Self-reported Eye Care Use Among US Adults Aged 50 to 80 Years

Key Points

Question

What factors are associated with receipt of eye care among US adults?

Findings

Results of this cross-sectional online survey study showed that more than 80% of US adults aged 50 to 80 years reported undergoing an eye examination in the past 2 years. Respondents who were unmarried, had lower incomes, or resided outside the northeast were less likely to report recent eye care; common reasons for not undergoing an eye examination included not having an eye problem, cost, and lack of insurance coverage.

Meaning

Overall, eye care use among US adults appears to be high; however, there are socioeconomic and demographic differences that might be addressed through targeted policy interventions.

Abstract

Importance

Contemporary data on use of eye care by US adults are critical, as the prevalence of age-related eye disease and vision impairment are projected to increase in the coming decades.

Objectives

To provide nationally representative estimates on self-reported use of eye care by adults aged 50 to 80 years, and to describe the reasons that adults do and do not seek eye care.

Design, Setting, and Participants

The National Poll on Healthy Aging, a cross-sectional, nationally representative online survey was conducted from March 9 to 24, 2018, among 2013 individuals aged 50 to 80 years.

Main Outcomes and Measures

The proportion of US adults who received an eye examination within the past 2 years as well as the sociodemographic and economic factors associated with receipt of eye care.

Results

Among 2013 adults aged 50 to 80 years (survey-weighted proportion of women, 52.5%; white non-Hispanic, 71.1%; mean [SD] age, 62.1 [9.0] years), the proportion reporting that they underwent an eye examination in the past year was 58.5% (95% CI, 56.1%-60.8%) and in the past 2 years was 82.4% (95% CI, 80.4%-84.2%). Among those with diabetes, 72.2% (95% CI, 67.2%-76.8%) reported undergoing an eye examination in the past year and 91.3% (95% CI, 87.7%-93.9%) in the past 2 years. The odds of having undergone an eye examination within the past 2 years were higher among women (adjusted odds ratio [AOR], 2.00; 95% CI, 1.50-2.67), respondents with household incomes of $30 000 or more (AOR, 1.57; 95% CI, 1.08-2.29), and those with a diagnosed age-related eye disease (AOR, 3.67; 95% CI, 2.37-5.69) or diabetes (AOR, 2.30; 95% CI, 1.50-3.54). The odds were lower for respondents who were unmarried (AOR, 0.71; 95% CI, 0.53-0.96), from the Midwest (AOR, 0.55; 95% CI, 0.34-0.87) or West (AOR, 0.60; 95% CI, 0.38-0.94), or reported fair or poor vision (AOR, 0.43; 95% CI, 0.28-0.65). Reasons reported for not undergoing a recent eye examination included having no perceived problems with their eyes or vision (41.5%), cost (24.9%), or lack of insurance coverage (23.4%).

Conclusions and Relevance

In this study, the rate of eye examinations was generally high among US adults aged 50 to 80 years, yet there were several significant demographic and socioeconomic differences in the use of eye care. These findings may be relevant to health policy efforts to address disparities in eye care and to promote care for those most at risk for vision problems.

This cross-sectional online survey study provides nationally representative estimates on self-reported use of eye care by US adults aged 50 to 80 years and describes the reasons that adults do and do not seek eye care.

Introduction

Vision impairment and blindness affect 9% of US adults 65 years or older, and the annual economic burden of vision problems for this population is $77 billion.¹ Poor vision is associated with an increased risk of falls, cognitive decline, and decreased independence.² The prevalence of many common eye conditions increases with age, and poor and minority populations are disproportionately affected.² However, most vision impairment is preventable or treatable with timely diagnosis and care.

In a 2016 report on eye health in the United States, the National Academies of Sciences, Engineering, and Medicine identified the examination of disparities in access to eye and vision care for medically underserved populations as a key research need.² Most recently published studies on national patterns of the use of eye care relied on data that were collected before the implementation of the Patient Protection and Affordable Care Act was completed in 2014.^3,4,5,6,7 Accordingly, the objective of this study was to provide contemporary national estimates on self-reported use of eye care and disparities in the use of eye care for US adults aged 50 to 80 years, and to describe the reasons that adults do not seek eye care.

Methods

Sample

The National Poll on Healthy Aging is a recurring survey of adults aged 50 to 80 years designed to inform the public, health care professionals, and policy makers on issues related to health.⁸ The National Poll on Healthy Aging vision survey was deployed in March 2018 by GfK Custom Research for the University of Michigan Institute for Healthcare Policy and Innovation.⁹ The survey was administered online to a randomly selected, stratified sample of 2013 individuals from GfK’s KnowledgePanel, which resembles the US population.¹⁰ The sample was weighted to reflect data from the US Census Bureau. Respondents were provided with a computer and internet access if needed to complete the survey. The Callegaro-DiSogra algorithms¹¹ were used to calculate the survey response rate, and any differential nonresponse was accounted for in adjustment of the survey design weights. The University of Michigan Institutional Review Board reviewed this study and deemed it exempt from human subjects review because it was a study of deidentified respondents.

Eye Care Questions

Respondents were asked when they last had their eyes examined by an “eye doctor” (ophthalmologist or optometrist). Responses were dichotomized into those who had received recent eye care (within 2 years) and those who had not. Self-reported near and distance vision was rated on a 5-point scale (where 1 indicated excellent and 5 indicated poor). Participants were also asked if they had received a diagnosis of an age-related eye disease, defined as cataracts, glaucoma, age-related macular degeneration, or diabetic eye disease. Respondents who had not undergone a recent eye examination were asked to report the reason(s) they had not received care. Those who reported receiving recent eye care were asked to select the main reason for seeking care. The complete vision survey is available in the eAppendix in the Supplement.

Statistical Analysis

The weighted proportion of respondents for each covariate, stratified by receipt of recent eye care, was calculated and χ² tests were performed. Multivariable logistic regression was used to estimate the odds of recent eye care; this model contained covariates predictive of recent eye care with P < .10 from χ² tests, as well as race/ethnicity, a conceptually important factor.^3,4,5,6 Self-rated distance vision was included but near vision was not because they were highly correlated. Analyses were conducted using Stata, version 15.1 (StataCorp) and accounted for the complex survey design.¹² All P values were from 2-tailed tests and results were deemed statistically significant at P ≤ .05

Results

Respondent characteristics are presented in Table 1 stratified by receipt of eye care. Overall, 58.5% of respondents (95% CI, 56.1%-60.8%) reported having undergone an eye examination in the past year and 82.4% (95% CI, 80.4%-84.2%) in the past 2 years. Among those with diabetes, 72.2% (95% CI, 67.2%-76.8%) reported undergoing an eye examination in the past year and 91.3% (95% CI, 87.7%-93.9%) in the past 2 years. In a multivariable model (Table 2), those who reported recent eye care were significantly more likely to be female (adjusted odds ratio [AOR], 2.00; 95% CI, 1.50-2.67), married or partnered, have a household income of $30 000 or more (AOR, 1.57; 95% CI, 1.08-2.29), live in the northeast United States, have diabetes (AOR, 2.30; 95% CI, 1.50-3.54) or an age-related eye disease (AOR, 3.67; 95% CI, 2.37-5.69), and have better self-reported vision. The odds were lower for respondents who were unmarried (AOR, 0.71; 95% CI, 0.53-0.96), from the midwestern (AOR, 0.55; 95% CI, 0.34-0.87) or western United States (AOR, 0.60; 95% CI, 0.38-0.94), or had self-reported fair or poor vision (AOR, 0.43; 95% CI, 0.28-0.65). The adjusted odds of receiving recent eye care were not significantly associated with age, race/ethnicity, or employment status.

Table 1. Weighted Sample Characteristics by Report of Recent Eye Examination Among US Older Adults.

Characteristic	Respondents, % (95% CI)		P Valuea
	Eye Examination Within the Past 2 y (n = 1692)	Eye Examination >2 y in the Past or Not Sure (n = 315)
Total (n = 2007)b	82.4 (80.4-84.2)	17.6 (15.8-19.6)
Sex
Male	77.8 (74.7-80.6)	22.2 (19.4-25.3)	<.001
Female	86.6 (84.0-88.8)	13.4 (11.2-16.0)
Age, y
50-64	79.6 (76.8-82.2)	20.4 (17.8-23.2)	<.001
65-80	87.0 (84.4-89.3)	13.0 (10.7-15.6)
Race/ethnicity
Black non-Hispanic	84.8 (77.9-89.8)	15.2 (10.2-22.1)	.77
Hispanic	81.8 (74.7-87.2)	18.2 (12.8-25.3)
White non-Hispanic	82.4 (80.2-84.5)	17.6 (15.5-19.8)
Other	79.3 (68.0-87.4)	20.7 (12.6-32.0)
Employment status
Employed	80.9 (78.0-83.5)	19.1 (16.5-22.0)	.003
Retired	86.4 (83.5-88.9)	13.6 (11.1-16.5)
Not working at this time	76.3 (69.1-82.4)	23.7 (17.6-30.9)
Annual household income, $
<30 000	76.1 (70.7-80.7)	23.9 (19.3-29.3)	.001
30 000-59 999	81.6 (77.4-85.1)	18.4 (14.9-22.6)
≥60 000	85.2 (82.7-87.4)	14.8 (12.6-17.3)
Marital status
Married or partnered	84.5 (82.2-86.5)	15.5 (13.5-17.8)	.002
Not married or partnered	78.1 (74.2-81.6)	21.9 (18.4-25.8)
Region
Northeast	87.0 (82.8-90.4)	13.0 (9.6-17.2)	.06
Midwest	80.0 (75.5-83.9)	20.0 (16.1-24.5)
South	83.2 (79.9-86.0)	16.8 (14.0-20.1)
West	79.7 (75.0-83.7)	20.3 (16.3-25.0)
Self-rated distance vision
Excellent	84.9 (81.1-88.0)	15.1 (12.0-18.9)	<.001
Very good	85.9 (82.9-88.5)	14.1 (11.5-17.1)
Good	78.5 (73.9-82.4)	21.5 (17.6-26.1)
Fair	73.7 (65.4-80.7)	26.3 (19.3-34.6)
Poor	74.0 (59.8-84.5)	26.0 (15.5-40.2)
Self-rated near vision
Excellent	88.2 (84.4-91.2)	11.8 (8.8-15.6)	<.001
Very good	84.8 (81.6-87.5)	15.2 (12.5-18.4)
Good	82.4 (77.9-86.0)	17.7 (14.0-22.1)
Fair	71.5 (65.0-77.2)	28.5 (22.8-35.0)
Poor	74.7 (65.6-82.1)	25.3 (17.9-34.4)
Diabetes
No	80.4 (78.0-82.5)	19.6 (17.5-22.0)	<.001
Yes	91.3 (87.7-93.9)	8.7 (6.1-12.3)
Age-related eye diseasec
No	78.3 (75.8-80.7)	21.7 (19.3-24.2)	<.001
Yes	93.4 (90.6-95.4)	6.6 (4.6-9.4)
Not sure	77.8 (62.7-87.9)	22.2 (12.1-37.3)

^aCalculated using design-adjusted Pearson χ² tests.

^bA total of 2013 individuals completed the survey; however, 2007 provided complete data on receipt of eye examinations.

^cSelf-reported diagnosis of cataracts, glaucoma, macular degeneration, or diabetic eye disease.

Table 2. Factors Associated With Undergoing an Eye Examination in the Past 2 Years Among US Older Adults.

Factor	Recent Eye Examination
	AOR (95% CI)a	P Value
Sex
Male	1 [Reference]
Female	2.00 (1.50-2.67)	<.001
Age, y
50-64	1 [Reference]
65-80	1.19 (0.83-1.69)	.34
Race/ethnicity
White	1 [Reference]
Black	1.33 (0.80-2.23)	.28
Hispanic	1.25 (0.77-2.03)	.37
Other	0.762 (0.40-1.26)	.42
Employment status
Employed	1 [Reference]
Retired	1.07 (0.72-1.59)	.74
Not working at this time	0.66 (0.42-1.04)	.07
Annual household income, $
<30 000	1 [Reference]
≥30 000	1.57 (1.08-2.29)	.02
Marital status
Married or partnered	1 [Reference]
Not married or partnered	0.71 (0.53-0.96)	.03
Region
Northeast	1 [Reference]
Midwest	0.55 (0.34-0.87)	.01
South	0.66 (0.43-1.02)	.06
West	0.60 (0.38-0.94)	.03
Self-rated distance vision
Excellent or very good	1 [Reference]
Good	0.59 (0.43-0.82)	.002
Fair or poor	0.43 (0.28-0.65)	<.001
Diabetes
No	1 [Reference]
Yes	2.30 (1.50-3.54)	<.001
Age-related eye disease
No or not sure	1 [Reference]
Yes	3.67 (2.37-5.69)	<.001

Abbreviation: AOR, adjusted odds ratio.

^aOdds ratios are adjusted for all other variables listed in this table.

Reasons cited for undergoing and not undergoing a recent eye examination are depicted in the Figure. Respondents who underwent a recent eye examination did so most frequently to “check their glasses or contact lens prescription” and/or “for routine care” (42.5%). Respondents who did not undergo a recent eye examination most frequently reported they “had not had problems with their eyes” (41.5%). Respondents with lower household incomes were more likely to cite cost (income <$30 000, 34.3%; vs income ≥$30 000, 17.8%; P = .05) and lack of insurance coverage (income <$30 000, 37.4%; vs income ≥$30 000, 16.5%; P = .01) as reasons for not receiving recent eye care.

Figure. Reasons Reported for Obtaining and Not Obtaining Recent Eye Care Among Older US Adults Aged 50 to 80 Years.

Proportions are weighted to represent the total population of US adults aged 50 to 80 years. Error bars indicate 95% CIs, and eye doctor indicates ophthalmologist or optometrist.

^aRespondents were asked to select the main reason for receiving eye care.

^bRespondents were asked to select the reason(s) they had not received eye care.

Discussion

This nationally representative survey provides contemporary data on self-reported use of eye care for adults aged 50 to 80 years. Although most respondents reported receiving recent eye care, 27.8% of those with diabetes had not undergone an eye examination in the past year, and there were sociodemographic differences in the self-reported receipt of eye care.

The frequency of eye care in the past year was similar to that reported in some prior nationally representative studies.^4,13 Among the 17.6% respondents who had not had an eye examination in the past 2 years in this study, the most commonly cited reason was that they had not had problems with their eyes. However, common progressive conditions such as glaucoma may be present and treatable before symptoms occur. Nonetheless, guidelines for routine preventive eye care remain controversial and the US Preventive Services Task Force states that there is insufficient evidence to support routine vision screening in older adults.¹⁴ Accordingly, future research should develop and evaluate optimized screening protocols that prevent vision loss and maintain quality of life, even in the absence of known vision problems.

For adults with diabetes, both the American Diabetes Association and American Academy of Ophthalmology recommend eye examinations at least annually.^15,16 Studies using older data from the National Health and Nutrition Examination Survey¹⁷ and Medicare claims¹⁸ reported that approximately 60% of adults with diabetes had undergone an eye examination in the prior year. The fact that respondents with diabetes in our study reported more frequent eye examinations is encouraging and may reflect public health messaging or improved access to care. Future studies should use both self-reported data and administrative claims to examine adherence with eye examination recommendations.

There is some disagreement on the association of race/ethnicity with use of eye care. Our study, like some prior investigations, failed to detect such an association,⁷ while others have reported both higher⁵ and lower¹³ use of eye care among racial/ethnic minorities. Additional work is needed to better characterize the association between race/ethnicity and eye care and determine whether it varies by socioeconomic status, geography, age, or other key factors that could help target those most at risk for not receiving eye care. In addition, observed differences related to sex, marital status, income, and geography may suggest the need for focused policy changes and public health messaging.

Limitations

There were several limitations to this study. Surveys are subject to recall, desirability, and healthy respondent biases. Adults with vision impairment may have been less likely to participate in the survey because it was administered online. Also, it was not possible to determine the need for eye examinations or infer causation from these data.

Conclusions

These contemporary data on self-reported use of eye care may help inform public health approaches to promote eye health and improve health equity for an aging population. Policy changes to encourage eye care for those at greatest risk for vision problems may be warranted. Additional studies using both survey and claims data are needed to provide a more comprehensive understanding of the association of health policy changes with trends in vision health and the use of eye care.

Supplement.

eAppendix. National Poll on Healthy Aging Vision Module