Social factors associated with diabetic retinopathy visit adherence

(Image credit: AdobeStock/tyyang)

Diabetic retinopathy is in the leading causes of blindness among American adults,¹ with prevalence rates projected to grow in the coming years.² Although significant advances in the treatment of diabetes in general and diabetic retinopathy specifically have made the disease more manageable, these benefits are only realized if patients have access to care. Indeed, regular eye care clinic follow-up is essential to disease monitoring and timely intervention.³ For these reasons, the American Academy of Ophthalmology and the American Diabetes Association recommend annual eye examinations beginning 5 years after diagnosis for those with type 1 diabetes and immediately after diagnosis for those with type 2 diabetes.^3,4 For those with more advanced disease, follow-up intervals may be even more frequent, especially for those requiring intravitreal injections or other treatments.⁴

Unfortunately, patients can be lost to follow-up, only to present later with complications like macular edema, vitreous hemorrhage, neovascular glaucoma, retinal detachment, and other ailments associated with irreversible vision loss.^4,5 The cause of nonadherence is often multifactorial, possibly driven by lack of knowledge or indifference to potential consequences, need for accompaniment, transportation challenges, or financial restraints. In this study, we explore social factors associated with clinic visit adherence among those diagnosed with diabetic retinopathy in a nationwide cohort.

METHODS

We used the National Institutes of Health All of Us Research Program, a nationwide electronic health record–based database with linked survey elements.⁶ Responses from the latest Healthcare Access and Utilization Survey⁷ were compared between those who had seen an eye doctor in the previous 12 months and those who had not. Pearson χ2 tests compared demographic and survey responses between groups. Unadjusted logistic regression generated ORs and 95% CIs for the association between select demographic factors and visit adherence.

RESULTS

Of the 1818 patients with diabetic retinopathy in our cohort, 1518 (83.5%) saw an eye doctor in the previous 12 months, whereas 300 (16.5%) did not. Demographic factors significantly associated with not seeing an eye doctor in the prior 12 months included younger age, female sex, non-White race, birthplace outside of the US, lower education, lower income, and Medicaid or no insurance status (Table 1). Social factors significantly associated with not seeing an eye doctor in the prior 12 months included not having transportation, being unable to afford follow-up care, being concerned about stable housing, and not feeling respected by a provider (Table 2).

In univariable logistic regression, those older than 75 vs younger than 65 years (OR, 2.32; 95% CI, 1.67-3.27), males vs females (OR, 1.40; 95% CI, 1.08-1.81), college education and above vs less than high school diploma (OR, 3.44; 95% CI, 2.32-5.09), and those with annual incomes above $100,000 vs less than $25,000 (OR, 2.17; 95% CI, 1.42-3.40) were all significantly more likely to have seen an eye doctor in the prior 12 months than their counterparts, whereas both non-Hispanic African American people (OR, 0.46; 95% CI, 0.33-0.64) and Hispanic people (any race) (OR, 0.36; 95% CI, 0.27-0.49) were significantly less likely than non-Hispanic White people to have seen an eye doctor in the prior 12 months. Further, those with Medicaid or no insurance (OR, 0.52; 95% CI, 0.39-0.70) were significantly less likely than those with other insurance types to have seen an eye doctor in the prior 12 months (Figure).

DISCUSSION

This study found that several socioeconomic factors were significantly associated with adherence to follow-up among those with diabetic retinopathy. Race, ethnicity, education, income, and insurance coverage have previously been demonstrated to be predictors of outpatient vision care utilization.⁸ Further, not having transportation or being at a distance to specialty care, in particular, have been consistently demonstrated as barriers to care for those with diabetic retinopathy.⁹ Although these are vital access-to-care issues that municipalities and greater health care systems must address to reduce disparities in care and outcomes, individual eye care providers may feel limited in their ability to tackle these systems-level issues in their respective practices.

Of note, we also found that those who did not see an eye doctor in the past 12 months were significantly more likely to express not feeling respected by their provider. The quality of the patient-doctor relationship and feeling respected by a provider has been shown to be factors in adherence to care among ophthalmology patients¹⁰ and patients as a whole.¹¹ One meta-analysis of over 100 studies estimated a 19% higher risk of nonadherence among patients whose physicians communicate poorly than those who communicate well.¹² Although many reasons why patients are lost to follow-up are outside the clinician’s control, efforts to optimize patient communication and build patient rapport may improve care adherence in this population, and further study is warranted. •

REFERENCES

1. Treatments for diabetes eye complications. Centers for Disease Control and Prevention. Updated May 15, 2024. Accessed March 3, 2024. https://www.cdc.gov/diabetes/data-research/research/eye-complications.html

2. Lundeen EA, Burke-Conte Z, Rein DB, et al. Prevalence of diabetic retinopathy in the US in 2021. JAMA Ophthalmol. 2023;141(8):747-754. doi:10.1001/jamaophthalmol.2023.2289

3. Solomon SD, Chew E, Duh EJ, et al. Diabetic retinopathy: a position statement by the American Diabetes Association. Diabetes Care. 2017;40(3):412-418. doi:10.2337/dc16-2641

4. Flaxel CJ, Adelman RA, Bailey ST, et al. Diabetic retinopathy preferred practice pattern. Ophthalmology. 2020;127(1):P66-P145. doi:10.1016/j.ophtha.2019.09.025

5. Suresh R, Yu HJ, Thoveson A, et al. Loss to follow-up among patients with proliferative diabetic retinopathy in clinical practice. Am J Ophthalmol. 2020;215:66-71. doi:10.1016/j.ajo.2020.03.011

6. All of Us Research Program Investigators; Denny JC, Rutter JL, Goldstein DB, et al. The “All of Us” Research Program. N Engl J Med. 2019;381(7):668-676. doi:10.1056/NEJMsr1809937

7. Healthcare Access and Utilization Survey. National Institutes of Health All of Us Research Hub. Accessed March 3, 2024. https://www.researchallofus.org/data-tools/survey-explorer/healthcare-access-utilization-survey/

8. Elam AR, Tseng VL, Rodriguez TM, Mike EV, Warren AK, Coleman AL; American Academy of Ophthalmology Taskforce on Disparities in Eye Care. Disparities in vision health and eye care. Ophthalmology. 2022;129(10):e89-e113. doi:10.1016/j.ophtha.2022.07.010

9. Solomon SD, Shoge RY, Ervin AM, et al. Improving access to eye care: a systematic review of the literature. Ophthalmology. 2022;129(10):e114-e126. doi:10.1016/j.ophtha.2022.07.012

10. Newman-Casey PA, Shtein RM, Coleman AL, Herndon L, Lee PP. Why patients with glaucoma lose vision: the patient perspective. J Glaucoma. 2016;25(7):e668-e675. doi:10.1097/IJG.0000000000000320

11. Flickinger TE, Saha S, Roter D, et al. Respecting patients is associated with more patient-centered communication behaviors in clinical encounters. Patient Educ Couns. 2016;99(2):250-255. doi:10.1016/j.pec.2015.08.020

12.Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826-834. doi:10.1097/MLR.0b013e31819a5acc

Arash Delavar, MD, MPH

Delavar received a bachelor’s degree in sociology and medical doctorate from the University of California, San Diego, and a master’s degree in public health with an emphasis in epidemiology and biostatistics from Washington University in St Louis, Missouri. He is a PGY-2 ophthalmology resident at Baylor College of Medicine in Houston, Texas. He has a strong interest in epidemiology and health disparities research as they apply to ophthalmology.

Amer Fadel Alsoudi, MD

Alsoudi completed medical school training at the University of California, San Francisco, and is a PGY-4 ophthalmology resident at Baylor College of Medicine in Houston, Texas. His career objective is to become a vitreoretinal surgeon, and he is applying in the 2024-2025 application cycle. He is passionate about education, mentorship, and research.

Asad Loya, MD

Loya is a PGY-4 resident at Baylor College of Medicine/Cullen Eye Institute in Houston, Texas. He received a bachelor’s degree in mathematical biology from the University of Houston in 2017 and completed a medical doctorate at Baylor College of Medicine in 2021. He aspires to be a retina specialist and is applying this year for vitreoretinal surgery fellowship. He has an interest in patient outcomes and health disparities research.

Christina Y. Weng, MD, MBA

Weng is an associate professor of ophthalmology and the vitreoretinal diseases and surgery fellowship program director at Baylor College of Medicine in Houston, Texas. She has a faculty appointment at Ben Taub Hospital, a level I trauma center in Houston. Weng graduated from Northwestern University in Evanston, Illinois, and attended medical school at the University of Michigan. While in Ann Arbor, she pursued an MBA from the University of Michigan Stephen M. Ross School of Business.
Weng completed her ophthalmology residency at the Johns Hopkins Wilmer Eye Institute in Baltimore, Maryland and her surgical retina fellowship at Bascom Palmer Eye Institute, University of Miami Health System, in Florida. Weng is involved with multiple clinical trials, leads research studies in her areas of interest, and is coeditor of the book Women in Ophthalmology: A Comprehensive Guide for Career and Life.

Disclosures: Alcon, Alimera Sciences, Allergan/AbbVie, Apellis, Carl Zeiss Meditec, DORC, EyePoint Pharmaceuticals, Genentech, Iveric Bio/Astellas, Novartis, Opthea, Regeneron, REGENXBIO, (consultant); AGTC, Alimera Sciences, DRCR Retina Network (research); Springer Publishers (royalties)