Disparities in care of retinal detachments

This article was reviewed by Natalia Callaway, MD, MS

Women are less likely to receive a repair for a retinal detachment compared with men, and data presented by Natalia Callaway, MD, MS, Byers Eye Institute at Stanford University School of Medicine, suggest that ophthalmology also may not be immune to gender disparities in care.

Over the years, investigators have documented the differences between men and women in the diagnosis, timing, and treatment of diseases and conditions in multiple medical disciplines. Women experience increased morbidity, and resulting mortality, particularly in cardiology.

Related: A rift in the retina may help repair the optic nerve

Study design and results
Retinal detachments are a serious ophthalmic diagnosis and can result in blindness if left untreated. Timely repair is vital to save the patient’s vision and avoid permanent disability.

To assess if there were differences between the sexes in the repair of this grave ophthalmologic emergency, Callaway et al examined data from approximately 61,000 cases of new rhegmatogenous retinal detachments, 23,933 of which were included in the primary analysis.

The cases, from between 2007 and 2015, were from the largest insurance claims database in the United States; they spanned more than 133 million records during the study period and were estimated to represent about 50% of the insured US working population.

Related: Risk awareness helps identify medication-induced retinal toxicity

Investigators found that a total of 43% of those cases (~26,000) were women with an overall retinal detachment repair rate of 93%.

The study’s primary outcome was the receipt of surgical intervention for a retinal detachment. Secondary outcomes were time to repair, type of intervention, and rate of reoperation by sex.

“We found across all models, including our primary model and our sensitivity models, [that] women had lower odds of receiving retinal detachment repair after adjusting for available confounders,” Callaway said. “Extrapolating the results presented here to the United States Census data for the applicable population covered by this type of insurance, …if the odds of repair of retinal detachment between men and women were equal, then 7029 more women would [have received] surgery during the study period.”

In addition, women who did receive repair more often experienced a delay, but the delay was minimal (< 1 day [0.17 days; P = .04]) and likely not clinically significant, the authors concluded.

Interestingly, women were more likely to undergo different types of repair for retinal detachment, including primary laser barricade, primary scleral buckle, or pneumatic retinopexy, compared with men, who were more likely to undergo pars plana vitrectomy. The odds of reoperation, however, were lower in women than in men.

Related: Intersection of glaucoma and retina at the pars plana

Regarding the reasons for the differences between the sexes in retinal detachment treatment, the investigators could not pin down one specific cause from this study alone.

Callaway said men and women are known to have different rates of trauma and retinal detachment, as one example.

Biology could be another factor, in that the sexes may present with different types and configurations of retinal detachment that result in differences in surgical repair.

However, biological differences do not explain the lower odds of surgical repair. Social differences likely play a role in the primary study finding, according to Callaway.

“Women are more often caregivers at every stage of life, and this carries significant informal responsibility that may limit their access to care,” Callaway said. “Women may also be less likely to voice concerns or challenge authority. Women are more likely to be widowed and live under the poverty line, and they may not have the support to travel to numerous appointments or access to the required medications.”

Related: Research is unfolding the proteins in retinitis pigmentosa

Callaway acknowledged that there are limitations to claims data that should be considered when evaluating these results.

Further, there may be other important confounders that the investigators could not assess in this study, including race, socioeconomic status, and insurance coverage levels.

To understand potential disparities in the health care field, additional research is necessary to identify the problem, Callaway urged. In particular, she recommended doing further studies, preferably with visual acuity data, would be ideal to better understand these data.

“This study represents the first to focus on the differences in the receipt of intervention for this ophthalmic emergency. [According to the results,] insured women are less likely than insured men to receive surgical repair for a vision-threatening emergency after controlling for available confounders,” she said, adding the paper has recently been published in American Journal of Ophthalmology.

Read more by Cheryl Guttman Krader

--

Natalia Callaway, MD, MS
p: 650/725-5555
This article is based on Callaway’s presentation at the virtual 2020 Retina Society Annual Scientific Meeting (abstract 1455). Callaway reports no relevant conflicts of interest or disclosures.