Race and Socioeconomic Status in Anti-VEGF Treatment of Diabetic Macular Edema

Abstract

BACKGROUND AND OBJECTIVE: Although people of low socioeconomic status (SES) and certain racial groups are at greater risk of developing diabetic macular edema (DME), the extent these high-risk groups experience treatment differences is unknown. This study characterizes anti-vascular endothelial growth factor (anti-VEGF) injection use for DME. PATIENTS AND METHODS: Data were collected from an electronic health record at the Cole Eye Institute, Cleveland Clinic Foundation for patients who received anti-VEGF treatment for DME between 2012 and 2019 ( N = 500). RESULTS: White patients on average received more injections over a 1-year period than Black patients (4.93 ± 3.14 vs 3.20 ± 2.43; P < .0001) and had fewer no-show appointments (1.39 ± 2.08 vs 3.23 ± 3.39; P < .0001). There is an association between living in communities with lower average incomes and receiving fewer anti-VEGF injections (3.06 ± 2.70 vs 4.88 ± 3.19; P = .005). CONCLUSIONS: DME treatment differs based on race and SES. Racial and SES associations with anti-VEGF injections present potential obstacles for delivering optimal ophthalmic care. [ Ophthalmic Surg Lasers Imaging Retina. 2021;52:578–585.]

Inequities and Research Gaps in Ophthalmology

“…Six studies demonstrated that patients with lower income were more likely to have vision impairment, 48,50,51 have worse postsurgical outcomes, 61 and/or use eye care services less. 35,41 Seven studies reported that lower-income patients had lower adherence to both eye examinations and glaucoma medication use, 22,38,62,63 received fewer anti-vascular endothelial growth factor injections, 64 and were more likely to report having glaucoma 65 or diabetic retinopathy. 66 Regarding patients with higher income, studies found that higher income was associated with lower prevalence of myopia, 45 glaucoma, 65 and diabetic retinopathy 66 as well as an increased likelihood of receiving an eye examination.…”

Social Determinants of Health and Impact on Screening, Prevalence, and Management of Diabetic Retinopathy in Adults: A Narrative Review

“…The 2-year follow-up results of the Protocol T study suggested that in patients presenting with lower baseline visual acuity, bevacizumab therapy resulted in smaller gains in visual acuity than aflibercept or ranibizumab [ 93 ]. Other recent studies reported that Hispanic, Black, and Medicaid-insured patients have worse DR severity and visual acuity (VA) at initiation of anti-VEGF treatment for DME [ 94 ], and that treatment-naive Black patients receiving intravitreal bevacizumab experience lower odds of VA improvement after the first and third injection [ 95 ], suggesting both a racial and socioeconomic disparity in the pharmacological treatment of DME. While racial and ethnic disparities have not been seen in treatment of commercially insured patients with diabetic retinopathy [ 96 ], other factors, such as having a co-pay, have reportedly lowered the odds of a patient receiving any treatment for DME (although having a high deductible and type of insurance plan were not associated with initiating treatment) [ 97 ].…”

“…Patients receiving real-world treatment for DME tend to follow-up less than in clinical trials and show fewer improvements in visual acuity than patients in clinical trials using the same anti-VEGF agents; real-world studies and a sub-analysis of protocol T showed an association between missed follow-up and worse visual outcomes [ 103 , 104 , 105 ]. In patients undergoing anti-VEGF treatment for DME, several factors are associated with loss to follow-up, including Hispanic ethnicity, residing in communities with lower average income, having government-provided insurance, and having lower visual acuity [ 94 , 106 , 107 ]. Efforts to recruit study participants who are typically underrepresented can help determine the impact of new DR treatments in all people with diabetes, while promoting health and equity.…”

Effect of Race and Insurance Status on Treatment and Outcomes in Diabetic Retinopathy: Analysis of 43 274 Eyes Using the IRIS Registry

“…Previous studies have analyzed racial and socioeconomic differences in the treatment of DR and wet age-related macular degeneration (AMD) with anti-VEGF injections. [21][22][23][24][25] However, these studies did not include specific disease severity metrics or insurance status when evaluating 1-year and 2-year outcomes. In addition, data from the DRCR Retina Protocol T trial showed that at 2 years, patients with a VA of 20/50 or worse had significantly greater improvements in VA after treatment with aflibercept relative to bevacizumab (P = .02).…”