Social Determinants of Health and Perceived Barriers to Care in Diabetic Retinopathy Screening

Abstract

ImportanceRegular screening for diabetic retinopathy often is crucial for the health of patients with diabetes. However, many factors may be barriers to regular screening and associated with disparities in screening rates.ObjectiveTo evaluate the associations between visiting an eye care practitioner for diabetic retinopathy screening and factors related to overall health and social determinants of health, including socioeconomic status and health care access and utilization.Design, Setting, and ParticipantsThis retrospective cross-sectional study included adults aged 18 years or older with type 2 diabetes who answered survey questions in the All of Us Research Program, a national multicenter cohort of patients contributing electronic health records and survey data, who were enrolled from May 1, 2018, to July 1, 2022.ExposuresThe associations between visiting an eye care practitioner and (1) demographic and socioeconomic factors and (2) responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys were investigated using univariable and multivariable logistic regressions.Main Outcome and MeasuresThe primary outcome was whether patients self-reported visiting an eye care practitioner in the past 12 months. The associations between visiting an eye care practitioner and demographic and socioeconomic factors and responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys in All of Us were investigated using univariable and multivariable logistic regression.ResultsOf the 11 551 included participants (54.55% cisgender women; mean [SD] age, 64.71 [11.82] years), 7983 (69.11%) self-reported visiting an eye care practitioner in the past year. Individuals who thought practitioner concordance was somewhat or very important were less likely to have seen an eye care practitioner (somewhat important: adjusted odds ratio [AOR], 0.83 [95% CI, 0.74-0.93]; very important: AOR, 0.85 [95% CI, 0.76-0.95]). Compared with financially stable participants, individuals with food or housing insecurity were less likely to visit an eye care practitioner (food insecurity: AOR, 0.75 [95% CI, 0.61-0.91]; housing insecurity: AOR, 0.86 [95% CI, 0.75-0.98]). Individuals who reported fair mental health were less likely to visit an eye care practitioner than were those who reported good mental health (AOR, 0.84; 95% CI, 0.74-0.96).Conclusions and RelevanceThis study found that food insecurity, housing insecurity, mental health concerns, and the perceived importance of practitioner concordance were associated with a lower likelihood of receiving eye care. Such findings highlight the self-reported barriers to seeking care and the importance of taking steps to promote health equity.

Limitations of Assessing Barriers in Diabetic Retinopathy Screening

“…Furthermore, the study highlights a significant link between practitioner concordance and delayed eye care, influenced by factors including race, ethnicity, religion, and language. Further analysis will identify the key factors on concordance to overcome the overall health care barriers.…”

“…To the Editor It was with great interest that we read the article by Ravindranath et al, which found that factors, such as food and housing insecurity, mental health, and practitioner concordance, hinder diabetic retinopathy screening. However, several limitations not necessarily completely addressed by the authors should be considered when interpreting the study’s conclusions.…”

“…A previous study showed that fear of SARS-CoV-2 exposure was associated with patients missing ophthalmic care appointments, suggesting this confounding factor should be considered. Could the authors pursue sensitivity analyses wherein participants enrolled after the COVID-19 outbreak to consider the potential effect of the pandemic on the results?…”

“…Second, the authors defined patients with type 2 diabetes (T2D) as those who use diabetes drugs or with codes for T2D complications. We wonder why the authors did not use International Classification of Diseases Ninth Revision or Tenth Revision T2D diagnosis codes to include patients instead of the SNOMED codes listed in eTable 1, which seem to be incomplete with many codes missing?…”

“…Third, self-report surveys may involve recall or nonresponse bias due to unwillingness or inability to participate. Could the authors opine on the degree to which the All of Us Research Program’s self-registration attracted individuals with a positive health attitude may have influenced the outcomes? Specifically, participants who completed surveys may not have had severe diabetic retinopathy, contributing to selection bias …”