Disparities in Vison Loss and Eye Health

Disparities in Vison Loss and Eye Health Xinzhi Zhang, MD, PhD, FACE, FRSM National Institute on Minority Health and Health Disparities National Institutes of Health

Disclaimer The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the National Institutes of Health. Financial Disclosure: I have no relevant commercial entity relationships or financial interests to disclose.

Background One of Healthy People 2010/2020 goals is to reduce health disparities, including differences that occur by gender, race/ethnicity, education, income, disability, geographic location, or sexual orientation. Addressing disparities in vision health would help enhance public health programs to reduce the gaps and improve the Nation s vision and eye health.

Definition of Health Disparities Health Disparities - A population is a health disparity population if there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality or survival rates in the population as compared to the health status of the general population. Minority Health and Health Disparities Research and Education Act, United States Public Law 106-525 (2000), p. 2498

Warnecke et al. AJPH 2008. Approaching Health Disparities From a Population Perspective: The National Institutes of Health Centers for Population Health and Health Disparities.

Disparities in Eye Diseases and Visual Impairment

Vitale et al. JAMA. 2006. Prevalence of Visual Impairment in the United States

Kemper et al. Journal of Adolescent Health. 2012. Uncorrected Distance Visual Impairment Among Adolescents in the United States.

Zhang et al. Arch Ophthalmol. 2008. Diabetes Mellitus and Visual Impairment. National Health and Nutrition Examination Survey, 1999-2004

Chou et al. AJPH. 2015. Association of Socioeconomic Position With Sensory Impairment Among US Working-Aged Adults

Tielsch et al. JAMA. 1991. Racial Variations in the Prevalence of Primary Open-angle Glaucoma: The Baltimore Eye Survey

Friedman et al. Ophthalmology. 1999. Racial Differences in the Prevalence of Age-related Macular Degeneration: The Baltimore Eye Survey.

Zhang et al. Am J Ophthalmol. 2012. Vision Health Disparities in the United States by Race/ Ethnicity, Education, and Economic Status: Findings From Two Nationally Representative Surveys.

Diabetic Retinopathy NHANESIII NHANES 2005-2008 % 95%CI % 95%CI Non-Hispanic white 1.9 (1.3-2.6) 3.2 (2.5-4.2) Non-Hispanic black 4.9 (3.9-6.0) 8.7 (6.6-11.5) Mexican American 6.8 (4.6-10.0) 5.0 (3.1-7.8) P, White vs. Black <0.001 <0.001 P, White vs. Mexican 0.001 0.136 P, Black vs. Mexican 0.170 0.068 <HIGH SCHOOL 2.8 (2.2-3.6) 6.9 (5.1-9.2) HIGH SCHOOL 3.0 (2.0-4.4) 3.5 (2.3-5.2) >HIGH SCHOOL 1.1 (0.6-2.0) 2.7 (2.1-3.6) p, <HS vs. >HS 0.001 0.001 PIR <1.00 2.4 (1.6-3.5) 5.1 (3.4-7.8) 1.00-1.99 2.6 (1.7-3.8) 4.8 (3.3-6.9) 2.00-3.99 2.2 (1.3-3.6) 3.8 (2.5-5.7) >=4.00 1.9 (1.1-3.2) 2.2 (1.4-3.5) PIR<1.00 vs. >=4.00 0.405 0.030

Age related Macular Degeneration NHANESIII NHANES 2005-2008 % 95%CI % 95%CI Non-Hispanic white 12.9 (11.5-14.4) 8.3 (7.0-9.8) Non-Hispanic black 9.9 (8.1-11.9) 3.1 (1.9-4.9) Mexican American 10.4 (7.9-13.6) 9.8 (6.5-14.3) P, White vs. Black 0.017 <0.001 P, White vs. Mexican 0.072 0.449 P, Black vs. Mexican 0.756 0.003 <HIGH SCHOOL 12.8 (11.2-14.6) 6.7 (5.1-9.1) HIGH SCHOOL 11.7 (9.8-14.0) 7.9 (5.8-10.5) >HIGH SCHOOL 13.6 (11.5-16.0) 8.3 (6.7-10.2) p, <HS vs. >HS 0.490 0.210 PIR <1.00 17.9 (13.8-23.0) 10.4 (7.6-14.1) 1.00-1.99 12.1 (10.2-14.2) 7.1 (5.1-9.8) 2.00-3.99 13.0 (10.9-15.5) 8.3 (6.9-10.1) >=4.00 11.5 (9.6-13.7) 6.8 (5.0-9.2) PIR<1.00 vs. >=4.00 0.030 0.057

Cataract Surgery NHANESIII NHANES 2005-2008 % 95%CI % 95%CI Non-Hispanic white 19.3 (17.6-21.1) 18.4 (16.8-20.1) Non-Hispanic black 16.4 (14.5-18.4) 13.5 (11.3-16.1) Mexican American 20.5 (18.6-22.6) 16.4 (13.2-20.2) P, White vs. Black 0.018 <0.001 P, White vs. Mexican 0.283 0.274 P, Black vs. Mexican 0.002 0.182 <HIGH SCHOOL 19.5 (17.8-21.4) 19.1 (16.3-22.3) HIGH SCHOOL 17.8 (14.7-21.3) 17.1 (14.7-19.9) >HIGH SCHOOL 20.0 (17.6-22.7) 17.5 (15.7-19.4) p, <HS vs. >HS 0.763 0.309 PIR <1.00 17.2 (14.2-20.6) 16.7 (13.7-20.3) 1.00-1.99 21.1 (19.1-23.4) 21.3 (19.0-23.6) 2.00-3.99 17.5 (15.1-20.1) 18.5 (16.4-20.8) >=4.00 19.7 (17.3-22.3) 14 (11.4-17.0) PIR<1.00 vs. >=4.00 0.230 0.116

Glaucoma NHANESIII NHANES 2005-2008 % 95%CI % 95%CI Non-Hispanic white N/A N/A 6.9 (5.9-8.0) Non-Hispanic black N/A N/A 11.5 (9.6-13.8) Mexican American N/A N/A 6.5 (4.5-9.3) P, White vs. Black N/A <0.001 P, White vs. Mexican N/A 0.757 P, Black vs. Mexican N/A 0.006 <HIGH SCHOOL N/A N/A 8.2 (6.7-9.8) HIGH SCHOOL N/A N/A 7.0 (5.0-9.7) >HIGH SCHOOL N/A N/A 7.1 (5.7-8.7) p, <HS vs. >HS N/A 0.397 PIR <1.00 N/A N/A 7.4 (5.9-9.1) 1.00-1.99 N/A N/A 8.3 (7.0-9.8) 2.00-3.99 N/A N/A 7.8 (5.6-10.8) >=4.00 N/A N/A 6.1 (4.4-8.4) PIR<1.00 vs. >=4.00 N/A 0.394

Klein & Klein. Invest Ophthalmol Vis Sci. 2013

Li et al. Ethn Dis. 2010 Asian American/Pacific Islander paradox in diabetic retinopathy: findings from the Behavioral Risk Factor Surveillance System, 2006-2008.

2000 2003 Medical Expenditure Panel Survey McCollister et al. Diabetes Care. 2012. Racial disparities in quality-adjusted life-years associated with diabetes and visual impairment.

Disparities in Eye Care Utilization

Zhang et al. Arch Ophthalmol. 2008. Health Insurance Coverage and Use of Eye Care Services.

Shi et al. Diabetes Care. 2014. Racial Disparity of Eye Examinations Among the U.S. Working-Age Population With Diabetes: 2002 2009 Medical Expenditure Panel Survey Household Component (2002 2009)

Jin et al. Can J Ophthalmol, 2011. Eye care utilization in Canada: disparity in the publicly funded health care system.

Zhang et al. Am J Ophthalmol. 2012. Vision Health Disparities in the United States by Race/ Ethnicity, Education, and Economic Status: Findings From Two Nationally Representative Surveys.

Zhang et al. Am J Ophthalmol. 2012. Vision Health Disparities in the United States by Race/ Ethnicity, Education, and Economic Status: Findings From Two Nationally Representative Surveys.

Annual Eye-care Visits 1999 2008 Trend % 95%CI % 95%CI P value Non-Hispanic white 51.1 (47.0-55.1) 52.6 (47.8-57.4) 0.807 Non-Hispanic black 47.8 (39.8-56.0) 47.2 (37.8-56.9) 0.272 Mexican American 39.5 (28.3-51.8) 36.9 (30.1-44.2) 0.630 P, White vs. Black 0.483 0.308 P, White vs. Mexican 0.070 <0.001 P, Black vs. Mexican 0.261 0.101 <HIGH SCHOOL 38.3 (31.9-45.1) 35.4 (28.6-42.8) 0.330 HIGH SCHOOL 52.9 (46.7-59.1) 54.9 (48.2-61.5) 0.312 >HIGH SCHOOL 54.1 (49.0-59.0) 59.0 (53.8-64.0) 0.637 p, <HS vs. >HS <0.001 <0.001 PIR <1.00 44.2 (35.9 52.8) 33.3 (23.6-44.7) 0.147 1.00-1.99 44.8 (37.9 51.9) 44.3 (37.1 51.9) 0.393 2.00-3.99 49.7 (43.6 55.8) 52.6 (44.5 60.6) 0.393 >=4.00 55.2 (46.9 63.2) 65.7 (57.9-72.7) 0.342 PIR<1.00 vs. >=4.00 0.070 <0.001

Unable to Afford Eyeglasses 1999 2008 Trend % 95%CI % 95%CI P value Non-Hispanic white 11.2 (9.5-13.1) 16.0 (13.3-19.2) 0.004 Non-Hispanic black 17.7 (12.6-24.3) 15.3 (11.1-20.7) 0.451 Mexican American 12.4 (8.9-17.0) 26.7 (19.1-36.1) 0.007 P, White vs. Black 0.035 0.803 P, White vs. Mexican 0.588 0.020 P, Black vs. Mexican 0.151 0.020 <HIGH SCHOOL 18.7 (14.2-24.2) 25.8 (19.6-33.2) 0.071 HIGH SCHOOL 11.0 (8.9-13.5) 17.4 (13.2-22.6) 0.036 >HIGH SCHOOL 10.7 (8.2-13.8) 12.6 (10.1-15.6) 0.058 p, <HS vs. >HS 0.007 <0.001 PIR <1.00 24.7 (18.4 32.4) 23.7 (17.8 30.8) 0.156 1.00-1.99 16.1 (12.7 20.4) 28.6 (22.7 35.3) 0.001 2.00-3.99 9.5 (7.2-12.5) 13.3 (9.9 17.5) 0.094 >=4.00 6.3 (3.9-10.2) 5.4 (3.7-7.8) 0.381 PIR<1.00 vs. >=4.00 <0.001 <0.001

Zhang et al. JAMA Ophthalmol. 2013 Socioeconomic Disparity in Use of Eye Care Services Among US Adults With Age-Related Eye Diseases National Health Interview Survey, 2002 and 2008

Zhang et al. JAMA Ophthalmol. 2013 Socioeconomic Disparity in Use of Eye Care Services Among US Adults With Age-Related Eye Diseases National Health Interview Survey, 2002 and 2008

Chou et al. Am J Ophthalmol 2012. Disparities in Eye Care Utilization Among the United States Adults With Visual Impairment: Findings From the Behavioral Risk Factor Surveillance System 2006-2009.

Zhang et al. Am J Prev Med 2012. Unmet Eye Care Needs Among U.S. 5th-Grade Students.

Luo et al. JPHMP. 2013. The Relationship Between County-Level Contextual Characteristics and Use of Diabetes Care Services

Chou et al. Ophthalmic Epidemiology. 2012. Impact of Geographic Density of Eye Care Professionals on Eye Care among Adults with Diabetes

Figure 1. Number of problem comments on barriers to eye care made in the older African-American focus groups, stratified by topic of comment. Owsley et al. Clinical and Epidemiologic Research. 2006. Perceived Barriers to Care and Attitudes about Vision and Eye Care: Focus Groups with Older African Americans and Eye Care Providers

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Conclusion Vision health disparities in the major eye diseases and eye care utilization exist in the US. Disparities by race/ethnicity, education, and economic status indicate that the greatest need for innovative interventions to reduce unnecessary visual loss is among socio-economically disadvantaged groups. Efforts to raise public awareness of the symptoms and significance of eye diseases and the detection and prevention of vision loss should be strengthened. A national surveillance system incorporating vision health could help to monitor trends and evaluate efforts to reduce the gaps and promote vision health for all Americans.