Place-Based Measures of Inequity and Vision Difficulty and Blindness.

Importance: Known social risk factors associated with poor visual and systemic health in the US include segregation, income inequality, and persistent poverty. Objective: To investigate the association of vision difficulty, including blindness, in neighborhoods with measures of inequity (Theil H index, Gini index, and persistent poverty). Design, Setting, and Participants: This cross-sectional study used data from the 2012-2016 American Community Survey and 2010 US census tracts as well as Theil H index, Gini index, and persistent poverty measures from PolicyMap. Data analysis was completed in July 2023. Main Outcomes and Measures: The main outcome was the number of census tract residents reporting vision difficulty and blindness (VDB) and the association with the Theil H index, Gini index, or persistent poverty, assessed using logistic regression. Results: In total, 73 198 census tracts were analyzed. For every 0.1-unit increase in Theil H index and Gini index, there was an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size (Theil H index: odds ratio [OR], 1.14 [95% CI, 1.14-1.14; P < .001]; Gini index: OR, 1.15 [95% CI, 1.15-1.15; P < .001]). Persistent poverty was associated with an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size compared with nonpersistent poverty (OR, 1.36; 95% CI, 1.35-1.36; P < .001). Conclusions and Relevance: In this cross-sectional study, residential measures of inequity through segregation, income inequality, or persistent poverty were associated with a greater number of residents living with VDB. It is essential to understand and address how neighborhood characteristics can impact rates of VDB.

Spatial Vision Inequalities: A Literature Review of the Impact of Place on Vision and Eye Health Outcomes.

"Neighborhood and built environment" is one of the five domains of social determinants of health that has been outlined by Healthy People 2030, and this domain impacts an individual's well-being, health, and quality of life. Social risk factors (SRFs) in the neighborhood and built environment domain include unstable or unsafe housing, poor access to transportation, lack of green spaces, pollution, safety concerns, and neighborhood measures of inequity. In this narrative literature review, we assess the relationship between neighborhood and built environment SRFs and eye health and vision outcomes. We explain how mapping neighborhood-level SRFs may be used to advance health equity in the field of eye health and vision care.

Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine Program: First-Year Outcomes and Implementation Costs.

PURPOSE: The Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (MI-SIGHT) program aims to engage people who are at high risk of glaucoma; we assess first-year outcomes and costs. DESIGN: Clinical cohort study. METHODS: Participants ≥18 years of age were recruited from a free clinic and a federally qualified health center in Michigan. Ophthalmic technicians in the clinics collected demographic information, visual function, ocular health history, measured visual acuity, refraction, intraocular pressure, pachymetry, pupils, and took mydriatic fundus photographs and retinal nerve fiber layer optical coherence tomography. Data were interpreted by remote ophthalmologists. During a follow-up visit, technicians shared ophthalmologist recommendations, dispensed low-cost glasses, and collected participant satisfaction. The primary outcome measures were prevalence of eye disease, visual function, program satisfaction, and costs. Observed prevalence was compared with national disease prevalence rates using z tests of proportions. RESULTS: Among 1171 participants, the average age was 55 years (SD 14.5 years), 38% were male, 54% identified as Black, 34% as White, 10% as Hispanic, 33% had less than or equal to a high school education, and 70% had an annual income <$30,000. The prevalence of visual impairment was 10.3% (national average 2.2%), glaucoma and suspected glaucoma 24% (national average 9%), macular degeneration 2.0% (national average 1.5%), and diabetic retinopathy 7.3% (national average 3.4%) (P < .0001). Seventy-one percent of participants received low-cost glasses, 41% were referred for ophthalmology follow-up, and 99% were satisfied or very satisfied with the program. Startup costs were $103,185; recurrent costs were $248,103 per clinic. CONCLUSIONS: Telemedicine eye disease detection programs in low-income community clinics effectively identify high rates of pathology.

Seeing Red: Associations between Historical Redlining and Present-Day Visual Impairment and Blindness.

PURPOSE: Redlining was a discriminatory housing policy in the United States that began in 1933 and denoted neighborhoods with high proportions of Black individuals as "undesirable" and a high risk for lending, which therefore excluded people from obtaining traditional insured mortgages to purchase a home. Simultaneously, realtors discouraged Black individuals from purchasing homes in predominantly non-Black neighborhoods. This resulted in decreased home ownership and wealth accumulation among Black individuals and neighborhoods with high proportions of Black individuals. This study investigated rates of visual impairment and blindness (VIB) in neighborhoods that at one time were graded for redlining. DESIGN: Secondary data analysis of American Community Survey data and historical grades for redlining. PARTICIPANTS: United States census tracts (CTs) from 2010 with historical grades for redlining. METHODS: One-way analysis of variance, Kruskal-Wallis test, chi-square test, and logistic regression modeling. MAIN OUTCOME MEASURES: The main outcome was CT percentage of residents reporting VIB and the association with historical grades for redlining. Grades were converted to numeric values (1 to 4, with higher values indicating worse grade) and aggregated over a CT based on the distribution of grades within to obtain a redlining score. Logistic regression was used to model the effect of redlining on the probability of having VIB. RESULTS: Eleven thousand six hundred sixty-eight CTs were analyzed. Logistic regression found that a 1-unit increase in average redlining score was associated with a 13.4% increased odds of VIB after controlling for CT measures of age, sex, people of color (any non-White race), state, and population size (odds ratio [OR], 1.134; 95% confidence interval [CI], 1.131-1.138; P < 0.001). Similar results were observed for an additional model that adjusted for the estimated percentage of Black residents within a CT (OR, 1.180; 95% CI, 1.177-1.183; P < 0.001). CONCLUSIONS: Historical government-sanctioned residential segregation through redlining was found to be associated with higher proportions of people living with VIB in these neighborhoods today. Understanding how neighborhood segregation impacts eye health is important for planning improved mechanisms of eye care delivery to mitigate health disparities. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Large Disparities in Receipt of Glaucoma Care between Enrollees in Medicaid and Those with Commercial Health Insurance.

PURPOSE: To determine whether the type of health insurance a patient possesses and a patient's race/ethnicity affect receipt of common tests to monitor open-angle glaucoma (OAG). DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: A total of 21 766 persons aged ≥40 years with newly diagnosed OAG between 2007 and 2011 enrolled in Medicaid or a large United States managed care network. METHODS: We determined the proportion of patients with newly diagnosed OAG who underwent visual field (VF) testing, fundus photography (FP), other ocular imaging (OOI), or none of these tests within the first 15 months after initial OAG diagnosis. Multivariable logistic regression was used to assess the extent by which health insurance type and race/ethnicity affected the odds of undergoing glaucoma testing. MAIN OUTCOME MEASURES: Odds ratios (OR) of undergoing VF testing, FP, OOI, or none of these tests in the 15 months after initial OAG diagnosis with 95% confidence intervals (CI). RESULTS: A total of 18 372 persons with commercial health insurance and 3394 Medicaid recipients met the study inclusion criteria. The proportions of persons with commercial health insurance with newly diagnosed OAG who underwent VF, FP, and OOI were 63%, 22%, and 54%, respectively, whereas the proportions were 35%, 19%, and 30%, respectively, for Medicaid recipients. Compared with those with commercial health insurance, Medicaid recipients were 234% more likely to not receive any glaucoma testing in the 15 months after initial diagnosis (OR = 3.34; 95% CI, 3.07-3.63). After adjustment for confounders, whites with OAG enrolled in Medicaid had 198% higher odds of receiving no glaucoma testing compared with whites possessing commercial health insurance (OR = 2.98; 95% CI, 2.66-3.33). Blacks with Medicaid insurance demonstrated 291% higher odds (OR = 3.91; 95% CI, 3.40-4.49) of not receiving any glaucoma testing compared with blacks with commercial health insurance. CONCLUSIONS: Irrespective of race/ethnicity, Medicaid recipients with OAG are receiving substantially less glaucoma testing compared with persons with commercial health insurance. Disparities in testing are observed across all races/ethnicities but were most notable for blacks. These findings are particularly disconcerting because blacks are more likely than whites to go blind from OAG and there are disproportionately more blacks in Medicaid. Efforts are needed to improve the quality of glaucoma care for Medicaid recipients, especially racial minorities.

High-risk populations for vision loss and eye care underutilization: a review of the literature and ideas on moving forward.

Much work has been done to highlight and understand the significant disparities in the use of eye care services, but they continue to exist. We review the existing literature on utilization in high-risk populations to provide a context for understanding what "high-risk" means, to understand the utilization patterns among high-risk populations, and to highlight barriers to appropriate eye care utilization. We also discuss potential approaches to reduce these disparities.