Health Equity Barriers Emerge in Access to Diabetic Retinopathy Screening

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Factors associated with receiving eye care in past 12 months included a higher educational level and income, while food and housing insecurity were associated with not receiving eye care.

A nationwide study encompassing individuals with type 2 diabetes (T2D) in the United States revealed complex barriers faced in visiting an eye care professional for diabetic retinopathy screening, with factors tied to social determinants of health and socioeconomic status.1

The study, including nearly 12,000 participants with T2D, revealed the factors associated with eye care in the prior 12 months included a higher educational level, income, and insurance status while experiencing food and housing insecurity were associated with not receiving eye care in the same period.

“Our results highlight self-reported barriers to seeking care and the potential importance of taking steps to promote health equity, such as providing a safe space to receive care, reducing implicit bias, and improving access to care,” wrote the investigative team, led by Sophia Y. Wang, MD, MS, of the department of ophthalmology at Byers Eye Institute, Stanford University.

Screening guidelines, including those from the American Academy of Ophthalmology (AAO), have recommended patients with T2D undergo an annual screening for diabetic retinopathy starting at diagnosis.2 Prior research has shown the association between various socioeconomic variables and lower adherence to diabetic retinopathy screening, but few have elaborated on the patient perspective to understand the reason behind this association.

In this analysis, Wang and colleagues assessed the differences in demographics, overall health, and social determinants of health between patients with T2D who did and did not self-report a visit to an eye care professional for diabetic retinopathy screening.1 The All of Us Research Database includes extensive health information from ≥250,000 individuals across the US and self-reported survey data. It puts an emphasis on capturing a diverse patient population, including traditionally underrepresented groups in medicine, to better understand health disparities.

The study used the All of Us version 7 cohort, the most recent version, which included data on participants aged ≥18 years enrolled from May 2018 to July 2022. The primary endpoint was patients' self-reported visit to an eye care practitioner, including an optometrist, ophthalmologist, or eye doctor, in the past 12 months. Primary variables included information from various surveys, measuring social determinants of health, health literacy, race and ethnicity, and income.

Among 11,551 analyzed participants with T2D, 7983 (69%) participants reported having visited an eye care practitioner in the past year. Characteristics revealed the overall mean age of participants was 65 years, 6301 (54.55%) were cisgender women, and 4456 patients (39%) reported a household income of <$50,000. Survey data revealed most measures differed significantly between patients who self-reported or did not self-report a visit to an eye care professional.

Upon analysis, investigators found individuals with food insecurity or housing insecurity were less likely to visit an eye care practitioner than those who were financially stable (food insecurity: adjusted odds ratio [aOR], 0.75 [95% CI, 0.61 - 0.91; housing insecurity: aOR, 0.86 [95% CI, 0.75 - 0.98]). Those with fair mental health were additionally less likely to visit an eye care practitioner (aOR, 0.84; 95% CI, 0.56 - 0.96) compared to those with good mental health.

The analysis also revealed factors connected to a participant’s attitude toward practitioner concordance were associated with not having seen an eye care practitioner. Those who believed practitioner concordance on race or ethnicity, gender, language, or religion to be somewhat or very important were less likely to see an eye practitioner (aOR, 0.83 [95% CI, 0.74 - 0.93]; aOR, 0.85 [95% CI, 0.76 - 0.95], respectively).

A shared identity between patient and physician has been linked to a higher quality patient experience and could lead to potentially improved outcomes. Wang and colleagues noted this may be a result of a patient’s trust in their clinician, due to commonalities that can improve the ways patients and physicians relate to one another.

“Our results demonstrated the importance of practitioner concordance in relation to delaying eye care, suggesting the potential importance of enhancing workforce diversity and implementing cultural competency training to bridge the gap between patient-physician discordance,” investigators wrote.


  1. Younessi DN, Lin JC, Janetos TM. Regulatory and Informational Gaps in the Over-the-Counter Eye Care Product Industry—Over the Counter, Under the Radar. JAMA Ophthalmol. Published online November 02, 2023. doi:10.1001/jamaophthalmol.2023.4961
  2. Flaxel CJ, Adelman RA, Bailey ST, et al. Diabetic Retinopathy Preferred Practice Pattern® [published correction appears in Ophthalmology. 2020 Sep;127(9):1279]. Ophthalmology. 2020;127(1):P66-P145. doi:10.1016/j.ophtha.2019.09.025