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Eye-Care Utilization Among Women Aged ≥40 Years with Eye Diseases --- 19 States, 2006--2008

Diabetic retinopathy (DR), glaucoma, and age-related macular degeneration (ARMD) are major causes of vision loss and blindness (1). Women have been found to have a higher prevalence of vision loss than men (2,3). Early detection and timely treatment by eye-care providers are necessary to delay disease progression and prevent vision loss. To assess the use of professional eye care among women aged ≥40 years, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for 19 U.S. states for the period 2006--2008. This report summarizes the results of that analysis, which indicated that 21% of women with self-reported DR, 12% of women with self-reported glaucoma, and 8% of women with self-reported ARMD did not visit an eye-care provider in the recommended follow-up period. Women who did not have insurance coverage for eye care or who did not receive routine medical check-ups were more likely to report not having the recommended follow-up eye care. The two most commonly cited reasons for not having an eye-care visit were cost or not having insurance (range across diseases: 40%--46%) and having no reason to go for follow-up (range: 20%--29%). Compliance with obtaining eye examinations at recommended intervals among women aged ≥40 years with eye diseases might be enhanced by improving access to health care and implementing and expanding existing educational programs to raise awareness regarding the importance of routine follow-up eye examinations.

BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. civilian population aged ≥18 years. With approximately 350,000 adults participating in the interview each year, BRFSS provides local, state, and national estimates of important information on sociodemographics, chronic illness, health behaviors, and access to health care. CDC analyzed data from the pooled respondents of 7,377 women aged ≥40 years with self-reported DR (322), glaucoma (356), or ARMD (244) by using results from the BRFSS Visual Impairment and Access to Eye Care Module for the period 2006--2008. Nineteen states* included the vision module in at least 1 year of their regular BRFSS survey during these years. Among the 19 states, the median Council of American Survey Research Organizations (CASRO) response rate (cooperation rate) was 49.0% (73.5%) for 2006, 48.2% (69.0%) for 2007, and 52.8% (73.3%) for 2008. Respondents were classified as having an eye disease if they answered "yes" to any one of the relevant questions regarding presence of DR, glaucoma, and/or ARMD.§

For this study, the recommended follow-up period for visiting an eye-care provider was defined as the maximum recommended follow-up period stated in disease-specific guidelines in effect during the reporting period from the American Academy of Ophthalmology (for all three diseases), the American Optometric Association (for all three diseases), and the American Diabetes Association (for DR only). For DR and glaucoma, this period is within 12 months of the most recent eye examination; for ARMD, the period is within 24 months of the most recent eye examination. The BRFSS vision module also incorporated questions related to use of eye-care services. Women were classified as not having visited an eye-care professional in the recommended follow-up period if they answered other than "within the past month" or "within the past year" (for the 12-month period) or "within the past month," "within the past year," or "within the past 2 years (for the 24-month period) to the question, "When was the last time you had your eyes examined by any doctor or eye-care provider?" In addition, respondents were asked to select the one main reason they had not visited an eye-care professional in the previous year.

Statistical software was used to account for the complex sampling design. All analyses were weighted to make estimates representative of the age, race, and sex of the civilian, noninstitutionalized population in the 19 states. In instances where a state had more than 1 year of data available, average weights for the number of years available were used. CDC used predictive margin probabilities and corresponding 95% confidence intervals to make comparisons among the levels of each factor while adjusting for differences in the distributions of all other factors. The crude rate represents the weighted proportion of persons who did not report receiving recommended follow-up eye care. Adjusted percentages were estimated using logistic regression models predicting eye-care utilization as a function of the following factors: age, race/ethnicity, marital status, education, income, diabetes status, eye-care insurance coverage, and general health care (Table 1).

The weighted BRFSS data indicated that 21% of women with DR, 12% of women with glaucoma, and 8% of women with ARMD did not visit an eye-care provider in the recommended follow-up period (Table 1). Women without eye-care insurance were more likely than those with insurance to report not having obtained recommended eye-care visits for DR, glaucoma, and ARMD (predictive margin probabilities: 34% versus 14%, 18% versus 10%, and 12% versus 6%, respectively). Women who did not have a routine medical check-up in the preceding 12 months were more likely than those who did so to report not having made the recommended eye-care visits (36% versus 20%, 21% versus 12%, and 16% versus 7%, respectively). Additionally, women aged 40--64 years with glaucoma or ARMD were more likely to report not having obtained recommended eye care than those aged ≥65 years (25% versus 5% and 18% versus 4%, respectively). Cost and not having eye-care insurance (range: 40%--46% for the three eye diseases) and having no reason to go (range: 20%--29%) were the two most commonly cited reasons women with eye diseases reported for not having visited an eye-care provider (Table 2).

Reported by

AF Elliott, PhD, CF Chou, PhD, X Zhang, MD, PhD, JE Crews, DPA, JB Saaddine, MD, GL Beckles, MD, MD Owens-Gary, PhD, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

These findings from 19 states implementing the BRFSS vision module during 2006--2008 demonstrated that 8%--21% of women aged ≥40 years with serious, generally progressive eye diseases did not report receiving eye-care follow-up as recommended by national professional organizations. Eye care is especially important for maintaining current vision and preventing further vision loss from each of these eye diseases. For example, a study of Medicare beneficiaries found that the predicted probability of low vision/blindness among persons with diabetes was reduced by nearly 11 percentage points over 3 years among persons who received recommended levels of eye care compared with those who did not (4).

In this analysis, 20%--29% of women who did not seek eye-care follow-up reported having no reason to go. These findings point to the critical role of strengthening patient education through health-care providers and public health efforts to inform women with eye diseases about the importance of routine follow-up once an eye condition is diagnosed. Public health interventions that increase patient awareness of diabetic retinopathy can substantially increase its screening (5); Project DIRECT (Diabetes Intervention Reaching and Educating Communities Together) found that providing eye-care education was independently associated with receipt of dilated eye examinations (6). To preserve the vision of women who are not receiving the recommended follow-up care, the public health community, including CDC, state health departments, and federally funded programs, should increase awareness of the importance of regular follow-up eye care. The Diabetes Prevention and Control Program reports to CDC the number of dilated eye examinations received in states. Additionally, the finding that 40%--46% of these women reported that cost and/or insurance concerns hindered their follow-up care underscores the need for public health to play a role in addressing eye-care cost and insurance needs, and to implement policy changes more directly related to the clinical-care system. One study found that even among persons with insurance, the cost of copayments might still be a factor limiting access of eye care (7). Cost-reducing interventions, such as providing services at reduced rates or eliminating the cost entirely, have been effective at increasing use of cataract surgery (8).

The findings in this report are subject to at least four limitations. First, all data gathered by BRFSS are self-reported and might be subject to reporting errors. Self-reported responses for both presence of disease and obtaining an eye examination might differ from objective clinical data. Second, several groups of persons might be unrepresented or underrepresented in these population estimates, including persons without telephones (because the data are collected by telephone survey); institutionalized populations, who are not included in BRFSS; and persons with severe disabilities, including vision loss, who might be less likely to respond to a telephone survey. BRFSS questions also might not reflect respondents who are following their own doctor's recommendations regarding follow-up care, which might differ from the national guidelines. Third, although data were adjusted to be representative of surveyed states, they are not nationally representative because only 19 states used the BRFSS vision module in this study. Finally, the response rates for these survey years were low, increasing the risk for nonresponse bias.

CDC continues to provide resources and technical assistance to state health departments to increase surveillance of visual impairment and eye diseases. The findings in this report can be used to help public health agencies plan, implement, and evaluate programs on vision-loss prevention and eye-health promotion at national, state, and local levels and can help allocate scarce resources and target effective intervention activities to similar populations.

References

  1. Congdon N, O'Colmain B, Klaver CC, et al. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol 2004;122:477--84.
  2. CDC. Visual impairment and eye care among older adults---five states, 2005. MMWR 2006;55:1321--5.
  3. International Agency for the Prevention of Blindness. World sight day 2009 report. Gender and eye health: equal access to care. Available at http://www.vision2020.org/documents/world_sight_day_2009/wd09_downloads/wsd_report_2009_final_v2.pdf. Accessed May 13, 2010.
  4. Sloan FA, Grossman DS, Lee PP. Effects of receipt of guideline-recommended care on onset of diabetic retinopathy and its progression. Ophthalmology 2009;116:1515--21.
  5. Zhang X, Norris SL, Saaddine J, et al. Effectiveness of interventions to promote screening for diabetic retinopathy. Am J Prev Med 2007;33:318--35.
  6. Zhang X, Williams DE, Beckles GL, et al. Diabetic retinopathy, dilated eye examination, and eye care education among African Americans, 1997 and 2004. J Natl Med Assoc 2009;101:1015--21.
  7. Ellish NJ, Royak-Schaler R, Passmore SR, Higginbotham EJ. Knowledge, attitudes, and beliefs about dilated eye examinations among African-Americans. Invest Ophthalmol Vis Sci 2007;48:1989--94.
  8. Brilliant GE, Lepkowski JM, Zurita B, Thulasiraj RD. Social determinants of cataract surgery utilization in South India. Arch Ophthalmol 1991;109:584--9.

* The 19 states using the BRFSS vision module at least once during the years 2006--2008 include Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Indiana , Iowa, Kansas, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia, and Wyoming.

The response rate is the percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted. The cooperation rate is the percentage of persons who completed interviews among all eligible persons who were contacted.

§ "Have you ever been told by an eye doctor or other health-care professional that you had glaucoma?" "Have you ever been told by an eye doctor or other health-care professional that you had macular degeneration?" DR was identified (from the BRFSS diabetes module) if respondents with diabetes answered "yes" to the question, "Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?"

Responses for this question for persons with ARMD did not include persons who had received care within 12--23 months of their most recent eye examination. The specific question was stated, "What is the main reason you have not visited an eye-care professional in the past 12 months?" Respondents were presented a list of options from which they chose the one best answer. The "other" option was coded in the same manner as all other possible selections; it was not analyzed as an open-ended question.


What is already known on this topic?

Early detection and timely treatment of diabetic retinopathy, glaucoma, and age-related macular degeneration by eye-care providers are necessary to delay disease progression and prevent vision loss.

What is added by this report?

During 2006--2008, an estimated 8%--21% of women aged ≥40 years did not receive recommended follow-up eye care despite self-reported diagnoses of diabetic retinopathy, glaucoma, or age-related macular degeneration; most attributed this to cost/lack of insurance or having no reason to go.

What are the implications for public health practice?

Compliance with obtaining eye examinations at recommended intervals among women aged ≥40 years with eye diseases might be enhanced by improving access to health care and implementing and expanding existing educational programs (e.g., to raise awareness regarding the importance of routine follow-up eye examinations).


TABLE 1. Crude rate* and predictive margin for women aged ≥40 years not receiving recommended follow-up care for three major eye-related diseases,§ by selected characteristics --- 19 states, Behavioral Risk Factor Surveillance System (BRFSS), 2006--2008

 

Diabetic retinopathy

Glaucoma

Age-related macular degeneration

 

Crude rate

Predictive margin

Crude rate

Predictive margin

Crude rate

Predictive margin

Characteristic

Rate (%)

(95% CI**)

Rate (%)

(95% CI)

Rate (%)

(95% CI)

Rate (%)

(95% CI)

Rate (%)

(95% CI)

Rate (%)

(95% CI)

Age group (yrs)

40--64

24.3

(20.1--29.2)

24.3

(19.6--29.0)

24.3

(20.2--28.9)

25.1

(20.2--30.0)

14.6

(11.5--18.4)

17.8

(12.1--23.5)

≥65

17.8

(14.2--22.0)

18.3

(13.2--23.4)

5.4

(4.3--6.9)

4.9

(3.5--6.3)

4.0

(3.0--5.4)

4.0

(2.4--5.6)

Race/Ethnicity

White, non-Hispanic

22.4

(19.2--26.2)

23.8

(19.7--27.9)

11.6

(9.7--13.9)

13.8

(11.1--16.5)

7.6

(6.2--9.4)

9.6

(7.2--12.0)

Black, non-Hispanic

21.0

(15.8--27.3)

18.8

(12.9--24.7)

13.2

(9.6--18.0)

12.7

(8.4--17.0)

11.9

(7.2--19.1)

10.2

(4.5--15.9)

Hispanic

19.5

(10.7--33.1)

18.3

(8.1--28.5)

12.6

(6.8--22.3)

9.4

(2.0--16.8)

8.0

(3.4--17.8)

4.9

(0.8--9.0)

Other

22.2

(11.3--39.1)

22.3

(6.0--38.6)

19.1

(8.5--37.5)

14.9

(3.9--25.9)

12.5

(6.7--22.0)

6.9

(1.6--12.2)

Marital status

Married

21.1

(16.5--26.6)

22.2

(16.3--28.1)

11.5

(9.2--14.2)

11.0

(8.5--13.5)

8.1

(6.2--10.5)

9.0

(6.5--11.5)

Not married

21.7

(18.3--25.6)

21.4

(17.3--25.5)

13.0

(10.6--15.9)

15.4

(12.1--18.7)

7.7

(5.9--10.0)

9.0

(6.3--11.7)

Educational attainment

<High school diploma

23.7

(17.3--31.6)

24.2

(17.3--31.1)

16.2

(12.1--21.5)

17.0

(11.7--22.3)

10.6

(6.8--16.1)

10.6

(5.9--15.3)

High school diploma

22.0

(17.8--26.9)

19.0

(14.5--23.5)

11.3

(9.0--14.0)

12.0

(8.9--15.1)

8.3

(5.9--11.6)

9.5

(6.0--13.0)

More than a high school diploma

19.3

(15.3--24.2)

22.6

(16.9--28.3)

11.3

(8.6--14.7)

12.5

(9.0--16.0)

6.9

(5.4--8.7)

8.2

(6.0--10.4)

Annual household income

<$35,000

24.1

(20.1--28.7)

23.4

(19.1--27.7)

15.3

(12.6--18.6)

14.7

(11.6--17.8)

10.6

(8.3--13.5)

12.4

(8.9--15.9)

≥$35,000

15.8

(11.1--22.0)

17.1

(10.6--23.6)

10.4

(7.6--14.1)

10.6

(7.3--13.9)

6.2

(4.4--8.5)

5.2

(3.2--7.2)

Diabetes status

Yes

21.5

(18.6--24.6)

21.8

(18.3--25.3)

12.2

(8.4--17.5)

12.1

(7.4--16.5)

5.9

(3.9--9.0)

6.7

(3.4--10.0)

No

0.0

---

0.0

---

12.3

(10.4--14.4)

13.6

(11.2--16.0)

8.2

(6.7--10.1)

9.4

(7.2--11.6)

Eye-care insurance coverage

Coverage

14.1

(11.2--17.7)

14.4

(10.7--18.1)

8.1

(6.4--10.1)

9.9

(7.5--12.3)

5.1

(3.7--7.1)

6.4

(4.0--8.8)

No coverage

33.7

(28.5--39.4)

33.5

(27.2--39.8)

18.9

(15.4--23.0)

18.4

(14.3--22.5)

11.6

(9.2--14.5)

12.1

(9.2--15.0)

General health care

Check up in the past year

18.9

(16.1--22.1)

19.7

(16.2--23.2)

9.8

(8.0--11.8)

11.6

(9.1--14.1)

6.2

(4.9--7.9)

7.3

(5.3--9.3)

No check up in the past year

42.2

(31.3--53.9)

36.2

(24.4--48.0)

29.3

(23.3--36.0)

20.7

(14.4--27.0)

17.0

(12.5--22.6)

16.0

(11.3--20.7)

Total

21.5

(18.6--24.6)

 

 

12.3

(10.6--14.2)

 

 

7.9

(6.5--9.5)

 

 

* The crude rate represents the weighted proportion of persons who did not report receiving recommended follow-up eye care.

The recommended follow-up period for visiting an eye-care provider was defined as the maximum recommended follow-up period stated in disease-specific guidelines in effect during the reporting period from the American Academy of Ophthalmology (for all three diseases), the American Optometric Association (for all three diseases), and the American Diabetes Association (for diabetic retinopathy only). For diabetic retinopathy and glaucoma, this period is within 12 months of the most recent eye examination; for age-related macular degeneration, the period is within 24 months of the most recent eye examination.

§ Respondents were classified as having an eye disease if they answered "yes" to any one of the relevant questions regarding presence diabetic retinopathy, glaucoma, and/or age-related macular degeneration. Respondents were classified as not having visited an eye-care professional in the recommended follow-up period if they answered other than "within the past month" or "within the past year" (for the 12-month period) or "within the past month," "within the past year," or "within the past 2 years (for the 24-month period) to the question, "When was the last time you had your eyes examined by any doctor or eye-care provider?"

The 19 states using the BRFSS vision module at least once in the years 2006--2008 include Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Indiana , Iowa, Kansas, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia, and Wyoming.

** Confidence interval.


TABLE 2. Reasons given by women aged ≥40 years for not receiving recommended follow-up care* for three major eye-related diseases --- 19 states, Behavioral Risk Factor Surveillance System (BRFSS), 2006--2008§

Reason

Diabetic retinopathy (N = 322)(%)

Glaucoma (N = 356)(%)

Age-related macular degeneration (N = 244)(%)

Cost/Insurance

43

46

40

No reason to go

20

23

29

Do not have/know an eye doctor

2

1

2

Too far/No transportation

4

1

1

Could not get an appointment

5

3

3

Have not thought of it

5

7

3

Other**

21

19

23

* The recommended follow-up period for visiting an eye-care provider was defined as the maximum recommended follow-up period stated in disease-specific guidelines in effect during the reporting period from the American Academy of Ophthalmology (for all three diseases), the American Optometric Association (for all three diseases), and the American Diabetes Association (for diabetic retinopathy only). For diabetic retinopathy and glaucoma, this period is within 12 months of the most recent eye examination; for age-related macular degeneration, the period is within 24 months of the most recent eye examination.

Respondents were classified as having an eye disease if they answered "yes" to any one of the relevant questions regarding presence diabetic retinopathy, glaucoma, and/or age-related macular degeneration. Respondents were classified as not having visited an eye-care professional in the recommended follow-up period if they answered other than "within the past month" or "within the past year" (for the 12-month period) or "within the past month," "within the past year," or "within the past 2 years (for the 24-month period) to the question, "When was the last time you had your eyes examined by any doctor or eye-care provider?" In addition, respondents were asked to select the one main reason they had not visited an eye-care professional in the previous year. Responses for this latter question for persons with age-related macular degeneration did not include persons who had received care within 12--23 months of their most recent eye examination. The specific question asked was stated, "What is the main reason you have not visited an eye-care professional in the past 12 months?" The question presented a list of options from which respondents chose the one best answer.

§ The 19 states using the BRFSS vision module at least once in the years 2006--2008 include Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Indiana , Iowa, Kansas, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia, and Wyoming.

Percentages do not sum to 100% because of rounding.

** The "other" option was coded in the same manner as all other possible selections; it was not analyzed as an open-ended question.



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