Racial Disparities Persist in Glaucoma Testing

Neil Canavan

April 16, 2012

April 16, 2012 (New York, New York) — An analysis of healthcare utilization records indicates that, despite a long-standing healthcare initiative to address the issue, people belonging to racial minority groups are less likely to undergo ophthalmologic testing than white people, according to a report presented here at the American Glaucoma Society 22nd Annual Meeting.

Findings from this study are particularly striking in that all records analyzed represented people who had health insurance, said Joshua Stein, MD, assistant professor of ophthalmology and visual sciences at the Kellogg Eye Center, University of Michigan, Ann Arbor.

In 2000, US Health and Human Services launched the Healthy People 2010 initiative, with "a set of goals and objectives aimed at improving health and eliminating health disparities over the course of a decade."

The analysis by Dr. Stein and colleagues was performed to assess whether those disparities still exist in ophthalmology, and if so, whether the disparities are greater for any particular racial group.

"Previous studies have shown a higher prevalence of open-angle glaucoma in patients belonging to racial minority groups than whites," Dr. Stein said. "This is compounded by the fact that minorities receive less vision testing."

To determine whether ocular healthcare use has improved since the launch of Healthy People 2010, the team analyzed retrospective data from 2001 to 2009 in the i3 inVision Data Mart database.

People older than 40 years with at least 1 year of continuous insurance coverage were included in the analysis. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9CM) diagnostic codes were used to identify people with any ocular condition that would warrant visual field testing, fundus photography, or other ocular imaging.

The researchers used these findings to assess black, white, Hispanic, and Asian American male and female cohorts.

They estimated the likelihood of undergoing each diagnostic procedure for patients with diagnosed open-angle glaucoma in each year of the analysis. Models were adjusted for comorbidities, sociodemographics, age, education, estimated net worth, region of residence, and the type of eye care provider involved.

The records of 149,018 people with open-angle glaucoma were analyzed. Mean age was 61.3 years, 118,062 were white, 15,905 were black, 9376 were Hispanic, 4350 were Asian, and 53.8% were women.

The odds of undergoing visual field testing actually decreased for all racial groups, including whites, from 2001 to 2009, with the largest decreases among Hispanic men (63%) and women (57%). The smallest decrease was among Asian men.

In comparison, the odds of undergoing other ocular imaging increased for all groups, increasing the most for black men and women (173%) and the least for Hispanic women (77%).

For fundus photography, Hispanic women faired worse than their white counterparts, with an odds ratio (OR) of 1.11 (95% confidence interval [CI], 0.92 to 1.33), compared with 1.15 (95% CI, 1.08 to 1.22), Despite improvements across the board for all racial groups, Hispanics were still less likely than whites to undergo other ocular imaging, with an OR of 2.13 (95% CI, 1.77 to 2.57), compared with 2.24 (95% CI, 2.14 to 2.35).

"It was certainly encouraging that rates of diagnostic testing procedures increased for black patients over the study period," said Dr. Stein, but he added that he is somewhat dismayed by the relative lack of progress for Hispanic people.

"There are several studies that show that [Hispanics] are not being as aggressively treated as they should be, according to practice guidelines." He explained: "If they are not going to see an eye doctor, then what can we do? We need to work in those communities and try to understand if it is an education issue, a language issue, or perhaps a cultural issue of maybe not trusting doctors."

Dr. Stein acknowledged that the results of this study led to other questions, "but unfortunately, I can't even guess at the answers from these data."

Is it Race, Class, or Coverage?

"We did a similar study in Canada," said Yvonne Buys, MD, FRCSC, professor in the Department of Ophthalmology and Visual Sciences at the University of Toronto, Ontario, Canada. "We were looking more at socioeconomic levels though, based mostly on level of education. We found that those who were in the lower socioeconomic strata had less access, or more accurately, less utilization of health resources for the eye."

Coverage for routine eye exams under the Canadian healthcare system was delisted a number of years ago for people 19 to 64 years of age. "We looked at statistics prior to delisting and after, and we found that that the [lower strata] cohort has less utilization. This shows us that [our system] is not really universal healthcare for certain segments of the population." (This research is in press in the Canadian Journal of Ophthalmology.)

Extrapolating from the disparity in ophthalmology care that she sees in Canada, Dr. Buy is greatly concerned about access in less affluent countries.

"I've heard about all sorts of new implants lately, which is very exciting, but nobody really talks about the cost of the implants. My concern is that they are so expensive that we are creating disparities in our communities, as well as in countries with developing economies. As healthcare professionals, we need to ask ourselves: Are these devices only going to be available for the wealthy?"

Dr. Stein and Dr. Buys have disclosed no relevant financial relationships.

American Glaucoma Society 22nd Annual Meeting: Abstract 58. Presented March 1, 2012.

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