES), and insurance status. Specifically, retinoblastoma exhibits disparities in survival rates, with lower-income countries experiencing substantially lower survival rates compared to high-income countries. Similarly, racial and SES disparities exist in the United States, impacting treatment choices and outcomes in children with retinoblastoma. Disparities in treatment modalities based on race and SES have been reported in uveal melanoma, with non-White and economically disadvantaged patients more likely to undergo primary enucleation. Ocular surface squamous neoplasia (OSSN) also exhibits racial and socioeconomic disparities in treatment outcomes. Black patients with OSSN face higher mortality risks, independent of tumor size, eye laterality, or tumor behavior. Given the rarity of the disease, currently, there is no data on disparities in the management of vitreoretinal lymphoma. When looking at data on primary central nervous system lymphoma as a surrogate of vitreoretinal lymphoma, management and survival outcomes vary based on factors such as race, socioeconomic status, and insurance status. This article aims to review the current literature on disparities in ocular oncology, highlighting the need for more granular data to better understand and bridge the existing gaps in care within ocular oncology.

The Sleep Health of Individuals with Visual Impairments: A Scoping Review

PURPOSE

Amidst the global aging population and an increasing prevalence of visual impairment across all age groups, this study aims to investigate the current state of research on sleep health in visually impaired populations.

METHODS

A scoping review was conducted to synthesize the existing literature on sleep health and visual impairment. We employed conceptual mapping to identify key research topics, analyzing data from four databases: PubMed (n = 290), CINAHL (n = 81), Scopus (n = 117), and PsycInfo (n = 96). A total of 83 peer-reviewed articles, published from 1977 to August 2023, were included in the review.

RESULTS

Our analysis identified 11 distinct eye health conditions including blindness, glaucoma, diabetic retinopathy, low vision, cataract, retinitis pigmentosa, macular degeneration, optic neuropathy, visual field defects, ocular hypertension, and retinal vein occlusion. Additionally, 8 major sleep problems were recognized: abnormal sleep duration, daytime sleepiness, insomnia, Non-24-Hour Sleep Wake Disorder, sleep apnea, sleep disorders, sleep disturbances, and sleep disordered breathing. The dominant research themes were (1) poor sleep quality in individuals with visual impairments and ophthalmic diseases, (2) high prevalence of sleep issues in patients with ophthalmic diseases, (3) sleep apnea in patients with ophthalmic conditions, and (4) circadian rhythm disruptions in blind individuals.

CONCLUSION

This review highlights research gaps that, when addressed, could greatly enhance our comprehension of the interplay between visual impairment and sleep health. Bridging these gaps promises to lead to more holistic care strategies, potentially improving vision functioning and rehabilitation outcomes for individuals with visual impairments.

Place-Based Measures of Inequity and Vision Difficulty and Blindness

Importance

Known social risk factors associated with poor visual and systemic health in the US include segregation, income inequality, and persistent poverty.

Objective

To investigate the association of vision difficulty, including blindness, in neighborhoods with measures of inequity (Theil H index, Gini index, and persistent poverty).

Design, Setting, and Participants

This cross-sectional study used data from the 2012-2016 American Community Survey and 2010 US census tracts as well as Theil H index, Gini index, and persistent poverty measures from PolicyMap. Data analysis was completed in July 2023.

Main Outcomes and Measures

The main outcome was the number of census tract residents reporting vision difficulty and blindness (VDB) and the association with the Theil H index, Gini index, or persistent poverty, assessed using logistic regression.

Results

In total, 73 198 census tracts were analyzed. For every 0.1-unit increase in Theil H index and Gini index, there was an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size (Theil H index: odds ratio [OR], 1.14 [95% CI, 1.14-1.14; P < .001]; Gini index: OR, 1.15 [95% CI, 1.15-1.15; P < .001]). Persistent poverty was associated with an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size compared with nonpersistent poverty (OR, 1.36; 95% CI, 1.35-1.36; P < .001).

Conclusions and Relevance

In this cross-sectional study, residential measures of inequity through segregation, income inequality, or persistent poverty were associated with a greater number of residents living with VDB. It is essential to understand and address how neighborhood characteristics can impact rates of VDB.

Sociodemographic and Visual Outcomes of Juvenile Idiopathic Arthritis Uveitis: IRIS® Registry Study

Purpose

Understanding sociodemographic factors associated with poor visual outcomes in children with juvenile idiopathic arthritis-associated uveitis may help inform practice patterns.

Patients and Methods

Retrospective cohort study on patients <18 years old who were diagnosed with both juvenile idiopathic arthritis and uveitis based on International Classification of Diseases tenth edition codes in the Intelligent Research in Sight Registry through December 2020. Surgical history was extracted using current procedural terminology codes. The primary outcome was incidence of blindness (20/200 or worse) in at least one eye in association with sociodemographic factors. Secondary outcomes included cataract and glaucoma surgery following uveitis diagnosis. Hazard ratios were calculated using multivariable-adjusted Cox proportional hazards models.

Results

Median age of juvenile idiopathic arthritis-associated uveitis diagnosis was 11 (Interquartile Range: 8 to 15). In the Cox models adjusting for sociodemographic and insurance factors, the hazard ratios of best corrected visual acuity 20/200 or worse were higher in males compared to females (HR 2.15; 95% CI: 1.45-3.18), in Black or African American patients compared to White patients (2.54; 1.44-4.48), and in Medicaid-insured patients compared to commercially-insured patients (2.23; 1.48-3.37).

Conclusion

Sociodemographic factors and insurance coverage were associated with varying levels of risk for poor visual outcomes in children with juvenile idiopathic arthritis-associated uveitis.

Barriers to Care Among Glaucoma Patients With a Missed Appointment and Interest in a Navigator Program

PRCIS

Most glaucoma patients with missed appointments report barriers to care and social risk factors. One third expressed interest in engaging with a patient navigator program. Most expressed interest in rescheduling.

PURPOSE

The purpose of this study was to identify barriers to care among glaucoma patients with missed appointments and to assess their interest in a patient navigator program.

MATERIAL AND METHODS

A cross-sectional study involving adult glaucoma patients from an academic eye center who missed their scheduled appointment between April 18 and July 25, 2022. Participants were surveyed about reasons for missed appointments, barriers to care, social risk factors, and interest in consulting with our patient navigator program.

RESULTS

Of 172 patients with a missed glaucoma appointment, 73% (126/172) were contacted, and 40% (51/126) of those completed the survey. Participant age averaged 67±14 years, half were female (25/51, 49%), and most identified as Black (27/51, 53%) or White (21/51, 40%). Barriers to seeing a doctor including difficulty scheduling appointments (13/51, 26%), transportation (12/51, 24%), and cost or insurance barriers (8/51, 16%). Twenty-eight (55%) respondents reported at least one social risk factor. A positive association was found between having at least one risk factor and expressing interest in consulting our patient navigator (odds ratio=6.7, P =0.009). Overall, a third of respondents expressed interest in engaging with our patient navigator program (17/51, 33%). Two thirds of participants reported awareness of missed appointments (34/51, 67%), of whom 35% (12/34) reported having already rescheduled, 41% (14/34) expressed interest in rescheduling, and 24% (8/34) did not wish to return.

CONCLUSIONS

Glaucoma patients with missed appointments report barriers to care and face social risk factors. Telephone outreach may help to re-engage them with care, and patients expressed interest in a patient navigator program to address social needs.

Treatment rate of strabismus and amblyopia is associated with the location of pediatric ophthalmologists in the United States

PURPOSE

To determine whether the geographic density of pediatric ophthalmologists is associated with the rate of children treated for strabismus and amblyopia.

METHODS

This cross-sectional study included children treated for strabismus and amblyopia 0-17 years of age with commercial insurance who were included in the Vision and Eye Health Surveillance System. Additionally, pediatric ophthalmologists by state were determined using the American Association for Pediatric Ophthalmology and Strabismus website. Unadjusted linear regression was used to compare the geographic density of pediatric ophthalmologists and the rate of children treated for strabismus and amblyopia by state in 2016. This was repeated using multivariable linear regression, controlling for race, poverty, non-English-speaking children, and insurance coverage for children by state.

RESULTS

New York and Mississippi had the highest and lowest rates of treatment of strabismus and amblyopia, with 3.97 and 0.83 children treated per 100 children, respectively. The geographic density of pediatric ophthalmologists was associated with the rate of children treated for strabismus and amblyopia in unadjusted analyses (β = 0.62, P < 0.001). Further, the geographic density of pediatric ophthalmologists was associated with the rate of children treated for strabismus and amblyopia in adjusted analyses (β = 0.61, P < 0.001).

CONCLUSIONS

The geographic density of pediatric ophthalmologists by state was positively associated with the rate of children treated for strabismus and amblyopia.

Significance of Social Determinants of Health in Tumor Presentation, Hospital Readmission, and Overall Survival in Ocular Oncology

PURPOSE

To evaluate the association between social determinants of health (SDH) with presentation and outcomes in patients with ocular cancer.

METHODS

The National Cancer Database was queried for primary clinical tumor (cT) classifications of T1 to T4 N0M0 uveal melanoma, conjunctival melanoma, or retinoblastoma diagnosed between January 2006 and December 2017. Pearson χ2 analysis assessed differences in SDH-related characteristics between cancer cohorts. Binary logistic regression with adjusted odds ratios (aORs) and multivariate Cox proportional hazards ratios (HRs) with 95% confidence intervals (CIs) were performed.

DESIGN

Cross-sectional with a nationally representative sample.

RESULTS

Three thousand nine hundred sixty-eight uveal melanoma cases, 352 conjunctival melanoma cases, and 480 retinoblastoma cases were included. Differences in race, primary payer status, income quartile, population density, facility location, Charlson-Deyo comorbidity score, history of malignancy, cT classification at presentation, surgical treatment, radiotherapy, chemotherapy, 30-day readmission, and overall survival (OS) were observed among the cancers. Female sex (aOR 0.819 [95% CI 0.689-0.973]) and top income quartile (aOR 0.691 [95% CI 0.525-0.908]) had decreased likelihood of advanced cT classification at presentation. No insurance (aOR 1.736 [95% CI 1.159-2.601]) and Medicaid primary payer status (aOR 1.875 [95% CI 1.323-2.656]) had increased likelihood of advanced cT classification. Patients in rural areas (aOR 7.157 [95% CI 1.875-27.320]) were more likely to be readmitted within 30 days after initial treatment. Increased age was associated with decreased 5-year OS (HR 1.040 [95% CI 1.033-1.047]).

CONCLUSIONS

SDH may influence advanced cT classification at presentation and 30-day readmission compared with OS in patients with ocular cancer, highlighting the need for ophthalmologists and public health efforts to address disparities in SDH.

Social Risk Groups in Patients With Diabetes With Differing Eye Care Utilization and Vision Outcomes

Purpose

To evaluate whether latent class analysis on social determinants of health (SDoH) data can identify social risk groups that differ by adverse SDoH and vision outcomes in patients with diabetes.

Methods

This was a prospective cohort study of adults ≥18 years with diabetes who completed a SDoH survey. Latent class analysis was used to cluster patients into social risk groups. The association of social risk group and severity of diabetic retinopathy, history of lapses in diabetic retinopathy care, and visual acuity was evaluated.

Results

A total of 1006 participants were included. The three social risk groups differed by sociodemographic characteristics. The average age was 65, 60, and 54 in Groups 1, 2, and 3 respectively. Most (51%) patients in group 1 were non-Hispanic White, 66% in group 2 were non-Hispanic Black, and 80% in group 3 were Hispanic. Group 1 had the lowest burden of adverse SDoH per person (average 3.6), group 2 had 8.2, and group 3 had 10.5. In general, group 1 lacked diabetic retinopathy knowledge, group 2 had financial insecurity and difficulties with transportation, and group 3 had financial insecurity and did not have health insurance. Social risk group was associated with a history of lapses in diabetic retinopathy care, and presenting with worse vision.

Conclusions and Translational Relevance

We identified distinct social risk groups among patients seeking care for diabetic retinopathy that differed by social needs, eye care utilization, and vision. Identifying these groups and their specific needs can help guide interventions to effectively address adverse SDoH and improve eye care utilization and vision outcomes among patients with diabetes.

Knowledge about age-related eye diseases in the general population in Germany

BACKGROUND

With a rising prevalence of age-related eye diseases, prevention and early diagnosis of these conditions are key goals of public eye health. Disease-related knowledge in the general public supports these goals but there is little data available. Thus, we have assessed knowledge of cataract, glaucoma, age-related macular degeneration (AMD) and diabetic eye disease in the German adult general population in a cross-sectional study and identified target groups for health education interventions.

METHODS

Knowledge assessment content was identified based on a literature review, expert input, and a list of items was generated after a qualitative selection process. The resulting 16-item instrument (4 items per condition) was administered to 1,008 participants from a survey panel, demographically representative of the adult German population. Test properties were evaluated based on a Rasch model and multiple correspondence analysis (MCA). Binary-logistic regression analysis was performed to investigate associations with age, sex, education level, employment status, marital status, income, reported health status, visual difficulties, and recent general practitioner (GP) and ophthalmologist consultations.

RESULTS

Replies were correct for a median of 9 out of 16 (range 2 - 16) items, which differed between conditions (p < 0.0001). Most responses were correct for cataract items (median: 3 / 4) and least were correct for AMD items (median: 2 / 4). 27%, 9%, 1% and 19% of respondents replied correctly to all cataract, glaucoma, AMD and diabetic eye disease-related items, respectively. Rasch analysis suggested an adequate targeting of items and in MCA, no evidence of multidimensionality was present. Older age, being retired, decreased general health and recent GP or ophthalmology consultations were significantly associated with more knowledge about common eye conditions (p ≤ 0.005). GP or ophthalmology consultations remained significant in a multivariable model (p ≤ 0.011).

CONCLUSIONS

Knowledge gaps regarding eye health are considerable in the German general population and should therefore be addressed in educational interventions targeting the public. Special attention when designing such campaigns needs to be paid to infrequent users of the healthcare system. Knowledge of AMD seems to be poorer compared to other eye conditions.

Sex or Gender Reporting in Ophthalmology Clinical Trials Among US Food and Drug Administration Approvals, 1995 to 2022

Importance

As critical determinants of scientific rigor, reproducibility, and equity, sex and gender should be considered in clinical trial design and reporting.

Objective

To evaluate the accuracy of sex and gender reporting and extent of sex- and gender-based analysis in clinical trials associated with US Food and Drug Administration (FDA) drug approvals between January 1, 1995, and December 31, 2022.

Design, Setting, and Participants

In this cross-sectional study of participants enrolled in FDA ophthalmology trials, the following trial documents were reviewed by pairs of independent reviewers in decreasing order of priority: peer-reviewed publication, ClinicalTrials.gov report, and FDA medical and statistical reviews. Trial protocols and supplementary materials were also reviewed.

Main Outcome and Measures

The proportion of trials that correctly applied sex and gender terminology, reported the method of assessing sex or gender, and conducted sex- or gender-based data analysis; incorrect application of sex and gender terminology was defined as interchangeable use of sex- and gender-related terms without a clear justification.

Results

Between 1995 and 2022, 34 ophthalmic drugs corresponding to 85 trials (34 740 participants) received FDA approval, of which 16 drugs (47.1%) corresponding to 32 trials (18 535 participants [37.6%]) were associated with peer-reviewed publications. Sixteen trials used sex and gender terminology correctly (19.5%). No trial reported how sex and gender were collected nor enrolled participants from sexual and gender identity minority populations. Most trials reported sex- and gender-disaggregated demographic data (96.5%), but few conducted sex- or gender-based analysis for data on dropout (1.2%), primary outcomes (28.2%), secondary outcomes (2.4%), and adverse events (9.4%). Erroneous sex and gender reporting was associated with later publication year (2008.5 vs 2001.0; median difference, 7.5; 95% CI, -6.0 to 11.0; P < .001) and higher journal influence metrics, including 2022 journal impact factor (13.7 vs 5.9; median difference, 7.8; 95% CI, -1.4 to 152.4, P < .001) and 2022 journal citation indicator (4.9 vs 2.1; median difference, 2.9; 95% CI, 0-20.0, P < .001).

Conclusions and Relevance

In this observational study, over three-quarters of ophthalmology trials associated with FDA drug approvals conflated sex and gender and over two-thirds lacked sex- and gender-based analyses. More rigorous integration of sex and gender appears warranted for FDA, and presumably other trials, to improve their validity, reproducibility, and equity.

Spatial Vision Inequalities: A Literature Review of the Impact of Place on Vision and Eye Health Outcomes

"Neighborhood and built environment" is one of the five domains of social determinants of health that has been outlined by Healthy People 2030, and this domain impacts an individual's well-being, health, and quality of life. Social risk factors (SRFs) in the neighborhood and built environment domain include unstable or unsafe housing, poor access to transportation, lack of green spaces, pollution, safety concerns, and neighborhood measures of inequity. In this narrative literature review, we assess the relationship between neighborhood and built environment SRFs and eye health and vision outcomes. We explain how mapping neighborhood-level SRFs may be used to advance health equity in the field of eye health and vision care.

Predictors of Clinic Attendance After Community-Based Vision Screening

Purpose

The purpose of this study was to analyze appointment attendance rates and patient characteristics associated with follow-up adherence after referral from a community vision screening event.

Methods

A retrospective chart review of patients who attended a 2021 or 2022 community vision screening event and were referred to the university clinic for further care. Appointments were offered without charge and scheduled at the event. Associations between patients' clinical and demographic characteristics and appointment attendance were assessed by binary logistical regression.

Results

A total of 935 patients attended the annual community vision screening events held in 2021 and 2022. Of these patients, 117 (13%) were referred to the clinic for follow-up, of whom 56 (48%) attended their scheduled follow-up appointment. The most common reasons for clinic referral included cataract (12, 10%), diabetic retinopathy (11, 9%), glaucoma (9, 8%), and challenging refractive error (9, 8%). Health insurance and male gender were predictors of follow-up (odds ratio [OR] = 3.08, 95% confidence interval [CI] = 1.19-7.99, P = 0.021 and OR = 2.72, 95% CI = 1.10-6.61, P = 0.035, respectively).

Conclusions

Half of the referred patients followed up after vision screening. Providing appointment scheduling at the point of care and offering follow-up care at no cost may help to promote clinic follow-up, but further assessment of barriers to regular eye care is warranted. Health insurance most strongly predicted successful clinic attendance.

Translational Relevance

This study emphasizes the enduring impact of health insurance status as a barrier to accessing comprehensive vision care.

Association Between Sociodemographic Factors and Vision Difficulty in the National Health Interview Survey: A Population-Based Analysis

PURPOSE

To investigate the relationship between social determinants of health with self-reported vision difficulty.

DESIGN

Cross-sectional, population-based analysis.

METHODS

The National Health Interview Survey (NHIS) is an annual survey based on the U.S. population ≥18 years of age. It provides self-reported data on demographic characteristics, socioeconomic factors, health status, and health care access. The 2021 NHIS database was used in this study. Adult participants of the NHIS who responded to the vision difficulty question "Do you have difficulty seeing, even when wearing glasses or contact lenses?" were included in this analysis. The outcome of interest was self-reported vision difficulty by participants. Analysis was done through univariable and multivariable logistic regression.

RESULTS

Overall, there were 29,464 participants included in the analysis. Univariable logistic regression showed an increased odds of self-reported vision difficulty among female (odds ratio [OR] 1.28 [95% confidence interval {CI} 1.20-1.38]; P < .001), gay, lesbian, or bisexual participants (OR 1.24 [95% CI 1.04-1.49]; P = .02), those who possessed public compared with private insurance (OR 1.83 [95% CI 1.69-1.99]; P < .001), those with less than a high school education (OR 1.88 [95% CI 1.67-2.13]; P < .001), and those with an income below the poverty threshold (OR 2.22 [95% CI 1.96-2.51]; P < .001). Multivariable analysis revealed an increased risk of vision difficulty reported amongst non-Hispanic Black participants (OR 1.65 [95% CI 1.21-2.25]; P = .002).

CONCLUSIONS

A multitude of sociodemographic factors are associated with self-reported vision difficulty in the U.S.

POPULATION

Our findings emphasize the importance of considering factors of social determinants of health in clinical practice and policymaking for patients with vision loss.

Social Determinants of Health in Pediatric Ophthalmology Patients: Availability of Data in the Electronic Health Record and Association With Clinic Attendance

Purpose

To characterize the availability of social determinants of health data in the electronic health record of pediatric ophthalmology patients and to examine the association of social determinants of health with attendance at scheduled operating room and clinic visits.

Methods

This was a retrospective cohort study of pediatric ophthalmology patients seen at The Hospital for Sick Children between June 1, 2018, and May 23, 2022. Data were collected on demographics, diagnosis, and management-plan. The χ2 tests and multivariable regression were used to examine associations between social determinants of health and attendance at scheduled operating room and clinic visits.

Results

The cohort consisted of 26,102 study subjects with 31,288 unique eye-related diagnoses representing 57 unique ICD-10 codes. Availability of data in the electronic health record ranged from 100% for sex, age and postal code to 0.1% for ethnic group. Female sex (P = 0.004) and urbanicity (P = 0.05) were associated with higher operating room visit cancellations. Female sex (P = 0.002), age group 0-13 (P ≤ 0.001), low-medium neighborhood income quintile (P ≤ 0.001), residence of Northern Ontario (P ≤ 0.001), and urbanicity (P ≤ 0.001) were associated with higher clinic visit cancellations and no-shows.

Conclusions

At a major tertiary-care hospital in Canada, key social determinant data such as ethnicity are not consistently available in the electronic health record of pediatric ophthalmology patients. Female sex, younger age, and living in a rural area or neighborhood with low-medium income quintile may be predictors of missed visits and require further study.

Translational Relevance

This study highlights a need for improved documentation of social determinants of health variables in electronic health records.

Barriers and Facilitators to Ophthalmology Visit Adherence in an Urban Hospital Setting

Purpose

To explore barriers and facilitators to completing scheduled outpatient appointments at an urban academic hospital-based ophthalmology department.

Methods

Potential participants were stratified by neighborhood Social Vulnerability Index (SVI) (range, 0-1.0, higher scores indicate greater vulnerability), and semistructured interviews were conducted with individuals 18 years and older with an SVI of greater than 0.61 (n = 17) and providers delivering care in the General Eye Clinic of the University of Illinois Chicago (n = 8). Qualitative analysis informed by human-centered design methods was conducted to classify barriers and facilitators into three domains of the Consolidated Framework for Implementation Research: outer setting, inner setting, and characteristics of individuals.

Results

There were four main themes-transportation, time burden, social support, and economic situation-all of which were within the outer setting of the Consolidated Framework for Implementation Research; transportation was most salient. Although providers perceived health literacy as a barrier affecting motivation, patients expressed a high motivation to attend visits and felt well-educated about their condition.

Conclusions

A lack of resources outside of the health system presents significant barriers for patients from neighborhoods with high SVI. Future efforts to improve adherence should focus on resource-related interventions in the outer setting. Improving access to eye care will require community-level interventions, particularly transportation.

Translational Relevance

Understanding the barriers and facilitators within the Consolidated Framework for Implementation Research provides useful guidance for future interventions, specifically to focus future efforts to improve adherence on resource-related interventions.

The Impact of Social Determinants of Health on Eye Care Utilization in a National Sample of People with Diabetes

PURPOSE

To evaluate the association of social determinants of health (SDoH) with eye care utilization among people with diabetes mellitus using the 2013-2017 National Health Interview Survey (NHIS).

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Participants ≥ 18 years of age with self-reported diabetes.

METHODS

The SDoH in the following domains were used: (1) economic stability; (2) neighborhood, physical environment, and social cohesion; (3) community and social context; (4) food environment; (5) education; and (6) health care system. An aggregate SDoH score was calculated and divided into quartiles, with Q4 representing those with the highest adverse SDoH burden. Survey-weighted multivariable logistic regression models evaluated the association of SDoH quartile with eye care utilization in the preceding 12 months. A linear trend test was conducted. Domain-specific mean SDoH scores were calculated, and the performance of domain-specific models was compared using area under the curve (AUC).

MAIN OUTCOME MEASURE

Eye care utilization in the preceding 12 months.

RESULTS

Of 20 807 adults with diabetes, 43% had not used eye care. Greater adverse SDoH burden was associated with decrements in odds of eye care utilization (P < 0.001 for trend). Participants in the highest quartile of adverse SDoH burden (Q4) had a 58% lower odds (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.37-0.47) of eye care utilization than those in Q1. The domain-specific model using economic stability had the highest performing AUC (0.63; 95% CI, 0.62-0.64).

CONCLUSIONS

Among a national sample of people with diabetes, adverse SDoH were associated with decreased eye care utilization. Evaluating and intervening upon the effects of adverse SDoH may be a means by which to improve eye care utilization and prevent vision loss.

FINANCIAL DISCLOSURE(S)

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

What We Learned About the Economic and Workforce Issues in Pediatric Ophthalmology: Access to Eye Care and Possible Solutions

PURPOSE

To provide a blueprint reviewing the major economic and workforce issues in pediatric ophthalmology and its effect on access to pediatric eye care, as well as potential solutions.

METHODS

This was a systematic review of the landmark studies examining the economic and workforce issues in pediatric ophthalmology was performed.

RESULTS

The number of residents pursuing pediatric ophthalmology fellowship has steadily declined since the early 2000s. Increasing overhead costs, low Medicaid reimbursements, practice pattern changes, and workforce shortages have all contributed to a significant crisis in access to pediatric eye care.

CONCLUSIONS

Solutions to improve access to pediatric eye care involve pursuing more economical strategies within the confines of the pediatric ophthalmology practice, early exposure to the field during medical education, and enhancing residents' interest through faculty mentorship. Low reimbursements are a major driver contributing to extended appointment wait times for pediatric ophthalmology visits at major academic eye centers. Legislative changes at both the federal and state levels are needed to make appropriate increases in reimbursements, starting with states in the lowest quartile of Medicaid reimbursements. [J Pediatr Ophthalmol Strabismus. 2023;60(5):323-329.].

Social Risk Factor Associations With Presenting Visual Acuity in Patients With Microbial Keratitis

Importance

Neighborhood-level social risk factors may contribute to health disparities in microbial keratitis (MK) disease presentation. Understanding neighborhood-level factors may identify areas for revised health policies to address inequities that impact eye health.

Objective

To investigate if social risk factors were associated with presenting best-corrected visual acuity (BCVA) for patients with MK.

Design, Setting, and Participants

This was a cross-sectional study of patients with a diagnosis of MK. Patients presenting to the University of Michigan with a diagnosis of MK between August 1, 2012, and February 28, 2021, were included in the study. Patient data were obtained from the University of Michigan electronic health record.

Main Outcomes and Measures

Individual-level characteristics (age, self-reported sex, self-reported race and ethnicity), presenting log of the minimum angle of resolution (logMAR) BCVA, and neighborhood-level factors, including measures on deprivation, inequity, housing burden, and transportation at the census block group, were obtained. Univariate associations of presenting BCVA (< 20/40 vs ≥20/40) with individual-level characteristics were assessed with 2-sample t, Wilcoxon, and χ2 tests. Logistic regression was used to test associations of neighborhood-level characteristics with the probability of presenting BCVA worse than 20/40 after adjustment for patient demographics.

Results

A total of 2990 patients with MK were identified and included in the study. Patients had a mean (SD) age of 48.6 (21.3) years, and 1723 were female (57.6%). Patients self-identified with the following race and ethnicity categories: 132 Asian (4.5%), 228 Black (7.8%), 99 Hispanic (3.5%), 2763 non-Hispanic (96.5%), 2463 White (84.4%), and 95 other (3.3%; included any race not previously listed). Presenting BCVA had a median (IQR) value of 0.40 (0.10-1.48) logMAR units (Snellen equivalent, 20/50 [20/25-20/600]), and 1508 of 2798 patients (53.9%) presented with BCVA worse than 20/40. Patients presenting with logMAR BCVA less than 20/40 were older than those who presented with 20/40 or higher (mean difference, 14.7 years; 95% CI, 13.3-16.1; P < .001). Furthermore, a larger percentage of male vs female sex patients presented with logMAR BCVA less than 20/40 (difference, 5.2%; 95% CI, 1.5-8.9; P = .04), as well as Black race (difference, 25.7%; 95% CI, 15.0%-36.5%;P < .001) and White race (difference, 22.6%; 95% CI, 13.9%-31.3%; P < .001) vs Asian race, and non-Hispanic vs Hispanic ethnicity (difference, 14.6%; 95% CI, 4.5%-24.8%; P = .04). After adjusting for age, self-reported sex, and self-reported race and ethnicity, worse Area Deprivation Index (odds ratio [OR], 1.30 per 10-unit increase; 95% CI, 1.25-1.35; P < .001), increased segregation (OR, 1.44 per 0.1-unit increase in Theil H index; 95% CI, 1.30-1.61; P < .001), higher percentage of households with no car (OR, 1.25 per 1 percentage point increase; 95% CI, 1.12-1.40; P = .001), and lower average number of cars per household (OR, 1.56 per 1 less car; 95% CI, 1.21-2.02; P = .003) were associated with increased odds of presenting BCVA worse than 20/40.

Conclusion and Relevance

Findings of this cross-sectional study suggest that in a sample of patients with MK, patient characteristics and where they live were associated with disease severity at presentation. These findings may inform future research on social risk factors and patients with MK.

Association of Gaps in Health Insurance Coverage With Unmet Needs for Vision Care Among Adults in Ohio

Importance

Access to vision care is vital to diagnose and treat vision impairment and diseases. Previous studies found that currently uninsured adults have limited access to vision care. It is unclear whether a recent history (past 12 months) of gaps in insurance coverage likewise adversely affects access to vision care.

Objective

To determine whether gaps in insurance coverage within the past 12 months are associated with higher risk of unmet needs for vision care among adults in Ohio.

Design, Setting, and Participants

This cross-sectional study analyzed data for adults in Ohio from the 2021 Ohio Medicaid Assessment Survey (OMAS), which is conducted via web, telephone, and mail. Participants were residents 19 years or older who reported needing vision care or eyeglasses within the past 12 months.

Exposures

Insurance coverage over the past 12 months, classified as continuous private, continuous public, gap in coverage, or year-round uninsured.

Main Outcomes and Measure

Self-reported unmet need for vision care over the past 12 months.

Results

Based on a sample of 19 036 participants, we calculated that 4% of adults experienced recent coverage gaps (weighted total in the population, 180 259 of 4 518 841) while another 4% were year-round uninsured (187 552 adults). Unmet needs for vision care were reported by 13% (590 015 adults). On multivariable logistic regression, adults with gaps in coverage were at a higher risk of unmet vision care needs compared with adults who had continuous private coverage (odds ratio [OR], 2.9; 95% CI, 2.1-3.9; P < .001) or continuous public coverage (OR, 1.7; 95% CI, 1.3-2.4; P = .001).

Conclusions and Relevance

This study found that gaps in health insurance coverage were associated with increased risk of unmet vision care needs among adults in Ohio compared with continuous private or public coverage. Policies that protect the continuity of health insurance coverage may help reduce the rate of unmet needs for vision care.

Factors Associated with Annual Vision Screening in Diabetic Adults: Analysis of the 2019 National Health Interview Survey

Purpose

To determine the association(s) between receiving an annual eye exam and various economic, social, and geographic factors assessed in the 2019 National Health Interview Survey (NHIS) among adults with diabetes.

Patients and Methods

Data from adults 18 years of age and older relevant to self-reported non-gestational diabetes diagnosis and eye exam within the last 12 months were extracted from the 2019 NHIS dataset. A multivariate logistic regression model was used to determine associations between receiving an eye exam in the preceding 12 months and various economic, insurance-related, geographic, and social factors. Outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI).

Results

Among diabetic adults in the US, receiving an eye exam within the last 12 months was significantly associated with female sex (OR 1.29; 95% CI 1.05-1.58), residence in the Midwestern United States (OR 1.39; 95% CI 1.01-1.92), use of Veteran's Health Administration healthcare (OR 2.15; 95% CI 1.34-3.44), having a usual place to go for healthcare (OR 3.89; 95% CI 2.16-7.01), and the use of Private, Medicare Advantage, or other insurance (OR 3.66; 95% CI 2.42-5.53), use of Medicare only excluding Medicare Advantage (OR 3.18; 95% CI 1.95-5.30), dual eligibility for Medicare and Medicaid (OR 3.88; 95% CI 2.21-6.79), and use of Medicaid and other public health insurance (OR 3.04; 95% CI 1.89-4.88) compared to those without insurance. An educational attainment of less than high school (OR 0.66; 95% CI 0.48-0.92), and an educational attainment of high school or GED without any college (OR 0.62; 95% CI 0.47-0.81) reduced the odds of having an annual eye exam.

Conclusion

Economic, social, and geographic factors are associated with diabetic adults receiving an annual eye exam.

Effect of a Patient Navigator Program to Address Barriers to Eye Care at an Academic Ophthalmology Practice

Purpose  The aim of this study was to determine whether a patient navigator program can address patient-reported barriers to eye care and to understand patient perceptions of a patient navigator program in ophthalmology. Design  This is a retrospective cohort study and cross-sectional patient survey. Subjects and Methods  A cohort of patients was recruited from a single academic ophthalmology department in the Mid-Atlantic region. Patients included in the study had received referral to the patient navigator program in the first quarter of 2022. Our patient navigator program provided patients with resources to address barriers to care such as transportation and financial assistance. Outcomes of the study included indications for referral, case resolution rate, and patient satisfaction. Results  In total, 130 referrals for 125 adult patients were included. The mean ± standard deviation age was 59 ± 17 years, 54 (44%) were male, 77 were white (62%), and 17 patients (14%) were uninsured. Common reasons for referral were transportation (52, 40%), insurance (34, 26%), and financial assistance (18, 14%). Among the 130 cases referred, 127 (98%) received an intervention from the patient navigator, who was able to resolve the referring issue in 90% of cases (117/130). Among 113 patients contacted for a follow-up telephone survey, 56 (50%) responded. Patients rated the program highly at a mean Likert rating of 4.87 out of 5. Moreover, 72% (31/43) of respondents stated their interactions with the patient navigator assisted them with taking care of their eyes. Conclusions  A patient navigator program can address barriers to eye care by connecting patients with community resources.