Diversity & Inclusion

Diversity & Inclusion

Diversity & Inclusion

Race, Gender, and Ethnicity Differences in Ocular Disease

Ocular diseases, such as diabetic retinopathy (DR), age-related macular degeneration (AMD), and glaucoma affect people of different races, genders, and ethnicities in various ways. Some population groups are more likely to develop certain ocular diseases for physiological reasons. However, access to care and other disparities can also affect the quality of healthcare many people receive, which, in turn, can affect disease prevalence and outcomes.1 Here are several examples of how certain ocular diseases, including retina-related ones, affect people of different races, genders, and ethnicities:

  • Black or Latino individuals are more likely to develop open-angle glaucoma (OAG) than Whites2
  • The rate of OAG is twice as likely among Blacks compared with Whites in the United States (US)2
  • In a study focusing on anti-vascular endothelial growth factor therapy for diabetic macular edema, White and non-Hispanic patients presented with a higher baseline visual acuity than Blacks and Hispanics. Having Medicare or private insurance also contributed to a higher visual acuity3
  • Non-Hispanic Whites have a higher prevalence of AMD compared with non-Hispanic Blacks4
  • In an analysis of annual eye exams recommended for Medicare beneficiaries with diabetes, researchers found that 55.6% of non-Hispanic Whites completed their annual exam compared with only 48.9% among Blacks and 48.2% among Hispanics5
  • Women are at an overall greater risk for vision loss compared with men6
  • When comparing men and women with central retinal vein occlusion (CRVO), visual outcomes and treatment burden were similar; however, gender differences were present in perfusion status, subfoveal choroidal thickness, central subfield thickness, and prevalence of foveal avascular zone enlargement7
  • An analysis of glaucoma patients from the National Institutes of Health’s (NIH) All of Us database [https://allofus.nih.gov/] found that African American/Black and Hispanic patients were more likely to have higher odds of discordance between glaucoma diagnosis by self-report and electronic health records compared with White patients.8 Further attention is needed to help all patients better understand their diagnosis, the authors concluded
  • Another analysis of a subset of patients from the NIH’s All of Us database that was focused on diabetic retinopathy (DR) patients, found that Hispanic and non-Hispanic Black patients reported greater barriers to care, including implicit bias and challenges accessing childcare to attend appointments.9 A separate study from Cai et al. that also focused on DR found these same population groups experienced lapses in care 75% of the time. Insurance was a major factor for lapse of care10
  • An analysis of data from more than 996,000 glaucoma patients in the American Academy of Ophthalmology’s Intelligent Research in Sigh registry found that Black and Native American patients were more likely to have poor vision outcomes compared with White glaucoma patients, even when stratified by socioeconomic status. Native Americans had the lower utilization rate among all races11
  • A study of dry eye patients found that minority patients presented with worse dry eye parameters and less prior care visits for dry eye.12 Both healthcare access and income did not seem to fully explain undertreatment at presentation
  • Transgender patients may face unique challenges, such as increased vulnerability to certain eye diseases, including central serous retinopathy and ophthalmic conditions mediated by inflammation, due to the use of sex hormones.13,14 Additionally, HIV infection among transgender women is 49 times higher than that of other groups, yet transgender women are underserved in HIV care due to stigmatization and fear of potential treatment interactions with hormone therapy14

Other Factors That Can Contribute to Eye Disease

As mentioned previously, other factors beyond physiological reasons can contribute to the prevalence of eye disease in certain population groups. Many of these factors fall under the umbrella of social determinants of health, defined by the US Department of Health and Human Services as “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”15

Social determinants of health are grouped under five categories: Economic Stability, Education Access and Quality, Healthcare Access and Quality, Neighborhood and Built Environment, and Social and Community Context. Within eyecare, several prominent social determinants of health can contribute to the prevalence of eye disease including:15

Finding Solutions to Improve Ocular Disease Prevention and Outcomes

Recognizing a greater need to assist population groups that are more vulnerable to certain ocular diseases, the field of ophthalmology as a whole is making efforts toward improvement. Below is a sampling of some of the changes underway on the organizational, practice, and individual levels:

The American Academy of Ophthalmology (AAO) has its Task Force on Disparities in Visual Health and Eye Care to address health equity in eyecare. This group will help address social determinants of health and medical care, access to care, and outcomes.20

It also has released a collection of seminal articles that address inequities in eye care Telehealth options will likely increase going forward. Telehealth can be a favored option to reach a greater percentage of patients who require care.21 However, physicians and their staff must make sure that patients have access to the technology required for Telehealth and that they are comfortable with it.

Including more patients from underrepresented minority groups in clinical trials can give a broader perspective on side effects and outcomes related to certain treatments.22

Personalized patient education and/or education via video can help increase awareness of health conditions and overcome barriers related to health literacy.16 Sleath et al. conducted a randomized controlled trial focused on encouraging Black patients to ask more questions of their glaucoma providers after watching a video that empowered them to do so. Compared with a control group, the intervention group patients were more likely (odds ratio, 5.4) to ask one or more questions of their providers. This simple type of measure may help improve medication adherence and reduce intraocular pressure23

Reminders regarding health appointments and help with scheduling follow-up are effective ways to ensure that patients maintain eye appointments.24

Adding eye exam lanes to community health centers can highlight the importance of vigilant eyecare24

More eye doctors in “provider deserts” can help reach a broader range of patients who otherwise may not have access to eyecare.24 This approach also gives more patients a stable provider, which can improve adherence to appointments and care.

Identification of patients with lapses in care can be useful both to encourage these patients to seek more frequent eye care but also so providers can make treatment decisions that may last longer compared with patients who can return more frequently.10

Awareness of implicit bias could help address perceptions of disrespect or lack of courtesy perceived by some non-White patients9

Childcare or adult caregiving resources could help patients who do not come for regular appointments due to challenges in these areas9

Artificial intelligence and other new, effective technologies can enhance point-of-care exam for DR among pediatric patients with diabetes. AI-assisted visits led to an exam completion rate of 100% versus 22% among the control group. Of those with an abnormal result, 64% followed up with a provider compared with 22% in the control arm.25

Differences in ocular disease prevalence and outcomes vary widely and encompass a large number of factors. Efforts to make improvements can and should eliminate barriers, ideally improving care for all patients.

References

  1. US Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Access to Health Services. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/access-health-services
  2. Ou Y. Health Disparities in Glaucoma. BrightFocus Foundation®. October 4, 2021. https://www.brightfocus.org/ glaucoma/article/health-disparities-glaucoma
  3. Malhotra NA, Greenlee TE, Iyer AI, et al. Racial, ethnic, and insurance-based disparities upon initiation of anti-vascular endothelial growth factor therapy for diabetic macular edema in the US. Ophthalmology. 2021;128:1438-1447. https://www.aaojournal.org/article/S0161-6420(21)00196-2/abstract
  4. Zhang X, Cotch MF, Ryskulova A, et al. Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys. Am J Ophthalmol. 2012;154:S53-S62.e1. https://pubmed.ncbi.nlm.nih.gov/23158224/
  5. Lundeen EA, Wittenborn J, Benoit SR, Saaddine J. Disparities in receipt of eye exams among Medicare Part B fee-for-service beneficiaries with diabetes — United States, 2017. MMWR Morb Wkly Rep. 2019;68:1020-1023. https://www.cdc.gov/mmwr/volumes/68/wr/mm6845a3.htm
  6. Zambelli-Weiner A, Crews JE, Friedman DS. Disparities in adult vision health in the United States. Am J Ophthalmol. 2012;154:S23-S30.e1. https://www.ajo.com/article/S0002-9394(12)00209-7/abstract
  7. Mirzania D, Thomas AS, Stinnett SS, Fekrat S. Gender differences in presentation, treatment patterns, and clinical outcomes in central retinal vein occlusion. Invest Ophthalmol Vis Sci. 2019;60:3943. https://iovs.arvojournals.org/article.aspx?articleid=2743641
  8. Paul ME, Tseng VL, Kitayama K, Yu F, Coleman AL. Evaluating discrepancies in self-reporting glaucoma and electronic health records in the National Institutes of Health All of Us database. Ophthalmol Glaucoma. 2023;6:521-529.
  9. Huang BB, Radha Saseendrakumar B, Delavar A, Baxter SL. Racial disparities in barriers to care for patients with diabetic retinopathy in a nationwide cohort. Transl Vis Sci Technol. 2023;12:14. https://tvst.arvojournals.org/article.aspx?articleid=2785447
  10. Cai CX, Tran D, Tang T, et al. Health disparities in lapses in diabetic retinopathy care. Ophthalmol Sci. 2023;3:100295.
  11. American Academy of Ophthalmology. New study: Racial Disparities in Glaucoma Care Exist, Regardless of Socioeconomic Status. November 4, 2023. https://www.aao.org/newsroom/news-releases/detail/new-study-racial-disparities-in-glaucoma-care
  12. Cui D, Mathews PM, Li G, et al. Racial and ethnic disparities in dry eye diagnosis and care. Ophthalmic Epidemiol. 2023;30:484-491. https://www.tandfonline.com/doi/full/10.1080/09286586.2022.2131834
  13. Nuzzi R, Scalabrin S, Becco A, Panzica G. Gonadal hormones and retinal disorders: A review. Front Endocrinol (Lausanne). 2018;9:66. https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2018.00066/full
  14. Hollar MW, Zhang MM, Mawn LA. Ophthalmic disparities in transgender patients. Semin Ophthalmol. 2016;31:426-431. https://pubmed.ncbi.nlm.nih.gov/27128494/
  15. US Department of Health and Human Services. Social Determinants of Health. https://health.gov/healthypeople/objectives-and-data/social-determinants-health
  16. Capó H. The importance of health literacy in addressing eye health and eye care disparities. Presented at the American Academy of Ophthalmology 2021 annual meeting, New Orleans, Louisiana.
  17. Soares R, Parikh D, Shields CN, et al. Geographic access disparities to clinical trials in diabetic eye disease in the United States. Ophthalmol Retina. 2021;5:879-887. https://www.sciencedirect.com/science/article/abs/pii/S2468653020304875
  18. Cai CX, Li Y, Zeger SL, McCarthy ML. Social determinants of health impacting adherence to diabetic retinopathy examinations. BMJ Open Diabetes Res Care. 2021;9:e002374. https://drc.bmj.com/content/9/1/e002374
  19. Lu Y, Serpas L, Genter P, Mehranbod C, Campa D, Ipp E. Disparities in diabetic retinopathy screening rates within minority populations: Differences in reported screening rates among African American and Hispanic patients. Diabetes Care. 2016;39:e31-e32. https://diabetesjournals.org/care/article/39/3/e31/37157/Disparities-in-Diabetic-Retinopathy-Screening
  20. American Academy of Ophthalmology. Diversity, Equity, Inclusion, and Accessibility. https://www.aao.org/diversity-equity-and-inclusion
  21. Smith GL, Dixon WA, Phillips M. Expanding health care access and equity through telehealth. October 22, 2021. https://www.kevinmd.com/blog/2021/10/expanding-health-care-access-and-equity-through-telehealth.html
  22. Younossi A, Sanhai W, Shah S, Chang C. Enhancing clinical trial diversity. November 11, 2021. https://www2.deloitte.com/us/en/insights/industry/life-sciences/lack-of-diversity-clinical-trials.html
  23. Sleath B, Carpenter DM, Davis SA, et al. Improving Black question-asking and provider education during glaucoma visits. Ophthalmol Glaucoma. 2023;6:206-214.
  24. Shoge RY. Improving access to eye care. Presented at the American Academy of Ophthalmology 2021 annual meeting, New Orleans, Louisiana.
  25. Wolf RM, Channa R, Liu TYA, et al. Autonomous artificial intelligence increases screening and follow up for diabetic retinopathy in youth: The ACCESS randomized control trial. Nat Commun. 2024;15:421.

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