Health Care Access and Use Among Adults With and Without Vision Impairment: Behavioral Risk Factor Surveillance System, 2018.

INTRODUCTION: Adults with vision impairment may have unique needs when accessing health care to maintain good health. Our study examined the relationship between vision status and access to and use of health care. METHODS: We analyzed data on adults aged 18 years or older who participated in the 2018 Behavioral Risk Factor Surveillance System. Vision impairment was identified by a yes response to the question "Are you blind or do you have serious difficulty seeing, even when wearing glasses?" Survey questions assessed health care access over the past year (having health insurance coverage, a usual health care provider, or unmet health care needs because of cost) and use of health care during that period (routine checkup and dental visit). We estimated age-adjusted prevalence of our outcomes of interest and used bivariate analyses to compare estimates of the outcomes by vision impairment status. RESULTS: The prevalence of self-reported vision impairment was 5.3%. Compared with adults without impaired vision, adults with vision impairment had a lower prevalence of having health insurance coverage (80.6% vs 87.6%), a usual health care provider (71.9% vs 75.7%), or a dental visit in the past year (52.9% vs 67.2%) and a higher prevalence of having an unmet health care need in the past year because of cost (29.2% vs 12.6%). CONCLUSION: Adults with vision impairment reported lower access to and use of health care than those without. Further research can better identify and understand barriers to care to improve access to and use of health care among this population.

Philadelphia Telemedicine Glaucoma Detection and Follow-Up Study: Cataract Classifications Following Eye Screening.

Background:Cataracts are a major cause of visual impairment and blindness in the United States and worldwide.Introduction:Risk factors for cataracts include age over 40 years, smoking, diabetes, low socioeconomic status, female sex, steroid use, ocular trauma, genetic factors, and exposure to ultraviolet-B light. Community-based telemedicine vision screenings can be an efficient method for detecting cataracts in underserved populations. The Philadelphia Telemedicine Glaucoma Detection and Follow-Up Study reports the prevalence and risk factors for cataracts in individuals screened and examined for glaucoma and other eye diseases.Materials and Methods:A total of 906 high-risk individuals were screened for glaucoma using telemedicine in seven primary care practices and four Federally Qualified Health Centers in Philadelphia. Participants with suspicious nerves or other abnormalities on fundus photographs, unreadable images, and ocular hypertension returned for an eye examination with an ophthalmologist at the same community location.Results:Of the participants screened through telemedicine, 347 (38.3%) completed a follow-up eye examination by an ophthalmologist. Of these, 267 (76.9%) were diagnosed with cataracts, of which 38 (14.2%) had visually significant cataracts. Participants who were diagnosed with visually significant cataract were more likely to be older (p < 0.001), have diabetes (p = 0.003), and worse visual acuity (p < 0.001).Discussion:Our study successfully detected and confirmed cataracts in a targeted, underserved urban population at high risk for eye disease.Conclusions:Telemedicine programs offer an opportunity to identify and refer individuals who would benefit from continuous follow-up eye care and treatment to improve visual function and quality of life.

Achievement of goals in U.S. diabetes care, 1999-2010.

BACKGROUND: Tracking national progress in diabetes care may aid in the evaluation of past efforts and identify residual gaps in care. METHODS: We analyzed data for adults with self-reported diabetes from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System to examine risk-factor control, preventive practices, and risk scores for coronary heart disease over the 1999-2010 period. RESULTS: From 1999 through 2010, the weighted proportion of survey participants who met recommended goals for diabetes care increased, by 7.9 percentage points (95% confidence interval [CI], 0.8 to 15.0) for glycemic control (glycated hemoglobin level <7.0%), 9.4 percentage points (95% CI, 3.0 to 15.8) for individualized glycemic targets, 11.7 percentage points (95% CI, 5.7 to 17.7) for blood pressure (target, <130/80 mm Hg), and 20.8 percentage points (95% CI, 11.6 to 30.0) for lipid levels (target level of low-density lipoprotein [LDL] cholesterol, <100 mg per deciliter [2.6 mmol per liter]). Tobacco use did not change significantly, but the 10-year probability of coronary heart disease decreased by 2.8 to 3.7 percentage points. However, 33.4 to 48.7% of persons with diabetes still did not meet the targets for glycemic control, blood pressure, or LDL cholesterol level. Only 14.3% met the targets for all three of these measures and for tobacco use. Adherence to the recommendations for annual eye and dental examinations was unchanged, but annual lipid-level measurement and foot examination increased by 5.5 percentage points (95% CI, 1.6 to 9.4) and 6.8 percentage points (95% CI, 4.8 to 8.8), respectively. Annual vaccination for influenza and receipt of pneumococcal vaccination for participants 65 years of age or older rose by 4.5 percentage points (95% CI, 0.8 to 8.2) and 6.9 percentage points (95% CI, 3.4 to 10.4), respectively, and daily glucose monitoring increased by 12.7 percentage points (95% CI, 10.3 to 15.1). CONCLUSIONS: Although there were improvements in risk-factor control and adherence to preventive practices from 1999 to 2010, tobacco use remained high, and almost half of U.S. adults with diabetes did not meet the recommended goals for diabetes care.

The Philadelphia Glaucoma Detection and Treatment Project: Detection Rates and Initial Management.

PURPOSE: To evaluate the detection rates of glaucoma-related diagnoses and the initial treatments received in the Philadelphia Glaucoma Detection and Treatment Project, a community-based initiative aimed at improving the detection, treatment, and follow-up care of individuals at risk for glaucoma. DESIGN: Retrospective analysis. PARTICIPANTS: A total of 1649 individuals at risk for glaucoma who were examined and treated in 43 community centers located in underserved communities of Philadelphia. METHODS: Individuals were enrolled if they were African American aged ≥50 years, were any other adult aged ≥60 years, or had a family history of glaucoma. After attending an informational glaucoma workshop, participants underwent a targeted glaucoma examination including an ocular, medical, and family history; visual acuity testing, intraocular pressure (IOP) measurement, and corneal pachymetry; slit-lamp and optic nerve examination; automated visual field testing; and fundus color photography. If indicated, treatments included selective laser trabeculoplasty (SLT), laser peripheral iridotomy (LPI), or IOP-lowering medications. Follow-up examinations were scheduled at the community sites after 4 to 6 weeks or 4 to 6 months, depending on the clinical scenario. MAIN OUTCOME MEASURES: Detection rates of glaucoma-related diagnoses and types of treatments administered. RESULTS: Of the 1649 individuals enrolled, 645 (39.1%) received a glaucoma-related diagnosis; 20.0% (n = 330) were identified as open-angle glaucoma (OAG) suspects, 9.2% (n = 151) were identified as having narrow angles (or as a primary angle closure/suspect), and 10.0% (n = 164) were diagnosed with glaucoma, including 9.0% (n = 148) with OAG and 1.0% (n = 16) with angle-closure glaucoma. Overall, 39.0% (n = 64 of 164) of those diagnosed with glaucoma were unaware of their diagnosis. A total of 196 patients (11.9%) received glaucoma-related treatment, including 84 (5.1%) who underwent LPI, 13 (0.8%) who underwent SLT, and 103 (6.2%) who were prescribed IOP-lowering medication. CONCLUSIONS: Targeting individuals at risk for glaucoma in underserved communities in Philadelphia yielded a high detection rate (39.1%) of glaucoma-related diagnoses. Providing examinations and offering treatment, including first-line laser procedures, at community-based sites providing services to older adults are effective to improve access to eye care by underserved populations.

Falls Among Persons Aged ≥65 Years With and Without Severe Vision Impairment - United States, 2014.

In 2014, an estimated 2.8 million persons aged ≥65 years in the United States reported severe vision impairment* defined as being blind or having severe difficulty seeing, even with eyeglasses. Good vision is important for maintaining balance as well as for identifying low-contrast hazards, estimating distances, and discerning spatial relationships. Conversely, having poor vision increases the risk for falls (1,2). Falls among older adults are common and can cause serious injuries, disabilities, and premature death (1,3). To date, no state-level investigations have examined the annual prevalence of falls among persons with and without severe vision impairment. CDC analyzed data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS) to estimate the state-specific annual prevalence of falls among persons aged ≥65 years with and without self-reported severe vision impairment. Overall, 46.7% of persons with, and 27.7% of older adults without, self-reported severe vision impairment reported having fallen during the previous year. The state-specific annual prevalence of falls among persons aged ≥65 years with severe vision impairment ranged from 30.8% (Hawaii) to 59.1% (California). In contrast, the prevalence of falls among persons aged ≥65 years without severe vision impairment ranged from 20.4% (Hawaii) to 32.4% (Alaska). Developing fall-prevention interventions intended for persons with severe vision impairment will help states manage the impact of vision impairment and falls on health care resources, and can inform state-specific fall prevention initiatives.

Association of Socioeconomic Position With Sensory Impairment Among US Working-Aged Adults.

OBJECTIVES: We examined the relationship between socioeconomic position (SEP) and sensory impairment. METHODS: We used data from the 2007 to 2010 National Health Interview Surveys (n = 69 845 adults). Multivariable logistic regressions estimated odds ratios (ORs) for associations of educational attainment, occupational class, and poverty-income ratio with impaired vision or hearing. RESULTS: Nearly 20% of respondents reported sensory impairment. Each SEP indicator was negatively associated with sensory impairment. Adjusted odds of vision impairment were significantly higher for farm workers (OR = 1.41; 95% confidence interval [CI] = 1.01, 2.02), people with some college (OR = 1.29; 95% CI = 1.16, 1.44) or less than a high school diploma (OR = 1.36; 95% CI = 1.19, 1.55), and people from poor (OR = 1.35; 95% CI = 1.20, 1.52), low-income (OR = 1.28; 95% CI = 1.14, 1.43), or middle-income (OR = 1.19; 95% CI = 1.07, 1.31) families than for the highest-SEP group. Odds of hearing impairment were significantly higher for people with some college or less education than for those with a college degree or more; for service groups, farmers, and blue-collar workers than for white-collar workers; and for people in poor families. CONCLUSIONS: More research is needed to understand the SEP-sensory impairment association.

Geographic disparity of severe vision loss - United States, 2009-2013.

Vision loss and blindness are among the top 10 disabilities in the United States, causing substantial social, economic, and psychological effects, including increased morbidity, increased mortality, and decreased quality of life.* There are disparities in vision loss based on age, sex, race/ethnicity, socioeconomic status, and geographic location. Current surveillance activities using national and state surveys have characterized vision loss at national and state levels. However, there are limited data and research at local levels, where interventions and policy decisions to reduce the burden of vision loss and eliminate disparities are often developed and implemented. CDC analyzed data from the American Community Survey (ACS) to estimate county-level prevalence of severe vision loss (SVL) (being blind or having serious difficulty seeing even when wearing glasses) in the United States and to describe its geographic pattern and its association with poverty level. Distinct geographic patterns of SVL prevalence were found in the United States; 77.3% of counties in the top SVL prevalence quartile (≥4.2%) were located in the South. SVL was significantly correlated with poverty (r = 0.5); 437 counties were in the top quartiles for both SVL and poverty, and 83.1% of those counties were located in southern states. A better understanding of the underlying barriers and facilitators of access and use of eye care services at the local level is needed to enable the development of more effective interventions and policies, and to help planners and practitioners serve the growing population with and at risk for vision loss more efficiently.

The economic burden of vision loss and eye disorders among the United States population younger than 40 years.

OBJECTIVE: To estimate the economic burden of vision loss and eye disorders in the United States population younger than 40 years in 2012. DESIGN: Econometric and statistical analysis of survey, commercial claims, and census data. PARTICIPANTS: The United States population younger than 40 years in 2012. METHODS: We categorized costs based on consensus guidelines. We estimated medical costs attributable to diagnosed eye-related disorders, undiagnosed vision loss, and medical vision aids using Medical Expenditure Panel Survey and MarketScan data. The prevalence of vision impairment and blindness were estimated using National Health and Nutrition Examination Survey data. We estimated costs from lost productivity using Survey of Income and Program Participation. We estimated costs of informal care, low vision aids, special education, school screening, government spending, and transfer payments based on published estimates and federal budgets. We estimated quality-adjusted life years (QALYs) lost based on published utility values. MAIN OUTCOME MEASURES: Costs and QALYs lost in 2012. RESULTS: The economic burden of vision loss and eye disorders among the United States population younger than 40 years was $27.5 billion in 2012 (95% confidence interval, $21.5-$37.2 billion), including $5.9 billion for children and $21.6 billion for adults 18 to 39 years of age. Direct costs were $14.5 billion, including $7.3 billion in medical costs for diagnosed disorders, $4.9 billion in refraction correction, $0.5 billion in medical costs for undiagnosed vision loss, and $1.8 billion in other direct costs. Indirect costs were $13 billion, primarily because of $12.2 billion in productivity losses. In addition, vision loss cost society 215 000 QALYs. CONCLUSIONS: We found a substantial burden resulting from vision loss and eye disorders in the United States population younger than 40 years, a population excluded from previous studies. Monetizing quality-of-life losses at $50 000 per QALY would add $10.8 billion in additional costs, indicating a total economic burden of $38.2 billion. Relative to previously reported estimates for the population 40 years of age and older, more than one third of the total cost of vision loss and eye disorders may be incurred by persons younger than 40 years. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Smoking and visual impairment among older adults with age-related eye diseases.

INTRODUCTION: Tobacco use is the leading preventable cause of death in the United States. Visual impairment, a common cause of disability in the United States, is associated with shorter life expectancy and lower quality of life. The relationship between smoking and visual impairment is not clearly understood. We assessed the association between smoking and visual impairment among older adults with age-related eye diseases. METHODS: We analyzed Behavioral Risk Factor Surveillance System data from 2005 through 2008 on older adults with age-related eye diseases (cataract, glaucoma, age-related macular degeneration, and diabetic retinopathy; age ≥50 y, N = 36,522). Visual impairment was defined by self-reported difficulty in recognizing a friend across the street or difficulty in reading print or numbers. Current smokers were respondents who reported having smoked at least 100 cigarettes ever and still smoked at the time of interview. Former smokers were respondents who reported having ever smoked at least 100 cigarettes but currently did not smoke. We used multivariate logistic regressions to examine the association and to adjust for potential confounders. RESULTS: Among respondents with age-related eye diseases, the estimated prevalence of visual impairment was higher among current smokers (48%) than among former smokers (41%, P < .05) and respondents who had never smoked (42%, P < .05). After adjustment for age, sex, race/ethnicity, education, and general health status, current smokers with age-related eye diseases were more likely to have visual impairment than respondents with age-related eye diseases who had never smoked (odds ratio, 1.16, P < .05). Furthermore, respondents with cataract who were current smokers were more likely to have visual impairment than respondents with cataract who had never smoked (predictive margin, 44% vs 40%, P = .03), and the same was true for respondents with age-related macular degeneration (65% of current smokers vs 57% of never smokers, P = .02). This association did not hold true among respondents with glaucoma or diabetic retinopathy. CONCLUSION: Smoking is linked to self-reported visual impairment among older adults with age-related eye diseases, particularly cataract and age-related macular degeneration. Longitudinal evaluation is needed to assess smoking cessation's effect on vision preservation.

Manhattan Vision Screening and Follow-up Study in Vulnerable Populations (NYC-SIGHT): Design and Methodology.

PRCIS: The Manhattan Vision Screening and Follow-up Study in Vulnerable Populations is a 5-year prospective, cluster-randomized study to improve detection and management of glaucoma and other eye diseases in vulnerable populations living in affordable housing developments. PURPOSE: To describe the study design and methodology of the Manhattan Vision Screening and Follow-up Study in Vulnerable Populations, which aims to investigate whether community-based vision screenings can improve detection and management of glaucoma, vision impairment, cataract, and other eye diseases among vulnerable populations living in affordable housing developments in upper Manhattan. MATERIALS AND METHODS: This 5-year prospective, cluster-randomized, controlled trial consists of vision screening and referral for follow-up eye care among eligible residents aged 40 and older. Visual acuity, intraocular pressure (IOP), and fundus photography are measured. Participants with visual worse than 20/40, or IOP 23 to 29 mm Hg, or unreadable fundus images fail the screening and are scheduled with the on-site optometrist. Those with an abnormal image and/or IOP ≥30 mm Hg, are assigned as "fast-track" and referred to ophthalmology. Participants living in 7 developments randomized to the Enhanced Intervention Group who fail the screening and need vision correction receive complimentary eyeglasses. Those referred to ophthalmology receive enhanced support with patient navigators to assist with follow-up eye care. Participants living in 3 developments randomized to the Usual Care Group who fail the screening and need vision correction are given an eyeglasses prescription only and a list of optical shops. No enhanced support is given to the Usual Care Group. All participants referred to ophthalmology are assisted in making their initial eye exam appointment. CONCLUSION: This study targets vulnerable populations where they live to ensure improved access to and utilization of eye care services in those who are least likely to seek eye care.

Manhattan Vision Screening and Follow-Up Study in Vulnerable Populations: 1-Month Feasibility Results.

Purpose/Aim: In the United States, high rates of vision impairment and eye disease disproportionately impact those who lack access to eye care, specifically vulnerable populations. The objective of our study was to test instruments, implement protocols, and collect preliminary data for a larger 5-year study, which aims to improve detection of eye diseases and follow-up eye care in vulnerable populations using community health workers (CHW) and patient navigators. In the study, trained CHWs conducted vision screening and patient navigators scheduled on-site eye exams and arranged appointments for those referred to ophthalmology to improve adherence to follow-up eye care.Materials and Methods: Eligible individuals age 40-and-older were recruited from the Riverstone Senior Center in Upper Manhattan, New York City. Participants underwent on-site vision screening (visual acuity with correction, intraocular pressure measurements, and fundus photography). Individuals who failed the vision screening were scheduled with an on-site optometrist for an eye exam; those with ocular pathologies were referred to an ophthalmologist. Participants were also administered the National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ-8) and Stopping Elderly Accidents, Deaths, and Injuries (STEADI) test by community health workers.Results:Participants (n = 42) were predominantly older adults, with a mean age of 70.0 ± 9.8, female (61.9%), and Hispanic (78.6%). Most individuals (78.6%, n = 33) failed vision screening. Of those who failed, 84.8% (n = 28) attended the on-site eye exam with the optometrist. Ocular diagnoses: refractive error 13/28 (46.4%), glaucoma/glaucoma suspect 9/28 (32.1%), cataract 7/28 (25.0%), retina abnormalities 6/28 (21.4%); 13 people required eyeglasses.Conclusion: This study demonstrates the feasibility of using CHWs and patient navigators for reducing barriers to vision screening and optometrist-based eye exams in vulnerable populations, ultimately improving early detection of eye disease and linking individuals to additional eye care appointments. The full five-year study aims to further examine these outcomes.

Prevalence of diabetic retinopathy in the United States, 2005-2008.

CONTEXT: The prevalence of diabetes in the United States has increased. People with diabetes are at risk for diabetic retinopathy. No recent national population-based estimate of the prevalence and severity of diabetic retinopathy exists. OBJECTIVES: To describe the prevalence and risk factors of diabetic retinopathy among US adults with diabetes aged 40 years and older. DESIGN, SETTING, AND PARTICIPANTS: Analysis of a cross-sectional, nationally representative sample of the National Health and Nutrition Examination Survey 2005-2008 (N = 1006). Diabetes was defined as a self-report of a previous diagnosis of the disease (excluding gestational diabetes mellitus) or glycated hemoglobin A(1c) of 6.5% or greater. Two fundus photographs were taken of each eye with a digital nonmydriatic camera and were graded using the Airlie House classification scheme and the Early Treatment Diabetic Retinopathy Study severity scale. Prevalence estimates were weighted to represent the civilian, noninstitutionalized US population aged 40 years and older. MAIN OUTCOME MEASUREMENTS: Diabetic retinopathy and vision-threatening diabetic retinopathy. RESULTS: The estimated prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy was 28.5% (95% confidence interval [CI], 24.9%-32.5%) and 4.4% (95% CI, 3.5%-5.7%) among US adults with diabetes, respectively. Diabetic retinopathy was slightly more prevalent among men than women with diabetes (31.6%; 95% CI, 26.8%-36.8%; vs 25.7%; 95% CI, 21.7%-30.1%; P = .04). Non-Hispanic black individuals had a higher crude prevalence than non-Hispanic white individuals of diabetic retinopathy (38.8%; 95% CI, 31.9%-46.1%; vs 26.4%; 95% CI, 21.4%-32.2%; P = .01) and vision-threatening diabetic retinopathy (9.3%; 95% CI, 5.9%-14.4%; vs 3.2%; 95% CI, 2.0%-5.1%; P = .01). Male sex was independently associated with the presence of diabetic retinopathy (odds ratio [OR], 2.07; 95% CI, 1.39-3.10), as well as higher hemoglobin A(1c) level (OR, 1.45; 95% CI, 1.20-1.75), longer duration of diabetes (OR, 1.06 per year duration; 95% CI, 1.03-1.10), insulin use (OR, 3.23; 95% CI, 1.99-5.26), and higher systolic blood pressure (OR, 1.03 per mm Hg; 95% CI, 1.02-1.03). CONCLUSION: In a nationally representative sample of US adults with diabetes aged 40 years and older, the prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy was high, especially among Non-Hispanic black individuals.

Eye Care Among US Adults at High Risk for Vision Loss in the United States in 2002 and 2017.

Importance: Timely eye care can prevent unnecessary vision loss. Objectives: To estimate the number of US adults 18 years or older at high risk for vision loss in 2017 and to evaluate use of eye care services in 2017 compared with 2002. Design, Setting, and Participants: This survey study used data from the 2002 (n = 30 920) and 2017 (n = 32 886) National Health Interview Survey, an annual, cross-sectional, nationally representative sample of US noninstitutionalized civilians. Analysis excluded respondents younger than 18 years and those who were blind or unable to see. Covariates included age, sex, race/ethnicity, marital status, educational level, income-to-poverty ratio, health insurance status, diabetes diagnosis, vision or eye problems, and US region of residence. Main Outcomes and Measures: Three self-reported measures were visiting an eye care professional in the past 12 months, receiving a dilated eye examination in the past 12 months, and needing but being unable to afford eyeglasses in the past 12 months. Adults at high risk for vision loss included those who were 65 years or older, self-reported a diabetes diagnosis, or had vision or eye problems. Multivariable logistic regression models incorporating sampling weights were used to investigate associations between measures and covariates. Temporal comparisons between 2002 and 2017 were derived from estimates standardized to the US 2010 census population. Results: Among 30 920 individuals in 2002, 16.0% were 65 years or older, and 52.0% were female; among 32 886 individuals in 2017, 20.0% were 65 years or older, and 51.8% were female. In 2017, more than 93 million US adults (37.9%; 95% CI, 37.0%-38.7%) were at high risk for vision loss compared with almost 65 million (31.5%; 95% CI, 30.7%-32.3%) in 2002, a difference of 6.4 (95% CI, 5.2-7.6) percentage points. Use of eye care services improved (56.9% [95% CI, 55.7%-58.7%] reported visiting an eye care professional annually, and 59.8% [95% CI, 58.6%-61.0%] reported receiving a dilated eye examination), but 8.7% (95% CI, 8.0%-9.5%) said they could not afford eyeglasses (compared with 51.1% [95% CI, 49.9%-52.3%], 52.4% [95% CI, 51.2%-53.6%], and 8.3% [95% CI, 7.7%-8.9%], respectively, in 2002). In 2017, individuals with lower income compared with high income were more likely to report eyeglasses as unaffordable (13.6% [95% CI, 11.6%-15.9%] compared with 5.7% [95% CI, 4.9%-6.6%]). Conclusions and Relevance: Compared with data from 2002, more US adults were at high risk for vision loss in 2017. Although more adults used eye care, a larger proportion reported eyeglasses as unaffordable. Focusing resources on populations at high risk for vision loss, increasing awareness of the importance of eye care, and making eyeglasses more affordable could promote eye health, preserve vision, and reduce disparities.

Self-Reported Oral Health Status Among Adults Aged 40+ Years With and Without Vision Impairment: National Health Interview Study, 2008.

PURPOSE: To examine self-reported oral health among adults aged 40 years and older with and without vision impairment. DESIGN: Cross-sectional, with a nationally representative sample. METHODS: We used publicly available data from the Oral Health Module, last administered in 2008, of the National Health Interview Survey. Outcome variables included fair/poor oral health status, mouth condition compared to others the same age, mouth problems (mouth sores, difficulty eating, dry mouth, bad breath, and/or jaw pain), teeth problems (toothache; broken/missing fillings or teeth; loose, crooked, or stained teeth; and/or bleeding gums), and lack of social participation. Using descriptive statistics and multivariate logistic regression, we examined the association (P < .05) between vision impairment and oral health outcomes by age group, sociodemographics, and other explanatory variables. RESULTS: Our study sample included 12,090 adults; 12.8% of adults aged 40-64 years reported vision impairment, and among them, 44.5% reported fair/poor oral health status and 47.2% reported any mouth problems. Among adults aged ≥65 years, 17.3% reported vision impairment, of whom 36.3% reported fair/poor oral health status and 57.3% reported any mouth problems. There is a strong association between vision impairment and poorer oral health of adults; adults aged 40-64 years with vision impairment reported 90%-150% greater odds of oral health problems, including fair/poor oral health status, mouth problems, and teeth problems, compared to people without vision impairment. CONCLUSIONS: Oral health disparities exist between adults with and without vision impairment. Targeted interventions are required to improve oral health in this vulnerable population.

The cost-effectiveness of routine office-based identification and subsequent medical treatment of primary open-angle glaucoma in the United States.

OBJECTIVE: To estimate the incremental cost-effectiveness of routine glaucoma assessment and treatment under current eye care visit and treatment patterns and different levels of treatment effectiveness (from randomized trials). DESIGN: We compared the costs and benefits of routine glaucoma assessment and treatment compared with no treatment using conservative and optimistic assumptions regarding treatment efficacy and including and excluding prediagnostic assessment costs. PARTICIPANTS AND CONTROLS: Computer simulation of 20 million people followed from age 50 years to death or age 100 years. METHODS: With the use of a computer model, we simulated glaucoma incidence, natural progression, diagnosis, and treatment. We defined glaucoma incidence conservatively as a mean deviation of -4 decibels (dB) on visual field testing in either eye for all diagnoses to be both clinically meaningful and unambiguous. We simulated the annual probability of subsequent progression and the quantity of visual field lost when progression occurred. MAIN OUTCOME MEASURES: Visual field loss, ophthalmologic and nursing home costs, quality-adjusted life years (QALYs), cost per QALY gained, and cost per year of sight gained. Costs and QALYs were discounted to 2005 values using a 3% rate. RESULTS: Compared with no treatment and when including diagnostic assessment costs, the incremental cost-effectiveness of routine assessment and treatment was $46,000 per QALY gained, assuming conservative treatment efficacy, and $28,000 per QALY gained, assuming optimistic treatment efficacy. Compared with no treatment and when excluding diagnostic assessment costs, the incremental cost-effectiveness of routine assessment and treatment was $20,000 per QALY gained, assuming conservative treatment efficacy, and $11,000 per QALY gained, assuming optimistic treatment efficacy. The cost-effectiveness was most sensitive to the treatment costs and the value of QALY losses assigned to visual field losses. CONCLUSIONS: Glaucoma treatment was highly cost-effective when the costs of diagnostic assessments were excluded or when we assumed optimistic treatment efficacy. The cost was reasonable and in line with other health interventions even when diagnostic assessment costs were included and assuming conservative efficacy. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Three decade change in the prevalence of hearing impairment and its association with diabetes in the United States.

OBJECTIVE: To examine the secular change of the prevalence of hearing impairment over three decades in U.S. adults with and without diabetes. METHODS: The cross-sectional National Health and Nutrition Examination Surveys (NHANES, the 1971-1973 [NHANES I] and the 1999-2004 [NHANES 1999-2004]) were used. Average pure-tone audiometry thresholds in decibels (dB) at 1, 2, 3, and 4 kHz frequencies of the worse ear were used to represent the participants' hearing status. Any hearing impairment was defined as average pure-tone audiometry threshold of the worse ear >25 dB. RESULTS: From 1971 to 2004, among adults without diabetes aged 25 to 69 years, the unadjusted prevalence of hearing impairment decreased from 27.9% to 19.1% (P<0.001), but among adults with diabetes there was no significant change (46.4% to 48.5%). After adjustment for age, sex, race, and education, the prevalence of hearing impairment in the NHANES I and NHANES 1999-2004, respectively, was 24.4% (95% confidence interval [CI], 22.3-26.6%) and 22.3% (95% CI, 20.4-24.2) for adults without diabetes and 28.5% (95% CI, 20.4-36.6%) and 34.4 (95% CI, 29.1-39.7%) for adults with diabetes. The adjusted prevalence ratios of hearing impairment for persons with diabetes vs. those without diabetes was 1.17 (95% CI, 0.87-1.57) for the NHANES I and 1.53 (95% CI, 1.28-1.83) for NHANES 1999-2004. CONCLUSIONS: Persons with diabetes have a higher prevalence of hearing impairment, and they have not achieved the same reductions in hearing impairment over time as have persons without diabetes.

Diabetic retinopathy, dilated eye examination, and eye care education among African Americans, 1997 and 2004.

OBJECTIVE: To examine diabetic retinopathy, dilated eye examination, and eye care education among African Americans before and after a community-level public health intervention. METHODS: We analyzed data from Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) participants with self-reported diabetes (617 in 1996-1997 and 672 in 2003-2004) in Raleigh (intervention community) and Greensboro (comparison community), North Carolina. All analyses were weighted to adjust for the complex sample design of pre and post cross-sectional surveys. Estimates were age standardized to the 2000 US Census population. We used multivariate logistic regression to calculate odds ratios and corresponding 95% confidence intervals. RESULTS: We found no significant difference in prevalence of diabetic retinopathy between the control and intervention communities (p > .05). However, after adjusting for other confounders, receipt of eye care education (OR, 1.59; 95% CI, 1.19-2.13) was independently associated with receipt of dilated eye examination among African Americans with diabetes. Compared with individuals without diabetic retinopathy, those with diabetic retinopathy were more likely to use eye care services (OR, 1.89; 95% CI, 1.41-2.54). CONCLUSIONS: Diabetic retinopathy is a considerable problem among African American communities. Community intervention efforts, such as comprehensive eye care education, that specifically target improvement in diabetic retinopathy and use of eye are services could help better serve this population.

Prevalence of Diabetic Retinopathy and Associated Mortality Among Diabetic Adults With and Without Chronic Kidney Disease.

PURPOSE: To estimate prevalence and severity of diabetic retinopathy (DR) among U.S. adults with diabetes and with or without chronic kidney disease (CKD), and assess associated risk of mortality. DESIGN: Cross-sectional study with national survey data. METHODS: The cohort included adults ≥40 years old with diabetes in the National Health and Nutrition Examination Surveys (NHANES) 2005-2008. Vital status was determined through December 31, 2011. We defined diabetes as hemoglobin A1c ≥6.5% or self-report and CKD by urinary albumin/creatinine ≥30 mg/g or glomerular filtration rate <60 mL/min/1.73 m2. The main outcomes were DR and mortality. RESULTS: Prevalence of DR was 27.8% (95% CI 24.3-31.7), 36.2% (95%CI 30.1-42.7), and 23.4% (95% CI 19.2-28.1), overall, with and without CKD. Prevalence of vision-threatening DR was 4.2% (95% CI 3.2-5.5), 8.2% (95% CI 5.4-12.2), and 2.0% (95% CI 1.2-3.5), respectively. In a multivariable adjusted model, DR was positively but nonsignificantly associated with CKD (OR = 1.1, 95% CI 0.7-1.7), was 40% higher per 1% increase in hemoglobin A1c (OR = 1.4, 95% CI 1.1-1.6), was 30% higher per 5 years additional diabetes duration (OR = 1.3, 95% CI 1.1-1.5), was 30% higher per 10 mm Hg increase in systolic blood pressure (OR = 1.3, 95% CI 1.1-1.5), and was 6-fold higher with insulin treatment (OR = 6.2, 95% CI 2.6-14.8). Compared with diabetic participants with neither DR nor CKD, those with DR and CKD had a 3.6-fold (95% CI 1.5-9.1) increased adjusted risk for all-cause mortality. CONCLUSIONS: Over one third of persons with diabetes and CKD had DR. The risk of death was higher with than without CKD and DR. Many of the studied risk factors associated with DR are modifiable.

Eye Care Utilization Among Insured People With Diabetes in the U.S., 2010-2014.

OBJECTIVE: Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults, and although screening with eye exams is effective, screening rates are low. We evaluated eye exam visits over a 5-year period in a large population of insured patients 10-64 years of age with diabetes. RESEARCH DESIGN AND METHODS: We used claims data from IBM Watson Health to identify patients with diabetes and continuous insurance coverage from 2010 to 2014. Diabetes and DR were defined using ICD-9 Clinical Modification codes. We calculated eye exam visit frequency by diabetes type over a 5-year period and estimated period prevalence and cumulative incidence of DR among those receiving an eye exam. RESULTS: Among the 298,383 insured patients with type 2 diabetes and no diagnosed DR, almost half had no eye exam visits over the 5-year period and only 15.3% met the American Diabetes Association (ADA) recommendations for annual or biennial eye exams. For the 2,949 patients with type 1 diabetes, one-third had no eye exam visits and 26.3% met ADA recommendations. The 5-year period prevalence and cumulative incidence of DR were 24.4% and 15.8%, respectively, for patients with type 2 diabetes and 54.0% and 33.4% for patients with type 1 diabetes. CONCLUSIONS: The frequency of eye exams was alarmingly low, adding to the abundant literature that systemic changes in health care may be needed to detect and prevent vision-threatening eye disease among people with diabetes.