Vision Health Disparities in the United States by Race/Ethnicity, Education, and Economic Status: Findings From Two Nationally Representative Surveys

doi:10.1016/j.ajo.2011.08.045

American Journal of Ophthalmology

Volume 154, Issue 6, Supplement, December 2012, Pages S53-S62.e1

https://doi.org/10.1016/j.ajo.2011.08.045 Get rights and content

Purpose

To assess vision health disparities in the United States by race/ethnicity, education, and economic status.

Design

Cross-sectional, nationally representative samples.

Methods

We used national survey data from the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey (NHIS). Main outcome measures included, from NHANES, age-related eye diseases (ie, age-related macular degeneration [AMD], cataract, diabetic retinopathy [DR], glaucoma) and from NHIS, eye care use (ie, eye doctor visits and cannot afford eyeglasses when needed) among those with self-reported visual impairment. The estimates were age- and sex-standardized to the 2000 US Census population. Linear trends in the estimates were assessed by weighted least squares regression.

Results

Non-Hispanic whites had a higher prevalence of AMD and cataract surgery than non-Hispanic blacks, but a lower prevalence of DR and glaucoma (all P < .001 in NHANES 2005-2008). From 1999 to 2008, individuals with less education (ie, <high school vs >high school) and lower income (poverty income ratio [PIR] <1.00 vs ≥4.00) were consistently less likely to have had an eye care visit in the past 12 months compared with their counterparts (all P < .05). During this period, inability to afford needed eyeglasses increased among non-Hispanic whites and Hispanics (trend P = .004 and P = .007; respectively), those with high school education (trend P = .036), and those with PIR 1.00-1.99 (trend P < .001).

Conclusions

Observed vision health disparities suggest a need for educational and innovative interventions among socioeconomically disadvantaged groups.

Section snippets

National Health and Nutrition Examination Survey

The National Health and Nutrition Examination Survey (NHANES) (www.cdc.gov/nchs/nhanes.htm) is a national representative survey conducted by the National Center for Health Statistics, the Centers for Disease Control and Prevention (CDC). The NHANES was conducted during 1960-1962 (NHES I), 1963-1965 (NHES II), 1966-1970 (NHES III), 1971-1974 (NHANES I), 1976-1980 (NHANES II), 1982-1984 (HHANES), and 1988-1994 (NHANES III). Since 1999, the NHANES has been conducted continuously. The NHANES survey

Prevalence of Eye Diseases by Race/Ethnicity, Educational Attainment, and Economic Status

The observed racial/ethnic differences of DR among non-Hispanic whites and non-Hispanic blacks remained during the decade (Table 1). The prevalence of DR was significantly higher among non-Hispanic blacks than among non-Hispanic whites in NHANES III and NHANES 2005-2008 (4.9% vs 1.9%, 8.7% vs 3.2%; both P < .001). Some significant differences in age- and sex-standardized prevalence of AMD or cataract surgery by race/ethnicity were also present. For example, the prevalence of AMD was higher

Vision Health Disparities

We report observed disparities by race/ethnicity, education, and economic status in the prevalence of the major eye diseases and the use of eye care services. We also found that these disparities existed previously and have persisted over a decade.

Our survey-based evidence of racial/ethnic differences for the effects of major eye diseases is consistent with previous literature.27, 32, 33, 34 We found that the prevalence of DR and glaucoma among Americans 40 years of age or older is greater in

Xinzhi Zhang, MD, PhD, is an epidemiologist at the Centers for Disease Control and Prevention (CDC), Atlanta, Georgia. He received his medical degree from Peking Union Medical College and PhD in Health Services Administration from the University of Alabama at Birmingham (UAB), where he is also an adjunct professor. He has received awards from Agency for Healthcare Research and Quality, CDC, and American Public Health Association. Dr Zhang is an overseas fellow of the Royal Society of Medicine.

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Vision improvement compared with baseline was determined at 1 year after surgery. A multivariable generalized estimating equation model adjusting for demographic factors and baseline vision was used to identify factors associated with VA worse than 20/40 at 1 year.
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A total of 46 063 procedures (n = 41 925 unique patients) were included in the analysis. Overall, VA improved from a mean ± standard deviation (SD) of 0.53 ± 0.58 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/70) before surgery to a mean ± SD of 0.31 ± 0.40 logMAR (Snellen equivalent, 20/40) at 1 year. Among eyes with VA recorded at both baseline and 1 year after surgery, 60.5% achieved VA of 20/40 or better at 1 year. Vision of worse than 20/40 at 1 year was associated with greater age (odds ratio [OR], 1.16 per 5-year increase; 95% confidence interval [CI], 1.14–1.18) and higher logMAR baseline VA (OR, 1.14 per 0.1-logMAR increase; 95% CI, 1.14–1.15), as well as Black or African American (OR, 1.96; 95% CI, 1.68–2.28), Hispanic (OR, 1.82; 95% CI, 1.59–2.08), and Asian (OR, 1.48; 95% CI, 1.21–1.81) race or ethnicity versus White race, Medicaid (OR, 1.78; 95% CI, 1.40–2.25) versus private insurance, smoking history (OR, 1.22; 95% CI, 1.11–1.35), and concurrent anterior (OR, 1.65; 95% CI, 1.51–1.81) and posterior (OR, 1.53; 95% CI, 1.41–1.66) vitrectomy versus no vitrectomy. Female sex was associated with better VA at 1 year. At 1 year, epiretinal membrane (10.9%), mechanical lens complication (9.4%), and dislocation of the replacement lens (7.1%) were the most common complications.
In this large national cohort, the annual number of IOL exchanges rose steadily over time. Vision improved in 60.2% of patients; worse visual outcomes were associated with greater age, worse baseline vision, Black race, Hispanic ethnicity, Medicaid insurance, smoking, and concurrent vitrectomy. Epiretinal membrane was the most common complication.
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Incidence of POAG, OHT, and OHT progression.
The overall 6-year age-adjusted incidences of POAG and OHT were 1.31% (95% confidence interval [CI], 1.04–1.62) and 0.47% (95% CI, 0.30–0.70). The rate of progression of baseline OHT to POAG at 6 years was 5.32%. Primary open-angle glaucoma incidence was similar (1.37%) in Chinese and Indians and lower (0.80%) in Malays. Malays had higher incidence (0.79%) of OHT than Indians (0.38%) and Chinese (0.37%). Baseline parameters associated with higher risk of POAG were older age (per decade: odds ratio [OR], 1.90; 95% CI, 1.54–2.35; P < 0.001), higher baseline IOP (per mmHg: OR, 1.20; 95% CI, 1.12–1.29; P < 0.001) and longer axial length (per mm: OR, 1.22; 95% CI, 1.07–1.40, P = 0.004).
Six-year incidence of POAG was 1.31% in a multiethnic Asian population. Older age, higher IOP, and longer axial length were associated with higher risk of POAG. These findings can help in future projections and guide public healthcare policy decisions for screening at-risk individuals.
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Disparities in Retinal Vein Occlusion Presentation and Initiation of Anti-VEGF Therapy: An Academy IRIS® Registry Analysis
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A total of 304 558 eligible patients with RVO and ME were identified. Age at presentation varied by race, ethnicity, sex, and RVO type (all P values < 0.001). Within the first year after RVO presentation, 192 602 (63.2%) patients received ≥ 1 anti-VEGF injection. In a multivariable regression model adjusting for relevant covariates, female (vs. male) patients had lower odds of receiving injections (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.93–0.96; P < 0.0001) as did Black/African American (vs. White) patients (OR, 0.90; 95% CI, 0.88–0.92; P < 0.0001) and Asian (vs. White) patients (OR, 0.95; 95% CI, 0.91–0.99; P = 0.02), whereas older patients (vs. patients aged < 51 years) had higher odds (61–70 years: OR, 1.20; 95% CI, 1.16–1.24; 71–80 years: OR, 1.20; 95% CI, 1.16–1.24; > 80 years: OR, 1.15; 95% CI, 1.11–1.18; all P values < 0.0001). Hispanic (vs. non-Hispanic) patients had a small increased odds of treatment initiation (OR, 1.08; 95% CI, 1.04–1.11; P < 0.0001). Results were similar in the subset of 226 143 patients with VA data. In this subset, patients with presenting VA < 20/40 to 20/200 were most frequently treated in the first year after diagnosis (∼ 70%) and patients with light perception/no light perception (LP-NLP) vision or VA of 20/20 or better were treated least frequently (36.9% and 41.9%, respectively).
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We examined the racial and ethnic demographic distribution of participants in clinical trials related to DME across a 20-year period from 2002 to 2021. Clinical trials were screened from ClinicalTrials.gov for DME, US trial location, study completion, and > 50 patient enrollment. Descriptive statistics, proportions, odds ratios (ORs), and chi-square tests were reported and compared with 2021 US Census demographic data and diagnosed patients with diabetes demographic data.
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ArticleVision Health Disparities in the United States by Race/Ethnicity, Education, and Economic Status: Findings From Two Nationally Representative Surveys

Purpose

Design

Methods

Results

Conclusions

Section snippets

National Health and Nutrition Examination Survey

Prevalence of Eye Diseases by Race/Ethnicity, Educational Attainment, and Economic Status

Vision Health Disparities

Ophthalmology

Can J Ophthalmol

Ophthalmology

Global initiative for the elimination of avoidable blindness: Action plan 2006-2011

Prevalence of age-related macular degeneration in the United States

Arch Ophthalmol

Prevalence of cataract and pseudophakia/aphakia among adults in the United States

Arch Ophthalmol

Prevalence of open-angle glaucoma among adults in the United States

Arch Ophthalmol

The prevalence of diabetic retinopathy among adults in the United States

Arch Ophthalmol

The prevalence of refractive errors among adults in the United States, Western Europe, and Australia

Arch Ophthalmol

Causes and prevalence of visual impairment among adults in the United States

Arch Ophthalmol

Impact of unilateral and bilateral vision loss on quality of life

Br J Ophthalmol

Function and visual impairment in a population-based study of older adultsThe SEE project. Salisbury Eye Evaluation

Invest Ophthalmol Vis Sci

Visual impairment and falls in older adults: the Blue Mountains Eye Study

J Am Geriatr Soc

Visual impairment and risk of hip fracture

Am J Epidemiol

The relationship between chronic illness and depression in a community of urban black elderly persons

J Gerontol B Psychol Sci Soc Sci

Depression and disability associated with impaired vision: the MoVies Project

J Am Geriatr Soc

The Beaver Dam Health Outcomes Study: initial catalog of health-state quality factors

Med Decis Making

Visual impairment, age-related macular degeneration, cataract, and long-term mortality: the Blue Mountains Eye Study

Arch Ophthalmol

Age-related eye disease and survivalThe Beaver Dam Eye Study

Arch Ophthalmol

Visual impairment and morbidity in community-residing adults: the national health interview survey 1986-1996

Ophthalmic Epidemiol

Vision impairment predicts 5 year mortality

Br J Ophthalmol

Healthy People 2010: Understanding and Improving Health

Article
Vision Health Disparities in the United States by Race/Ethnicity, Education, and Economic Status: Findings From Two Nationally Representative Surveys