Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Department of Ophthalmology and Visual Sciences, University of Michigan Kellogg Eye Center, Ann Arbor.
JAMA Ophthalmol. 2024 Oct 1;142(10):961-970. doi: 10.1001/jamaophthalmol.2024.3528.
Besides race, little is known about how other social determinants of health (SDOH) affect quality of diabetic eye care.
To evaluate the association between multiple SDOH and monitoring for diabetic retinopathy (DR) in accordance with clinical practice guidelines (CPGs).
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted in 11 US medical centers and included adult patients (18-75 years old) with diabetes. Patients received care from 2012 to 2023 and had 18 months or more of follow-up.
Multiple SDOH and associated factors, including ethnicity, urbanicity of residence, health insurance type, and diabetes type.
Adjusted odds ratio (aOR) of receiving 1 or more eye-care visits and 1 or more dilated fundus examinations in accordance with CPGs.
The study cohort included 37 397 adults with diabetes: 10 157 Black patients and 27 240 White patients. The mean (SD) age was 58 (11) years for Black patients and 59 (11) years for White patients. Of the Black patients, 6422 (63.2%) were female and 3735 (36.8%) male; of the White patients, 13 120 (48.1) were female and 14 120 (51.8) were male. Compared with those of the same race in urban communities, Black patients (aOR, 0.12; 95% CI, 0.04-0.31) and White patients (aOR, 0.75; 95% CI, 0.62-0.91) with diabetes living in rural communities had 88% and 25% lower odds of having eye-care visits, respectively. Sicker Black and White patients, defined by the Charlson Comorbidity Index, had 4% (aOR, 1.04; 95% CI, 1.02-1.06) and 5% (aOR, 1.05, CI 1.04-1.06) higher odds of having an eye-care visit, respectively. Black patients with preexisting DR had 15% lower odds of visits (aOR, 0.85, CI 0.73-0.99) compared with those without preexisting DR while White patients with preexisting DR had 16% higher odds of eye-care visits (aOR, 1.16; 95% CI, 1.05-1.28). White patients with Medicare (aOR, 0.85; 95% CI, 0.80-0.91) and Medicaid (aOR, 0.81; 95% CI, 0.68-0.96) had lower odds of eye-care visits vs patients with commercial health insurance. Hispanic White patients had 15% lower odds of eye-care visits (aOR, 0.85; 95% CI, 0.74-0.98) vs non-Hispanic White patients. White patients with type 1 diabetes had 17% lower odds of eye-care visits (aOR, 0.83; 95% CI, 0.76-0.90) vs those with type 2 diabetes. Among patients who had eye-care visits, those with preexisting DR (Black: aOR, 1.68; 95% CI, 1.11-2.53; White: aOR, 1.51; 95% CI, 1.16-1.96) were more likely to undergo dilated fundus examinations.
This study found that certain SDOH affected monitoring for DR similarly for Black and White patients with diabetes while others affected them differently. Patients living in rural communities, Black patients with preexisting DR, and Hispanic White patients were not receiving eye care in accordance with CPGs, which may contribute to worse outcomes.
除了种族之外，关于其他社会决定因素（SDOH）如何影响糖尿病眼病护理的质量，人们知之甚少。
评估多种 SDOH 与根据临床实践指南（CPG）监测糖尿病视网膜病变（DR）之间的关联。
设计、地点和参与者：这项队列研究在美国 11 家医疗中心进行，纳入了患有糖尿病的成年患者（18-75 岁）。患者在 2012 年至 2023 年期间接受了治疗，并接受了至少 18 个月的随访。
多种 SDOH 及相关因素，包括种族、居住地的城市性、医疗保险类型和糖尿病类型。
根据 CPG 接受 1 次或多次眼科就诊和 1 次或多次散瞳眼底检查的调整后优势比（aOR）。
该研究队列包括 37397 名患有糖尿病的成年人：10157 名黑人患者和 27240 名白人患者。黑人患者的平均（SD）年龄为 58（11）岁，白人患者的平均（SD）年龄为 59（11）岁。黑人患者中，6422 名（63.2%）为女性，3735 名（36.8%）为男性；白人患者中，13120 名（48.1%）为女性，14120 名（51.8%）为男性。与同一种族居住在城市社区的患者相比，居住在农村社区的黑人（aOR，0.12；95%CI，0.04-0.31）和白人（aOR，0.75；95%CI，0.62-0.91）患者接受眼科就诊的可能性分别低 88%和 25%。根据 Charlson 合并症指数定义的病情较重的黑人和白人患者，分别有 4%（aOR，1.04；95%CI，1.02-1.06）和 5%（aOR，1.05，95%CI，1.04-1.06）更高的就诊可能性。与没有预先存在的 DR 的患者相比，有预先存在的 DR 的黑人患者就诊的可能性低 15%（aOR，0.85，95%CI，0.73-0.99），而有预先存在的 DR 的白人患者就诊的可能性高 16%（aOR，1.16；95%CI，1.05-1.28）。与有商业健康保险的患者相比，有 Medicare（aOR，0.85；95%CI，0.80-0.91）和 Medicaid（aOR，0.81；95%CI，0.68-0.96）的白人患者就诊的可能性较低。与非西班牙裔白人患者相比，西班牙裔白人患者就诊的可能性低 15%（aOR，0.85；95%CI，0.74-0.98）。与 2 型糖尿病患者相比，1 型糖尿病患者就诊的可能性低 17%（aOR，0.83；95%CI，0.76-0.90）。在接受眼科就诊的患者中，有预先存在的 DR 的患者（黑人：aOR，1.68；95%CI，1.11-2.53；白人：aOR，1.51；95%CI，1.16-1.96）更有可能接受散瞳眼底检查。
本研究发现，某些 SDOH 以类似的方式影响黑人和白人糖尿病患者的 DR 监测，而其他 SDOH 则以不同的方式影响他们。居住在农村社区、有预先存在的 DR 的黑人患者和西班牙裔白人患者未按照 CPG 接受眼科护理，这可能导致预后更差。
