Seeing Red: Associations between Historical Redlining and Present-Day Visual Impairment and Blindness

Socioeconomic Disparities in Glaucoma Severity at Initial Diagnosis: A Nationwide Electronic Health Record Cohort Analysis

PURPOSE

To assess disparities in initial disease severity among open-angle glaucoma (OAG) patients.

DESIGN

Cross-sectional study.

METHODS

In this analysis of Epic Cosmos, an aggregated electronic health record dataset encompassing >213 million patients, OAG patients examined in ophthalmology or optometry clinics between January 1, 2013, and June 1, 2023, were evaluated. OAG severity at presentation was classified as mild, moderate, or severe using International Classification of Disease-10 codes. Demographics, social vulnerability index (SVI) scores, and rural-urban commuting area codes were evaluated as predictors of disease stage using ordinal logistic regression. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Of 245,669 patients, 38.1% had mild, 32.5% moderate, and 29.3% severe disease at presentation. In multivariable analyses, significant determinants of worse severity included older age (OR: 1.23 per decade, 95% CI: 1.22-1.23), male sex (OR: 1.37, 95% CI: 1.35-1.39), Black race (OR: 1.61, 95% CI: 1.58-1.65), Hispanic ethnicity (OR: 1.15, 95% CI: 1.11-1.18), non-commercial insurance or uninsured status (OR: 2.53, 95% CI: 2.33-2.74), secondary OAGs (eg, pseudoexfoliative glaucoma - OR: 1.65, 95% CI: 1.58-1.72), and higher socioeconomic SVI scores (OR: 1.25 for highest versus lowest quartile, 95% CI: 1.22-1.28). Black and Hispanic patients were diagnosed at younger ages compared to White patients (mean ages: 67.8 ± 12.3 and 68.1 ± 12.8 vs 73.3 ± 11.8 years respectively, P < .001).

CONCLUSIONS

Worse OAG at presentation was associated with older age, male sex, Black race, Hispanic ethnicity, non-commercial insurance or uninsured status, secondary OAGs, and greater socioeconomic vulnerability in this nationwide cohort. These findings can help tailor screening programs towards vulnerable populations.

Place-Based Measures of Inequity and Vision Difficulty and Blindness

Importance

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

Objective

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

Design, Setting, and Participants

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Historic redlining and health outcomes: A systematic review

OBJECTIVE

The purpose of this systematic review was to synthesize the existing literature on the associations between historic redlining and modern-day health outcomes across the lifespan.

METHOD

This review searched PubMed and CINAHL for peer-reviewed, data-based articles examining the relationship between historic redlining and any health outcome. Articles were appraised using the JBI critical appraisal checklist. The results were synthesized using a narrative summary approach.

RESULTS

Thirty-six articles were included and focused on various health outcomes, including cardiovascular outcomes, breast cancer incidence and mortality, firearm injury or death, birth-related outcomes, and asthma outcomes. Most of the included articles (n = 31; 86%) found significant associations between historic redlining and adverse health outcomes such as increased cardiovascular disease, higher rates of preterm births, increased cancer incidence, reduced survival time after breast cancer diagnosis, and increased firearm injury incidence.

DISCUSSION

This review demonstrates the persistent effect of historic redlining on individuals' health. Public health nurses should recognize redlining as a form of structural racism when caring for affected communities and should advocate for policies and programs that advance health equity. Nurse researchers should develop and test multilevel interventions to address systemic racism and improve health outcomes in communities affected by redlining.

Vision Need Profiles for the City of Richmond, Virginia: A Pilot Application of Calibration Methods to Vision Surveillance

Purpose

People with vision problems (VPs) have different needs based on their age, economic resources, housing type, neighborhood, and other disabilities. We used calibration methods to create synthetic data to estimate census tract-level community need profiles (CNPs) for the city of Richmond, Virginia.

Design

Cross-sectional secondary data analysis.

Subjects

Anonymized respondents to the 2015 to 2019 American Community Survey (ACS).

Methods

We used calibration methods to transform the ACS 5-year tabular (2015-2019) and Public Use Microdata estimates into a synthetic data set of person-level records in each census tract, and subset the data to persons who answered yes to the question "Are you blind or do you have serious difficulty seeing even when wearing glasses?" To identify individual need profiles (INPs), we applied divisive clustering to 17 variables measuring individual demographics, nonvision disability status, socioeconomic status (SES), housing, and access and independence. We labeled tracts with CNP names based on their predominant INPs and performed sensitivity analyses. We mapped the CNPs and overlayed information on the number of people with VP, the National Walkability Index, and an uncertainty measure based on our sensitivity analysis.

Main Outcome Measures

Individual need profiles and CNPs.

Results

Compared with people without VP, people with VP exhibited higher rates of disabilities, having low incomes, living alone, and lacking access to the internet or private home vehicles. Among people with VP, we identified 7 INP clusters which we mapped into 6 CNPs: (1) seniors (≥ age 65); (2) low SES younger; (3) low SES older; (4) mixed SES; (5) higher SES; and (6) adults and children in group quarters. Three CNPs had lower-than-average walkability. Community need profile assignments were somewhat sensitive to calibration variables, with 18 tracts changing assignments in 1 sensitivity analysis, and 4 tracts changing assignments in ≥ 2 sensitivity analyses.

Conclusions

This pilot project illustrates the feasibility of using ACS data to better understand the support and service needs of people with VP at the census tract level. However, a subset of categorical CNP assignments were sensitive to variable selection leading to uncertainty in CNP assignment in certain tracts.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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

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

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Main Outcomes and Measures

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

Results

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

Conclusion and Relevance

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