Area deprivation index as a neighborhood-level indicator of vision health outcomes

Ong et al. investigated the impact of area deprivation index (ADI), a measure of neighborhood-level socioeconomic deprivation, on baseline severity of rhegmatogenous retinal detachments (RRDs), as measured by visual acuity and foveal involvement at the time of presentation to ophthalmologic care (1). Their key finding was that a presenting visual acuity worse than 20/40 and/or foveal involving RRD were associated with a high ADI, suggesting that higher ADI (meaning greater socioeconomic disadvantage) contributes to the delay in presentation to care. It is well understood that the delayed care for RRDs leads to worse ultimate visual outcomes and surgical success rates (2-4). Further, their findings contribute to the existing body of literature that suggests socioeconomic deprivation contributes overall to poor health. Specifically in this context, their findings can be interpreted as part of the self-perpetuating cycle of poor health outcomes contributing to further worse health outcomes. For example, even if only unilateral vision loss results from this delay in care, activities of daily living are still impacted (5), potentially worsening a patient’s downstream health outcomes by making it more difficult to adhere to medications and perform other tasks necessary to manage other health conditions (6).

A mitigating factor of studying RRD in relation to ADI is that patients with socioeconomic disadvantage tend to have less myopia, which is directly related to RRD risk (7). Therefore, when taken in this context, this study may underestimate the impact of ADI on other ocular health conditions, compared to problems like diabetic retinopathy or microbial keratitis (8,9).

We further highlight that the discrepancies in RRD presentation noted by Ong et al. were studied in an urbanized area, with local access to multiple academic eye centers, as well as other surgical retina practices, in the region. The effects noted could be even further exacerbated if they had been studied in more rural areas, where subspecialist surgical care may be sparser, and higher ADI may limit a patient’s ability to not only present to care in a timely manner, but also appropriately receive the frequent post-operative care required after most retinal detachment surgeries.

There is also evidence that vitrectomy surgery has been found, in some cases, to loss of money on average for practices (10,11). Exacerbating this problem are the opportunity costs of doing surgery, as the time spent seeing patients in clinic for intravitreal injections presents a 76% increase in profits compared to time spent performing vitrectomy in the operating room (OR), not including the costs that may be associated with using on-call resources that may be needed for urgent retinal detachment repairs (12). One academic eye center showed a significant increase in retinal detachment referrals over a ten-year span compared to national trends and routine surgical referrals over the timespan (13). These financial data are purely circumstantial to the question of whether patient access to care may be limited by market forces, potentially increasing possible travel time or delay to care. This may be a future line of research inquiry along the lines of Ong et al.’s investigation to ensure health disparities are minimized. Fortunately, others have found that those who live in remote, rural areas in North Dakota do not necessarily have worse final outcomes than those who have easier access, though it is unknown if these findings would generalize to other regions (14). While the systemic effects of socioeconomic disparities cannot be solved by vitreoretinal surgeons alone, our community, as well as policymakers, can consciously attempt to minimize the effects found by Ong et al.

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-24-43/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-24-43/coif). The authors have no conflicts of interest to declare.

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