Race, Neighborhood Influence Lapses in Diabetic Retinopathy Care

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Areas with socioeconomic disadvantage often face concentrated poverty, poor walkability, and few healthcare facilities, creating challenges in eye care follow-up.

A new analysis identified a significant lapse in diabetic retinopathy care over 2 years, with the most disadvantaged neighborhoods demonstrating an interaction with race and ethnicity.

Non-Hispanic White patients from areas of socioeconomic disadvantage were more likely to have lapses in diabetic retinopathy care, compared with those from less disadvantaged neighborhoods.

Meanwhile, non-Hispanic Black and Hispanic patients from nearly all examined neighborhoods exhibited a greater risk of experiencing lapses in care, compared with non-Hispanic White patients from the least socioeconomically disadvantaged areas.

“For racial and ethnic minority groups, the impacts of structural racism and its downstream effects on the maldistribution of individual-level resources may compound the adverse outcomes associated with neighborhood socioeconomic disadvantage,” wrote the investigative team, led by Cindy X. Cai, MD, Wilmer Eye Institute, Johns Hopkins School of Medicine.

Health outcomes correlate with SDOH, with individual- and neighbor-level criteria influencing the roles of diabetic retinopathy screening.2 Minority populations are known to experience poorer health outcomes because of these neighborhood socioeconomic disadvantages, ranging from lack of access to care, food deserts, or environmental hazards.

This retrospective cohort study investigated whether the association of neighborhood-level SDOH with the threat of lapses in care for diabetic retinopathy was altered by race and ethnicity.1 Adults with diabetes were observed at the investigator’s institution from 2013 to 2022 for diabetic retinopathy screening or treatment. The analysis outcomes were lapses in diabetic retinopathy care over 2 years.

Primary exposures were the patient neighborhood socioeconomic disadvantage, determined using the 2019 area deprivation index (ADI)—divided into quartiles, Q4 represented those at the most socioeconomic disadvantage. The electronic health record was used to extra baseline characteristics, such as race and ethnicity, other demographic data, clinic, residential distance from clinic, severity of diabetic retinopathy, other retinal disorders, and glaucoma.

For the analysis, multivariable logistic regression models were created to evaluate the association between ADI quartile and lapses in care, after adjusting for baseline characteristics. Across 36,487 patients, 63% had a lapse in care, including 60% in ADI Q1, 62% in Q2, 66% in Q3, and 68% in Q4.

Cai and colleagues identified an interaction between ADI and race and ethnicity (P = .005). In particular, non-Hispanic White patients from areas of more socioeconomic disadvantage experienced an increased risk of lapses in care.

Pairwise comparisons were performed using contrast coefficients adjusted with Bonferroni correction. In the pairwise comparisons, non-Hispanic Black, and Hispanic patients, as well as patients with other races and ethnicities, from high ADI quartiles exhibited a greater likelihood of lapses in care, compared with non-Hispanic White patients in Q1 and Q2. Particularly, non-Hispanic Black patients from Q1 showed lower odds of care lapses, compared with non-Hispanic White patients from Q4.

Overall, Cai and colleagues indicated place and race “clearly matter” regarding lapses in diabetic retinopathy care. Areas with socioeconomic disadvantage can display factors, including concentrated poverty, issues with walkability, limited access to public transportation, and lack of health care access, that make follow-up to eye care challenging for patients.3

“Given that health and health behaviors represent a complex interplay among individual, community, and societal factors, future studies of diabetic retinopathy care should consider individual and neighborhood-level SDOH and their interactions toward the goal of informing public policies to eliminate disparities in vision health,” they wrote.1


  1. Tang T, Tran D, Han D, Zeger SL, Crews DC, Cai CX. Place, Race, and Lapses in Diabetic Retinopathy Care. JAMA Ophthalmol. Published online April 25, 2024. doi:10.1001/jamaophthalmol.2024.0974
  2. Gaskin DJ, Thorpe RJ Jr, McGinty EE, et al. Disparities in diabetes: the nexus of race, poverty, and place. Am J Public Health. 2014;104(11):2147-2155. doi:10.2105/AJPH.2013.301420
  3. Yusuf R, Chen EM, Nwanyanwu K, Richards B. Neighborhood Deprivation and Adherence to Initial Diabetic Retinopathy Screening. Ophthalmol Retina. 2020;4(5):550-552. doi:10.1016/j.oret.2020.01.016