Neighborhood Deprivation and Risk of Age-Related Eye Diseases: A Follow-up Study in Sweden

Social Vulnerability, Prevalence of Glaucoma, and Incidence of Glaucoma Surgery in the California Medicare Population

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.

Environmental influences on ophthalmic conditions: A scoping review

BACKGROUND

Environmental factors have been implicated in various eye pathologies. The purpose of this review is to synthesise the published research on environmental effects on eye disease.

METHODS

Four databases were searched for terms relating to environmental exposures and ophthalmic disease. Titles and abstracts were screened followed by full-text review. Data was extracted from 118 included studies. Quality assessment was conducted for each study.

RESULTS

Air pollutants, including nitrogen dioxide, nitrites, sulphur dioxide, particulate matter, carbon monoxide, ozone and hydrocarbons are associated with ocular conditions ranging from corneal damage to various retinopathies, including central retinal artery occlusion. Certain chemicals and metals, such as cadmium, are associated with increased risk of age-related macular degeneration. Climate factors, such as sun exposure, have been associated with the development of cataracts. Living in rural areas was associated with various age-related eye diseases whereas people living in urban settings had higher risk for dry eye disease and uveitis.

CONCLUSION

Environmental exposures in every domain are associated with various ophthalmic conditions. These findings underscore the importance of continued research on the interplay between the environment and eye health.

Addressing Social Determinants of Vision Health

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.

Association of the Robert Wood Johnson Foundations' Social Determinants of Health and Medicare Ocular Hospitalizations: A Cross Sectional Data Analysis

INTRODUCTION

Social determinants of health (SDH) may influence inpatient utilization rates and outcomes but have yet to be associated with ocular diagnoses. The purpose of this paper was to determine whether the SDH are associated with ocular hospitalizations.

METHODS

Patients from the national Medicare 100% Inpatient Limited Dataset were examined and linked to SDH measures from the Robert Wood Johnson Foundation (RWJF) County Health Rankings. Patients were included in the study group with either an admitting or primary diagnosis of an ophthalmic condition. All other hospitalized Medicare patients served in the comparison group. Nested logistic regression of these Medicare patients was conducted in their respective communities at the county level. SDH measures were benchmarked above or below the national median.

RESULTS

Positively associated SDH factors included communities with air pollution exceeding 11.62 micro grams per cubic meter (OR 1.05; 95% CI 1.01-1.08), communities where severe housing problems exceeding 14.38% (OR 1.13; 95% CI 1.09-1.18), children in single parent households exceeding 32.13% (OR 1.06; 95% CI 1.02-1.11), violent crime rate exceeding 250.54 per 100,000 (OR 1.07; 95% CI 1.03-1.12), diabetes exceeding 10.95% (OR 1.09: 95% CI 1.04-1.14), and drug poisoning deaths including opioids exceeding 14.17 per 100,000 (OR 1.04; 95% CI 1.01-1.08).

CONCLUSION

When compared to an all-condition, hospitalized population, ocular hospitalizations tended to have small, yet statistically significant associations with health behaviors, socioeconomic, and physical environment factors. Further research will be needed on how the physical environment, social, and community variables affect ocular health relative to all-cause hospitalizations.

Socio-economic status and outcomes for patients with age-related macular degeneration

OBJECTIVES

To explore disparities in severity of baseline disease, treatment completion, and treatment outcomes among patients with wet age-related macular degeneration (AMD) receiving anti-vascular endothelial growth factor therapy by socio-economic status (SES) and distance from home to hospital.

STUDY DESIGN

Retrospective cohort study.

METHODS

Data from clinic records of 756 wet AMD patients receiving treatment for wet AMD with aflibercept between May 2013 and Jan 2017 were obtained. Area SES (using Index of Multiple Deprivation (IMD) 2015) and distance from hospital (dichotomized > = 10 vs. <10 km) were derived from anonymized postcodes. Univariate and multivariable logistic regression models were used to identify associations of area deprivation and distance from hospital at baseline-with visual acuity (VA) at baseline-treatment completion, and treatment outcome.

RESULTS

Living in the most deprived compared with less deprived areas was associated with a significantly higher risk of presenting with severe reduction in VA (OR = 3.59; 95% CI = 1.39-9.27; P = .01). This association was maintained after adjustment for age, gender, and distance from hospital. On univariate analysis, delayed treatment completion was more likely in those living in most deprived areas (OR = 2.80; 95% CI = 1.21-6.47; P = .04), though this association was attenuated after adjustment for age, gender, and distance from hospital. No association was observed between SES and treatment outcomes or between distance from hospital and baseline VA, treatment completion or treatment outcome.

CONCLUSION

This study found poorer baseline VA among people with wet AMD from more deprived areas. This work suggests a need for earlier identification of AMD among more deprived populations.

Neighborhood Environments and Diabetes Risk and Control

PURPOSE OF REVIEW

The objective of this review is to highlight the evidence on the association between contextual characteristics of residential environments and type 2 diabetes, to provide an overview of the methodological challenges and to outline potential topics for future research in this field.

RECENT FINDINGS

The link between neighborhood socioeconomic status or deprivation and diabetes prevalence, incidence, and control is robust and has been replicated in numerous settings, including in experimental and quasi-experimental studies. The association between characteristics of the built environment that affect physical activity, other aspects of the built environment, and diabetes risk is robust. There is also evidence for an association between food environments and diabetes risk, but some conflicting results have emerged in this area. While the evidence base on the association of neighborhood socioeconomic status and built and physical environments and diabetes is large and robust, challenges remain related to confounding due to neighborhood selection. Moreover, we also outline five paths forward for future research on the role of neighborhood environments on diabetes.

Influence of new societal factors on neovascular age-related macular degeneration outcomes

BACKGROUND

To assess the impact of unstudied societal factors for neovascular age-related macular degeneration (nAMD) on functional outcomes after anti-VEGFs.

METHODS

Charts of 94 nAMD patients treated in the Monticelli-Paradis Centre, Marseille, France, were reviewed. Phone interviews were conducted to assess societal factors, including transportation, living status, daily reading and social security scheme (SSS). Primary outcome was the impact of family support and disease burden on functional improvement in nAMD.

RESULTS

Between baseline and month 24 (M24), 42.4% of the variability in best-corrected visual acuity (BCVA) was explained by the cumulative effect of the following societal factors: intermittent out-patient follow-up, marital status, daily reading, transportation type, commuting time. No isolated societal factor significantly correlated with ETDRS BCVA severity at M24. A trend to correlation was observed between the EDTRS score at M24 and the SSS (P = 0.076), economic burden (P = 0.075), time between diagnosis and treatment initiation (P = 0.070). A significant correlation was found for the disease burdensome on the patient (P = 0.034) and low vision rehabilitation (P = 0.014).

CONCLUSIONS

Societal factors could influence functional outcomes in nAMD patients treated with anti-VEGFs. They could contribute to the healing process or sustain disease progression.

Association between Childhood Obesity and Neighbourhood Accessibility to Fast-Food Outlets: A Nationwide 6-Year Follow-Up Study of 944,487 Children

OBJECTIVES

The aim of this 6-year follow-up study was to examine whether neighbourhood accessibility to fast-food outlets was associated with diagnosed childhood obesity, after adjustment for neighbourhood- and individual-level socio-demographic factors.

METHODS

This 6-year follow-up study comprised 484,677 boys and 459,810 girls aged 0-14 years in Sweden. The follow-up period ran from January 1, 2005, until hospitalisation/out-patient treatment for obesity, death, emigration or the end of the study period on December 31, 2010. Multilevel logistic regression models (individual-level factors at the first level and neighbourhood-level factors at the second level) were used to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

We identified 6,968 obesity cases (3,878 boys and 3,090 girls) during the follow-up period. Higher odds of childhood obesity for those living in neighbourhoods with accessibility to fast-food outlets was observed (OR = 1.14, 95% CI = 1.07-1.22) that remained significant after adjustments (OR = 1.06, 95% CI = 1.00-1.13).

CONCLUSIONS

This prospective nationwide study showed that the neighbourhood accessibility to fast-food outlets was independently associated with increased odds of diagnosed childhood obesity. This finding implicates that residential environments should be considered when developing health promotion programmes.

The Incidence of Senile Cataract and Glaucoma is Increased in Patients with Plasma Cell Dyscrasias: Etiologic Implications

Plasma cell dyscrasias, including monoclonal gammopathy of undetermined significance (MGUS), multiple myeloma (MM), Waldenström macroglobulinemia (WM) and light chain AL amyloidosis, are characterized by clonal expansion of plasma cells which produce a vast amount of an immunoglobulin-derived M-protein. We noted that MGUS diagnosis often coincided with diagnoses of senile cataract and glaucoma and tested the associations of MGUS, MM, WM and AL amyloidosis with subsequent eye diseases identified from the Swedish patient registers between 1997 and 2012. Standardized incidence ratios (SIRs) for senile cataract was significantly increased to 1.80 after MGUS, 1.70 after MM, 1.85 after WM and 2.31 after AL amyloidosis. The SIR for glaucoma was 1.60 after MGUS, 1.76 after WM and 2.18 after AL amyloidosis. All SIRs decreased systematically from age below 60 years to over 79 years, but most risks were also significant in age group over 79 years. The M-protein and the related increase in blood viscosity could be a novel etiologic discovery for these common eye diseases. As MGUS prevalence is around 3% at 60 years and close to 10% at age over 80 years, its contribution to the eye disease burden is expected to be remarkably high.