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    Factors Associated With Worse OAG at Initial Diagnosis

    Glaucoma

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    Worse open-angle glaucoma (OAG) at initial presentation may be associated with male sex, Black race, Hispanic ethnicity, older age, having noncommercial insurance or being uninsured, and living at a lower socio­economic level, according to research­ers who analyzed the electronic health record data of hundreds of thousands of eye patients.

    The study findings, published in the American Journal of Ophthalmology, of­fer a potential road map to developing more tailored screening approaches, the authors wrote.1

    Methodology. The researchers, from Bascom Palmer Eye Institute, in Miami, culled data from an Epic Cosmos ag­gregated electronic health record data­set of more than 213 million people. Patients with OAG, who were exam­ined in ophthalmology and optometry clinics between January 2013 and June 2023, were classified by OAG severity at initial presentation and identified as having mild, moderate, or severe disease. For their analysis, the research­ers also factored in patients’ social vulnerability index (SVI) scores (a U.S. census measurement that uses 16 variables to help officials identify communities that may need support), demographics, and rural-to-urban commuting area codes (a census-based classification that uses standard measures of urbanization, pop ulation density, and daily commuting).

    Findings. Of 245,669 patients, 29.3% had severe OAG at their initial visit, while 32.5% had moderate disease, and 38.1% were diagnosed with mild OAG.

    Patients who were Black made up a quarter (25.2%) of the total study cohort and had a much higher preva­lence of severe disease (31.2%). Black patients were diagnosed at an average age of 67.8. Hispanic patients were diagnosed at an average age of 68.1 years. And White patients were diag­nosed at an average age of 73.3 years. The researchers also found that average age increased slightly with severity of disease at presentation (69, 71, and 72 years for mild, moderate, and severe OAG, respectively).

    The authors said that higher SVI quartiles were tied to “more advanced disease.” In the socioeconomic and minority status SVI sub-categories, 50% of patients with severe glaucoma were in the highest SVI quartile.

    More female patients were in the mild and moderate OAG groups (56.6% and 54.1%, respectively). The majority of patients in the study had commercial insurance (73.4%), and only 0.9% were uninsured.

    Social determinants of health mat­ter. Lead author Swarup Swaminathan, MD, Assistant Professor of Clinical Ophthalmology and the Mary Lee and Richard E. Bastin Chair in Oph­thalmology at the Bascom Palmer Eye Institute, said that while prior studies have demonstrated that patients who are underinsured or uninsured, as well as those from some racial and ethnic demographics, have worse glaucoma, this study shows “that a sociodemo­graphic, social determinant-type of metric is important” when it comes to identifying worse disease at clinical baseline.

    “Patients who are from areas that have higher social vulnerability index scores were at greater risk for having worse disease at initial presentation, and that is something that is unique,” said Dr. Swaminathan.

    He said, “Unfortunately, some of those things trend together, and in the paper, we demonstrate the distribution of SVI scores. Those really indicate how a geographic variable is associated with worse initial disease.”

    It is important to recognize the impact of social determinants of health, including barriers to accessing eye care and variations in insurance coverage, said Sally Liu Baxter, MD, MSc, Assis­tant Professor and Division Chief for Ophthalmology Informatics and Data Science at the Shiley Eye Institute at the University of California, in San Diego.

    Study significance. Dr. Baxter said that the findings build upon prior studies that show a link between socio­economic disparities and worse cases of OAG, and the study’s size adds weight to previous findings.

    “The dataset used in this study has nationwide scope and includes data from multiple practice settings, as opposed to being limited to academic medical centers. However, its general­izability may still be limited given that the majority of practicing ophthalmologists in the United States do not use the Epic electronic health record system,” said Dr. Baxter, who was not involved with the study.

    Catching disease early. “One of the main challenges of glaucoma is that it can be a symptomless disease in the early and moderate stages. Patients often don’t experience any pain, and often they don’t see any discernible changes in their vision. This means that they can have glaucoma but remain undiagnosed until the disease is ad­vanced,” Dr. Baxter said.

    Even with symptoms, some people can face greater barriers to accessing eye care—and medical care in general—and as a result, the initial diagnosis can be delayed, leading to more severe disease at onset, she said.

    From findings to solutions. Dr. Swaminathan said research like this can help target who is in most need of screenings and interventions, adding that it is less about targeting a predom­inantly Black or Hispanic neighbor­hood and more about using the study findings, which offer a geographic marker that indicates areas with greater vulnerability, to come up with a plan.

    With these findings, he said, “Screen­ing activities could be set up in certain areas to reach high-risk individuals, so that they do not wait a long period of time to receive care.”

    Dr. Baxter said that clinicians could also do a better job of encouraging patients with glaucoma to educate their families and communities and encour­age their networks to see a clinician for an evaluation.

    Insurance. “Another consideration from a clinical and health policy per­spective is that many patients may have insurance but are effectively underin­sured if they struggle to find physicians who will accept their insurance. We see this with Medicaid patients, where some physicians will not accept patients on Medicaid, or their health systems and upper management will not allow them to see patients on Medicaid,” Dr. Baxter said. “This presents another barrier to care for patients.”

    Raising awareness. Dr. Swaminathan hopes clinicians will develop more awareness of which individuals are at greater risk for severe disease.

    “Clinicians may need to spend more time counseling and discussing medica­tion, and visit adherence with patients who are high-risk to minimize poor outcomes,” he said.

    The study findings are “just a piece of the puzzle,” he said, adding that he hopes to continue researching how fac­tors associated with social determinants meaningfully affect patient outcomes.

    —Brian Mastroianni

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    1 Swaminathan SS, Medeiros FA. Am J Ophthal­mol. 2024;263:50-60.

    ___________________________

    Relevant financial disclosures—Dr. Baxter: None. Dr. Swaminathan: AbbVie: C; Heidelberg Engineering: S; Lumata Health: C, PS; National Institutes of Health: S; Topcon: C.

    For full disclosures and the disclosure key, see below.

    Full Financial Disclosures

    Dr. Baxter None

    Dr. McCourt None 

    Dr. Sabater AbbVie: C; Brill Pharma: C; Laboratorios Sophia: C; Ocubio: EO; Tissue-Cor: EO. 

    Dr. Swaminathan AbbVie: C; Heidelberg Engineering: S; Lumata Health: C, PS; National Institutes of Health: S; Topcon: C. 

    Dr. Tam None

    Dr. Wong Astellas: C; Bayer: C; Boehringer-Ingelheim: C; Genentech: C; Novartis: C; Plano: C; Roche: C; Sanofi: C; Shanghai Henlius: C; EyRIS: P; Visre: P.

    Disclosure Category

    Code

    Description

    Consultant/Advisor C Consultant fee, paid advisory boards, or fees for attending a meeting.
    Employee E Hired to work for compensation or received a W2 from a company.
    Employee, executive role EE Hired to work in an executive role for compensation or received a W2 from a company.
    Owner of company EO Ownership or controlling interest in a company, other than stock.
    Independent contractor I Contracted work, including contracted research.
    Lecture fees/Speakers bureau L Lecture fees or honoraria, travel fees or reimbursements when speaking at the invitation of a commercial company.
    Patents/Royalty P Beneficiary of patents and/or royalties for intellectual property.
    Equity/Stock/Stock options holder, private corporation PS Equity ownership, stock and/or stock options in privately owned firms, excluding mutual funds.
    Grant support S Grant support or other financial support from all sources, including research support from government agencies (e.g., NIH), foundations, device manufacturers, and\or pharmaceutical companies. Research funding should be disclosed by the principal or named investigator even if your institution receives the grant and manages the funds.
    Stock options, public or private corporation SO Stock options in a public or private company.
    Equity/Stock holder, public corporation US Equity ownership or stock in publicly traded firms, excluding mutual funds (listed on the stock exchange).

     

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