Investigation Exposes Inequities in Access for Patients With Diabetic Eye Disease

LOS ANGELES, CA – OCTOBER 20: Women get their eyes checked during during a free health clinic at the Los Angeles Memorial Sports Arena on October 20, 2011 in Los Angeles, California. The clinic operated by CareNow LA, a Los Angeles-based nonprofit group, will serve nearly 5,000 uninsured and underinsured people over next four days. The goal is to serve about 1,200 people each day, providing free medical, dental or vision care by more than 800 medical professionals. Services being offered at the clinic include medical screenings, women’s health exams and chiropractors, acupuncturists and other specialists. (Photo by Kevork Djansezian/Getty Images)
The study advocates for investments in public health initiatives to achieve earlier treatment.

Patients who are of Hispanic ethnicity, those who are Black, and those insured with Medicaid have worse baseline diabetic retinopathy (DR) severity and visual acuity (VA) upon initiation of anti-vascular endothelial growth factor (VEGF) treatment, researchers found in a study published in Ophthalmology.

While previous research has indicated risk factors for developing DR and diabetic macular edema (DME), leading causes of irreversible visual impairment, little is published regarding delays in diagnosis and treatment.

The researchers included 203,673 adult patients from the IRIS Registry (Intelligent Research in Sight) database who were initiated on anti-VEGF injections between 2012 and 2020 for the treatment on DME associated with any severity of DR without concomitant maculopathy. Only 1 eye per patient was included for statistical modeling.

The majority (58.5%) of the patients were White and not Hispanic or Latino (67.2%). Private insurance was most common (32.2%) followed by Medicare (22.9%) and Medicaid (8.8%). 

Patients on Medicare and private insurance presented with better baseline VA compared with patients on Medicaid (median of 2.31 and 4.17 greater Early Treatment Diabetic Retinopathy Scale (ETDRS) letters, respectively P <.01).

DR severity was inversely associated with the patients’ age. As proliferative diabetic retinopathy (PDR) severity increased, the proportion of patients who were Black  (46.7%) increased when compared with patients who were White (41.3%). The proportion of Hispanic or Latino patients (53.9%) increased when compared with other groups (41.5%) as well. Additionally, the proportion of Medicaid patients with PDR (52.2%) increased compared with Medicare (42.4%) and private insurance patients (43.8%).

“These social factors when viewed in cross-section with each other may help clinicians be cognitive of disparities in initiation of treatment. This is particularly important given that Black and Hispanic patients with DME are insured by Medicaid at higher proportions,” investigators report. “While this study does not support treating demographics differently based solely on race, ethnicity, or insurance status, it is important for clinicians to understand the various social factors that have historically influenced patients’ abilities to receive optimal ophthalmic care.”

Limitations of the study included that 89.5% of patients did not have specified DME laterality and 15.1% of patients had documented DME diagnosis after first anti-VEGF injection. The confounding variable of HbA1c and the confounding factor of socioeconomic status could not be accounted for.

The research team, which includes the Cleveland Clinic’s Rishi Singh, MD, presented these findings at the American Academy of Ophthalmology’s 2020 meeting.


Malhotra NA, Greenlee TE, Iyer AI, et al. Racial, ethnic, and insurance-based disparities upon initiation of anti-VEGF therapy for diabetic macular edema in the United States. Ophthalmol. Published online March 10, 2021. doi:10.1016/j.ophtha.2021.03.010