Racial, Ethnic, and Insurance-Based Disparities Upon Initiation of Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema in the US

PURPOSE

This study characterizes the association of risk factors including race, ethnicity, and insurance status with presenting visual acuity (VA) and diabetic retinopathy (DR) severity in patients initiating treatment with anti-vascular endothelial growth factor (VEGF) therapy for diabetic macular edema (DME).

DESIGN

Retrospective, cross-sectional study.

PARTICIPANTS

The Academy Intelligent Research in Sight (IRIS) Registry database was queried for patients who initiated anti-VEGF injection treatment for DME between 2012 and 2020 (n = 203 707).

METHODS

Multivariate regression analyses were conducted to understand how race, ethnicity, insurance status, and geographic location were associated with baseline features.

MAIN OUTCOME MEASURES

Visual acuity and DR severity.

RESULTS

Patients on Medicare and private insurance presented with higher baseline VA compared with patients on Medicaid (median of 2.31 and 4.17 greater Early Treatment Diabetic Retinopathy Scale [ETDRS] letters, respectively P < 0.01). White and non-Hispanic patients presented with better VA compared with their counterparts (median of 0.68 and 2.53 greater ETDRS letters, respectively; P < 0.01). Black and Hispanic patients presented with a worse baseline DR severity compared with White and non-Hispanic patients (odds ratio, 1.23 and 1.71, respectively; P < 0.01).

CONCLUSIONS

There are ethnic and insurance-based disparities in VA and disease severity upon initiation of anti-VEGF therapy for DME treatment. Public health initiatives could improve timely initiation of treatment.

Injury-induced gp130 cytokine signaling in peripheral ganglia is reduced in diabetes mellitus

Neuropathy is a major diabetic complication. While the mechanism of this neuropathy is not well understood, it is believed to result in part from deficient nerve regeneration. Work from our laboratory established that gp130 family of cytokines are induced in animals after axonal injury and are involved in the induction of regeneration-associated genes (RAGs) and in the conditioning lesion response. Here, we examine whether a reduction of cytokine signaling occurs in diabetes. Streptozotocin (STZ) was used to destroy pancreatic β cells, leading to chronic hyperglycemia. Mice were injected with either low doses of STZ (5×60mg/kg) or a single high dose (1×200mg/kg) and examined after three or one month, respectively. Both low and high dose STZ treatment resulted in sustained hyperglycemia and functional deficits associated with the presence of both sensory and autonomic neuropathy. Diabetic mice displayed significantly reduced intraepidermal nerve fiber density and sudomotor function. Furthermore, low and high dose diabetic mice showed significantly reduced tactile touch sensation measured with Von Frey monofilaments. To look at the regenerative and injury-induced responses in diabetic mice, neurons in both superior cervical ganglia (SCG) and the 4th and 5th lumbar dorsal root ganglia (DRG) were unilaterally axotomized. Both high and low dose diabetic mice displayed significantly less axonal regeneration in the sciatic nerve, when measured in vivo, 48h after crush injury. Significantly reduced induction of two gp130 cytokines, leukemia inhibitory factor and interleukin-6, occurred in diabetic animals in SCG 6h after injury compared to controls. Injury-induced expression of interleukin-6 was also found to be significantly reduced in the DRG at 6h after injury in low and high dose diabetic mice. These effects were accompanied by reduced phosphorylation of signal transducer and activator of transcription 3 (STAT3), a downstream effector of the gp130 signaling pathway. We also found decreased induction of several gp130-dependent RAGs, including galanin and vasoactive intestinal peptide. Together, these data suggest a novel mechanism for the decreased response of diabetic sympathetic and sensory neurons to injury.

Race and Socioeconomic Status in Anti-VEGF Treatment of Diabetic Macular Edema

BACKGROUND AND OBJECTIVE

Although people of low socioeconomic status (SES) and certain racial groups are at greater risk of developing diabetic macular edema (DME), the extent these high-risk groups experience treatment differences is unknown. This study characterizes anti-vascular endothelial growth factor (anti-VEGF) injection use for DME.

PATIENTS AND METHODS

Data were collected from an electronic health record at the Cole Eye Institute, Cleveland Clinic Foundation for patients who received anti-VEGF treatment for DME between 2012 and 2019 (N = 500).

RESULTS

White patients on average received more injections over a 1-year period than Black patients (4.93 ± 3.14 vs 3.20 ± 2.43; P < .0001) and had fewer no-show appointments (1.39 ± 2.08 vs 3.23 ± 3.39; P < .0001). There is an association between living in communities with lower average incomes and receiving fewer anti-VEGF injections (3.06 ± 2.70 vs 4.88 ± 3.19; P = .005).

CONCLUSIONS

DME treatment differs based on race and SES. Racial and SES associations with anti-VEGF injections present potential obstacles for delivering optimal ophthalmic care. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:578-585.].

Association of Socioeconomic Health Care Disparities With Use of Anti-Vascular Endothelial Growth Factor and Visual Acuity Outcomes in Patients With Diabetic Macular Edema

BACKGROUND AND OBJECTIVE

This study characterizes the impact of race, ethnicity, insurance status, and geographic location on anti-vascular endothelial growth factor (VEGF) use for the treatment of diabetic macular edema (DME).

PATIENTS AND METHODS

This study is a retrospective cohort study. The American Academy of Ophthalmology Intelligent Research in Sight Registry was queried for patients diagnosed with DME who received at least one anti-VEGF injection between 2012 and 2020 (n = 203,707). Multivariate regression analyses investigated associations between race, ethnicity, insurance status, and geographic location and anti-VEGF use and visual outcomes.

RESULTS

White race, non-Hispanic/Latino ethnicity, and private insurance were associated with higher use of anti-VEGF injections during a 60-month period (incidence rate ratio, 1.2, 1.25, and 1.17, respectively; P < .01). Furthermore, being of non-Hispanic/Latino ethnicity and having private health insurance were associated with higher longitudinal visual acuity (odds ratio, 1.44 [P = .02] and odds ratio, 1.43 [P < .01], respectively).

CONCLUSION

Ethnicity and insurance status are associated with anti-VEGF use and visual acuity outcomes in DME. [Ophthalmic Surg Lasers Imaging Retina 2022; 53:380-391.].

Education Research: Utilization of Simulation in Residency Programs: A Survey of Adult Neurology Residency Program Directors

Background and Objectives

Previous research has demonstrated that simulation-based medical education (SBME) can improve neurology trainees' confidence, knowledge, and competence. However, a general needs assessment and review of current SBME used within neurology are needed to guide SBME curriculum development. The objective of this study was to describe the current use of SBME in resident education and to assess perceived barriers to expanding SBME interventions.

Methods

We surveyed adult neurology residency program directors (PDs) listed in the Accreditation Council for Graduate Medical Education directory using a Qualtrics-based survey platform. Survey questions addressed current utilization of SBME and barriers to SBME growth.

Results

Seventy-five PDs of 171 contactable PDs responded to our survey (response rate 44%). Of the respondents, 84% (64/75) report using SBME in their adult neurology residencies. Of those using SBME, 87% (55/64) programs create their own cases. Most programs use simulation to teach neurocritical care topics (63%) and vascular neurology (78%); few use simulation to teach outpatient topics and teleneurology. Among programs that use SBME, there was variability in the frequency of the SBME interventions and in the target trainee cohort. Among responding programs, most expressed interest in expanding SBME in their curriculum (69%, 52/64), but frequently cited lack of faculty protected time (55%), funding (35%), and resident availability (32%) as barriers to doing so.

Discussion

Most responding programs use SBME. However, the frequency and target learner for SBME interventions varied between programs. Many programs wish to expand SBME at their institutions but are constrained by limited protected time and institutional financial support. We discuss potential solutions to the perceived barriers to SBME, including intra-institutional collaboration to advance SBME use and case diversity for learners and help innovate neurology medical education.

Medicaid's EPSDT Benefit: An Opportunity to Improve Pediatric Screening for Social Determinants of Health

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is a key component of Medicaid policy intended to define an essential set of services provided to patients younger than age 21. Given increasing attention to social determinants of health in pediatric health care, this qualitative review examines the extent to which EPSDT might be used to implement structured screening to identify environmental and social factors affecting children's health. Themes derived from semistructured interviews conducted in 2017 were triangulated with a review of the recent literature to describe how states currently consider the EPSDT benefit with respect to social determinants of health screening. Our findings suggest that, with sufficient stakeholder advocacy given the evidence supporting social determinants of health screening as "medically necessary," EPSDT benefits could be considered as a funding source to incentivize the incorporation of social determinants of health screening into the basic package of well-child care.

The American Headache Society First Contact-Headache in Primary Care program: Current metrics, knowledge assessments, and direction for future initiatives

OBJECTIVE

This study examines the American Headache Society First Contact-Headache in Primary Care program metrics to date in order to assess the program's reach and provide direction for future initiatives.

BACKGROUND

Approximately 4 million primary care office visits annually are headache-specific encounters. Therefore, it is important that primary care providers are knowledgeable about headache management. Recognizing the need, the American Headache Society First Contact designed the comprehensive First Contact-Headache in Primary Care program with input from an advisory board comprised of a diverse group of physicians and advanced practice providers with backgrounds in family and internal medicine, pediatrics, obstetrics and gynecology, and neurology. This is the first study to assess the reach of the program and critically examine how to best meet the needs of clinicians and patients going forward.

METHODS

We report descriptive statistics for the First Contact website metrics from October 2020 to June 2023 and grand rounds program data from May 2020 to December 2023. We also conducted a cross-sectional analysis of survey data from presentations conducted at two large national family medicine symposia, as well as a thematic analysis of the question: "Please indicate what areas of your practice could be enhanced or improved with additional education?"

RESULTS

The First Contact program homepage was the second most visited page on the American Headache Society website (>100,000 views). A total of 20 podcast episodes were created for the program (>3500 plays). The First Contact program held 99 events (72 institutional grand rounds, 22 State-level meetings, and five national meetings), reaching >7000 clinicians. The institutional grand rounds and state-level meetings were held across 27 States and Washington D.C. Only 31.9% (30/94) of First Contact program events (excluding national meetings) occurred in the West census region, which has the fewest headache subspecialists and lowest headache subspecialist density in the United States. When examining survey data of participants who attended the two virtual national family medicine symposia (39.3% response rate, N = 636/1620), 85.7% (544/635) reported being "completely confident" or "very confident" in their ability to recognize and accurately diagnose patients presenting with a primary complaint of headache and 81.5% (517/634) reported being "completely confident" or "very confident" in their ability to develop evidence-based treatment plans that are tailored to the needs of individual patients. The use of diagnostic tools to recognize patients with migraine (60.4%, 384/636) and translating standards of care to the practice setting (42.5%, 270/636) were the most reported intended changes by participants. Most participants reported that program content was of clinical relevance and would improve their patients' outcomes (90.5% [571/631] and 90.6% [572/631], respectively). Over three-quarters (77.8%, 495/636) of participants reported areas of their practice that can be improved by additional education specifically regarding workflow, diagnosis, and management.

CONCLUSION

This study evaluates one of the first national initiatives for primary care education. Data from the two First Contact Family Medicine national symposia indicate the program is generally well received with most participants reporting improved confidence and intention to implement key changes in practice to improve care for patients with headache; however, there remain areas of exploration for education that could further enhance participant experience and expand the reach of the initiatives. Areas for future programming include continued education on multifactorial approaches to headache treatment and suggestions for addressing cost, insurance, and time constraints. Also, future work may examine where the First Contact program might focus initiatives based on specific areas of need in headache care, such as geographic "desert" areas, racial and ethnic disparities, and uninsured/underinsured populations.