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Williams AM, Wasser LM, Cassidy J, Lin HHS. Loss to Follow Up Among Glaucoma Patients: An IRIS® Registry (Intelligent Research in Sight) Retrospective Cohort Analysis. Semin Ophthalmol 2024:1-8. [PMID: 39149966 DOI: 10.1080/08820538.2024.2391826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 08/05/2024] [Accepted: 08/08/2024] [Indexed: 08/17/2024]
Abstract
PURPOSE To identify prevalence of and risk factors for loss to follow up (LTFU) among a national cohort of patients with primary open-angle glaucoma (POAG). METHODS This retrospective cohort study analyzed data from the IRIS® Registry (Intelligent Research in Sight) database from 2014 through 2019 to assess LTFU among adult patients with POAG. POAG patients with at least one clinical encounter in 2014 were included. LTFU was defined as exceeding one year without a clinical encounter during the study period. RESULTS Among 553,663 glaucoma patients, 277,019 (50%) became LTFU, of whom 184,548 (67%) never returned to care and 92,471 (33%) re-established follow-up after a lapse. Risk of LTFU was greatest among those younger than 60 years (RR = 1.38; 95% CI: 1.36-1.39) or older than 80 years (RR = 1.39; 95% CI: 1.38-1.40) compared to those in their 60s. Compared to White race, risk for LTFU was highest among Native Hawaiian/Pacific Islander (RR = 1.24; 95% CI: 1.17-1.31), Hispanic ethnicity (RR = 1.19; 95% CI: 1.18-1.20), and Black race (RR = 1.10; 95% CI: 1.09-1.11). Medicare insurance was associated with lower risk of LTFU (RR = 0.79; 95% CI: 0.78-0.79), whereas unknown/missing/no insurance was associated with greater risk (RR = 1.33; 95% CI: 1.32-1.34), compared to private insurance. Compared to mild-stage POAG, risk of LTFU was higher for moderate-stage (RR = 1.10; 95% CI: 1.08-1.13) and severe-stage disease (RR = 1.35; 95% CI: 1.32-1.38). CONCLUSION We found a 50% prevalence of LTFU among POAG patients in the IRIS Registry over a 6-year study period, with greater risk among minority groups and those with more advanced disease.
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Affiliation(s)
- Andrew M Williams
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lauren M Wasser
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Ophthalmology, Shaare Zedek Medical Center, Affiliated with the Hebrew University, Jerusalem, Israel
| | - Julie Cassidy
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Hsing-Hua Sylvia Lin
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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Ong SS, Tran D, Westlund E, Ahmed I, Russell GB, Gonzales A, Handa JT, Cai CX. Neighborhood-Level Social Determinants of Health and Presenting Characteristics for Rhegmatogenous Retinal Detachments. JAMA Ophthalmol 2024:2822171. [PMID: 39115836 PMCID: PMC11310845 DOI: 10.1001/jamaophthalmol.2024.2889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/03/2024] [Indexed: 08/11/2024]
Abstract
Importance Functional outcomes after repair of rhegmatogenous retinal detachments (RRDs) are highly dependent on baseline visual acuity and foveal status. Adverse social determinants of health (SDOH) can present barriers to timely presentation for repair and limit vision outcomes. Objective To evaluate the association between neighborhood-level SDOH with baseline severity (visual acuity and fovea status) of RRD. Design, Setting, and Participants This was a retrospective cohort study that included adult patients 18 years and older who underwent primary repair of uncomplicated RRD at the Wilmer Eye Institute from January 2008 to December 2018. Study data were analyzed from December 2023 to April 2024. Exposures The census block group of patient home addresses were matched to multiple neighborhood-level SDOH including the Area Deprivation Index (ADI), per capita income, percentage of renters, percentage of rent burden, percentage of people using a food assistance program, percentage of uninsured individuals, mode of transportation to work, distance to the nearest transit stop, total road density, National Walkability Index, Index of Medical Underservice score, and aggregate cost of medical care. Main Outcomes and Measures Odds of presenting with vision worse than 20/40 or fovea-involving RRD using multivariable logistic regression adjusting for age, sex, race and ethnicity, and insurance. Results A total of 700 patients (mean [SD] age, 57.9 [12.4] years; 432 male [61.7%]) were included. Every decile increase in ADI, indicating more socioeconomic disadvantage, was associated with an increased odds of presenting with worse visual acuity and fovea-involving RRD (odds ratio [OR], 1.14; 95% CI, 1.04-1.24; P = .004 and OR, 1.13; 95% CI, 1.04-1.22; P = .005, respectively). Each $1000 increase in per capita income was associated with lower odds of presenting with worse vision (OR, 0.99; 95% CI, 0.98-0.99; P = .001). Every 1% increase in percentage of workers who drove to work was associated with an increased odds of presenting with worse vision and fovea-involving RRD (OR, 1.02; 95% CI, 1.01-1.03; P = .005 and OR, 1.01; 95% CI, 1.00-1.03; P = .04, respectively). Conclusions and Relevance Results of this cohort study suggest that patients with a residence in neighborhoods with more socioeconomic deprivation or a higher percentage of workers who drove to work were more likely to present with more severe RRD even after accounting for multiple individual-level characteristics. These findings support consideration of public policy changes to address the barriers faced by patients residing in certain neighborhoods who seek prompt surgical intervention for RRD to reduce health disparities in RRD outcomes.
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Affiliation(s)
- Sally S. Ong
- Department of Ophthalmology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Diep Tran
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Erik Westlund
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ishrat Ahmed
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gregory B. Russell
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anthony Gonzales
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - James T. Handa
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Cindy X. Cai
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Biomedical Informatics and Data Science, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Jan C, He M, Vingrys A, Zhu Z, Stafford RS. Diagnosing glaucoma in primary eye care and the role of Artificial Intelligence applications for reducing the prevalence of undetected glaucoma in Australia. Eye (Lond) 2024; 38:2003-2013. [PMID: 38514852 PMCID: PMC11269618 DOI: 10.1038/s41433-024-03026-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/05/2024] [Accepted: 03/08/2024] [Indexed: 03/23/2024] Open
Abstract
Glaucoma is the commonest cause of irreversible blindness worldwide, with over 70% of people affected remaining undiagnosed. Early detection is crucial for halting progressive visual impairment in glaucoma patients, as there is no cure available. This narrative review aims to: identify reasons for the significant under-diagnosis of glaucoma globally, particularly in Australia, elucidate the role of primary healthcare in glaucoma diagnosis using Australian healthcare as an example, and discuss how recent advances in artificial intelligence (AI) can be implemented to improve diagnostic outcomes. Glaucoma is a prevalent disease in ageing populations and can have improved visual outcomes through appropriate treatment, making it essential for general medical practice. In countries such as Australia, New Zealand, Canada, USA, and the UK, optometrists serve as the gatekeepers for primary eye care, and glaucoma detection often falls on their shoulders. However, there is significant variation in the capacity for glaucoma diagnosis among eye professionals. Automation with Artificial Intelligence (AI) analysis of optic nerve photos can help optometrists identify high-risk changes and mitigate the challenges of image interpretation rapidly and consistently. Despite its potential, there are significant barriers and challenges to address before AI can be deployed in primary healthcare settings, including external validation, high quality real-world implementation, protection of privacy and cybersecurity, and medico-legal implications. Overall, the incorporation of AI technology in primary healthcare has the potential to reduce the global prevalence of undiagnosed glaucoma cases by improving diagnostic accuracy and efficiency.
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Affiliation(s)
- Catherine Jan
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia.
- Ophthalmology, Department of Surgery, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
- Lost Child's Vision Project, Sydney, NSW, Australia.
| | - Mingguang He
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
- Ophthalmology, Department of Surgery, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Centre for Eye and Vision Research, The Hong Kong Polytechnic University, Kowloon, TU428, Hong Kong SAR
| | - Algis Vingrys
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
- Ophthalmology, Department of Surgery, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Department of Optometry and Vision Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Zhuoting Zhu
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
- Ophthalmology, Department of Surgery, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Randall S Stafford
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
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Xie J, Patil NS, Popovic MM, Kertes PJ, Muni RH, Schlenker MB, Ahmed IIK, Kohly RP. Association Between Sociodemographic Factors and Self-reported Glaucoma in the National Health Interview Survey: A Population-Based Analysis. Am J Ophthalmol 2024; 263:81-92. [PMID: 38387827 DOI: 10.1016/j.ajo.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024]
Abstract
PURPOSE To investigate the association between social determinants of health (SDH) in the domains of social and community context, education access, environmental context, economic stability, and healthcare access, with glaucoma prevalence. DESIGN Cross-sectional study. METHODS The study population consisted of adult participants who answered glaucoma-related questions on the 2017 National Health Interview Survey (NHIS), the most recent iteration that includes glaucoma-related questions. The main outcome measures included the relationships between SDH-related factors and self-reported glaucoma diagnosis as well as self-reported glaucomatous vision loss were examined using univariable and multivariable regression models. RESULTS In total, 26,696 of 26,742 (99.83%) NHIS respondents were included, of whom 880 (3.30%) reported a glaucoma diagnosis and 275 (1.03%) reported glaucomatous vision loss. Participants were predominantly middle-aged (50.95 ± 18.60 years), female (54.75%), and non-Hispanic White (70.49%). In age-adjusted multivariable regression (n = 25,456), non-Hispanic Black race (odds ratio [OR] = 1.87, 99% CI = [1.37, 2.55], P < .001, compared to non-Hispanic White race) and poor health status (OR = 1.54, 99% CI = [1.00, 2.37], P = .01, compared to good health status) were significant predictors of glaucoma diagnosis. For glaucomatous vision loss, having an income below the poverty threshold (OR = 2.41, 99% CI = [1.12, 5.20], P = .003, compared to income ≥5 times the poverty threshold) was the only significant predictor in univariable analyses. No SDH-related factors were significantly associated with glaucomatous vision loss in multivariable analysis (n = 848). Multicollinearity was minimal (variation inflation factor<1.6 for all independent variables). CONCLUSIONS Non-Hispanic Black race and poor health status were associated with self-reported glaucoma diagnosis. Physicians and policymakers may consider SDH when assessing clinical risk and designing public health interventions.
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Affiliation(s)
- Jim Xie
- From the Michael G. DeGroote School of Medicine (J.M., N.P.), McMaster University, Hamilton, Ontario, Canada
| | - Nikhil S Patil
- From the Michael G. DeGroote School of Medicine (J.M., N.P.), McMaster University, Hamilton, Ontario, Canada
| | - Marko M Popovic
- Department of Ophthalmology and Vision Sciences (M.P., P.K., R.M., M.S., I.A., R.K.), University of Toronto, Toronto, Ontario, Canada
| | - Peter J Kertes
- Department of Ophthalmology and Vision Sciences (M.P., P.K., R.M., M.S., I.A., R.K.), University of Toronto, Toronto, Ontario, Canada; John and Liz Tory Eye Centre (P.K, R.K.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Kensington Eye Institute (P.K., M.S.), Toronto, Ontario, Canada
| | - Rajeev H Muni
- Department of Ophthalmology and Vision Sciences (M.P., P.K., R.M., M.S., I.A., R.K.), University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology (R.M.), St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada
| | - Matthew B Schlenker
- Department of Ophthalmology and Vision Sciences (M.P., P.K., R.M., M.S., I.A., R.K.), University of Toronto, Toronto, Ontario, Canada; Kensington Eye Institute (P.K., M.S.), Toronto, Ontario, Canada; Institute for Better Health, Trillium Health Partners (M.S., I.A.), Mississauga, Ontario, Canada
| | - Iqbal Ike K Ahmed
- Department of Ophthalmology and Vision Sciences (M.P., P.K., R.M., M.S., I.A., R.K.), University of Toronto, Toronto, Ontario, Canada; Institute for Better Health, Trillium Health Partners (M.S., I.A.), Mississauga, Ontario, Canada
| | - Radha P Kohly
- Department of Ophthalmology and Vision Sciences (M.P., P.K., R.M., M.S., I.A., R.K.), University of Toronto, Toronto, Ontario, Canada; John and Liz Tory Eye Centre (P.K, R.K.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Lee KE, Sussberg JA, Nelson LB, Thuma TBT. Review of the Disparities in Access to Pediatric Eye Care Among Low Socioeconomic Status and Underrepresented Racial Minority Groups Exacerbated by the Economic Downturn in Pediatric Ophthalmology. J Pediatr Ophthalmol Strabismus 2024; 61:172-178. [PMID: 38112388 DOI: 10.3928/01913913-20231026-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
PURPOSE To explore the association between race and socioeconomic status on health disparities in pediatric eye care, characterize the status of diversity within the pediatric ophthalmology workforce, and propose potential solutions to improve access to vision care, particularly for children from vulnerable populations. METHODS The major studies examining the socioeconomic and racial disparities in visual outcomes and the impact of diversity in the ophthalmology workforce were reviewed. RESULTS Currently, the pediatric ophthalmology workforce has limited racial diversity, and increasing the number of underrepresented in medicine providers has potential to improve access to pediatric eye care, particularly for underserved populations. Mobile eye clinics, school-based vision programs, and health literacy initiatives may engage communities to bring eye care directly to children and enhance follow-up. CONCLUSIONS Families with lower socioeconomic status may represent a vulnerable population facing significant access to pediatric eye care barriers, particularly for asymptomatic pediatric eye conditions. Emphasis on strategies that directly engage communities and bring free vision care to families should be given to improve disparities in visual health outcomes. Ophthalmologists and pediatric ophthalmologists should be aware of the current racial underrepresentation within the pediatric ophthalmology workforce, and the importance of workforce diversity in accelerating physician-patient concordance and access to eye care. [J Pediatr Ophthalmol Strabismus. 2024;61(3):172-178.].
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Madu CT, Lee TF, Sohn A, Hu J, Matayev R, Paranjpe V, Fam J, Wronka A, Kim ET, Zambrano R, Wollstein G, Schuman JS. Disparities in Visual Field Testing Frequency Among Subjects With Glaucoma. Transl Vis Sci Technol 2024; 13:2. [PMID: 38564202 PMCID: PMC10996970 DOI: 10.1167/tvst.13.4.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 01/23/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose Prior evidence suggests racial disparities in the utilization of visual field testing (VFT) for the diagnosis and monitoring of glaucoma. In this study, we considered the effect of baseline glaucoma severity and socioeconomic disadvantage along with other potential confounders such as test reliability, ancillary tests, and glaucoma surgeries on racial disparity in the frequency of VFT. Methods The records of all subjects with a diagnosis of glaucoma who received VFT at an academic, tertiary care facility from January 2018 to December 2021 were accessed. Analysis was performed to compare VFT frequency, the total number of office visits (DoS), and the ratio of VFT frequency to DoS (VFT/DoS) across self-reported races while controlling for sex, age, socioeconomic disadvantage (Area Deprivation Index), VF reliability indicators and baseline mean deviation, optical coherence tomography frequency, and glaucoma surgeries. Results Among the 2654 subjects (1515 White, 782 Black, and 357 Asian) included in this study, Black subjects had the worst socioeconomic status and disease severity at baseline. They also experienced a 3% lower VFT/DoS ratio compared to White subjects (P = 0.031). Asian subjects had a 5% lower VFT/DoS ratio compared to White subjects (P = 0.015). Discussion We identified racial disparity in performing VFT in subjects with glaucoma even when multiple confounders were considered. Further investigation is necessary to identify other race-associated factors to work toward reducing racial disparities in VFT. Translational Relevance Black and Asian subjects with glaucoma receive fewer VFT per visit compared to White subjects even when considering socioeconomic disadvantage and disease severity.
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Affiliation(s)
- Chisom T Madu
- Department of Ophthalmology, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Ting-Fang Lee
- Department of Ophthalmology, NYU Grossman School of Medicine, New York University, New York, NY, USA
- Department of Population Health, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Ashley Sohn
- Department of Ophthalmology, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Jiyuan Hu
- Department of Population Health, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Rachel Matayev
- Department of Ophthalmology, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Vikram Paranjpe
- Department of Ophthalmology, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Jonathan Fam
- Department of Ophthalmology, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Andrew Wronka
- Department of Ophthalmology, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Eleanore T Kim
- Department of Ophthalmology, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | | | - Gadi Wollstein
- Glaucoma Service, Wills Eye Hospital, Philadelphia, PA, USA
| | - Joel S Schuman
- Glaucoma Service, Wills Eye Hospital, Philadelphia, PA, USA
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Son HS, Chang DF, Li C, Liu L, Zafar S, Lum F, Woreta FA. Visual Acuity Outcomes and Complications after Intraocular Lens Exchange: An IRIS® Registry (Intelligent Research in Sight) Analysis. Ophthalmology 2024; 131:403-411. [PMID: 37858872 DOI: 10.1016/j.ophtha.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 09/27/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023] Open
Abstract
PURPOSE To assess risk factors for worse visual acuity (VA) outcomes after intraocular lens (IOL) exchange, and the most common postsurgical complications. DESIGN Retrospective cohort study. PARTICIPANTS Eyes from patients 18 years of age and older in the IRIS® Registry (Intelligent Research in Sight) that underwent IOL exchange in the United States between 2013 and 2019. METHODS Vision improvement compared with baseline was determined at 1 year after surgery. A multivariable generalized estimating equation model adjusting for demographic factors and baseline vision was used to identify factors associated with VA worse than 20/40 at 1 year. MAIN OUTCOME MEASURES Visual outcomes and postoperative complications after lens exchange. RESULTS A total of 46 063 procedures (n = 41 925 unique patients) were included in the analysis. Overall, VA improved from a mean ± standard deviation (SD) of 0.53 ± 0.58 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/70) before surgery to a mean ± SD of 0.31 ± 0.40 logMAR (Snellen equivalent, 20/40) at 1 year. Among eyes with VA recorded at both baseline and 1 year after surgery, 60.5% achieved VA of 20/40 or better at 1 year. Vision of worse than 20/40 at 1 year was associated with greater age (odds ratio [OR], 1.16 per 5-year increase; 95% confidence interval [CI], 1.14-1.18) and higher logMAR baseline VA (OR, 1.14 per 0.1-logMAR increase; 95% CI, 1.14-1.15), as well as Black or African American (OR, 1.96; 95% CI, 1.68-2.28), Hispanic (OR, 1.82; 95% CI, 1.59-2.08), and Asian (OR, 1.48; 95% CI, 1.21-1.81) race or ethnicity versus White race, Medicaid (OR, 1.78; 95% CI, 1.40-2.25) versus private insurance, smoking history (OR, 1.22; 95% CI, 1.11-1.35), and concurrent anterior (OR, 1.65; 95% CI, 1.51-1.81) and posterior (OR, 1.53; 95% CI, 1.41-1.66) vitrectomy versus no vitrectomy. Female sex was associated with better VA at 1 year. At 1 year, epiretinal membrane (10.9%), mechanical lens complication (9.4%), and dislocation of the replacement lens (7.1%) were the most common complications. CONCLUSIONS In this large national cohort, the annual number of IOL exchanges rose steadily over time. Vision improved in 60.2% of patients; worse visual outcomes were associated with greater age, worse baseline vision, Black race, Hispanic ethnicity, Medicaid insurance, smoking, and concurrent vitrectomy. Epiretinal membrane was the most common complication. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Hyeck-Soo Son
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Ophthalmology, University of Heidelberg, Heidelberg, Baden-Wuerttemberg, Germany
| | | | - Charles Li
- American Academy of Ophthalmology, San Francisco, California
| | - Lynn Liu
- American Academy of Ophthalmology, San Francisco, California
| | - Sidra Zafar
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Flora Lum
- American Academy of Ophthalmology, San Francisco, California
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Acuff K, Wu JH, Varkhedi V, Baxter SL. Social determinants of health and health disparities in glaucoma: A review. Clin Exp Ophthalmol 2024; 52:276-293. [PMID: 38385607 PMCID: PMC11038416 DOI: 10.1111/ceo.14367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/23/2024]
Abstract
Social determinants of health and barriers to care can significantly impact patients' access to glaucoma care and treatment, resulting in disparities within disease presentation, progression, management, and treatment outcomes. The widespread adoption of electronic health record systems has allowed researchers and clinicians to further explore these relationships, identifying factors such as race, ethnicity, and socioeconomic status to be risk factors for more severe disease and lower treatment adherence. These disparities highlight potential targets for interventions to combat these disparities and improve overall patient outcomes. This article provides a summary of the available data on health disparities within glaucoma disease presentation, progression, management, treatment, and outcomes and discusses interventions to improve care delivery and outcomes among patients with glaucoma.
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Affiliation(s)
- Kaela Acuff
- Division of Ophthalmology Informatics and Data Science, Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, California, USA
- Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California, USA
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
| | - Jo-Hsuan Wu
- Division of Ophthalmology Informatics and Data Science, Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, California, USA
- Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California, USA
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
| | - Varsha Varkhedi
- Division of Ophthalmology Informatics and Data Science, Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, California, USA
- Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California, USA
| | - Sally L. Baxter
- Division of Ophthalmology Informatics and Data Science, Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, California, USA
- Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California, USA
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
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Barquet-Pizá V, Siegfried CJ. Understanding racial disparities of glaucoma. Curr Opin Ophthalmol 2024; 35:97-103. [PMID: 37922412 DOI: 10.1097/icu.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2023]
Abstract
PURPOSE OF REVIEW Increased prevalence, earlier onset, and more rapid progression to vision loss from glaucoma has demonstrated racial disparity in numerous studies over decades. Precise etiologies of these important differences among patients of African and Hispanic ancestral background have not been elucidated. This review focuses on currently available epidemiologic/population, genetic, socioeconomic and physiologic studies of racial disparities in this blinding disease. RECENT FINDINGS In depth reviews of several landmark studies of glaucoma prevalence in various racial groups have highlighted potential challenges of lack of recruitment of diverse populations in genetic studies and clinical trials, challenges of racial stratification of subjects, and the impact of socioeconomic variables. SUMMARY Through a more comprehensive analysis of racial disparities of glaucoma, both clinicians and researchers may provide more effective population screening and management with a holistic approach for individualized patient care to provide improved outcomes. Future studies of interventions in sociodemographic factors and genetic/physiologic variables that influence the prevalence, access, and consequential vision loss from glaucoma will be crucial to minimize/eliminate racial disparities and improve outcomes for all.
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Affiliation(s)
- Viviana Barquet-Pizá
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
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Rehman M, Nanni A, Suresh S, Saleh I, Dalal S, Firoz M, Patel M, Georges B, Rehman AS, Kooner KS. Exploring Underrepresentation: The Role of Diversity Statements in Ophthalmology Residency Programs. Cureus 2024; 16:e56569. [PMID: 38646330 PMCID: PMC11031127 DOI: 10.7759/cureus.56569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
INTRODUCTION The underrepresentation of underrepresented minorities (URMs) in the medical field, particularly in ophthalmology, poses a critical challenge to achieving diversity and equity. While URMs constitute 19% of medical school attendees, their presence is markedly lower in ophthalmology residency programs and among practicing ophthalmologists. This study seeks to investigate the prevalence of diversity statements on ophthalmology residency program websites and their role in the underrepresentation of URMs within the field. METHODS This observational, cross-sectional study analyzed the websites of 126 ophthalmology residency programs listed on the San Francisco (SF) Match website. Diversity statements were categorized based on their inclusion of specific underrepresented groups (race or ethnicity, gender, sexual orientation, and disability) and analyzed for correlation with program characteristics. Descriptive statistics and Chi-squared tests were utilized to assess the prevalence of diversity statements and their association with program size, ranking, geographical location, and institutional nature. RESULTS Of the 126 programs analyzed, 21 (16.7%) had diversity statements specific to the ophthalmology residency program, and 115 (91.3%) featured institutional-level diversity statements. Race or ethnicity was the most commonly addressed category in diversity statements (75.3%), followed by gender (65.9%), sexual orientation (61.1%), and disability (53.2%). Statistical analyses revealed no significant correlation between program size and the presence of diversity statements. However, higher-ranked programs were more likely to mention sexual orientation and disability. Significant differences were observed at the institutional level, with public institutions more likely to include specific diversity categories. CONCLUSION The study highlights a significant disparity in the presence and focus of diversity statements across ophthalmology residency programs. Despite a high prevalence of institutional-level diversity statements, program-specific initiatives are lacking, particularly in addressing disability inclusion. The findings suggest a need for a more comprehensive and targeted effort to address underrepresentation in ophthalmology.
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Affiliation(s)
- Mahad Rehman
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Amber Nanni
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Sruthi Suresh
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Ibrahim Saleh
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Sujata Dalal
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Masuma Firoz
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Monica Patel
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Brandon Georges
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Ahmed S Rehman
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Karanjit S Kooner
- Ophthalmology, University of Texas Southwestern Medical Center, Dallas, USA
- Ophthalmology, Veterans Affairs North Texas Health Care System, Dallas, USA
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11
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Rathore M, Shweikh Y, Kelly SR, Crabb DP. Measures of multiple deprivation and visual field loss in glaucoma clinics in England: lessons from big data. Eye (Lond) 2023; 37:3615-3620. [PMID: 37165010 PMCID: PMC10686257 DOI: 10.1038/s41433-023-02567-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/17/2023] [Accepted: 04/25/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND/OBJECTIVES To examine the association between multiple deprivation with late diagnosis and rapid worsening of glaucoma in patients in English hospital eye services (HES). METHODS 602,439 visual fields (VFs) were extracted from five regionally different glaucoma clinics in England. Mean Deviation (MD) worse than -12 dB was used as a surrogate definition for advanced VF loss at diagnosis in patients with ≥2 reliable VF records. MD loss worse than -1 dB per year was used to define rapid VF progression in patients with ≥6 VFs. Patient data were stratified into deciles of the Index of Multiple Deprivation (IMD) from residential postcodes. RESULTS There was an association between IMD and advanced VF loss at diagnosis in 44,956 patients with 18% (293/1608) and 11% (771/6929) in the most and least deprived IMD decile, respectively. Age-corrected odds ratio (OR) for having advanced VF loss at entry into HES was 1.42 (95% confidence interval [CI] 1.21-1.67) and 0.75 (95% CI: 0.66-0.85) in the most and least deprived IMD decile respectively (reference = fifth decile). In 15,094 patients with follow up data (median [interquartile range] of 6.9 [4.5, 10.0] years), the proportion having rapid VF progression did not differ across the IMD spectrum. CONCLUSION Large-scale VF data from clinics indicates that glaucoma severity at presentation to English HES is associated with levels of multiple deprivation. We found no evidence to suggest likelihood of having rapid VF progression during follow-up is associated with IMD; this hints at equity of glaucoma care and outcomes once patients are in English HES.
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Affiliation(s)
- Mehal Rathore
- Department of Optometry and Visual Sciences, School of Health & Psychological Sciences, City, University of London, London, UK
| | - Yusrah Shweikh
- Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust, West Sussex, UK
| | - Stephen R Kelly
- Department of Optometry and Visual Sciences, School of Health & Psychological Sciences, City, University of London, London, UK
| | - David P Crabb
- Department of Optometry and Visual Sciences, School of Health & Psychological Sciences, City, University of London, London, UK.
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12
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Brant A, Kolomeyer N, Goldberg JL, Haller J, Lee CS, Lee AY, Lorch AC, Lum F, Miller JW, Parke DW, Hyman L, Pershing S. United States Population Disparities in Ophthalmic Care: Blindness and Visual Impairment in the IRIS® Registry (Intelligent Research in Sight). Ophthalmology 2023; 130:1121-1137. [PMID: 37331480 PMCID: PMC10592479 DOI: 10.1016/j.ophtha.2023.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/20/2023] Open
Abstract
PURPOSE To evaluate associations of patient characteristics with United States eye care use and likelihood of blindness. DESIGN Retrospective observational study. PARTICIPANTS Patients (19 546 016) with 2018 visual acuity (VA) records in the American Academy of Ophthalmology's IRIS® Registry (Intelligent Research in Sight). METHODS Legal blindness (20/200 or worse) and visual impairment (VI; worse than 20/40) were identified from corrected distance acuity in the better-seeing eye and stratified by patient characteristics. Multivariable logistic regressions evaluated associations with blindness and VI. Blindness was mapped by state and compared with population characteristics. Eye care use was analyzed by comparing population demographics with United States Census estimates and proportional demographic representation among blind patients versus a nationally representative US population sample (National Health and Nutritional Examination Survey [NHANES]). MAIN OUTCOME MEASURES Prevalence and odds ratios for VI and blindness; proportional representation in the IRIS® Registry, Census, and NHANES by patient demographics. RESULTS Visual impairment was present in 6.98% (n = 1 364 935) and blindness in 0.98% (n = 190 817) of IRIS patients. Adjusted odds of blindness were highest among patients ≥ 85 years old (odds ratio [OR], 11.85; 95% confidence interval [CI], 10.33-13.59 vs. those 0-17 years old). Blindness also was associated positively with rural location and Medicaid, Medicare, or no insurance vs. commercial insurance. Hispanic (OR, 1.59; 95% CI, 1.46-1.74) and Black (OR, 1.73; 95% CI, 1.63-1.84) patients showed a higher odds of blindness versus White non-Hispanic patients. Proportional representation in IRIS Registry relative to the Census was higher for White than Hispanic (2- to 4-fold) or Black (11%-85%) patients (P < 0.001). Blindness overall was less prevalent in NHANES than IRIS Registry; however, prevalence in adults aged 60+ was lowest among Black participants in the NHANES (0.54%) and second highest among comparable Black adults in IRIS (1.57%). CONCLUSIONS Legal blindness from low VA was present in 0.98% of IRIS patients and associated with rural location, public or no insurance, and older age. Compared with US Census estimates, minorities may be underrepresented among ophthalmology patients, and compared with NHANES population estimates, Black individuals may be overrepresented among blind IRIS Registry patients. These findings provide a snapshot of US ophthalmic care and highlight the need for initiatives to address disparities in use and blindness. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Arthur Brant
- Spencer Center for Vision Research, Byers Eye Institute at Stanford, Department of Ophthalmology, Stanford University, Palo Alto, California
| | - Natasha Kolomeyer
- Wills Eye Hospital, Department of Ophthalmology, Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jeffrey L Goldberg
- Spencer Center for Vision Research, Byers Eye Institute at Stanford, Department of Ophthalmology, Stanford University, Palo Alto, California; Ophthalmology and Eye Care Services, VA Palo Alto Health Care System, Palo Alto, California
| | - Julia Haller
- Wills Eye Hospital, Department of Ophthalmology, Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Cecilia S Lee
- Department of Ophthalmology, University of Washington, Seattle, Washington; Roger and Angie Karalis Johnson Retina Center, Seattle, Washington
| | - Aaron Y Lee
- Department of Ophthalmology, University of Washington, Seattle, Washington; Roger and Angie Karalis Johnson Retina Center, Seattle, Washington
| | - Alice C Lorch
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Flora Lum
- American Academy of Ophthalmology, San Francisco, California
| | - Joan W Miller
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - David W Parke
- American Academy of Ophthalmology, San Francisco, California; Verana Health, San Francisco, California
| | - Leslie Hyman
- Wills Eye Hospital, Department of Ophthalmology, Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania; Vickie and Jack Farber Vision Research Center at Wills Eye Hospital, Philadelphia, Pennsylvania
| | - Suzann Pershing
- Spencer Center for Vision Research, Byers Eye Institute at Stanford, Department of Ophthalmology, Stanford University, Palo Alto, California; Ophthalmology and Eye Care Services, VA Palo Alto Health Care System, Palo Alto, California.
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Tseng VL, Kitayama K, Yu F, Pan D, Coleman AL. Social Vulnerability, Prevalence of Glaucoma, and Incidence of Glaucoma Surgery in the California Medicare Population. Ophthalmol Glaucoma 2023; 6:616-625. [PMID: 37211091 DOI: 10.1016/j.ogla.2023.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/02/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE To examine associations of Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI) scores with prevalence of glaucoma and incidence of glaucoma surgery in 2019 California Medicare beneficiaries. DESIGN Retrospective cross-sectional study. PARTICIPANTS 2019 California Medicare beneficiaries ≥ 65 years old with part A and part B coverage. METHODS The exposure of interest was SVI score, which was assessed overall and by themes. Outcomes included prevalence of glaucoma in the study population and incidence of glaucoma surgery in beneficiaries with glaucoma. Logistic regression modeling was performed to assess associations between quartiles of each type of SVI score, prevalence of glaucoma, and incidence of glaucoma surgery, controlling for age, sex, race/ethnicity, Charlson Comorbidity Index score, pseudophakia, and age-related macular degeneration. MAIN OUTCOME MEASURES Prevalence of any glaucoma, primary open angle glaucoma (POAG), secondary open angle glaucoma (SOAG), and angle closure glaucoma in all beneficiaries. Incidence of any glaucoma surgery, trabeculectomy, tube shunt, minimally invasive glaucoma surgery (MIGS), and cyclophotocoagulation (CPC) in beneficiaries with glaucoma. RESULTS Of 5 725 245 beneficiaries in the total study population, there were 215 814 (3.8%) with any glaucoma, and of those with glaucoma, 10 135/215 814 (4.7%) underwent glaucoma surgery. In adjusted analyses for overall SVI score, where higher levels of SVI refer to higher levels of social vulnerability, there were decreased odds of any glaucoma (adjusted odds ratio [aOR] = 0.83; 95% confidence interval [CI] = 0.82, 0.84 for Q4 vs. Q1), POAG (aOR = 0.85; 95% CI = 0.84, 0.87 for Q4 vs. Q1), and SOAG (aOR = 0.59; 95% CI = 0.55, 0.63 for Q4 vs. Q1) in higher (Q4) vs. lower (Q1) SVI quartile. There were increased odds of any glaucoma surgery (aOR = 1.19; 95% CI = 1.12, 1.26 for Q4 vs. Q1), MIGS (aOR = 1.24; 95% CI = 1.15, 1.33 for Q4 vs. Q1), and CPC (aOR = 1.49; 95% CI = 1.29, 1.76 for Q4 vs. Q1) for higher (Q4) vs. lower (Q1) SVI quartile. CONCLUSIONS In the 2019 California Medicare population, there were variable associations between SVI score, prevalence of glaucoma, and incidence of glaucoma surgery. Further investigation is needed to understand the role of social, economic, and demographic factors in glaucoma care on the individual and structural levels. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Victoria L Tseng
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California
| | - Ken Kitayama
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California; Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Fei Yu
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California; Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Deyu Pan
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California
| | - Anne L Coleman
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California; Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California.
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14
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Gill ZS, Marin AI, Caldwell AS, Mehta N, Grove N, Seibold LK, Puente MA, De Carlo Forest TE, Oliver SCN, Patnaik JL, Manoharan N. Limited English Proficiency Is Associated With Diabetic Retinopathy in Patients Presenting for Cataract Surgery. Transl Vis Sci Technol 2023; 12:4. [PMID: 37796496 PMCID: PMC10561792 DOI: 10.1167/tvst.12.10.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 08/30/2023] [Indexed: 10/06/2023] Open
Abstract
Purpose To investigate the relationship between limited English proficiency (LEP) and diabetic retinopathy (DR) in patients presenting for cataract surgery. Methods This is a retrospective observational study of patients who underwent cataract surgery between January 2014 and February 2020. Patients who self-identified as needing or preferring an interpreter were defined as having LEP. Differences in demographics, characteristics, and outcomes including history of type 2 diabetes (T2DM), DR, preoperative best corrected visual acuity (BCVA), macular edema, and anti-vascular endothelial growth factor injections were analyzed. Statistical comparisons were assessed using logistic regression with generalized estimating equations. Results We included 13,590 eyes. Of these, 868 (6.4%) were from LEP patients. Patients with LEP were more likely to be Hispanic (P < 0.001), female sex (P = 0.008), or older age (P = 0.003) and have worse mean BCVA at presentation (P < 0.001). Patients with LEP had a significantly higher rate of T2DM (P < 0.001), macular edema (P = 0.033), and DR (18.1% vs. 5.8%, P < 0.001). Findings remained significant when controlling for age, sex, race/ethnicity, and type of health insurance. Patients with LEP and DR were more likely to have had later stages of DR (P = 0.023). Conclusions Patients with LEP presenting for cataract surgery had a higher rate of DR and associated complications compared to patients with English proficiency. Further studies are needed to understand how language disparities influence health and what measures could be taken to improve healthcare in this vulnerable population. Translational Relevance Our study highlights healthcare disparities within ophthalmology and emphasizes the importance of advocating for improved healthcare delivery for patients with LEP.
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Affiliation(s)
- Zafar S. Gill
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - A. Itzam Marin
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anne Strong Caldwell
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nihaal Mehta
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nathan Grove
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Leonard K. Seibold
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Michael A. Puente
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Scott C. N. Oliver
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer L. Patnaik
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Niranjan Manoharan
- Sue Anschutz-Rodgers Eye Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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15
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Davuluru SS, Jess AT, Kim JSB, Yoo K, Nguyen V, Xu BY. Identifying, Understanding, and Addressing Disparities in Glaucoma Care in the United States. Transl Vis Sci Technol 2023; 12:18. [PMID: 37889504 PMCID: PMC10617640 DOI: 10.1167/tvst.12.10.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023] Open
Abstract
Glaucoma is the leading cause of irreversible blindness worldwide, currently affecting around 80 million people. Glaucoma prevalence is rapidly rising in the United States due to an aging population. Despite recent advances in the diagnosis and treatment of glaucoma, significant disparities persist in disease detection, management, and outcomes among the diverse patient populations of the United States. Research on disparities is critical to identifying, understanding, and addressing societal and healthcare inequalities. Disparities research is especially important and impactful in the context of irreversible diseases such as glaucoma, where earlier detection and intervention are the primary approach to improving patient outcomes. In this article, we first review recent studies identifying disparities in glaucoma care that affect patient populations based on race, age, and gender. We then review studies elucidating and furthering our understanding of modifiable factors that contribute to these inequities, including socioeconomic status (particularly age and education), insurance product, and geographic region. Finally, we present work proposing potential strategies addressing disparities in glaucoma care, including teleophthalmology and artificial intelligence. We also discuss the presence of non-modifiable factors that contribute to differences in glaucoma burden and can confound the detection of glaucoma disparities. Translational Relevance By recognizing underlying causes and proposing potential solutions, healthcare providers, policymakers, and other stakeholders can work collaboratively to reduce the burden of glaucoma and improve visual health and clinical outcomes in vulnerable patient populations.
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Affiliation(s)
- Shaili S. Davuluru
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alison T. Jess
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Kristy Yoo
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Van Nguyen
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Benjamin Y. Xu
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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16
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Cui D, Mathews PM, Li G, Guo L, VanCourt S, Saldanha IJ, Karamursel Akpek E. Racial and Ethnic Disparities in Dry Eye Diagnosis and Care. Ophthalmic Epidemiol 2023; 30:484-491. [PMID: 36200798 DOI: 10.1080/09286586.2022.2131834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 07/10/2022] [Accepted: 09/26/2022] [Indexed: 10/10/2022]
Abstract
PURPOSE To investigate health disparities in racial and ethnic minorities with dry eye. METHODS Medical records were reviewed for demographics, socioeconomic factors, treatments, and objective dry eye parameters. Race/ethnicity was self-reported as delineated by the U.S. Census. The reference group comprised of randomly selected White patients, with number equal to the largest minority group. RESULTS The study included 465 patients (157 Black, 157 White, 85 Asian, and 66 Hispanic). Compared to White (3.2%) patients, larger proportion of minorities used Medicaid or lacked health insurance (Black 8.3%, P = .054; Asian 10.6%, P = .019; Hispanic 18.2%, P < .001). Black and Hispanic patients had lower estimated median household income than Whites (White $98,472, Black $75,554, P < .001; Asian $105,503, P = .088; Hispanic $86,839, P = .030). Prior to presentation, fewer minority patients received prescription treatments or procedures (White 61.8%; Black 30.6%, P < .001; Asian 43.5%, P = .006; Hispanic 43.9%, P = .014). Although at baseline visit minorities had worse mean conjunctival (White, 1.7; Black 2.2, P = .136, Asian 2.4, P = .022; Hispanic 2.6, P = .005) and corneal staining scores (White, 1.6; Black 2.5, P < .001; Asian 2.3, P = .003; Hispanic 2.4, P = .001), no differences were noted at final visit. CONCLUSION Minorities presented with worse objective dry eye parameters, and less prior dry eye care. Income and health care access may not fully explain the observed undertreatment at presentation. Differential management by eye care providers and patient attitudes warrant further investigation.
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Affiliation(s)
- David Cui
- The Ocular Surface Disease Clinic, the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Krieger Eye Institute of Sinai Hospital, Baltimore, Maryland, USA
| | - Priya M Mathews
- The Ocular Surface Disease Clinic, the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gavin Li
- The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lee Guo
- The Ocular Surface Disease Clinic, the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shanna VanCourt
- The Ocular Surface Disease Clinic, the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ian J Saldanha
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, and Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Esen Karamursel Akpek
- The Ocular Surface Disease Clinic, the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Gervasio KA, Camarena J, Hampton J, Chopra N, Kalosza B, Shumate L, Wu AY. Demographic and socioeconomic disparities in receipt of ophthalmology consultation for facial trauma. BMJ Open Ophthalmol 2023; 8:e001259. [PMID: 37797981 PMCID: PMC10551933 DOI: 10.1136/bmjophth-2023-001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/11/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Functional outcomes following facial and ocular trauma are time-sensitive and require prompt evaluation to minimise long-term vision loss, yet few studies have systematically evaluated disparities in the management of these cases. This study investigates whether a patient's race/ethnicity, primary language, insurance status, gender or age affects receipt of ophthalmology consultation for facial trauma. METHODS AND ANALYSIS This study was a retrospective cohort analysis of patients from the Elmhurst City Hospital Trauma Registry in Queens, New York who were seen for facial trauma including open globe injuries and orbital fractures between January 2014 and May 2016. RESULTS Of the 264 patients included, 43% reported as Hispanic, 23% white, 11% Asian, 8% black and 15% other/unknown. After controlling for confounding variables by multivariable logistic regression, neither race/ethnicity, gender, nor primary language were significantly associated with the likelihood of receiving an ophthalmology consult. However, patients with private insurance had 2.57 times greater odds of receiving an ophthalmology consultation than those with Medicaid or state corrections insurance (95% CI 1.37 to 4.95). As age increased, the likelihood of receiving an ophthalmology consultation decreased (p=0.009); patients 60 years of age and older had one-third the odds of ophthalmology consultation as younger patients (OR 0.33; 95% CI 0.16 to 0.68). CONCLUSIONS This study highlights that lack of ophthalmology consultation in patients with facial trauma is linked to age and underinsurance. Extra attention must be paid during primary assessments to ensure elderly patients and those with public insurance have equitable access to timely and appropriate care for facial trauma.
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Affiliation(s)
- Kalla A Gervasio
- Wills Eye Hospital, Philadelphia, Pennsylvania, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joab Camarena
- Stanford University School of Medicine, Stanford, California, USA
| | - Jessica Hampton
- Stanford University School of Medicine, Stanford, California, USA
| | - Nitin Chopra
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Trauma Research, Emergency Department, Elmhurst Hospital Center, Elmhurst, Queens, New York, USA
| | - Brittany Kalosza
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lauren Shumate
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Trauma Research, Emergency Department, Elmhurst Hospital Center, Elmhurst, Queens, New York, USA
| | - Albert Y Wu
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California, USA
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Andoh JE, Ezekwesili AC, Nwanyanwu K, Elam A. Disparities in Eye Care Access and Utilization: A Narrative Review. Annu Rev Vis Sci 2023; 9:15-37. [PMID: 37254050 DOI: 10.1146/annurev-vision-112122-020934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This narrative review summarizes the literature on factors related to eye care access and utilization in the United States. Using the Healthy People 2030 framework, this review investigates social determinants of health associated with general and follow-up engagement, screenings, diagnostic visits, treatment, technology, and teleophthalmology. We provide hypotheses for these documented eye care disparities, featuring qualitative, patient-centered research. Lastly, we provide recommendations in the hopes of appropriately eliminating these disparities and reimagining eye care.
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Affiliation(s)
- Joana E Andoh
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Agnes C Ezekwesili
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kristen Nwanyanwu
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Angela Elam
- Department of Ophthalmology, WK Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA;
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Hicks PM, Niziol LM, Newman-Casey PA, Salami K, Singh K, Woodward MA. Social Risk Factor Associations With Presenting Visual Acuity in Patients With Microbial Keratitis. JAMA Ophthalmol 2023; 141:727-734. [PMID: 37318786 PMCID: PMC10273131 DOI: 10.1001/jamaophthalmol.2023.2415] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/23/2023] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Patrice M. Hicks
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Leslie M. Niziol
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Paula Anne Newman-Casey
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Kassim Salami
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Karandeep Singh
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Maria A. Woodward
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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20
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Garzon C, Mihailovic A, E JY, West SK, Gitlin LN, Friedman DS, Ramulu PY. The Impact of Neighborhood Factors on Physical Activity in Older Adults With Visual Impairment. Am J Ophthalmol 2023; 250:49-58. [PMID: 36682519 PMCID: PMC10175110 DOI: 10.1016/j.ajo.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE To investigate the associations of neighborhood-level socioeconomic and environmental characteristics with physical activity in persons with glaucoma. DESIGN Cross-sectional study (N = 230). METHODS Home addresses were used to extract neighborhood factors (NFs): Area Deprivation Index, crime rate, and the proportion of racial and ethnic minorities, poverty, college graduates, and park area in their census tract. Participants' average number of daily steps and nonsedentary minutes were collected over 7 days using an accelerometer. Visual field (VF) loss was quantified as integrated VF sensitivity. Multivariable negative binomial regression models and additional models with an interaction term evaluated the effect of NF on physical activity and whether these relationships differed by VF loss severity. RESULTS Participants were on average 70.6 years of age, 51.7% were male, and 27.8% were black. A higher Area Deprivation Index or poverty share was associated with fewer NSM (incidence rate ratio [IRR] = 0.96 per 1 Area Deprivation Index decile increment, P = .01; IRR = 0.92 per 10% poverty share increment, P = .02), while higher share of college graduates was associated with greater NSM (IRR = 1.03 per 10% increment; P = .03). Stronger associations were noted between both high crime rate and poverty share with NSM in individuals with severe VF damage as opposed to no/mild VF damage (IRR = 0.44, P = .001; IRR = 0.81, P = .02). CONCLUSIONS Select NFs (poverty share and crime rate) may disproportionately affect physical activity in patients with severe VF loss. Interventions to overcome activity limitations within the context of poverty and high socioeconomic disadvantage are important for addressing glaucoma-related disability, particularly in those with severe VF loss.
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Affiliation(s)
- Catalina Garzon
- From the Wilmer Eye Institute (C.G., A.M., J-Y.E., S.K.W., P.Y.R.), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aleksandra Mihailovic
- From the Wilmer Eye Institute (C.G., A.M., J-Y.E., S.K.W., P.Y.R.), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jian-Yu E
- From the Wilmer Eye Institute (C.G., A.M., J-Y.E., S.K.W., P.Y.R.), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheila K West
- From the Wilmer Eye Institute (C.G., A.M., J-Y.E., S.K.W., P.Y.R.), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura N Gitlin
- College of Nursing and Health Professions (L.N.G.), Drexel University, Philadelphia, Pennsylvania, USA
| | - David S Friedman
- and Massachusetts Eye and Ear(D.S.F.), Harvard Medical School, Boston, Massachusetts, USA
| | - Pradeep Y Ramulu
- From the Wilmer Eye Institute (C.G., A.M., J-Y.E., S.K.W., P.Y.R.), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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21
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Pandit S, Ho AC, Yonekawa Y. Recent advances in the management of proliferative diabetic retinopathy. Curr Opin Ophthalmol 2023; 34:232-236. [PMID: 36866849 DOI: 10.1097/icu.0000000000000946] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW The prevalence of diabetic retinopathy continues to rise. This review highlights advances in imaging, medical, and surgical management of proliferative diabetic retinopathy (PDR) in recent years. RECENT FINDINGS Ultra-widefield fluorescein angiography has been shown to better characterize which patients have predominantly peripheral lesions and who may advance to more advanced forms of diabetic retinopathy. This was well demonstrated in DRCR Retina Network's Protocol AA. Protocol S demonstrated that antivascular endothelial growth factor (VEGF) treatment alone can be useful in the management of select PDR patients - particularly those without high-risk features. However, a growing body of literature highlights how lapse in care is a significant concern in PDR patients, and tailoring one's approach to treatment based on patient needs is recommended. In patients with high-risk features or where there is concern for lost-to-follow-up, incorporation of panretinal photocoagulation in the treatment paradigm is recommended. Protocol AB highlighted how patients with more advanced disease may benefit from earlier surgical intervention for earlier visual recovery but that continued anti-VEGF treatment may result in similar visual outcomes over a longer period. Finally, earlier surgical intervention for PDR without vitreous hemorrhage (VH) or retinal detachment is being considered a potential option to minimize treatment burden. SUMMARY Recent advances in imaging, as well as medical and surgical treatment options for PDR, have provided a deeper understanding of PDR management, which can be optimized for the individual patient.
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Affiliation(s)
- Saagar Pandit
- Retina Division, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
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22
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Ahmad TR, Kong AW, Turner ML, Barnett J, Kaur G, O’Brien KS, Pasricha ND, Indaram M. Socioeconomic Correlates of Keratoconus Severity and Progression. Cornea 2023; 42:60-65. [PMID: 35184126 PMCID: PMC10738272 DOI: 10.1097/ico.0000000000002993] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/06/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to investigate the social determinants of health for keratoconus. METHODS In this retrospective cohort study of patients with keratoconus, the electronic health record was reviewed for keratometry, treatments received, clinical comorbidities, and social characteristics. Outcomes included severe keratoconus at presentation (steep keratometry ≥52 diopters), disease progression (≥0.75 diopters increase from the first to the most recent clinical visit), and corneal transplantation. Logistic regression was used to evaluate factors associated with severity at presentation and corneal transplantation. Cox proportional hazards modeling was used to evaluate progression. RESULTS A total of 1038 patients with keratoconus were identified, 725 (70%) of whom had baseline imaging. Compared with commercially insured patients, Medicaid recipients were more likely to have severe keratoconus, independent of social and clinical confounders [odds ratio (OR) 1.94, 95% confidence interval (CI), 1.12-3.35, P = 0.017]. Male sex was independently associated with progression (hazard ratio = 1.38, 95% CI, 1.03-1.84, P = 0.030). Medicare and Medicaid recipients were more likely to require transplantation compared with commercially insured patients (OR 2.71, 95% CI, 1.65-4.46, P < 0.001 and OR 1.74, 95% CI, 1.08-2.80, P = 0.022, respectively). Other social determinants of health, including non-White race/ethnicity, limited English proficiency, and unemployment, were associated with the outcomes only in univariate analysis. Obstructive sleep apnea, atopy, body mass index, and tobacco use were not associated with any outcome. CONCLUSIONS Socioeconomic factors were more consistent predictors of keratoconus severity and corneal transplantation compared with clinical factors that have received relatively greater attention in the keratoconus literature.
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Affiliation(s)
- Tessnim R. Ahmad
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA
| | - Alan W. Kong
- School of Medicine, University of California San Francisco, San Francisco, CA
| | - Marcus L. Turner
- School of Medicine, University of California San Francisco, San Francisco, CA
| | - Jackson Barnett
- School of Medicine, University of California San Francisco, San Francisco, CA
| | - Gurbani Kaur
- School of Medicine, University of California San Francisco, San Francisco, CA
| | - Kieran S. O’Brien
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA
| | - Neel D. Pasricha
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA
| | - Maanasa Indaram
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA
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23
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Besagar S, Yonekawa Y, Sridhar J, Finn A, Padovani-Claudio DA, Sternberg P, Patel S. Association of Socioeconomic, Demographic, and Health Care Access Disparities With Severe Visual Impairment in the US. JAMA Ophthalmol 2022; 140:1219-1226. [PMID: 36326732 PMCID: PMC9634598 DOI: 10.1001/jamaophthalmol.2022.4566] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022]
Abstract
Importance Approximately 13% of US adults are affected by visual disability, with disproportionately higher rates in groups impacted by certain social determinants of health (SDOH). Objective To evaluate SDOH associated with severe visual impairment (SVI) to ultimately guide targeted interventions to improve ophthalmic health. Design, Setting, and Participants This quality improvement study used cross-sectional data from a telephone survey from the Behavioral Risk Factor Surveillance System (BRFSS) that was conducted in the US from January 2019 to December 2020. Participants were noninstitutionalized adult civilians who were randomly selected and interviewed and self-identified as "blind or having serious difficulty seeing, even while wearing glasses." Exposures Demographic and health care access factors. Main Outcomes and Measures The main outcome was risk of SVI associated with various factors as measured by odds ratios (ORs) and 95% CIs. Descriptive and logistic regression analyses were performed using the Web Enabled Analysis Tool in the BRFFS. Results During the study period, 820 226 people (53.07% female) participated in the BRFSS survey, of whom 42 412 (5.17%) self-identified as "blind or having serious difficulty seeing, even while wearing glasses." Compared with White, non-Hispanic individuals, risk of SVI was increased among American Indian/Alaska Native (OR, 1.63; 95% CI, 1.38-1.91), Black/African American (OR, 1.50; 95% CI, 1.39-1.62), Hispanic (OR, 1.65; 95% CI, 1.53-1.79), and multiracial (OR, 1.33; 95% CI, 1.15-1.53) individuals. Lower annual household income and educational level (eg, not completing high school) were associated with greater risk of SVI. Individuals who were out of work for 1 year or longer (OR, 1.78; 95% CI, 1.54-2.07) or who reported being unable to work (OR, 2.90; 95% CI, 2.66-3.16) had higher odds of SVI compared with the other variables studied. Mental health diagnoses and 14 or more days per month with poor mental health were associated with increased risk of SVI (OR, 1.87; 95% CI, 1.73-2.02). Health care access factors associated with increased visual impairment risk included lack of health care coverage and inability to afford to see a physician. Conclusions and Relevance In this study, various SDOH were associated with SVI, including self-identification as being from a racial or ethnic minority group; low socioeconomic status and educational level; long-term unemployment and inability to work; divorced, separated, or widowed marital status; poor mental health; and lack of health care coverage. These disparities in care and barriers to health care access should guide targeted interventions.
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Affiliation(s)
- Sonya Besagar
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yoshihiro Yonekawa
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jayanth Sridhar
- Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida
| | - Avni Finn
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Paul Sternberg
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shriji Patel
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
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24
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Ramachandran R, Joiner DB, Patel V, Popplewell D, Misra P, Kaplan CM, Hood DC, Al-Aswad LA. Comparison between the Recommendations of Glaucoma Specialists and OCT Report Specialists for Further Ophthalmic Evaluation in a Community-Based Screening Study. Ophthalmol Glaucoma 2022; 5:602-613. [PMID: 35688330 DOI: 10.1016/j.ogla.2022.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/12/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To compare glaucoma referral patterns between glaucoma and OCT report specialists and to determine what influence, if any, a designated OCT reading could have on a glaucoma specialist's judgments. DESIGN Retrospective, exploratory study. SUBJECTS We included 483 eyes (243 individuals) from high-risk New York City neighborhoods screened as part of a mobile van glaucoma screening study from July 2017 to October 2017. METHODS All participants underwent comprehensive testing, including visual acuity, commercial OCT imaging, gonioscopy, intraocular pressure, frequency-doubling testing, and funduscopic assessment. Three glaucoma specialists independently evaluated all the collected data to determine whether a further glaucoma workup referral was recommended. Two OCT report specialists evaluated only the OCT image for each eye using the commercial report as well as a specialized, customized report. In phase II, the glaucoma specialists then re-evaluated a subset of these eyes, this time with an OCT report specialist's judgments made available. MAIN OUTCOME MEASURES Comparison of glaucoma specialist referrals made by glaucoma specialists versus OCT report specialists. RESULTS Intergrader agreement between glaucoma specialists was 60% (κ = 0.43) and between report specialists was 95% (κ = 0.77). There was an agreement between a single OCT report specialist and the consensus (2 of 3) of glaucoma specialists in 74% of eyes (κ= 0.32). Of the eyes studied, 25% were referred for further glaucoma evaluation by the glaucoma specialists alone and 1% were referred for further glaucoma workup by only the report specialist. With the addition of the report specialist's judgments, referral pattern changes varied by glaucoma specialist but overall agreement increased to 85% (κ = 0.53). CONCLUSIONS There was a fair level of agreement regarding glaucoma referral recommendations between glaucoma specialists with access to comprehensive screening data and OCT report specialists with access to only OCT data. Overall agreement increased when the designated OCT evaluation was made available to the glaucoma specialists. These results may aid in the design of future large-scale glaucoma screening studies.
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Affiliation(s)
| | - Devon B Joiner
- Department of Psychology, Columbia University, New York, New York
| | - Vipul Patel
- Department of Ophthalmology, NYU Langone Health, New York, New York
| | | | - Poonam Misra
- Department of Ophthalmology, NYU Langone Health, New York, New York
| | - Chad M Kaplan
- Department of Ophthalmology, NYU Langone Health, New York, New York
| | - Donald C Hood
- Department of Psychology, Columbia University, New York, New York; Department of Ophthalmology, Columbia University, New York, New York
| | - Lama A Al-Aswad
- Department of Ophthalmology, NYU Langone Health, New York, New York; Department of Ophthalmology, Columbia University, New York, New York.
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25
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Elam AR, Tseng VL, Rodriguez TM, Mike EV, Warren AK, Coleman AL. Disparities in Vision Health and Eye Care. Ophthalmology 2022; 129:e89-e113. [PMID: 36058735 PMCID: PMC10109525 DOI: 10.1016/j.ophtha.2022.07.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 10/14/2022] Open
Abstract
Significant disparities in vision health and eye care exist. To achieve health equity, we must understand the root causes and drivers of health disparities and inequities, including social determinants of health and systemic racism.
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Affiliation(s)
- Angela R Elam
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Victoria L Tseng
- UCLA Stein and Doheny Eye Institutes, David Geffen School of Medicine, University of California, Los Angeles, California
| | | | - Elise V Mike
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexis K Warren
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Anne L Coleman
- UCLA Stein and Doheny Eye Institutes, David Geffen School of Medicine, University of California, Los Angeles, California; Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
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26
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Al-Aswad LA, Ramachandran R, Schuman JS, Medeiros F, Eydelman MB. Artificial Intelligence for Glaucoma: Creating and Implementing Artificial Intelligence for Disease Detection and Progression. Ophthalmol Glaucoma 2022; 5:e16-e25. [PMID: 35218987 PMCID: PMC9399304 DOI: 10.1016/j.ogla.2022.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 12/15/2022]
Abstract
On September 3, 2020, the Collaborative Community on Ophthalmic Imaging conducted its first 2-day virtual workshop on the role of artificial intelligence (AI) and related machine learning techniques in the diagnosis and treatment of various ophthalmic conditions. In a session entitled "Artificial Intelligence for Glaucoma," a panel of glaucoma specialists, researchers, industry experts, and patients convened to share current research on the application of AI to commonly used diagnostic modalities, including fundus photography, OCT imaging, standard automated perimetry, and gonioscopy. The conference participants focused on the use of AI as a tool for disease prediction, highlighted its ability to address inequalities, and presented the limitations of and challenges to its clinical application. The panelists' discussion addressed AI and health equities from clinical, societal, and regulatory perspectives.
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Affiliation(s)
- Lama A Al-Aswad
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York; Department of Population Health, NYU Langone Health, NYU Grossman School of Medicine, New York, New York.
| | - Rithambara Ramachandran
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York
| | - Joel S Schuman
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York; Department of Biomedical Engineering, New York University Tandon School of Engineering, Brooklyn, New York; Department of Electrical and Computer Engineering, New York University Tandon School of Engineering, Brooklyn, New York; Center for Neural Science, NYU, New York, New York; Neuroscience Institute, NYU Langone Health, New York, New York
| | - Felipe Medeiros
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina; Department of Electrical and Computer Engineering, Pratt School of Engineering, Duke University, Durham, North Carolina
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27
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Stagg BC, Mariottoni EB, Berchuck SI, Jammal AA, Elam AR, Hess R, Kawamoto K, Haaland B, Medeiros FA. Longitudinal visual field variability and the ability to detect glaucoma progression in black and white individuals. Br J Ophthalmol 2022; 106:1115-1120. [PMID: 33985963 PMCID: PMC8589883 DOI: 10.1136/bjophthalmol-2020-318104] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/25/2021] [Accepted: 02/20/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS To investigate racial differences in the variability of longitudinal visual field testing in a 'real-world' clinical population, evaluate how these differences are influenced by socioeconomic status, and estimate the impact of differences in variability on the time to detect visual field progression. METHODS This retrospective observational cohort study used data from 1103 eyes from 751 White individuals and 428 eyes from 317 black individuals. Linear regression was performed on the standard automated perimetry mean deviation values for each eye over time. The SD of the residuals from the trend lines was calculated and used as a measure of variability for each eye. The association of race with the SD of the residuals was evaluated using a multivariable generalised estimating equation model with an interaction between race and zip code income. Computer simulations were used to estimate the time to detect visual field progression in the two racial groups. RESULTS Black patients had larger visual field variability over time compared with white patients, even when adjusting for zip code level socioeconomic variables (SD of residuals for Black patients=1.53 dB (95% CI 1.43 to 1.64); for white patients=1.26 dB (95% CI 1.14 to 1.22); mean difference: 0.28 (95% CI 0.15 to 0.41); p<0.001). The difference in visual field variability between black and white patients was greater at lower levels of income and led to a delay in detection of glaucoma progression. CONCLUSION Black patients had larger visual field variability compared with white patients. This relationship was strongly influenced by socioeconomic status and may partially explain racial disparities in glaucoma outcomes.
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Affiliation(s)
- Brian C. Stagg
- Vision, Imaging and Performance (VIP) Laboratory, Duke Eye Center, Durham, North Carolina, USA,Moran Eye Center, University of Utah, Salt Lake City, Utah, USA,Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Eduardo B. Mariottoni
- Vision, Imaging and Performance (VIP) Laboratory, Duke Eye Center, Durham, North Carolina, USA
| | - Samuel I. Berchuck
- Vision, Imaging and Performance (VIP) Laboratory, Duke Eye Center, Durham, North Carolina, USA,Department of Statistical Science and Forge, Duke University, Durham, North Carolina, USA
| | - Alessandro A. Jammal
- Vision, Imaging and Performance (VIP) Laboratory, Duke Eye Center, Durham, North Carolina, USA
| | - Angela R. Elam
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA,Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Rachel Hess
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Ben Haaland
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Felipe A. Medeiros
- Vision, Imaging and Performance (VIP) Laboratory, Duke Eye Center, Durham, North Carolina, USA
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Ramsey DJ, Lasalle CC, Anjum S, Marx JL, Roh S. Telehealth Encourages Patients with Diabetes in Racial and Ethnic Minority Groups to Return for in-Person Ophthalmic Care During the COVID-19 Pandemic. Clin Ophthalmol 2022; 16:2157-2166. [PMID: 35814918 PMCID: PMC9268229 DOI: 10.2147/opth.s368972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose The COVID-19 pandemic had a disproportionate impact on patients from racial and/or ethnic minority groups, causing many to delay healthcare. This study evaluates the role telehealth visits played in helping patients with diabetes mellitus (DM) return for subsequent, in-person eye examinations after the outbreak of COVID-19. Methods This retrospective, cross-sectional study analyzed 8147 patients with DM who had completed an outpatient ophthalmology and/or optometry visit in 2019 and who were due for return evaluation after the outbreak of COVID-19 in 2020. Factors associated with return for subsequent, in-person eye examination were assessed. Results The mean age of patients was 68.8 (±13.0) years, and 42% were women. 7.4% of patients identified as Asian; 2.9% as Black; 3.4% as Hispanic or Latin American; 0.92%, as more than one race; 1.78%, as other races; and 80.7% as White. Patients from racial and/or ethnic minority groups completed fewer in-person eye examinations after the outbreak of COVID-19 compared with White patients (35.6% versus 44.5%, χ 2=36.172, P<0.001). However, both groups accessed telehealth services at a similar rate during this period (21.1% versus 21.9%, χ 2=0.417, P=0.518). Importantly, patients who received telehealth services returned for subsequent, in-person eye examinations at substantially higher rates, regardless of race (51.0% and 46.6%, respectively, χ 2=1.840, P=0.175). This offset the otherwise lower rate of return experienced by patients from racial and/or ethnic minority groups compared with White patients among the group of patients who did not receive any telehealth services (32.7% versus 42.7%, χ 2=36.582, P<0.001). The impact of telehealth on the likelihood of in-person return remained significant after taking into account age, gender, race, language, residence, severity of diabetic retinopathy (DR), and vision in a multivariate model. Conclusion Telehealth initiatives benefited patients from racial and/or ethnic minority groups by reducing disparities in access to eye care experienced during the COVID-19 pandemic.
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Affiliation(s)
- David J Ramsey
- Department of Surgery, Division of Ophthalmology, Lahey Hospital & Medical Center, Beth Israel Lahey Health, Burlington, MA, 01805, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, 02111, USA
| | - Claudia C Lasalle
- Department of Surgery, Division of Ophthalmology, Lahey Hospital & Medical Center, Beth Israel Lahey Health, Burlington, MA, 01805, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, 02111, USA
| | - Sidrah Anjum
- Department of Surgery, Division of Ophthalmology, Lahey Hospital & Medical Center, Beth Israel Lahey Health, Burlington, MA, 01805, USA
| | - Jeffrey L Marx
- Department of Surgery, Division of Ophthalmology, Lahey Hospital & Medical Center, Beth Israel Lahey Health, Burlington, MA, 01805, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, 02111, USA
| | - Shiyoung Roh
- Department of Surgery, Division of Ophthalmology, Lahey Hospital & Medical Center, Beth Israel Lahey Health, Burlington, MA, 01805, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, 02111, USA
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Glaucoma Treatment Outcomes in Open Angle Glaucoma Patients of African Descent. J Glaucoma 2022; 31:479-487. [PMID: 35353787 PMCID: PMC9246921 DOI: 10.1097/ijg.0000000000002027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/19/2022] [Indexed: 01/31/2023]
Abstract
Open angle glaucoma (OAG), characterized by structural changes to the optic nerve head and retinal nerve fiber layer, is a progressive multifactorial optic neuropathy and a leading cause of irreversible blindness globally. Currently, intraocular pressure is the only modifiable risk factor; however, others have been identified, including genetics and race. Importantly, OAG is much more prevalent in persons of African descent (AD) compared with those of European descent (ED). OAG patients of AD are also known to have a more severe course of the disease, a finding potentially explained by structural and/or vascular differences within eye tissues. In addition, disparities in treatment outcomes have been identified in OAG patients of AD. Specifically, prostaglandin analogues have been suggested to be more effective in patients of AD than in those ED, while beta-adrenergic receptors have been suggested to be less effective, although the evidence is inconsistent. AD has also been identified as a risk factor for trabeculectomy failure while laser trabeculoplasty has been conversely found to be very effective in lowering intraocular pressure in patients of AD. Alternative surgical options, including Ex-Press shunt implantation, viscocanalostomy, and canaloplasty are promising in equivalence but require further research to evaluate disparity in outcome properly. In addition to treatment outcomes, social disparities affecting clinical care also exist for AD persons in the form of reduced adherence, access, and choice. Overall, data suggest the need for properly designed prospective trials with AD populations as a primary focus to identify the potential mechanisms driving disparities in treatment and address overall potential bias in glaucoma management.
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Williams AM, Sahel JA. Addressing Social Determinants of Vision Health. Ophthalmol Ther 2022; 11:1371-1382. [PMID: 35674883 PMCID: PMC9174922 DOI: 10.1007/s40123-022-00531-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022] Open
Abstract
Social determinants of health encompass the quality of an individual’s social and physical environment and its effect on health outcomes. Disparities in these social and environmental factors have a significant role in vision health disparities and inequity in eye care. In this review, we discuss how disparities in visual impairment and eye care utilization are affected by each of the five core domains of social determinants of health, namely economic stability (income, employment, and food security), education (education level and health literacy), health care access (insurance and medical costs), neighborhood environment (housing conditions, home ownership, pollution, and crime), and social context (race and racism). Moreover, we describe a framework by which ophthalmologists can take action to address social determinants of vision health. These actionable strategies are guided by recommendations from the National Academies of Sciences, Engineering, and Medicine and have five complementary components to address social needs: awareness (screening for social needs), assistance (connecting patients with social care resources), adjustment (altering clinical care in recognition of social needs), alignment (understanding social assets and collaborating with community organizations), and advocacy (promoting policies to address social needs). Addressing social determinants of health is complex but achievable through collaborative strategies. Ophthalmologists have an important leadership role in addressing eye care disparities by taking action on underlying social determinants of vision health.
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Affiliation(s)
- Andrew M Williams
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - José-Alain Sahel
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Ross AG, Higginbotham EJ. Unpacking the Barriers to Medication Adherence May Move Us Closer to Eye Health Equity. JAMA Ophthalmol 2022; 140:361-362. [PMID: 35238916 DOI: 10.1001/jamaophthalmol.2022.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ahmara G Ross
- Scheie Eye Institute, University of Pennsylvania, Philadelphia
| | - Eve J Higginbotham
- Scheie Eye Institute, University of Pennsylvania, Philadelphia.,Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia
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Association of Race and Ethnicity with the Frequency of Outpatient Glaucoma Care. Ophthalmology 2021; 129:585-587. [PMID: 34902350 DOI: 10.1016/j.ophtha.2021.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 11/21/2022] Open
Abstract
This study examined 5815 adults with self-reported glaucoma in a representative US cohort. Non-Hispanic Black adults with glaucoma were significantly less likely to see an ophthalmologist or optometrist for glaucoma care, which may contribute to worse vision outcomes.
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Rowe LW, Scheive M, Tso HL, Wurster P, Kalafatis NE, Camp DA, Thau A, Yung CWR. A seven-year analysis of the role and impact of a free community eye clinic. BMC MEDICAL EDUCATION 2021; 21:596. [PMID: 34856952 PMCID: PMC8636581 DOI: 10.1186/s12909-021-03026-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/16/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The Indiana University Student Outreach Clinic (IUSOC) Eye Clinic is a monthly student-run eye clinic that provides free visual screening to the Near East Side community of Indianapolis, IN, USA. Screening includes assessments of visual acuity, intraocular pressure, peripheral visual fields, refraction, and non-mydriatic fundus photography. METHODS This is a retrospective chart review of 875 patients seen at the IUSOC Eye Clinic from October 2013 to February 2020. Data on demographics, insurance coverage, ocular history, physical examination, suspected diagnosis, referral status, and glasses provided were collected and analyzed. RESULTS 875 patients were seen at the IUSOC Eye Clinic from October 2013 to February 2020. 39.2% of the patients seen at the clinic reported being uninsured. 61.4% of patients were found to have visual acuity of 20/40 or worse, while 51.3% of patients were found to have a near visual acuity of 20/40 or worse. 20.3% of patients were referred to the local county hospital for further evaluation by an ophthalmologist, 14.4% of patients received free glasses prescriptions, and 27.9% of patients received free reading glasses. Common reasons for referral for further ophthalmology evaluation included glaucoma, decreased visual acuity, and diabetic retinopathy. An estimated value of services provided over the seven years of the clinic was 1271 relative value units. CONCLUSION The IUSOC Eye Clinic fills an important role in advancing ocular health and preventing irreversible blindness in an underserved Indianapolis community. Additionally, the clinic demonstrates an educational model for involving medical student volunteers.
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Affiliation(s)
- Lucas W Rowe
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Melanie Scheive
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hanna L Tso
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Wurster
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas E Kalafatis
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David A Camp
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Avrey Thau
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chi Wah Rudy Yung
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA.
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Vaughn D, Elam A. Addressing Structural Racism: Towards an Organization-Theoretical Approach. Am J Ophthalmol 2021; 232:A1-A3. [PMID: 33992613 DOI: 10.1016/j.ajo.2021.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Deonna Vaughn
- From the Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA..
| | - Angela Elam
- From the Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA
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Lu ES, Bannerman A, Miller JB. Strategies to Increase Underrepresented Minority Trainees in the Ophthalmology Pipeline: Perspective From a Large Retina Research Laboratory. JOURNAL OF VITREORETINAL DISEASES 2021; 5:531-533. [PMID: 37007174 PMCID: PMC9976142 DOI: 10.1177/2474126421998607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Edward S. Lu
- Harvard Retinal Imaging Laboratory, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Augustine Bannerman
- Harvard Retinal Imaging Laboratory, Boston, MA, USA
- Harvard College, Cambridge, MA, USA
| | - John B. Miller
- Harvard Retinal Imaging Laboratory, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Halawa OA, Kolli A, Oh G, Mitchell WG, Glynn RJ, Kim DH, Friedman DS, Zebardast N. Racial and Socioeconomic Differences in Eye Care Utilization among Medicare Beneficiaries with Glaucoma. Ophthalmology 2021; 129:397-405. [PMID: 34626697 DOI: 10.1016/j.ophtha.2021.09.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Evaluate differences in eye care utilization among patients with glaucoma by race and socioeconomic status (SES). DESIGN Retrospective cohort study. PARTICIPANTS Representative 5% sample of Medicare beneficiaries aged > 65 years with continuous part A/B enrollment between January 1, 2014, and July 1, 2014, at least 1 diagnosis code for glaucoma within that period, and a glaucoma diagnosis in the Chronic Conditions Warehouse before January 1, 2014. METHODS The following race/ethnicity categories were defined in our cohort: non-Hispanic White, Black/African American, Hispanic, and Asian/Pacific Islander. Low SES was defined as having 2 or more enrollment-based low-income indicators (dual eligibility for Medicare/Medicaid, Part D limited income subsidies, and eligibility for Part A and B State buy-in). Negative binomial regression analyses were carried out to compare relative rate ratios (RRs) of eye care utilization among racial groups stratified by low and non-low SES. MAIN OUTCOME MEASURES Measured from July 1, 2014, to December 31, 2016: eye examinations and eye care-related office visits; eye care-related inpatient and emergency department (ED) encounters; eye care-related nursing home and home-visit encounters; visual field and retinal nerve fiber OCT tests; glaucoma lasers and surgeries. RESULTS Among 78 526 participants with glaucoma, mean age was 79.1 years (standard deviation, 7.9 years), 60.9% were female, 78.4% were non-Hispanic White, and 13.8% met enrollment-based criteria for low-SES. Compared with White beneficiaries, Blacks had lower counts of outpatient visits (RR, 0.92; 95% confidence interval [CI], 0.90-0.93), visual field (VF) tests (RR, 0.92; 95% CI, 0.90-0.94), but more inpatient/ED encounters (RR, 2.42; 95% CI, 1.55-3.78) and surgeries (RR, 1.14; 95% CI, 1.03-1.27). Hispanics had fewer outpatient visits (RR, 0.97; 95% CI, 0.95-0.98) and retinal nerve fiber layer (RNFL) OCT tests (RR, 0.89; 95% CI, 0.86-0.93), but more inpatient/ED encounters (RR, 2.32; 95% CI, 1.18-4.57) and selective laser trabeculoplasty (SLT) (RR, 1.25; 95% CI, 1.11-1.42) versus non-Hispanic Whites. In the non-low SES group, Black versus White disparities persisted in outpatient visits (RR, 0.93; 95% CI, 0.92-0.95), VF (RR, 0.96; 95% CI, 0.94-0.98), RNFL OCT (RR, 0.81; 95% CI, 0.78-0.83), and inpatient/ED encounters (RR, 2.57; 95% CI, 1.55-4.26). CONCLUSIONS Disparities were found in eye care utilization among Black and Hispanic patients with glaucoma. These differences persisted among Blacks after stratification by SES, suggesting that systemic racism may be an independent driver in this population.
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Affiliation(s)
- Omar A Halawa
- Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Ajay Kolli
- University of Michigan Medical School, Ann Arbor, Michigan; Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Gahee Oh
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | | | - Robert J Glynn
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Dae Hyun Kim
- Harvard Medical School, Boston, Massachusetts; Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - David S Friedman
- Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Nazlee Zebardast
- Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.
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Chiam M, Kunselman AR, Chen MC. Characteristics Associated With New Patient Appointment No-Shows at an Academic Ophthalmology Department in the United States. Am J Ophthalmol 2021; 229:210-219. [PMID: 33626367 DOI: 10.1016/j.ajo.2021.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/29/2021] [Accepted: 02/16/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE This study aimed to identify patient and appointment characteristics associated with no-shows to new patient appointments at a US academic ophthalmology department. DESIGN Cross-sectional study. METHODS This was a study of all adult patients with new patient appointments scheduled with an attending ophthalmologist at Penn State Eye Center between January 1st and December 31st of 2019. A multiple logistic regression model was used to assess the association between characteristics and no-show status. RESULTS Of 4,628 patients, 759 (16.4%) were no-shows. From the multiple logistic regression model, characteristics associated with no-shows were age (Odds Ratio (OR) for 18-40 years vs. >60 years: 3.41, 95% Confidence Interval (CI) 2.57, 4.51, p <0.001 and OR for 41-60 years vs. >60 years: 2.14, 95% CI 1.67, 2.74, p<0.001), median household income (OR for <$35,667 vs. >$59,445: 1.59, 95% CI 1.08, 2.34, p<0.001), insurance (OR for None vs. Medicare: 6.92, 95% CI 4.41, 10.86, p<0.001 and OR for Medicaid vs. Medicare: 1.54, 95% CI 1.18, 2.01, p=0.002), race (OR for Black vs. White: 2.62, 95% CI 2.00, 3.43, p<0.001 and OR for Other vs. White: 2.02, 95% CI 1.58, 2.59, p<0.001), and commute distance (OR for 5-10 mi vs. ≤5 mi: 1.73, 95% CI 1.17, 2.55, p=0.006). Appointments with longer lead times and scheduled with glaucoma or retina specialists were also significantly associated with greater no-shows. CONCLUSION Certain patient and appointment characteristics were associated with no-show status. These findings may assist in the development of targeted interventions at the patient, practice, and health system levels to improve appointment attendance.
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Affiliation(s)
- Mckenzee Chiam
- From the Department of Ophthalmology (MC, MCC), Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA
| | - Allen R Kunselman
- Department of Public Health Sciences (ARK), Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA
| | - Michael C Chen
- From the Department of Ophthalmology (MC, MCC), Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA.
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Affiliation(s)
- Adrienne W Scott
- Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Angela R Elam
- Department of Ophthalmology and Visual Sciences, WK Kellogg Eye Center, University of Michigan, Ann Arbor
| | - Kristen Nwanyanwu
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut
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Al-Moujahed A, Vail D, Do DV. Racial Differences in Anti-VEGF Intravitreal Injections Among Commercially Insured Beneficiaries. Ophthalmic Surg Lasers Imaging Retina 2021; 52:208-217. [PMID: 34039186 DOI: 10.3928/23258160-20210330-05] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE This study assessed racial and ethnic differences in receiving anti-vascular endothelial growth factor (VEGF) intravitreal injections among commercially insured patients. PATIENTS AND METHODS A retrospective cohort study of 104,430 patients diagnosed with wet age-related macular degeneration (AMD), diabetic retinopathy, central retinal vein occlusion (CRVO), and branch retinal vein occlusion (BRVO) in the Optum Research Database between 2011 and 2016. Main outcomes included receiving an intravitreal anti-VEGF treatment; the first type of treatment received, if any; and subsequent treatment with ranibizumab or aflibercept among patients who were first treated with bevacizumab. RESULTS In a logistic regression model in all 104,430 patients, Asian patients were significantly less likely to receive an anti-VEGF treatment compared to white patients (odds ratio [OR] = 0.725; 95% confidence interval [CI], 0.667-0.789; P < .001), but Black and Hispanic patients were not. Overall, 19.9% (n = 20,753) of all included patients received treatment with intravitreal injections of anti-VEGF or steroids. In multinomial logistic models of treatment type among all patients who received intravitreal injections, Hispanic patients were less likely than white patients to initially be treated with ranibizumab (relative risk ratio [RRR] = 0.776; 95% CI, 0.647-0.929; P = .006) or aflibercept (RRR = 0.794; 95% CI, 0.654-0.964; P = .020). Black and Asian patients were not significantly more or less likely to receive different types of first-line injections compared to white patients. Among 17,092 patients who received bevacizumab as first-line therapy, Hispanic patients were less likely to subsequently transition to aflibercept than their white counterparts (RRR = 0.756; 95% CI, 0.634-0.903; P = .002). CONCLUSIONS The authors found minimal racial and ethnic differences in receiving anti-VEGF treatment among commercially insured patients with wet AMD, diabetic retinopathy, CRVO, and BRVO. These results are limited by the fact that all of the patients included were commercially insured, and there are limited data on the socioeconomic status of the patients in their sample. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:208-217.].
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PATIENTS PRESENTING EMERGENTLY WITH PROLIFERATIVE DIABETIC RETINOPATHY: Follow-up and Factors Associated With Compliance. Retina 2021; 40:928-935. [PMID: 30897069 DOI: 10.1097/iae.0000000000002481] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the rate of follow-up after emergent encounters for proliferative diabetic retinopathy and to identify patient or visit characteristics associated with follow-up compliance. METHODS A retrospective cohort study of patients presenting to an ophthalmic emergency department with active proliferative diabetic retinopathy between May 2014 and December 2016 was conducted. Demographic data and encounter data were gathered for each emergency department visit. Compliance with follow-up was defined as a completed clinic visit as scheduled after the emergency encounter. RESULTS A total of 590 emergency department encounters were included. The overall follow-up rate was 61.9%. Married patients and those with Public Health Trust insurance had increased odds of compliance (odds ratio [OR]: 1.507, P = 0.04; OR: 2.749, P < 0.0001). Patients with Medicaid had reduced odds (OR: 0.543, P = 0.004). Patients with longer emergency department encounters and longer intervals to follow-up had reduced odds (OR: 0.948, P = 0.001; OR of 0.941, P < 0.0001). The other characteristics were not significantly associated with follow-up compliance. CONCLUSION Patients who present emergently with active proliferative diabetic retinopathy are at high risk of following up noncompliance. Characteristics with significant effects on the odds of follow-up compliance include specific insurance payer, marriage status, length of visit, and interval to follow-up.
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Iorio-Aranha F, Peleteiro B, Rocha-Sousa A, Azevedo A, Barbosa-Breda J. A Scoping Review of Process Indicators for Measuring Quality of Care in Glaucoma. J Glaucoma 2021; 30:e198-e204. [PMID: 33675335 DOI: 10.1097/ijg.0000000000001825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 02/13/2021] [Indexed: 11/26/2022]
Abstract
PRCIS There are no standardized process quality indicators (QIs) in glaucoma care. Although they can be inferred from guidelines and trials, they should be designed and standardized to allow better assessment of the quality of care. PURPOSE QIs are crucial for assessing the performance of any health care system. To allow efficiency, effectiveness, and patient-centeredness, there is a need for prompt acquisition of up-to-date information. Among the available QIs, process indicators have the highest sensitivity to frequent changes and could better reflect the implementation outcomes of novel ideas and technology. This study aimed to map the available information regarding process QIs in glaucoma care, identify the current development stage of these indicators, and systematically synthesize them. MATERIALS AND METHODS We performed a scoping review of 4 electronic bibliographic databases for studies reporting on process QIs in glaucoma. We retrieved 7502 references and created a domain list reflecting the core idea underlying each indicator. RESULTS We summarized information from 18 documents and listed 20 domains. The most mentioned domains were follow-up, optic nerve head assessment, visual field test, and intraocular pressure. Indicators regarding the quality of life assessment, patient assistance, or presence of written protocols were less frequently mentioned. CONCLUSIONS There are notable variations among process QIs in glaucoma and significant heterogeneity in their descriptions in published studies. Although novel indicators can be inferred from guidelines and trials, they should be designed and standardized for better assessment of performance in health systems to improve their quality.
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Affiliation(s)
- Flavio Iorio-Aranha
- EPIUnit, Institute of Public Health, Universidade do Porto
- Department of Ophthalmology, Faculty of Medicine, Universidade de Brasilia, Brasilia, Brasil
| | - Bárbara Peleteiro
- EPIUnit, Institute of Public Health, Universidade do Porto
- Departments of Public Health and Forensic Sciences and Medical Education
- Hospital Epidemiology Center
| | - Amândio Rocha-Sousa
- Surgery and Physiology and Cardiovascular R&D Center, Faculty of Medicine, Universidade do Porto
- Department of Ophthalmology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Ana Azevedo
- EPIUnit, Institute of Public Health, Universidade do Porto
- Departments of Public Health and Forensic Sciences and Medical Education
- Hospital Epidemiology Center
| | - João Barbosa-Breda
- Surgery and Physiology and Cardiovascular R&D Center, Faculty of Medicine, Universidade do Porto
- Department of Ophthalmology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Neurosciences, Research Group Ophthalmology, KULeuven, Leuven, Belgium
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Zhao PY, Branham K, Schlegel D, Fahim AT, Jayasundera KT. Association of No-Cost Genetic Testing Program Implementation and Patient Characteristics With Access to Genetic Testing for Inherited Retinal Degenerations. JAMA Ophthalmol 2021; 139:449-455. [PMID: 33662097 PMCID: PMC7934082 DOI: 10.1001/jamaophthalmol.2021.0004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
IMPORTANCE The benefits of no-cost genetic testing initiatives have not been characterized. The no-cost My Retina Tracker Genetic Testing Study (MRT-GTS) research registry for inherited retinal degenerations (IRDs) was launched in 2017 in the US. OBJECTIVE To investigate the associations of MRT-GTS implementation and patient characteristics with access to genetic testing for IRDs. DESIGN, SETTING, AND PARTICIPANTS In a cross-sectional design, analysis of new patients evaluated 12 months before (July 1, 2016, to June 13, 2017) and 12 months after (June 14, 2017, to June 30, 2018) MRT-GTS implementation at a single academic referral eye center was conducted. Participants included 369 patients with IRD. Data analysis was conducted from February to June 2020. MAIN OUTCOMES AND MEASURES Change in rates of successfully obtaining genetic testing, odds ratios (ORs) of association between patient characteristics and obtaining testing, and days elapsed from clinic visit to reporting of results. RESULTS Among 369 patients (mean [SD] age, 39.5 [20.8] years; 193 [52.3%] women), 144 were evaluated in the pre-MRT-GTS period and 225 in the post-MRT-GTS period. The baseline rate of successfully obtaining testing was 51.4% (95% CI, 42.6%-60.2%). The initiation of MRT-GTS was associated with a 28.9-percentage point increase in testing rate (95% CI, 16.7%-41.1%; P < .001). Patient characteristics that increased the odds of obtaining testing were eligibility for MRT-GTS (OR, 14.15; 95% CI, 7.36-27.24; P < .001) and worse visual acuity (logMAR +1.0; Snellen equivalent decrease from 20/20 to 20/200) in the better-seeing eye (OR, 1.92; 95% CI, 1.27-2.91; P < .01). Patients had decreased odds when identifying as Black or African American (OR, 0.10; 95% CI, 0.04-0.24; P < .001) or other race (OR, 0.37; 95% CI, 0.15-0.91; P = .03) compared with White race, and when the primary language was not English (OR, 0.13; 95% CI, 0.03-0.55; P < .01). The proportion of test results reported within 90 days was 81.5% (95% CI, 74.8%-86.4%) when eligible for MRT-GTS compared with 48.1% (95% CI, 35.6%-58.1%) when not eligible (P < .001). CONCLUSIONS AND RELEVANCE In this study, the implementation of MRT-GTS was associated with an increase in the proportion of patients who successfully obtained testing, suggesting the potential clinical value of this approach. Patient-level demographic and clinical factors appear to be associated with decisions to pursue testing.
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Affiliation(s)
- Peter Y. Zhao
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Kari Branham
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Dana Schlegel
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Abigail T. Fahim
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - K. Thiran Jayasundera
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
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Ciarametaro M, Houghton K, Wamble D, Dubois R. The Dollar or Disease Burden: Caps on Healthcare Spending May Save Money, but at What "Cost" to Patients? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:388-396. [PMID: 33641773 DOI: 10.1016/j.jval.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 09/22/2020] [Accepted: 10/05/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Various strategies to address healthcare spending and medical costs continue to be debated and implemented in the United States. To date, these efforts have failed to adequately contain the growth of healthcare cost. An alternative strategy that has elicited rising interest among policymakers is budget caps. As budget caps become more prevalent, it is important to identify which features are needed to ensure success, both in terms of cost reduction and health improvement. METHODS We explored the impacts of different features of budget caps by comparing hypothetical service level and global budget caps across 3 annual budget cap growth strategies over a 10-year timeframe in 2005-2015 for 8 of the most commonly occurring conditions in the United States. Health was assessed by a measure of disease burden (disability-adjusted life years). RESULTS The results indicate that budget caps have the potential for creating savings but can also result in patient harm if not designed well. As a result of these findings, 5 principles were developed for designing budget caps and should guide the use of budget caps to address medical spending. CONCLUSIONS As public discussion grows about the use of budget caps to constrain health spending, it is critical to recognize that the budget cap design and the resulting healthcare provider behavior will determine whether there is potential harm to public health. Budget cap design should consider variability at the condition level, including patient population, improvements in health, treatment costs, and the innovations available, to both create savings and maximize patient health. In assessing the impact of healthcare spending caps on costs and disease burden, we demonstrate that budget cap design determines potential harm to public health.
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Affiliation(s)
| | - Katherine Houghton
- Research Triangle Institute Health Solutions (RTI-HS), Research Triangle Park, North Carolina, USA.
| | - David Wamble
- Research Triangle Institute Health Solutions (RTI-HS), Research Triangle Park, North Carolina, USA; Bristol Myers Squibb, Lawrence Township, New Jersey, USA
| | - Robert Dubois
- National Pharmaceutical Council, Washington, DC, USA
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Aguwa UT, Srikumaran D, Brown N, Woreta F. Improving Racial Diversity in the Ophthalmology Workforce: A Call to Action for Leaders in Ophthalmology. Am J Ophthalmol 2021; 223:306-307. [PMID: 33393483 PMCID: PMC7578664 DOI: 10.1016/j.ajo.2020.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 12/17/2022]
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Loss to Follow-Up Among Patients With Proliferative Diabetic Retinopathy in Clinical Practice. Am J Ophthalmol 2020; 215:66-71. [PMID: 32209344 DOI: 10.1016/j.ajo.2020.03.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine the proportion of patients with proliferative diabetic retinopathy (PDR) who were counted as loss to follow-up (LTFU) patients and to investigate predictive factors. DESIGN Retrospective cohort study. METHODS Information was collected for 4,423 patients with PDR between April 30, 2012, and April 30, 2017. Two definitions of LTFU were used. Complete LTFU referred to the population who never returned to care within the study period. Interval LTFU referred to the population who did not adhere to clinical recommendations and missed scheduled appointments, resulting in intervals longer than 6 months or 1 year between 2 appointments. Age, average gross income, and insurance were assessed as potential predictors of interval LTFU. RESULTS Among 4,423 patients with PDR, 2,407 (54.4%) and 2,320 (52.4%) were complete LTFU at 6 months and 1 year, respectively; 782 (17.7%) and 468 (10.6%) patients were interval LTFU for 6 months and 1 year, respectively. Age and average gross income were not found to be significant predictors of interval LTFU. Compared to self-pay, government and private insurance patients were more likely to be interval LTFU at 6 months (government, P = .035; private, P = .005). Private insurance patients were also more likely to be interval LTFU at 1 year (P = .003). CONCLUSIONS The identified complete LTFU rates were notably high and warrant further study. More than 1 of 6 patients were interval LTFU for at least 6 months, and 1 of 10 patients was interval LTFU for more than 1 year. Insurance status was significant in determining interval LTFU status. Consistent with other analyses, these results indicate that compliance with clinical appointments among patients with PDR is a substantial clinical challenge.
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Morse AR, Seiple W, Talwar N, Lee PP, Stein JD. Association of Vision Loss With Hospital Use and Costs Among Older Adults. JAMA Ophthalmol 2020; 137:634-640. [PMID: 30946451 DOI: 10.1001/jamaophthalmol.2019.0446] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patients with vision loss who are hospitalized for common illnesses are often not identified as requiring special attention. This perception, however, may affect the outcomes, resource use, and costs for these individuals. Objective To assess whether the mean hospitalization lengths of stay, readmission rates, and costs of hospitalization differed between individuals with vision loss and those without when they are hospitalized for similar medical conditions. Design, Setting, and Participants This analysis of health care claims data used 2 sources: Medicare database and Clinformatics DataMart. Individuals with vision loss were matched 1:1 to those with no vision loss (NVL), on the basis of age, years from initial hospitalization, sex, race/ethnicity, urbanicity of residence, and overall health. Both groups had the same health insurance (Medicare or a commercial health plan), and all had been hospitalized for common illnesses. Vision loss was categorized as either partial vision loss (PVL) or severe vision loss (SVL). Data were analyzed from April 2015 through April 2018. Main Outcomes and Measures The outcomes were lengths of stay, readmission rates, and health care costs during hospitalization and 90 days after discharge. Multivariable logistic and linear regression models were built to identify factors associated with these outcomes among the NVL, PVL, and SVL groups. Results Among Medicare beneficiaries, 6165 individuals with NVL (with a mean [SD] age of 82.0 [8.3] years, and 3833 [62.2%] of whom were female) were matched to 6165 with vision loss. Of those with vision loss, 3401 (55.2%) had PVL and 2764 (44.8%) had SVL. In the Clinformatics DataMart database, 5929 individuals with NVL (with a mean [SD] age of 73.7 [15.1] years, and 3587 [60.5%] of whom were female) were matched to 5929 individuals with vision loss. Of the commercially insured enrollees with vision loss, 3515 (59.3%) had PVL and 2414 (40.7%) had SVL. Medicare enrollees with SVL, compared with those with NVL, had longer mean lengths of stay (6.48 vs 5.26 days), higher readmission rates (23.1% vs 18.7%), and higher hospitalization and 90-day postdischarge costs ($64 711 vs $61 060). Compared with those with NVL, Medicare beneficiaries with SVL had 4% longer length of stay (estimated ratio, 1.04; 95% CI, 1.01-1.07; P = .02), 22% higher odds of readmission (odds ratio, 1.22; 95% CI, 1.06-1.41; P = .007), and 12% higher costs (estimated cost ratio, 1.12; 95% CI, 1.06-1.18; P < .001). Similar findings were obtained for those with commercial health insurance. When these findings were extrapolated to hospitalizations of patients with vision loss nationwide, an estimated amount of more than $500 million in additional costs annually were spent caring for these patients. Conclusions and Relevance These findings suggest that opportunities for improving outcomes and reducing costs exist in addressing patients' vision loss and concomitant functional difficulties during hospitalization and thereafter.
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Affiliation(s)
- Alan R Morse
- Lighthouse Guild, New York, New York.,Department of Ophthalmology, Columbia University, New York, New York
| | - William Seiple
- Lighthouse Guild, New York, New York.,Department of Ophthalmology, New York University School of Medicine, New York
| | - Nidhi Talwar
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Paul P Lee
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor.,Center for Eye Policy and Innovation, University of Michigan, Ann Arbor
| | - Joshua D Stein
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor.,Center for Eye Policy and Innovation, University of Michigan, Ann Arbor.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
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Stein JD, Rahman M, Andrews C, Ehrlich JR, Kamat S, Shah M, Boese EA, Woodward MA, Cowall J, Trager EH, Narayanaswamy P, Hanauer DA. Evaluation of an Algorithm for Identifying Ocular Conditions in Electronic Health Record Data. JAMA Ophthalmol 2020; 137:491-497. [PMID: 30789656 DOI: 10.1001/jamaophthalmol.2018.7051] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance For research involving big data, researchers must accurately identify patients with ocular diseases or phenotypes of interest. Reliance on administrative billing codes alone for this purpose is limiting. Objective To develop a method to accurately identify the presence or absence of ocular conditions of interest using electronic health record (EHR) data. Design, Setting, and Participants This study is a retrospective analysis of the EHR data of patients (n = 122 339) in the Sight Outcomes Research Collaborative Ophthalmology Data Repository who received eye care at participating academic medical centers between August 1, 2012, and August 31, 2017. An algorithm that searches structured and unstructured (free-text) EHR data for conditions of interest was developed and then tested to determine how well it could detect the presence or absence of exfoliation syndrome (XFS). The algorithm was trained to search for evidence of XFS among a sample of patients with and without XFS (n = 200) by reviewing International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-9 or ICD-10) billing codes, the patient's problem list, and text within the ocular examination section and unstructured (free-text) data in the EHR. The likelihood that each patient had XFS was estimated using logistic least absolute shrinkage and selection operator (LASSO) regression. The EHR data of all patients were run through the algorithm to generate an XFS probability score for each patient. The algorithm was validated with review of EHRs by glaucoma specialists. Main Outcomes and Measures Positive predictive value (PPV) and negative predictive value (NPV) of the algorithm were computed as the proportion of patients correctly classified with XFS or without XFS. Results This study included 122 339 patients, with a mean (SD) age of 52.4 (25.1) years. Of these patients, 69 002 (56.4%) were female and 99 579 (81.4%) were white. The algorithm assigned a less than 10% probability of XFS for 121 085 patients (99.0%) as well as an XFS probability score of more than 75% for 543 patients (0.4%), more than 90% for 353 patients (0.3%), and more than 99% for 83 patients (0.07%). Validated by glaucoma specialists, the algorithm had a PPV of 95.0% (95% CI, 89.5%-97.7%) and an NPV of 100% (95% CI, 91.2%-100%). When there was ICD-9 or ICD-10 billing code documentation of XFS, in 86% or 96% of the records, respectively, evidence of XFS was also recorded elsewhere in the EHR. Conversely, when there was clinical examination or free-text evidence of XFS, it was documented with ICD-9 codes only approximately 40% of the time and even less often with ICD-10 codes. Conclusions and Relevance The algorithm developed, tested, and validated in this study appears to be better at identifying the presence or absence of XFS in EHR data than the conventional approach of assessing only billing codes; such an algorithm may enhance the ability of investigators to use EHR data to study patients with ocular diseases.
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Affiliation(s)
- Joshua D Stein
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor.,Center for Eye Policy and Innovation, University of Michigan, Ann Arbor
| | - Moshiur Rahman
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor.,Center for Eye Policy and Innovation, University of Michigan, Ann Arbor
| | - Chris Andrews
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor.,Center for Eye Policy and Innovation, University of Michigan, Ann Arbor
| | - Joshua R Ehrlich
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor.,Center for Eye Policy and Innovation, University of Michigan, Ann Arbor
| | - Shivani Kamat
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Manjool Shah
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Erin A Boese
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Maria A Woodward
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor.,Center for Eye Policy and Innovation, University of Michigan, Ann Arbor
| | - Jeff Cowall
- Data Office for Clinical and Translational Research, University of Michigan Medical School, Ann Arbor
| | - Edward H Trager
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Prabha Narayanaswamy
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor.,Center for Eye Policy and Innovation, University of Michigan, Ann Arbor
| | - David A Hanauer
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor
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Lee YH, Chen AX, Varadaraj V, Hong GH, Chen Y, Friedman DS, Stein JD, Kourgialis N, Ehrlich JR. Comparison of Access to Eye Care Appointments Between Patients With Medicaid and Those With Private Health Care Insurance. JAMA Ophthalmol 2018; 136:622-629. [PMID: 29710290 PMCID: PMC6007883 DOI: 10.1001/jamaophthalmol.2018.0813] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/12/2018] [Indexed: 01/10/2023]
Abstract
Importance Although low-income populations have more eye problems, whether they face greater difficulty obtaining eye care appointments is unknown. Objective To compare rates of obtaining eye care appointments and appointment wait times for those with Medicaid vs those with private insurance. Design, Setting, and Participants In this prospective, cohort study conducted from January 1, 2017, to July 1, 2017, researchers made telephone calls to a randomly selected sample of vision care professionals in Michigan and Maryland stratified by neighborhood (urban vs rural) and professional type (ophthalmologist vs optometrist) to request the first available appointment. Appointments were sought for an adult needing a diabetic eye examination and a child requesting a routine eye examination for a failed vision screening. Researchers called each practice twice, once requesting an appointment for a patient with Medicaid and the other time for a patient with Blue Cross Blue Shield (BCBS) insurance, and asked whether the insurance was accepted and, if so, when the earliest available appointment could be scheduled. Main Outcomes and Measures Rate of successfully made appointments and mean wait time for the first available appointment. Results A total of 603 telephone calls were made to 330 eye care professionals (414 calls [68.7%] to male and 189 calls [31.3%] to female eye care professionals). The sample consisted of ophthalmologists (303 [50.2%]) and optometrists (300 [49.8%]) located in Maryland (322 [53.4%]) and Michigan (281 [46.6%]). The rates of successfully obtaining appointments among callers were 61.5% (95% CI, 56.0%-67.0%) for adults with Medicaid and 79.3% (95% CI, 74.7%-83.9%) for adults with BCBS (P < .001) and 45.4% (95% CI, 39.8%-51.0%) for children with Medicaid and 62.5% (95% CI, 57.1%-68.0%) for children with BCBS (P < .001). Mean wait time did not vary significantly between the BCBS and Medicaid groups for both adults and children. Adults with Medicaid had significantly decreased odds of receiving an appointment compared with those with BCBS (odds ratio [OR], 0.41; 95% CI, 0.28-0.59; P < .001) but had increased odds of obtaining an appointment if they were located in Michigan vs Maryland (OR, 2.40; 95% CI, 1.49-3.87; P < .001) or with an optometrist vs an ophthalmologist (OR, 1.91; 95% CI, 1.31-2.79; P < .001). Children with Medicaid had significantly decreased odds of receiving an appointment compared with those with BCBS (OR, 0.41; 95% CI, 0.28-0.60; P < .001) but had increased odds of obtaining an appointment if they were located in Michigan vs Maryland (OR, 1.68; 95% CI, 1.04-2.73; P = .03) or with an optometrist vs an ophthalmologist (OR, 8.00; 95% CI, 5.37-11.90; P < .001). Conclusions and Relevance Callers were less successful in trying to obtain eye care appointments with Medicaid than with BCBS, suggesting a disparity in access to eye care based on insurance status, although confounding factors may have contributed to this finding. Improving access to eye care professionals for those with Medicaid may improve health outcomes and decrease health care spending in the long term.
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Affiliation(s)
- Yoon H. Lee
- Department of Ophthalmology, Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland
| | - Andrew X. Chen
- Center for Eye Policy and Innovation, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Varshini Varadaraj
- Department of Ophthalmology, Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland
| | - Gloria H. Hong
- Department of Ophthalmology, Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland
| | - Yimin Chen
- Center for Eye Policy and Innovation, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - David S. Friedman
- Department of Ophthalmology, Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland
- Helen Keller International, New York, New York
| | - Joshua D. Stein
- Center for Eye Policy and Innovation, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Health Management and Policy, University of Michigan, Ann Arbor
| | | | - Joshua R. Ehrlich
- Center for Eye Policy and Innovation, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Higginbotham EJ. A Singular Focus on Insurance Coverage Will Not Lead to Eye Health Equity. Ophthalmology 2017; 124:1437-1439. [PMID: 28938921 DOI: 10.1016/j.ophtha.2017.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 10/18/2022] Open
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