Assessing financial insecurity among common eye conditions: a 2016-2017 national health survey study

Social Determinants of Health and Perceived Barriers to Care in Diabetic Retinopathy Screening

Importance

Regular screening for diabetic retinopathy often is crucial for the health of patients with diabetes. However, many factors may be barriers to regular screening and associated with disparities in screening rates.

Objective

To evaluate the associations between visiting an eye care practitioner for diabetic retinopathy screening and factors related to overall health and social determinants of health, including socioeconomic status and health care access and utilization.

Design, Setting, and Participants

This retrospective cross-sectional study included adults aged 18 years or older with type 2 diabetes who answered survey questions in the All of Us Research Program, a national multicenter cohort of patients contributing electronic health records and survey data, who were enrolled from May 1, 2018, to July 1, 2022.

Exposures

The associations between visiting an eye care practitioner and (1) demographic and socioeconomic factors and (2) responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys were investigated using univariable and multivariable logistic regressions.

Main Outcome and Measures

The primary outcome was whether patients self-reported visiting an eye care practitioner in the past 12 months. The associations between visiting an eye care practitioner and demographic and socioeconomic factors and responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys in All of Us were investigated using univariable and multivariable logistic regression.

Results

Of the 11 551 included participants (54.55% cisgender women; mean [SD] age, 64.71 [11.82] years), 7983 (69.11%) self-reported visiting an eye care practitioner in the past year. Individuals who thought practitioner concordance was somewhat or very important were less likely to have seen an eye care practitioner (somewhat important: adjusted odds ratio [AOR], 0.83 [95% CI, 0.74-0.93]; very important: AOR, 0.85 [95% CI, 0.76-0.95]). Compared with financially stable participants, individuals with food or housing insecurity were less likely to visit an eye care practitioner (food insecurity: AOR, 0.75 [95% CI, 0.61-0.91]; housing insecurity: AOR, 0.86 [95% CI, 0.75-0.98]). Individuals who reported fair mental health were less likely to visit an eye care practitioner than were those who reported good mental health (AOR, 0.84; 95% CI, 0.74-0.96).

Conclusions and Relevance

This study found that food insecurity, housing insecurity, mental health concerns, and the perceived importance of practitioner concordance were associated with a lower likelihood of receiving eye care. Such findings highlight the self-reported barriers to seeking care and the importance of taking steps to promote health equity.

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

PURPOSE

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

DESIGN

Cross-sectional, population-based analysis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

POPULATION

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

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

PURPOSE

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

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

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

METHODS

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

MAIN OUTCOME MEASURE

Eye care utilization in the preceding 12 months.

RESULTS

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

CONCLUSIONS

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

FINANCIAL DISCLOSURE(S)

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

Financial stress among skin cancer patients: a cross-sectional review of the 2013-2018 National Health Interview Survey

Financial stress among skin cancer patients may limit treatment efficacy by forcing the postponement of care or decreasing adherence to dermatologist recommendations. Limited information is available quantifying the anxiety experienced by skin cancer patients from both healthcare and non-healthcare factors. Therefore, the present study sought to perform a retrospective cross-sectional review of the 2013-2018 cycles of the National Health Interview Survey (NHIS) to determine the prevalence, at-risk groups, and predictive factors of skin cancer patient financial stress. Survey responses estimated that 11.45% (95% Cl 10.02-12.88%) of skin cancer patients experience problems paying medical bills, 20.34% (95% Cl 18.97-21.71%) of patients worry about the medical costs, 13.73% (95% Cl 12.55-14.91%) of patients worry about housing costs, and 37.48% (95% Cl 35.83-39.14%) of patients worry about money for retirement. Focusing on at-risk groups, black patients, uninsured patients, and patients with low incomes (< 200% poverty level) consistently experienced high rates of financial stress for each of the four measures. Multivariable logistic regression revealed low education, lack of insurance, and low income to be predictive of financial stress. These findings suggest that a considerable proportion of skin cancer patients experience financial stress related to both healthcare and non-healthcare factors. Where possible, the additional intricacy of treating patients at risk of high financial stress may be considered to optimize patient experience and outcomes.

Do Patients Reporting Fractures Experience Food Insecurity More Frequently Than the General Population?

BACKGROUND

The economic burden of traumatic injuries forces families into difficult tradeoffs between healthcare and nutrition, particularly among those with a low income. However, the epidemiology of food insecurity among individuals reporting having experienced fractures is not well understood.

QUESTIONS/PURPOSES

(1) Do individuals in the National Health Interview Survey reporting having experienced fractures also report food insecurity more frequently than individuals in the general population? (2) Are specific factors associated with a higher risk of food insecurity in patients with fractures?

METHODS

This retrospective, cross-sectional analysis of the National Health Interview Survey was conducted to identify patients who reported a fracture within 3 months before survey completion. The National Health Interview Survey is an annual serial, cross-sectional survey administered by the United States Centers for Disease Control, involving approximately 90,000 individuals across 35,000 American households. The survey is designed to be generalizable to the civilian, noninstitutionalized United States population and is therefore well suited to evaluate longitudinal trends in physical, economic, and psychosocial health factors nationwide. We analyzed data from 2011 to 2017 and identified 1399 individuals who reported sustaining a fracture during the 3 months preceding their survey response. Among these patients, 27% (384 of 1399) were older than 65 years, 77% (1074) were White, 57% (796) were women, and 14% (191) were uninsured. A raw score compiled from 10 food security questions developed by the United States Department of Agriculture was used to determine the odds of 30-day food insecurity for each patient. A multivariate logistic regression analysis was performed to determine factors associated with food insecurity among patients reporting fractures . In the overall sample of National Health Interview Survey respondents, approximately 0.6% (1399 of 239,168) reported a fracture.

RESULTS

Overall, 17% (241 of 1399) of individuals reporting broken bones or fractures in the National Health Interview Survey also reported food insecurity. Individuals reporting fractures were more likely to report food insecurity if they also were aged between 45 and 64 years (adjusted odds ratio 4.0 [95% confidence interval 2.1 to 7.6]; p < 0.001), had a household income below USD 49,716 (200% of the federal poverty level) per year (adjusted OR 3.1 [95% CI 1.9 to 5.1]; p < 0.001), were current tobacco smokers (adjusted OR 2.8 [95% CI 1.6 to 5.1]; p < 0.001), and were of Black race (adjusted OR 1.9 [95% CI 1.1 to 3.4]; p = 0.02).

CONCLUSION

Among patients with fractures, food insecurity screening and routine nutritional assessments may help to direct financially vulnerable patients toward available community resources. Such screening programs may improve adherence to nutritional recommendations in the trauma recovery period and improve the physiologic environment for adequate soft tissue and bone healing. Future research may benefit from the inclusion of clinical nutritional data, a broader representation of high-energy injuries, and a prospective study design to evaluate cost-efficient avenues for food insecurity interventions in the context of locally available social services networks.

LEVEL OF EVIDENCE

Level III, prognostic study.