Socioeconomics impact the use of CXL technology

Although certain socioeconomic factors such as insurance, gender, and race predict severity and rate of corneal transplantation in keratoconus, socioeconomic factors related to patients undergoing CXL had not previously been identified.

Reviewed by Angela Gupta, MD, PhD

Geographic location and type of insurance plan may limit accessibility of cross-linking (CXL) to patients.

CXL has been proven effective to treat patients with corneal ectasias. Although certain socioeconomic factors such as insurance, gender, and race predict severity and rate of corneal transplantation in keratoconus, socioeconomic factors related to patients undergoing CXL had not previously been identified, according to Angela Gupta, MD, PhD, and colleagues.

Gupta is a resident physician at Scheie Eye Institute in the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. She made a presentation on CXL at the American Academy of Ophthalmology’s 2022 annual meeting in Chicago.

Gupta explained that she and her colleagues conducted a retrospective study to identify patients in a national insurance claims database from 2015 to 2020 to determine reasons for not embracing the technology and the role that socioeconomic factors may play.

Database findings

The investigators found that a total of 108,504 patients had been diagnosed with keratoconus, keratomalacia, corneal deformity, or corneal ectasia during the study period. Of that number, 552 patients with keratoconus or corneal ectasia underwent CXL, and they were matched with 2723 controls who did not undergo CXL.

The results did indicate the increasing acceptance of CXL with time. Although the number of patients who opted for CXL in 2016 was in the single digits, that number increased to more than 250 by 2019 in this study, Gupta explained.

Patient age seemed to be a factor. Patients older than 30 years were associated with a significantly (P = .003) decreased likelihood of undergoing CXL; patients 30 years and younger represented more than 75% of those who opted to undergo CXL. The investigators suggested that the absence of acceptance of CXL by older patients was likely due to the utility of treatment in the early stages of keratoconus or corneal ectasia. Gender, race, education, and patient income were not correlated with the odds of undergoing or not undergoing CXL.

Gupta noted that patients who were members of a health maintenance group also were less likely to under CXL (P= .047). In addition, patients who lived on the East Coast and in the southern region of the Midwest had lower odds of undergoing CXL (P = .001 for both).

“This is the first study to identify socioeconomic characteristics of CXL, and [it] highlights [that] geographic location and insurance plans may limit accessibility to patients,” Gupta concluded. “We hope that identifying barriers to CXL can be the first step in ensuring all patients have equitable access to ophthalmologic care.”