Social Risk Factor Associations With Presenting Visual Acuity in Patients With Microbial Keratitis

Abstract

ImportanceNeighborhood-level social risk factors may contribute to health disparities in microbial keratitis (MK) disease presentation. Understanding neighborhood-level factors may identify areas for revised health policies to address inequities that impact eye health.ObjectiveTo investigate if social risk factors were associated with presenting best-corrected visual acuity (BCVA) for patients with MK.Design, Setting, and ParticipantsThis was a cross-sectional study of patients with a diagnosis of MK. Patients presenting to the University of Michigan with a diagnosis of MK between August 1, 2012, and February 28, 2021, were included in the study. Patient data were obtained from the University of Michigan electronic health record.Main Outcomes and MeasuresIndividual-level characteristics (age, self-reported sex, self-reported race and ethnicity), presenting log of the minimum angle of resolution (logMAR) BCVA, and neighborhood-level factors, including measures on deprivation, inequity, housing burden, and transportation at the census block group, were obtained. Univariate associations of presenting BCVA (< 20/40 vs ≥20/40) with individual-level characteristics were assessed with 2-sample t, Wilcoxon, and χ2 tests. Logistic regression was used to test associations of neighborhood-level characteristics with the probability of presenting BCVA worse than 20/40 after adjustment for patient demographics.ResultsA total of 2990 patients with MK were identified and included in the study. Patients had a mean (SD) age of 48.6 (21.3) years, and 1723 were female (57.6%). Patients self-identified with the following race and ethnicity categories: 132 Asian (4.5%), 228 Black (7.8%), 99 Hispanic (3.5%), 2763 non-Hispanic (96.5%), 2463 White (84.4%), and 95 other (3.3%; included any race not previously listed). Presenting BCVA had a median (IQR) value of 0.40 (0.10-1.48) logMAR units (Snellen equivalent, 20/50 [20/25-20/600]), and 1508 of 2798 patients (53.9%) presented with BCVA worse than 20/40. Patients presenting with logMAR BCVA less than 20/40 were older than those who presented with 20/40 or higher (mean difference, 14.7 years; 95% CI, 13.3-16.1; P < .001). Furthermore, a larger percentage of male vs female sex patients presented with logMAR BCVA less than 20/40 (difference, 5.2%; 95% CI, 1.5-8.9; P = .04), as well as Black race (difference, 25.7%; 95% CI, 15.0%-36.5%;P < .001) and White race (difference, 22.6%; 95% CI, 13.9%-31.3%; P < .001) vs Asian race, and non-Hispanic vs Hispanic ethnicity (difference, 14.6%; 95% CI, 4.5%-24.8%; P = .04). After adjusting for age, self-reported sex, and self-reported race and ethnicity, worse Area Deprivation Index (odds ratio [OR], 1.30 per 10-unit increase; 95% CI, 1.25-1.35; P < .001), increased segregation (OR, 1.44 per 0.1-unit increase in Theil H index; 95% CI, 1.30-1.61; P < .001), higher percentage of households with no car (OR, 1.25 per 1 percentage point increase; 95% CI, 1.12-1.40; P = .001), and lower average number of cars per household (OR, 1.56 per 1 less car; 95% CI, 1.21-2.02; P = .003) were associated with increased odds of presenting BCVA worse than 20/40.Conclusion and RelevanceFindings of this cross-sectional study suggest that in a sample of patients with MK, patient characteristics and where they live were associated with disease severity at presentation. These findings may inform future research on social risk factors and patients with MK.

Social Risk Groups in Patients With Diabetes With Differing Eye Care Utilization and Vision Outcomes

“… 8 Social risk groups were associated with vision of <20/40, again consistent with prior studies showing health disparities in the risk of vision impairment. 21 Although we chose to use the average visual acuity when bilateral measurements were available, sensitivity analyses (data not shown) suggested similar results when we chose the better visual acuity, a randomly selected eye, as well as only right eyes. Last, we did not find an association between social risk group and the most severe form of diabetic retinopathy, proliferative diabetic retinopathy.…”

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

“…Our group has reported on the association between ADI and presenting visual acuity in patients with corneal ulcers. 16 Among 2990 patients with corneal ulcers, for every 10-unit worse ADI score (measured on a 100-unit scale) there were 30% increased odds of presenting with best corrected visual acuity of less than 20/40 (OR, 1.30; 95% CI, 1.25–1.35; P < 0.001), after controlling for age, self-reported sex, self-reported race, and self-reported ethnicity. 16 Yusuf and colleagues 47 reported that patients who lived in the 30% most disadvantaged neighborhoods had 44% increased odds of non-adherence to initial diabetic retinopathy screening compared to patients living in more advantaged neighborhoods (OR = 0.65; 95% CI, 0.44–0.97; P = 0.035) after adjusting for age, race, and insurance status.…”

“…Our group evaluated the association between neighborhood-level transportation access and presenting visual acuity among patients presenting to eye clinics for microbial keratitis. 16 There were increased odds of presenting with visual acuity less than 20/40 in patients with microbial keratitis when a patient's neighborhood had a higher percentage of households with no car (OR = 1.25 per 1 percentage point increase; 95% CI, 1.12–1.40; P = 0.001) and a lower average number of cars per household (OR = 1.56 per one less car; 95% CI, 1.21–2.02; P = 0.003) after adjusting for age, self-reported sex, and self-reported race and ethnicity. 16 Kim et al, 17 utilizing the nationally representative National Health Interview Survey, found that transportation barriers were associated with delayed medical care in patients with glaucoma.…”

“… 16 There were increased odds of presenting with visual acuity less than 20/40 in patients with microbial keratitis when a patient's neighborhood had a higher percentage of households with no car (OR = 1.25 per 1 percentage point increase; 95% CI, 1.12–1.40; P = 0.001) and a lower average number of cars per household (OR = 1.56 per one less car; 95% CI, 1.21–2.02; P = 0.003) after adjusting for age, self-reported sex, and self-reported race and ethnicity. 16 Kim et al, 17 utilizing the nationally representative National Health Interview Survey, found that transportation barriers were associated with delayed medical care in patients with glaucoma. Participants who reported delayed medical care for glaucoma had a 2.22 greater adjusted odds ratio (aOR) of reporting that their care was delayed due to a lack of transportation (aOR = 2.22; 95% CI, 1.68–2.91; P < 0.0001) after adjusting for age, gender, race and ethnicity, income, insurance coverage geographic region, and Charlson Comorbidity Index.…”

Place-Based Measures of Inequity and Vision Difficulty and Blindness

“…In contrast to literature on systemic health, the link between vision and the neighborhood and built environment warrants further investigation . There is early literature suggesting an association between neighborhood deprivation and vision health . Individuals from neighborhoods with high deprivation scores may be at increased risk of screening positive for glaucoma and present with worse best-corrected visual acuity when experiencing microbial keratitis .…”