Julia A. Haller, MD: Disparities in Diabetic Macular Edema, Retinal Vein Occlusion Treatment

Disparities, in terms of race and gender, exist in diabetic macular edema and retinal vein occlusion as Black, Asian, and female patients receive less treatment than White and male patients.

A study analyzed the large American Academy of Ophthalmology database, Intelligent Research in Sight (IRIS®), to provide evidence of significant disparities in eye disease and care, as well as overall visual impairment, clinical trial access, and real-world treatment disparities. The investigators found significant differences in the numbers between patients with retinal vein occlusion and macular edema treated with anti-VEGF injections in the first year after diagnosis. Black, Asian, women, patients > 70 years old, and patients with visual acuity outside of the <20/40 to 20/200 range were less likely to receive treatment. Underrepresentation also takes place in clinical trials, which attributes to the disparity.

The team also examined a large Komodo database of patients > 65 years old with diabetic macular edema, which like the IRIS® database, showed that minority groups were less likely to receive anti-VEGF treatment than White patients.

Julia Haller, MD, from Wills Eye Hospital spoke about her team’s research at the 127th Annual American Academy of Ophthalmology (AAO) conference in San Francisco, California. In an interview with HCPLive, Haller discussed the findings of the study, what should be done about the disparities, and what should be covered by ophthalmologists in the healthcare disparity space.

“I would say my main takeaway is that we’re making progress, but we still have a long way to go,” Haller said. “Eliminating healthcare disparities is going to be a huge task for all of us in ophthalmology… fixing disparities in healthcare is a complicated problem, and it’s one worthy of a lot of attention.”

Haller explained the study had 3 parts. The first part examined clinical trial enrollment in diabetic macular edema from a big Genentech database. The team looked at enrollment in clinical trial sites across all regions in the United States, comparing the enrolled number of underrepresented groups to the number of available patients demographically who could have been enrolled.

After examination, Haller and colleagues found there were under enrollment of Black, Hispanic Latino, and Asian patients across all regions, compared to White people. Some regions under-enrolled females, but this did not apply to all clinical trial sites.

Part 2 of the study focused on looking at real world data on treatment of diabetic macular edema with a large Komodo database. They pinpointed patients with diabetic macular edema, >65 years old. Because of their age, patients qualified for Medicare. Yet, in those studies, Black, Hispanic, and Asian people were less likely to be treated for their diabetic macular edema than their White counterparts. For Black, Hispanic, and Asian people who were treated, they were more likely to be treated with off-label Bevacizumab than White people.

The third part of the study examined the IRIS database to look for patients newly diagnosed with retinal vein occlusion with macular edema. They sought to find out how many newly diagnosed patients began therapy in the first year after diagnosis.”

“What we found was only 64% start treatment in a timely manner,” Haller said.

Not only do minority groups get treated less than White people, but Haller said patients with visual acuity of 2040 to 2200 get treated more as well.

When asked if biosimilars or less expensive treatment methods would fix some of disparity issues, Haller said if cheaper options were more widely available, it could potentially help the financial barriers existing in the healthcare disparity issue. Cheaper treatments could help patients who are not Medicare age, as people on Medicare still face healthcare disparities.

Haller referenced the 80th Jackson Memorial Lecture at the opening session of AAO, presented by Eve Higginbotham, SM, MD, ML, also centered around healthcare disparities. Haller was interested in Higginbotham’s point about the lack of granularity in looking at racial and ethnic groups.

“She pointed out how we need to do a lot more in dissecting out, you know, what is Black? Is it Nigerian? Is it African American? Is it Afro Caribbean?” Haller said. “The level of granularity that we have is not great. And so, it’s harder to look at social determinants of health unless you have more granularity.”

Haller suggested a way to improve healthcare disparities was to increase the number of ophthalmologists and retina specialists who look like their patients, which would be a first step in addressing this issue.

“One of the ways to start treating it is to discover that it is in fact a problem and to highlight that and educate people about it so that they're aware of these disparities,” Haller said. “We have to figure out why are there these disparities and then try to get at the root causes and then work towards correcting them.”