Barriers Remain for Healthcare Access, Utilization for Diabetic Retinopathy Patients

Patients with diabetic retinopathy still struggle with access and utilization to healthcare services, according to new research.

A team, led by Alison X. Chan, Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, assessed whether social determinants were linked to an increased risk of developing proliferative diabetic retinopathy or related complications related to diagnosis or procedures.

The Problem

While some studies have focused on the socioeconomic risk factors associated with diabetic retinopathy progression, there is not much known on the patterns of healthcare utilization among those with the disease. This is especially true for those from backgrounds traditionally underrepresented in clinical trials.

Some of inadequacies in access and utilization to healthcare prevalent in the US could impact outcomes patients with diabetes. The All of Us database contains extensive survey data on social determinants that is not generally available in electronic health records.

The database contains information on over 364,000 adult participants beginning in May 2018.

The Patients

In the study, the investigators identified 729 adult patients with diabetic retinopathy in the National Institute of Health All of Us Research Program data repository with a mean age of 64.9 years. Each participant answered survey questions related to healthcare access and utilization.

In addition, 15.2% of patients identified as Hispanic or Latino (n = 111), 20.4% identified as Black (n = 149), 60.6% identified as White, 2.74% identified as Asian, and 16.6% identified as other.

Also, 31.4% (n = 229) of the patient population was diagnosed with proliferative diabetic retinopathy or related complications.

Common Problems

Some common ophthalmic complications included vitreous hemorrhage (n = 56; 7.7%) and requirement for photocoagulation (n = 35; 4.8%), while 141 patients (19.3%) had concurrent kidney disorder from diabetes, and less than 20 (<8.7%) had peripheral neuropathy associated with diabetes.

The investigators also extracted health record data on comorbidities, laboratory values, and procedures and used multivariable logistic regression with bi-directional stepwise variable selection from a wide range of predictors.

In total, 97 (13.3%) survey respondents endorsed that they had not spoken to an eye doctor within the previous 12 months. Also, 16.1% (n = 97) of patients reported delaying filling medication prescriptions to save money and 11.2% (n = 82) said they skipped their medications altogether to save money. Finally, 12.6% (n = 92) delayed seeking medical care because of having to pay out of pocket.

Other than financial concerns, 9-14% of patients said they faced additional barriers for timely care, including a lack of transportation, inadequate healthcare coverage, or feeling nervous.

The team found 10-20% of the patient population endorsed several different reasons for avoiding or delaying care, including financial concerns and a lack of access to transportation.

There were also significant social determinants including race and religion discordance between the healthcare provider and patient (OR, 1.20; 95% CI, 1.02-1.41; P = 0.03) and caregiver responsibilities toward others (OR, 3.14; 95% CI, 1.01-9.5; P = 0.04).

“Nationwide data demonstrate substantial barriers to healthcare access among DR patients,” the authors wrote. “In addition to financial and social determinants, race and religion discordance between providers and patients may increase the likelihood of PDR and related complications.”

The study, “Associations between healthcare utilization and access and diabetic retinopathy complications using All of Us nationwide survey data,” was published online in PLOS One.