Social determinants of health and retinal detachments

Rhegmatogenous retinal detachment (RRD) is a sight threatening condition in which the neurosensory retina separates from the underlying retinal pigment epithelium. With an incidence of 6.3 to 17.9 per 100,000 persons (1), RRD is a condition frequently encountered by vitreoretinal specialists. Because the fovea is responsible for central visual acuity, foveal detachment is associated with poor presenting vision and is the strongest prognostic factor predicting poor visual outcome after RRD repair (2). Furthermore, timely reattachment is critical to preserving visual function as greater duration of foveal detachment has been shown to correlate with worse visual outcomes (3). Additionally, longer duration of detachment is associated with the development of proliferative vitreoretinopathy (4) which is a major risk factor for surgical failure (5). Because timely presentation after RRD is crucial to ultimate visual prognosis, it is important to understand the social factors that predict delays in care.

In a recently published study by Ong et al. (6) titled “Neighborhood-Level Social Determinants of Health and Presenting Characteristics for Rhegmatogenous Retinal Detachments”, the authors examined the association between neighborhood-level social determinants of health (SDOH) with baseline severity (visual acuity and fovea status) of RRD. In this retrospective cohort study, patients 18 years or older who underwent primary RRD repair at the Wilmer Eye Institute over a 10-year period were analyzed. Best corrected visual acuity (BCVA) and foveal status (attached or detached) at presentation were collected as well as demographic characteristics including age, sex, race/ethnicity, and health insurance status. Additionally, patient home addresses were used to determine census block group (the smallest geographical area for which US census data is reported) in order to collect neighborhood-level data on SDOH, including the Area Deprivation Index, per capita income, percentage of renters, percentage of rent burden, percentage of people using food assistance programs, percentage of uninsured individuals, mode of transportation to work, distance from the nearest transit stop, total road density, National Walkability Index, Index of Medical Underservice Score, and aggregate cost of medical care.

A total of 700 patients were included in the study. On an individual level, the study found that older patients {BCVA <20/40: mean [standard deviation (SD)], 59.7 [12.5] vs. 55.2 [11.7] years; P<0.001 and fovea-involving RRD: mean [SD], 59.6 [12.8] vs. 57.2 [12.2] years; P=0.01}, non-Hispanic Black patients [BCVA <20/40: odds ratio (OR), 2.00; 95% confidence interval (CI): 1.18–3.38; P=0.01 and fovea-involving RRD: OR, 1.85; 95% CI: 1.15–2.98; P=0.01], and patients with public health insurance (BCVA <20/40: OR, 1.60; 95% CI: 1.17–2.20; P=0.004 and fovea-involving RRD: OR, 1.49; 95% CI: 1.07–2.07; P=0.02) had worse presenting BCVA and higher likelihood of foveal-involvement of RRD. Patients without insurance had worse presenting BCVA than those with private health insurance (OR, 2.58; 95% CI: 1.14–5.84; P=0.02). Neighborhood-level factors associated with worse visual acuity and/or foveal detachment at presentation included: higher Area Deprivation Index (i.e., more socioeconomic disadvantage) (BCVA <20/40: OR, 1.14; 95% CI: 1.04–1.24; P=0.004 and fovea-involving RRD: OR, 1.13; 95% CI: 1.04–1.22; P=0.005), lower per capita income (BCVA >20/40: OR, 0.99; 95% CI: 0.98–0.99; P=0.001), and higher percentage of workers who drove to work (BCVA <20/40: OR, 1.02; 95% CI: 1.01–1.03; P=0.005 and fovea-involving RRD: OR, 1.01; 95% CI: 1.00–1.03; P=0.04). The authors hypothesized that the latter factor may be a surrogate marker for infrastructural challenges in accessing health care centers.

This study is not without limitations. Firstly, because this study was collected census block group data rather than individualized metrics, the data may not accurately represent an individual’s true socioeconomic disadvantage as one’s circumstances may differ significantly from that of others in their neighborhood. Additionally, the SDOH data for some patients was not collected at the same time point as when they present with RRD. Because of this, the socioeconomic circumstances of each patient at the time they presented may have differed from what was recorded for the purposes of the study. Furthermore, SDOH data for some patients was unattainable and the effect this missing data would have had in the ultimate study results if available is unknown. Finally, because this study was conducted at a single urban institution and comprised of a primarily non-Hispanic white population, the generalizability of its results may be limited.

Overall, this study suggests that SDOH play an important role in RRD severity. These findings are in line with many studies that have found associations between socioeconomic hardship and higher severity of various other eye diseases (7) including glaucoma (8), amblyopia (9), diabetic retinopathy (10), and cataracts (11) among others.

RRD severity has been found previously to be correlated with lower socioeconomic status (12,13). Severity of detachment is highly related to delay in presentation (14), as the longer the retina is detached, the more likely it is that the detachment progresses to the fovea or that proliferative vitreoretinopathy (PVR) develops. While factors such as lack of public transportation to medical centers, inequities in health insurance coverage and subsequent differences in out-of-pocket cost burden, or other socioeconomic disparities are significant barriers to timely care, these systemic issues can be very challenging to resolve. Deficiencies in health literacy and RRD awareness, on the other hand, may be a more easily addressed with local public health initiatives. In fact, health literacy has been shown to be an important factor in time to presentation in RRD and other ophthalmic diseases (15,16). Awareness about emergent ophthalmic conditions among unaffected patients is low (17). A study by Ejik et al. (18) found that patients with macula-OFF detachments waited longer to seek care and more often attributed their initial symptoms to issues with glasses or contact lenses. Patients with macula-ON detachments, on the other hand, more often attributed their symptoms to a problem with the retina, and knew that prognosis would be worse with delayed treatment. Unfortunately, poor health literacy has been shown to be more prevalent in more socioeconomically disadvantaged neighborhoods (19).

Similarly, limited ophthalmic education in medical training (20) has resulted in gaps in knowledge about basics of ophthalmic disease among non-ophthalmologist health-care providers (HCP) (21-23). These deficiencies in both patient and provider familiarity with RRDs represent potential areas of opportunity to improve time to presentation. One avenue may be the development of educations programs through partnership with community health centers and local primary care providers (PCP) which may serve to inform HCPs and at-risk patients of the signs and symptoms of retinal tears and detachments. These initiatives could be organized by local academic ophthalmology and optometry departments in conjunction with students and focus on RRDs as well as other ophthalmic emergencies. Some possible projects could include organizing education tables at community health fairs, designing educational posters to be displayed in health centers and primary care offices, or arranging educational lectures for PCPs and trainees at local academic institutions.

The recent study, “Neighborhood-Level Social Determinants of Health and Presenting Characteristics for Rhegmatogenous Retinal Detachments” by Ong et al. (6) sheds light on the importance of considering SDOH when examining risk factors for suboptimal outcomes in RRDs. Continued research into understanding the effect of that socioeconomic disparities have on delayed access to care is needed to help design effective initiatives to mitigate these barriers to care and improve RRD outcomes for all patients.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Eye Science. The article has undergone external peer review.

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-24-39/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-24-39/coif). S.N. receives airfare and hotel support for twice yearly DRCR Retina network site meetings and serves as an unpaid member of fellowship directors and Education Committees of ASRS. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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