A recent study found that ethnic and insurance disparities are linked to visual acuity and disease severity upon initiation of anti-VEGF therapy for diabetic macular edema (DME).

The retrospective, cross-sectional study included 203,707 patients who received anti-VEGF treatment for DME. The researchers analyzed possible associations among baseline features and race, ethnicity, insurance status and geographic location.

They found that patients on Medicare and private insurance presented with significantly higher baseline visual acuity than patients on Medicaid (median of 2.31 and 4.17 greater ETDRS letters, respectively).

“A higher proportion of Black and Hispanic patients were insured by Medicaid, indicating that insurance status could potentially underscore some differences observed between race and ethnicity seen in the univariate analysis,” the researchers wrote in their paper. “While this finding isn’t surprising, there’s very little literature published on insurance as a risk factor for diabetic retinopathy (DR) and DME severity. There are substantial differences in timely treatment of DME based on insurer, and insurance status is an important area of future investigation to address disparities in ophthalmic care going forward.”

Black patients had worse baseline DR severity and overall visual acuity, the researchers found. White and non-Hispanic patients presented with better visual acuity, with white patients achieving a median of one ETDRS letter greater than Black patients in the first ETDRS quartile and 0.68 letters greater at the median level. Black and Hispanic patients presented with significantly worse baseline DR severity compared with white and non-Hispanic patients.

“This difference in baseline severity and visual acuity at the time of treatment initiation isn’t surprising, as racial disparities in DR and DME are well-represented in literature,” the investigators noted. “In this analysis, it’s crucial to consider the social circumstances affecting risk factors like race and ethnicity. Race, specifically, is a socially constructed phenomenon used in this study to understand how underserved patients may experience differences in care.”

They noted that Black patients presenting with worse baseline visual acuity are likely to have other contributing factors such as “the intersection systemic racism, socioeconomic status, poor access to care and nutrition, health literacy and education.”

            The researchers concluded that ethnicity, race and insurance were independently associated with worse visual acuity and DR severity, with Hispanic ethnicity and Medicaid insurance showing the strongest correlation with poor eye health. They noted that it’s important for clinicians to be aware of these social factors that may affect their patients’ abilities to receive care. “Further research is needed to understand specific barriers to care for demographics preferentially affected by DR and DME in order for public health interventions to improve ophthalmic care long term,” they wrote.

Malhotra NA, Greenlee TE, Iyer AI, et al. Racial, ethnic, and insurance-based disparities upon initiation of anti-VEGF therapy for diabetic macular edema in the United States. Ophthalmology. March 10, 2021. [Epub ahead of print].