Racial, Ethnic, and Insurance-Based Disparities Upon Initiation of Anti–Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema in the US


      This study characterizes the association of risk factors including race, ethnicity, and insurance status with presenting visual acuity (VA) and diabetic retinopathy (DR) severity in patients initiating treatment with anti–vascular endothelial growth factor (VEGF) therapy for diabetic macular edema (DME).


      Retrospective, cross-sectional study.


      The Academy Intelligent Research in Sight (IRIS) Registry database was queried for patients who initiated anti-VEGF injection treatment for DME between 2012 and 2020 (n = 203 707).


      Multivariate regression analyses were conducted to understand how race, ethnicity, insurance status, and geographic location were associated with baseline features.

      Main Outcome Measures

      Visual acuity and DR severity.


      Patients on Medicare and private insurance presented with higher baseline VA compared with patients on Medicaid (median of 2.31 and 4.17 greater Early Treatment Diabetic Retinopathy Scale [ETDRS] letters, respectively P < 0.01). White and non-Hispanic patients presented with better VA compared with their counterparts (median of 0.68 and 2.53 greater ETDRS letters, respectively; P < 0.01). Black and Hispanic patients presented with a worse baseline DR severity compared with White and non-Hispanic patients (odds ratio, 1.23 and 1.71, respectively; P < 0.01).


      There are ethnic and insurance-based disparities in VA and disease severity upon initiation of anti-VEGF therapy for DME treatment. Public health initiatives could improve timely initiation of treatment.


      Abbreviations and Acronyms:

      DM (diabetes mellitus), DME (diabetic macular edema), DR (diabetic retinopathy), ETDRS (Early Treatment Diabetic Retinopathy Study), HbA1c (glycated hemoglobin), IRIS (Intelligent Research in Sight), NPDR (nonproliferative diabetic retinopathy), OR (odds ratio), PDR (proliferative diabetic retinopathy), VA (visual acuity), VEGF (vascular endothelial growth factor)
      To read this article in full you will need to make a payment
      Subscribe to Ophthalmology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ciulla T.A.
        • Amador A.G.
        • Zinman B.
        Diabetic retinopathy and diabetic macular edema.
        Diabetes Care. 2003; 26: 2653LP-2664
      1. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States. CDC.
        • The Eye Diseases Prevalence Research Group
        The prevalence of diabetic retinopathy among adults in the United States.
        JAMA Ophthalmol. 2004; 122: 552-563
        • Solomon S.D.
        • Chew E.
        • Duh E.J.
        • et al.
        Diabetic retinopathy: a position statement by the American Diabetes Association.
        Diabetes Care. 2017; 40: 412-418
        • Van Leiden H.A.
        • Dekker J.M.
        • Moll A.C.
        • et al.
        Risk factors for incident retinopathy in a diabetic and nondiabetic population: The Hoorn Study.
        Arch Ophthalmol. 2003; 121: 245-251
        • Varma R.
        • Bressler N.M.
        • Doan Q.V.
        • et al.
        Prevalence of and risk factors for diabetic macular edema in the United States.
        JAMA Ophthalmol. 2014; 132: 1334-1340
        • Zebardast N.
        • Friedman D.S.
        • Vitale S.
        The prevalence and demographic associations of presenting near-vision impairment among adults living in the United States.
        Am J Ophthalmol. 2017; 174: 134-144
        • Qiu M.
        • Wang S.Y.
        • Singh K.
        • Lin S.C.
        Racial disparities in uncorrected and undercorrected refractive error in the United States.
        Invest Ophthalmol Vis Sci. 2014; 55: 6996-7005
        • Wong T.Y.
        • Klein R.
        • Islam F.M.A.
        • et al.
        Diabetic retinopathy in a multi-ethnic cohort in the United States.
        Am J Ophthalmol. 2006; 141: 446-455
        • Barker L.E.
        • Kirtland K.A.
        • Gregg E.W.
        • et al.
        Geographic distribution of diagnosed diabetes in the U.S.: A diabetes belt.
        Am J Prev Med. 2011; 40: 434-439
        • Ferris F.
        Early photocoagulation in patients with either type I or type II diabetes.
        Trans Am Ophthalmol Soc. 1996; 94: 505-537
        • Wong T.Y.
        • Cheung C.M.G.
        • Larsen M.
        • et al.
        Diabetic retinopathy.
        Nat Rev Dis Prim. 2016; 2: 16012
        • Varma R.
        • Macias G.L.
        • Torres M.
        • et al.
        Biologic risk factors associated with diabetic retinopathy. The Los Angeles Latino Eye Study.
        Ophthalmology. 2007; 114: 1332-1340
        • Klein R.
        • Klein B.E.K.
        • Moss S.E.
        • et al.
        The Wisconsin Epidemiologic Study of Diabetic Retinopathy: III. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years.
        Arch Ophthalmol. 1984; 102: 527-532
        • Hamman R.F.
        • Mayer E.J.
        • Moo-Young G.A.
        • et al.
        Prevalence and risk factors of diabetic retinopathy in non-Hispanic whites and Hispanics with NIDDM. San Luis Valley Diabetes Study.
        Diabetes. 1989; 38: 1231-1237
        • Hill J.
        • Nielsen M.
        • Fox M.H.
        Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill.
        Perm J. 2013; 17: 67-72
        • Rivich J.
        • Kosirog E.R.
        • Billups S.J.
        • et al.
        Social and psychosocial determinants of health associated with uncontrolled diabetes in a federally qualified health center population.
        Diabetes Spectr. 2019; 32: 145-151
        • Chiang M.F.
        • Sommer A.
        • Rich W.L.
        • et al.
        The 2016 American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) Database: Characteristics and Methods.
        Ophthalmology. 2018; 125: 1143-1148
      2. R Core Team. R: A Language and Environment for Statistical Computing.
        Date: 2019
        Date accessed: January 13, 2021
        • Gregori N.Z.
        • Feuer W.
        • Rosenfeld P.J.
        Novel method for analyzing Snellen visual acuity measurements.
        Retina. 2010; 30: 1046-1050
        • Diabetic Retinopathy Data and Statistics
        National Institutes of Health National Eye Institute.
        • Appalachian Diabetes Control and Translation Project
        Centers for Disease Control and Prevention.
        Date: 2017
        Date accessed: January 13, 2021
        • Gao X.
        • Obeid A.
        • Aderman C.M.
        • et al.
        Loss to follow-up after intravitreal anti-vascular endothelial growth factor injections in patients with diabetic macular edema.
        Ophthalmol Retin. 2019; 3: 230-236
        • Obeid A.
        • Gao X.
        • Ali F.S.
        • et al.
        Loss to follow-up among patients with neovascular age-related macular degeneration who received intravitreal anti–vascular endothelial growth factor injections.
        JAMA Ophthalmol. 2018; 136: 1251-1259
        • Haffner S.M.
        • Fong D.
        • Stern M.P.
        • et al.
        Diabetic retinopathy in Mexican Americans and non-Hispanic Whites.
        Diabetes. 1988; 37: 878-884
        • Harris M.I.
        • Klein R.
        • Cowie C.C.
        • et al.
        Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study.
        Diabetes Care. 1998; 21: 1230-1235
        • Signorello L.B.
        • Schlundt D.G.
        • Cohen S.S.
        • et al.
        Comparing diabetes prevalence between African Americans and Whites of similar socioeconomic status.
        Am J Public Health. 2007; 97: 2260-2267
        • Gravlee C.C.
        How race becomes biology: embodiment of social inequality.
        Am J Phys Anthropol. 2009; 139: 47-57
        • Hochman A.
        Racial discrimination: how not to do it.
        Stud Hist Philos Biol Biomed Sci. 2013; 44: 278-286
        • Foster M.W.
        • Sharp R.R.
        Race, ethnicity, and genomics: social classifications as proxies of biological heterogeneity.
        Genome Res. 2002; 12: 844-850
        • Williams D.R.
        • Priest N.
        • Anderson N.B.
        Understanding associations among race, socioeconomic status, and health: patterns and prospects.
        Health Psychol. 2016; 35: 407-411
        • Walker R.J.
        • Strom Williams J.
        • Egede L.E.
        Influence of race, ethnicity and social determinants of health on diabetes outcomes.
        Am J Med Sci. 2016; 351: 366-373
        • Villagra V.G.
        • Bhuva B.
        • Coman E.
        • et al.
        Health insurance literacy: disparities by race, ethnicity, and language preference.
        Am J Manag Care. 2019; (25e71-e75)
        • Meyer O.L.
        • Castro-Schilo L.
        • Aguilar-Gaxiola S.
        Determinants of mental health and self-rated health: a model of socioeconomic status, neighborhood safety, and physical activity.
        Am J Public Health. 2014; 104: 1734-1741
        • Roy M.S.
        • Affouf M.
        Six-year progression of retinopathy and associated risk factors in African American patients with type 1 diabetes mellitus: The New Jersey 725.
        Arch Ophthalmol. 2006; 125: 1297-1306
        • Hinkle J.W.
        • Flynn H.W.
        • Banta J.T.
        • Vanner E.A.
        Patients presenting emergently with proliferative diabetic retinopathy: follow-up and factors associated with compliance.
        Retina. 2020; 40: 928-935
        • Lachin J.M.
        • Genuth S.
        • Nathan D.M.
        • et al.
        Effect of glycemic exposure on the risk of microvascular complications in the diabetes control and complications trial--revisited.
        Diabetes. 2008; 57: 995-1001
      3. FDA Approves Lucentis (ranibizumab) for Treatment of Diabetic Macular Edema (DME).
        • Mbagwu M.
        • French D.D.
        • Gill M.
        • et al.
        Creation of an accurate algorithm to detect Snellen best documented visual acuity from ophthalmology electronic health record notes.
        J Med Internet Res. 2016; 4: A732
        • Macias E.P.
        • Lee D.A.
        • Oelrich F.O.
        Refractive errors and visual acuity impairment among self-selected Hispanic, white, and black adults examined by the UCLA Mobile Eye Clinic.
        Optometry. 1999; 70: 724-734