Assessing Eye Health and Eye Care Needs Among North American Native Individuals

Maria A Woodward; Kathleen Hughes; Dena Ballouz; Richard A Hirth; Josh Errickson; Paula Anne Newman-Casey

doi:10.1001/jamaophthalmol.2021.5507

. 2021 Dec 23;140(2):1–10. doi: 10.1001/jamaophthalmol.2021.5507

Assessing Eye Health and Eye Care Needs Among North American Native Individuals

Maria A Woodward ^1,^2,^✉, Kathleen Hughes ³, Dena Ballouz ¹, Richard A Hirth ^2,⁴, Josh Errickson ⁵, Paula Anne Newman-Casey ^1,²

¹Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor

²Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor

³Avalere Health, Washington, DC

⁴Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor

⁵Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor

Accepted for Publication: November 2, 2021.

Published Online: December 23, 2021. doi:10.1001/jamaophthalmol.2021.5507

^✉

Corresponding Author: Maria A. Woodward, MD, MSc, Department of Ophthalmology and Visual Sciences, University of Michigan, 1000 Wall St, Ann Arbor, MI 48105 (mariawoo@med.umich.edu).

Author Contributions: Dr Woodward had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Woodward, Hirth, Newman-Casey.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Woodward, Hughes, Ballouz, Hirth, Newman-Casey.

Critical revision of the manuscript for important intellectual content: Woodward, Ballouz, Hirth, Errickson, Newman-Casey.

Statistical analysis: Woodward, Ballouz, Hirth, Errickson.

Obtained funding: Woodward, Hughes, Hirth, Newman-Casey.

Administrative, technical, or material support: Woodward.

Supervision: Woodward, Newman-Casey.

Conflicts of Interest Disclosures: Dr Woodward, Ms Hughes and Drs Hirth and Newman-Casey report grants from Seva Foundation during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was supported by the Seva Foundation (Dr Woodward, Ms Hughes, Drs Hirth, Errickson, and Newman-Casey); National Eye Institute (R01EY031337 to Dr Newman-Casey and R01EY031033 to Dr Woodward), and a Research to Prevent Blindness Career Development Award (Dr Woodward).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This material was presented at the Association for Research in Vision and Ophthalmology Annual Meeting; May 2021; virtual meeting.

Additional Contributions: This project was supported in part by a gift by Ms Susan Lane and assistance in study development by Jennifer Huang, MD, University of California Irvine, who was not compensated for her contributions.

^✉

Corresponding author.

PMCID: PMC8855236 PMID: 34940785

Key Points

Question

Are there disparities in ophthalmic conditions and services between North American Native individuals and non-Hispanic White individuals in the US?

Findings

In this cross-sectional study, higher condition claim rates but lower service claim rates were found for North American Native individuals vs non-Hispanic White individuals for refractive errors; diabetic eye diseases; blindness and low vision; injury, burns, and surgical complications of the eye; and orbital and external disease, suggesting disparities in eye care among North American Native individuals.

Meaning

These findings support the need for policy changes and further research to explain and address disparities in eye care among North American Native individuals compared with non-Hispanic White individuals.

This cross-sectional study evaluates whether disparities in ophthalmic conditions and services exist between North American Native individuals and non-Hispanic White individuals in the US.

Abstract

Importance

There are few population-level studies on ophthalmic conditions and services among North American Native individuals.

Objective

To evaluate whether disparities in ophthalmic conditions and services exist between North American Native individuals and non-Hispanic White individuals in the US.

Design, Setting, and Participants

This cross-sectional study used 100% Medicare fee-for-service (MFFS) enrollment data from the Vision and Eye Health Surveillance System (VEHSS) to examine ophthalmic conditions and service use in North American Native individuals and non-Hispanic White individuals in the US. In this study North American Native individuals included those who identified as American Indian, Native Alaskan, Native Hawaiian, and Pacific Islander. Data were analyzed from August 2020 to April 2021.

Interventions

Claims and sociodemographic characteristics were extracted and means computed for categories of ophthalmic conditions and select ophthalmic services. Ophthalmic conditions and services were defined in the VEHSS using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Logistic regression was used to model differences between age-adjusted mean ophthalmic condition and service claim rates among North American Native individuals and non-Hispanic White individuals for each age cohort. Matching ophthalmic condition claim rates and ophthalmic service claim rates was performed to examine disparities by racial group.

Main Outcomes and Measures

Mean age-adjusted claim rates for ophthalmic conditions and services among North American Native individuals vs non-Hispanic White individuals per 100 persons.

Results

Claims were identified for 177 100 Native American Native individuals and 24 438 000 non-Hispanic White individuals. In 16 of 17 ophthalmic condition categories and 6 of 9 service categories, North American Native individuals had significantly different claim rates from non-Hispanic White individuals. There were higher ophthalmic condition claim rates but lower service claim rates for North American Native individuals (vs non-Hispanic White individuals) for refractive errors (ophthalmic condition, 17.2 vs 11.1; service, 48.3 vs 49.6, respectively; P < .001); blindness and low vision (ophthalmic condition, 1.48 vs 0.75: service, 19.2 vs 20.1, respectively; P < .001); injury, burns, and surgical complications (ophthalmic condition, 1.8 vs 1.7; service, 19.2 vs 20.1, respectively; P < .001); and orbital and external disease (ophthalmic condition, 15.7 vs 13.3; service, 48.3 vs 49.6, respectively; P < .001). For diabetic eye diseases, North American Native individuals had higher ophthalmic condition claim rates (5.22 vs 2.20) but no difference in service claim rates (14.4 vs 14.8; P = .26) compared with non-Hispanic White individuals.

Conclusions and Relevance

In this cross-sectional study, North American Native individuals had higher prevalence of ophthalmic conditions but no corresponding increase in services (treatment for most ophthalmic conditions) compared with non-Hispanic White individuals. These results suggest worse eye health and higher unmet eyecare needs for North American Native individuals with MFFS coverage compared with non-Hispanic White individuals with MFFS coverage.

Introduction

North American Native individuals represent 1.7% of the US population¹ and experience many health care disparities.² North American Native individuals in the US have higher rates of diabetes,³ cirrhosis,⁴ hypertension,⁵ and cardiovascular disease.⁵ They have lower life expectancy than other US individuals.⁶ Disparities have been attributed to higher poverty rates, less available education, and less health care access.^6,7 Regional studies report that North American Native individuals have a higher prevalence of visual impairments and treatable eye diseases compared with other US individuals.^8,9,10 However, prevalence and needs assessment studies have been limited to individual tribes.^8,9,10,11

The Vision and Eye Health Surveillance System (VEHSS), based on the 100% sample of Medicare fee-for-service (MFFS), claims is a publicly available data set that includes eye health, utilization metrics, and data on North American Native individuals,¹² enabling comparison between claim rates for ophthalmic conditions and services for US North American Native individuals and non-Hispanic White individuals. While North American Native individuals have higher rates of uninsurance, Medicaid coverage, and Indian Health Service (IHS) coverage, and less private insurance coverage than non-Hispanic White individuals,^13,14 North American Native individuals and non-Hispanic White individuals have comparable rates of Medicare coverage for persons 65 years and older (96% to 98%).¹⁵

The purpose of this study was to understand differences in ophthalmic condition identification and service utilization between US North American Native individuals and non-Hispanic White individuals with Medicare coverage using the VEHSS MFFS claims database. Absent disparities, the proportion of people with a given ophthalmic condition who use a service for that condition should be similar across racial and ethnic groups. With standardized Medicare benefits available to all users, any race or ethnicity differences noted may represent larger access difficulties outside of insurance status. Further, any North American Native individual vs non-Hispanic White individual differences noted in this data set would likely be an underestimation of disparities present in the wider North American Native population given the lower rate of insurance overall compared with the non-Hispanic White population.¹³

Methods

To determine the use of services by North American Native individuals compared with non-Hispanic White individuals, an analysis was performed using billing claims data from the 2017 VEHSS database for MFFS, which allowed the identification of beneficiaries diagnosed with ophthalmic diseases (ie, ophthalmic conditions) and receiving ophthalmic treatments (billed as services). In this study North American Native individuals included those who identified as American Indian, Native Alaskan, Native Hawaiian, and Pacific Islander. The 2017 database includes all MFFS beneficiaries, who make up 62% of the Medicare population.¹⁶ The MFFS database excludes those who are eligible for Medicare who enroll in Medicare Advantage, the set of managed care plans offered through Medicare, who make up the other 38% of the Medicare population. The VEHSS is a national data repository for vision and eye health data from the MFFS sample claims database alongside the American Community Survey (ACS) database. Methods used to abstract and analyze information from the aggregated MFFS claims section of the VEHSS are summarized in Table 1. This study was deemed exempt from review and consent by the University of Michigan Institutional Review Board because the data were deidentified.

Table 1. Simplified Study Methodology.

Abstract and compile ophthalmic information from VEHSS (data partially processed by NORC from 100% sample MFFS claims data set)	Claims files		Demographic files
	Beneficiaries with claims		All health care professionals and beneficiaries
	Diagnosis (ie, condition)	Treatment (ie, service)	Master files
	Abstract claims for beneficiaries in 17 major ophthalmic diagnosis groups (ICD-10-CM code and modifiers for severity, location, and subtype of disease process)	Abstract claims for beneficiaries by 9 major and 25 detailed service groups (CPT and HCPCS codes) matched with health care professionals in 4 identifier groups (ophthalmologist, other physician, optometrist, optician) and 2 groups (physician vs other)	Abstract information on all health care professionals by 4 identifier groups (ophthalmologist, other physician, optometrist, optician)
			Abstract information on all beneficiaries
	Within each condition and service group and master files, identify beneficiaries by age group (1-17 y, 18-39 y, 40-64 y, 65-84 y, ≥85 y)
	Within each condition and service group, identify beneficiaries by sex
	Within each condition and service group and master files, identify beneficiaries as North American Native or non-Hispanic White
	Compile condition claims data set	Compile service claims data set	Compile all-beneficiary data set
Compute and compare ophthalmic claim rates between North American Native individuals and non-Hispanic White individuals by condition and service groups	Age-adjusted claim totals from all cells in conditions and services data sets as applicable to North American Native individuals and non-Hispanic White individuals
	Divide age-adjusted claims from all cells (17 condition groups and 9 service groups) by all applicable North American Native beneficiaries and non-Hispanic White beneficiaries/100
	Compare and perform statistical tests for significance of North American Native vs non-Hispanic White condition and claim rate differences
Match ophthalmic condition and service groups and compare claim rates between North American Native individuals and non-Hispanic White individuals to identify disparities	Match 17 condition and 9 service groups using Medicare claims adjudication logic or professional judgment
	Compare and interpret 17 matched condition-service pairs for statistically significant claim rate differences between North American Native individuals vs non-Hispanic White individuals

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Abbreviations: CPT, Current Procedural Terminology; HCPCS, Healthcare Common Procedure Coding System; ICD-10-CM, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification; MFFS, Medicare fee-for-service; NORC, National Opinion Research Center; VEHSS, Vision and Eye Health Surveillance System.

Data Abstraction From VEHSS

The VEHSS raw data sources were processed for public use by the National Opinion Research Center (NORC) at the University of Chicago.^12,17 NORC abstracted claims for every person in the MFSS component (the Medicare standard analytic files) of the VEHSS database that includes International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes “that relate to vision, eye, ocular adnexa, including eye-related systems such as orbit and lacrimal system, including conjunctivitis.”¹⁷ These are known as condition claims. Ophthalmic conditions were identified using ICD-10-CM codes and 3 modifier categories applied to selective ophthalmic conditions to differentiate severity, location, and subtype of disease process (eMethods in the Supplement). For ophthalmic conditions, 17 major categories and 76 subgroups were identified based on clinical cohesiveness and grouped claims information. Within the VEHSS diagnostic category of blindness and low vision, subcategories are based on visual acuity. Visual function is measured based on best-corrected visual acuity in the better-seeing eye. Visual acuity categories are listed in eTable 1 in the Supplement.

NORC then assessed whether ophthalmic services were provided for those with ophthalmic diagnoses (ophthalmic conditions) by assessing the presence of service claims for ophthalmic care including both diagnostic and therapeutic care. For services, claims with first-listed ophthalmic diagnoses were abstracted by ICD-10-CM code and then matched with an associated Current Procedural Terminology and/or applicable Healthcare Common Procedure Coding System code (for physician-administered drugs or implantable devices). For service claims, 9 major categories and 25 subgroups were identified. To ensure information on eye examinations by all health care professionals was captured, Current Procedural Terminology/Healthcare Common Procedure Coding System code and health care professionals type code correspondences were used for claims identification, meaning that the eye service provided must have been provided by a qualified optometrist, optician, ophthalmologist, or physician who billed a general eye screening examination. These deidentified data are available publicly with classifications established by NORC. The aggregated metrics from NORC were used to calculate the claim rates for ophthalmic conditions and services.

Computing Claim Rates

Mean claim rates were calculated for the ophthalmic condition and service claim groups and subgroups described above for beneficiaries in 5 age groups (0-17 years, 18-39 years, 40-64 years, 65-84 years, and years and older), 2 sex groups (female and male), and 6 first-listed race or ethnicity groups (Asian, non-Hispanic Black, Hispanic, North American Native, non-Hispanic White, and other). This analysis was limited to comparisons of North American Native and non-Hispanic White individuals to specifically examine the eye health and ophthalmic service utilization of North American Native individuals. Mean claim rates were computed by dividing the total number of claims by applicable enrolled beneficiaries by 100 to yield a percentage. Mean claim rates for both ophthalmic conditions and services were compared between North American Native individuals and non-Hispanic White individuals.

Data abstracted from the ACS portion of the VEHSS were from a single question asking respondents about blindness or serious difficulty seeing even when wearing glasses. Blindness or low vision is 1 of the 17 major ophthalmic condition categories in the VEHSS. ACS results were used to support Medicare-based findings on refractive error. The results of the visual acuity question within the ACS and the statistical test result comparing North American Native individuals and non-Hispanic White individuals is shown in eTable 2 in the Supplement.

Statistical Analysis

To account for age discrepancies between North American Native individuals and non-Hispanic White individuals, mean claim rates for each cohort’s ophthalmic conditions and services were age adjusted. To generate predicted probabilities of an ophthalmic condition or service (ie, the claim rates of having an ophthalmic condition or service in the database), separate aggregated logistic regression models were performed for each ophthalmic condition or service. The outcome variable was the unadjusted claim rates. Age quintile and racial categories were the predictor variables. From this model, the predicted claim rates within each racial category were obtained by marginalizing over age to obtain the age-adjusted claim rates.¹⁸

After obtaining the age-adjusted mean claim rate, z tests were used to test for statistical differences between prevalence rates for ophthalmic conditions and services between North American Native individuals and non-Hispanic White individuals. Because this was an exploratory descriptive analysis, no adjustments for multiple comparisons were made when testing for statistical significance. This analysis was performed with Stata version 16 (StataCorp). All tests were 2-tailed, and significance was set at P < .05.

Matching Eye Conditions With Eye Services

Researchers paired ophthalmic conditions with their related services to understand whether there was a mismatch between claim rates for ophthalmic conditions and claim rates for services used. Matching was performed using key word association within ophthalmic condition and service category descriptors via Medicare claim adjudication logic or professional judgment as needed. For instance, a glaucoma group would be paired with the any-glaucoma-treatment service group. The ophthalmic condition categories not mapping to a specific service category were paired with broader service categories by the study ophthalmologists (M.A.W. and P.A.N.C.) and public health experts (K.H. and R.A.H.). The logic used in the pairing was the best fit of elements within broad service categories to diseases within a condition category. For example, diseases within the category of all disorders of optic nerve and visual pathways tended to need the types of diagnostic workups contained in the VEHSS-defined any-diagnostic-eye-test service category, so this pairing was made. Discrepancies between claim rates for North American Native individuals and non-Hispanic White individuals were noted to examine disparities.

Results

Using the 2017 MFSS claims database in the VEHSS, this cross-sectional analysis identified claims for 177 100 North American Native individuals (0.59%) and 24 438 000 non-Hispanic White individuals (80.82%) from the MFSS sample of 30 238 300 persons. The sample was 55.29% female. Age data were collected as categories and are reported in Table 2 along with demographic characteristics of North American Native individuals and non-Hispanic White individuals. There was a significant difference in age between North American Native individuals and non-Hispanic White individuals (P < .001). A total of 31% of MFFS claims for beneficiaries younger than 65 years came from North American Native individuals and 13% from non-Hispanic White individuals (Table 2). The North American Native population had slightly more female individuals (98 900; 56%) compared with non-Hispanic White individuals (13 510 500; 55%).

Table 2. Demographic Characteristics of the 2017 US Vision and Eye Health Surveillance System¹² Medicare Fee-for-Service Cohort.

Characteristic	No. (%)^a
Characteristic	North American Native	White, non-Hispanic
Age, y
0-17	0	700 (0)
18-39	10 600 (6)	469 200 (2)
40-64	45 000 (25)	2 791 000 (11)
65-84	108 900 (61)	17 952 500 (73)
≥85	12 700 (7)	3 224 600 (13)
All ages	177 100 (100)	24 438 000 (100)
P value	<.001
Sex
Female	98 900 (56)	13 510 500 (55)
Male	78 200 (44)	10 927 500 (45)
All	177 100 (100)	24 438 000 (100)
P value	<.001

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^{^a}

Counts of persons identifying as 1 race or ethnicity alone; counts are significantly higher when multiple identifications allowed (eg, 3 times higher for North American Native individuals). Numbers are rounded to the nearest 100 for presentation purposes in the VEHSS; totals were computed using actual numbers and then rounded, so they may not agree with the sum of the column entries presented in the table. Percentages are based on the numbers presented in the table.

Table 3 shows the difference in claims proportions between North American Native individuals and non-Hispanic White individuals for ophthalmic conditions within all 17 categories with relative reported claim rates differing by more than 10% for 11 measures. Higher claim rates for North American Native individuals (vs non-Hispanic White individuals) existed for 5 ophthalmic conditions: diabetic eye diseases; blindness and low vision; refraction and accommodation disorders; injury, burns, and surgical complications; and orbital and external diseases. Lower claim rates for North American Native individuals (vs non-Hispanic White individuals) were found for 12 ophthalmic conditions: cataracts, glaucoma, age-related macular degeneration, cornea disorders, strabismus and amblyopia, retinal detachment and defects, disorders of optic nerve and visual pathways, cancer and neoplasms of the eye, infectious and inflammatory disease, other retinal disorders, and other eye disorders.

Table 3. Ophthalmic Condition Claim Rates in North American Native Individuals vs Non-Hispanic White Individuals in the 2017 US Vision and Eye Health Surveillance System¹² Medicare Fee-for-Service Cohort.

Condition	% (95% CI)			Relative rate difference (North American Native individual − non-Hispanic White individual / non-Hispanic White individual), %	P value
	Age-adjusted rate per 100 persons in data set denominator		Rate difference
	North American Native	Non-Hispanic White	Rate difference
Diabetic eye diseases	5.22 (5.12 to 5.33)	2.20 (2.19 to 2.20)	3.03 (2.92 to 3.13)	138	<.001
Blindness and low vision	1.48 (1.42 to 1.53)	0.75 (0.75 to 0.76)	0.73 (0.67 to 0.78)	97	<.001
Refraction and accommodation disorders	17.21 (17.03 to 17.39)	11.09 (11.08 to 11.10)	6.12 (5.94 to 6.30)	55	<.001
Cataracts	30.06 (29.83 to 30.28)	34.41 (34.40 to 34.43)	−4.36 (−4.58 to −4.14)	−13	<.001
Glaucoma	11.86 (11.70 to 12.02)	12.38 (12.37 to 12.39)	−0.52 (−0.68 to −0.36)	−4	<.001
Age-related macular degeneration	7.13 (6.99 to 7.26)	9.82 (9.81 to 9.84)	−2.70 (−2.83 to −2.57)	−27	<.001
Cornea disorders	2.84 (2.76 to 2.92)	3.08 (3.07 to 3.09)	−0.24 (−0.32. −0.16)	−8	<.001
Strabismus and amblyopia	1.23 (1.18 to 1.28)	1.42 (1.41 to 1.53)	−0.18 (−0.24 to −0.13)	−13	<.001
Retinal detachment and defects	0.81 (0.77 to 0.85)	1.02 (1.01 to 1.02)	−0.20 (−0.25 to −0.16	−20	<.001
Injury, burns, and surgical complications of the eye	1.84 (1.78 to 1.91)	1.70 (1.69 to 1.70)	0.15 (0.08 to 0.21)	9	<.001
Orbital and external disease	15.72 (15.54 to 15.90)	13.26 (13.25 to 13.27)	2.46 (2.28 to 2.64)	19	<.001
Disorders of optic nerve and visual pathways	1.29 (1.24 to 1.34)	1.36 (1.35 to 1.36)	−0.07 (−0.12 to −0.02)	−5	.011
Cancer and neoplasms of the eye	0.76 (0.72 to 0.81)	1.68 (1.67 to 1.68)	−0.91 (−0.96 to −0.87)	−54	<.001
Infectious and inflammatory diseases	11.02 (10.87 to 11.17)	11.31 (11.29 to 11.32)	−0.28 (−0.43 to −0.13)	−2	<.001
Other retinal disorders	8.59 (8.45 to 8.73)	9.25 (9.24 to 9.26)	−0.66 (−0.80 to −0.52)	−7	<.001
Other visual disturbances	3.28 (3.20 to 3.37)	3.70 (3.70 to 3.71)	−0.42 (−0.51 to −0.34)	−11	<.001
Other eye disorders	8.44 (8.30 to 8.58)	12.47 (12.45 to 12.48)	−4.03 (−4.16 to −3.89)	−32	<.001

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Table 4 displays that 6 of 9 major service categories had significantly higher service claim rates for North American Native individuals (vs non-Hispanic White individuals) for any cataract treatment. Lower claim rates for North American Native individuals (vs non-Hispanic White individuals) were found for age-related macular degeneration, annual eye examinations, vision correction, any diagnostic eye test, and any vision screening. No service differences existed for receiving diabetic retinopathy treatment, retinal detachment repair, or glaucoma treatment.

Table 4. Ophthalmic Service Claim Rates in North American Native Individuals vs Non-Hispanic White Individuals in the 2017 US Vision and Eye Health Surveillance System¹² Medicare Fee-for-Service Cohort.

Service	% (95% CI)			Relative claim rate difference (North American Native individual − non-Hispanic White individual / non-Hispanic White individual), %	P value
	Age-adjusted claims rates per 100 persons in data set denominator
	North American Native		Claim rates difference between populations
	14.05 (13.35 to 14.75)	White, non-Hispanic	Claim rates difference between populations
Any age-related macular degeneration treatment	17.40 (17.05 to 17.74)	15.54 (15.50 to 15.59)	−1.49 (−2.19 to −0.79)	−10	<.001
Any cataract treatment	14.38 (13.67 to 15.09)	15.11 (15.09 to 15.14)	2.28 (1.94 to 2.63)	15	<.001
Any diabetic retinopathy treatment	0.76 (0.60 to 0.92)	14.79 (14.69 to 14.89)	−0.41 (−1.13 to 0.31)	−3	.26
Retinal detachment repair	48.31 (48.14 to 48.48)	0.61 (0.58 to 0.63)	0.15 (−0.01 to 0.31)	25	.07
Annual eye examination by any health care professional type	4.77 (4.46 to 5.08)	49.61 (49.60 to 49.62)	−1.30 (−1.47 to −1.13)	−3	<.001
Any glaucoma treatment	0.18 (0.16 to 0.20)	4.95 (4.92 to 4.97)	−0.17 (−0.49 to 0.14)	−4	.27
Any vision correction	19.23 (19.03 to 19.42)	0.24 (0.23 to 0.24)	−0.06 (−0.08 to −0.04)	−25	<.001
Any diagnostic eye test	0.12 (0.10 to 0.13)	20.57 (20.55 to 20.58)	−1.34 (−1.53 to −1.15)	−7	<.001
Any vision screening	0.12 (0.10 to 0.13])	0.14 (0.14 to 0.14])	−0.02 (−0.04 to −0.01)	−14	<.001

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Pairing of ophthalmic conditions with services with 95% CIs is shown in the Figure; a summary table showing pairings is in eTable 3 in the Supplement. Five of 17 major eye diagnosis categories showed higher ophthalmic condition claim rates, but lower or no different service claim rates for North American Native individuals vs non-Hispanic White individuals. Specifically, ophthalmic conditions of refractive and accommodation error, diabetic eye diseases, blindness and low vision, injury burns and surgical complications, and all orbital and external disease categories did not have correspondingly higher service claim rates for the North American Native population (vs the non-Hispanic White population).

There were lower ophthalmic condition and service claim rates for North American Native individuals compared with non-Hispanic White individuals for corneal disorders, optic nerve disorders, neoplasms of the eye, infectious or inflammatory disease, strabismus and amblyopia, age-related macular degeneration, retinal disorders, other visual disturbances, and all other eye disorders (eTable 3 in the Supplement). There were lower condition rates for North American Native individuals (vs non-Hispanic White individuals) of retinal detachments or defects and glaucoma, but there were no differences in the service rates. Cataracts was the only category where the ophthalmic condition claim rate for North American Native individuals (vs non-Hispanic White individuals) was lower, but the service claim rate was higher.

Discussion

Substantial disparities were identified in claim rates for diagnosed ophthalmic conditions and services for North American Native MFFS beneficiaries vs non-Hispanic White MFFS beneficiaries. While North American Native individuals and non-Hispanic White individuals aged 65 and older in the US have comparable rates of Medicare coverage (96% to 98%),¹⁵ 20% of North American Native individuals are uninsured compared with 8% of non-Hispanic White individuals.^13,19 As such, it is expected that disparities found in this study would be magnified in the wider North American Native population, despite the fact that dedicated resources have been made available through the IHS that serves approximately 40% of the North American Native population.¹⁴ North American Native individuals still report considerable barriers to accessing health care (any, not specifically ophthalmic) even when living in communities served by the IHS.²⁰ There were no categories in this study where both reported claim rates for ophthalmic conditions and services were comparable between the North American Native group and non-Hispanic White group, indicating pervasive disparities. To our knowledge, there are no known genetic bases to account for differences in rates of eye disease between North American Native individuals and non-Hispanic White individuals. Thus, differences approximated through MFFS ophthalmic condition and service claim rates for North American Native individuals vs non-Hispanic White individuals likely highlight disparities in health care access. Disparities may exist in part because North American Native populations are more likely to live in rural areas farther away from medical specialists, including ophthalmologists,^20,21,22 among other contributing social factors.

Many discrepancies in care between North American Native individuals and non-Hispanic White individuals were in cases where there were both lower condition and lower service claim rates for North American Native individuals vs non-Hispanic White individuals, likely representing both an underdiagnosis of eye disease and an undertreatment of that disease. Conditions for which North American Native individuals had lower rates diagnosis than non-Hispanic White individuals included common sight-threatening diagnoses, such as age-related macular degeneration, glaucoma, retinal detachment, and cataracts, even after adjustment for age. Although not specifically comparable with this study, other studies indicate that it is unlikely that North American Native individuals have a true lower prevalence of these conditions.²³ One study of North American Native individuals older than 40 years from 3 tribes in the northwestern US reported prevalence rates of age-related maculopathy to be 17.3%, cataracts 12.2%, and glaucoma 6.2%. All of these rates are greater than known prevalence rates for non-Hispanic White individuals older than 40 years.¹⁰ Other regional studies of North American Native tribes have shown higher age-adjusted prevalence of glaucoma^8,9 and similar prevalence of retinal detachments compared with non-Hispanic White individuals.²⁴ In a study of the Pima tribe, North American Native individuals had annual age-specific rates of cataract surgery 3.7 to 5.9 times higher than estimated rates in the US general population.²⁵ This in conjunction with the results from our study may represent that North American Native individuals seek ophthalmic service only when they have very advanced and visually impactful cataracts. Data from these studies and the present report support the inference that, even when insured, North American Native individuals have inferior access to ophthalmic services compared with that of non-Hispanic White individuals.

North American Native individuals with several ophthalmic conditions, including refractive errors, blindness and low vision, and diabetic eye diseases, showed significantly higher ophthalmic condition claim rates but lower service claim rates compared with non-Hispanic White individuals. North American Native individual tribal studies have reported higher rates of uncorrected or undercorrected refractive error,^10,26 higher prevalence of high astigmatism,^27,28 and higher rates of visual impairment compared with non-Hispanic White individuals.^8,29 Further, in the 2018 ACS, US North American Native individuals reported significantly higher rates of blindness or serious difficulty seeing even when wearing glasses (eTable 2 in the Supplement). Pertinent to diabetic eye diseases, North American Native individuals have the highest prevalence of diabetes of any racial or ethnic group in the US³ and high rates of diabetes-associated complications, including retinopathy.³⁰ This can be partially attributed to the nature of diabetes, where social determinants of health such as lack of easy access to healthy food confer an elevated risk of developing diabetes.^30,31 Rates of annual eye examinations, specifically in diabetics, have been found to be lower in North American Native populations than in non-Hispanic White populations,^32,33,34 and lack of access to eye care was cited as a driver for this disparity.³⁵ Not surprisingly, North American Native individuals have a higher rate of diabetic eye disease than that in the general US population.^36,37,38,39 To our knowledge, there is no previous literature discussing orbital or external disease and injury, burns, and surgical complications of the eye—2 categories that also had higher condition claim rates but lower service claim rates for North American Native individuals vs non-Hispanic White individuals.

The results of this study highlight the need for increased access to ophthalmologic care for North American Native individuals. North American Native populations often live in rural areas distant from eye care professionals.²³ Recognizing this, the IHS has a teleophthalmology program, including retinal imaging, available for North American Native individuals in many locations.¹⁷ One older study reports that while the number of diabetic eye examinations has increased, the proportion of North American Native individuals receiving diabetic retinopathy screening has remained relatively unchanged, perhaps because of rates of diabetes are growing and newer figures are not available.³⁵ Expanding the use of teleophthalmology platforms, such as those IHS uses to deliver annual eye screening, may be one avenue for improving access to eye care for North American Native populations.^21,22,40

This study uses the VEHSS MFFS module, the largest publicly available data set of ophthalmic care that identifies North American Native race. The strengths of using this source include large sample size (more than 30 million distinct beneficiaries), high prevalence of eye pathology among older adults, and Medicare coverage of the vast majority of North American Native individuals and non-Hispanic White individuals who are 65 years and 85 older and/or disabled.¹⁵ The near universality of Medicare coverage for those 65 years and older mitigates findings driven by a lack of insurance among North American Native individuals compared with non-Hispanic White individuals. However, access to treatment even through Medicare coverage can depend on individual ability to afford copayments, which may play a role in observed disparities in ophthalmic care among North American Native individuals. Roughly 20% to 25% of North American Native individuals live in poverty compared with 8% of non-Hispanic White individuals, and North American Native individuals have the highest poverty rate of any race or ethnicity in the US.⁴¹

Limitations

This study had limitations. The VEHSS MFFS database contains information only for MFSS beneficiaries 65 years and older and/or disabled, so inferences cannot be drawn about those who are not eligible for Medicare or those who select a Medicare Advantage plan. Routine annual eye examination is not an MFFS benefit unless the beneficiary has specific risk factors for disease. It is unclear what differential effect this coverage policy may have for North American Native individuals vs non-Hispanic White individuals. The MFFS portion of the VEHSS contains only claims submitted when Medicare is the primary insurer; claims with Medicare as a secondary insurer are excluded from the database, producing a claims undercount. Also, the MFFS database cannot capture data on nonclaimants, resulting in an inability to report true eye disease prevalence rates but rather surrogate relative claim rates for beneficiaries. Further, by definition, claims databases exclude the people potentially most in need of treatment—those whose eye conditions have not been formally diagnosed. As this analysis included only North American Native individuals with MFFS insurance, it is not generalizable to the entire population, with approximately 20% of adults lacking insurance coverage.⁴² This analysis demonstrates serious disparities in eye care even among Medicare-covered North American Native individuals; it may approximate a lower bound of need for ophthalmologic care for the US North American Native populations. In addition, by using the VEHSS version of the MFFS claims database rather than raw data, analytic methods needed fitting to available information. The foremost example of this was segregation of condition and service claim information and the amalgamation of both types of information into predetermined groups. Condition-service pairings which could be made directly through abstraction of both types of information from a single patient claim in the raw data set were made in later steps using pregrouped VEHSS data employing keyword matches and expert opinion.

Conclusions

The results of this study suggest substantial disparities in eye health and eye care needs among North American Native individuals in the US. Future research is needed to determine true prevalence rates of eye disease and eye care utilization in the North American Native population, but North American Native individuals with refractive errors, diabetic eye diseases, and blindness/low vision are surmised to be in greatest need. This article highlights critical needs for policy changes to further address the disparities in eye care among North American Native individuals compared with non-Hispanic White individuals.

Supplement.

eMethods. Coding definitions for eye conditions and service utilization

eTable 1. VEHSS visual acuity categories

eTable 2. Rates per 100 respondents answering yes to visual acuity question in American Community Survey (ACS), NAN vs. WNH in US (2018)

eTable 3. Matching for conditions and services performed by two ophthalmologists (MAW, PANC)

Click here for additional data file.^{(234.3KB, pdf)}

References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eMethods. Coding definitions for eye conditions and service utilization

eTable 1. VEHSS visual acuity categories

eTable 2. Rates per 100 respondents answering yes to visual acuity question in American Community Survey (ACS), NAN vs. WNH in US (2018)

eTable 3. Matching for conditions and services performed by two ophthalmologists (MAW, PANC)

Click here for additional data file.^{(234.3KB, pdf)}

[eoi210080r1] 1.Norris T, Vines PL, Hoeffel EM. The American Indian and Alaska Native population: 2010. United States Census Bureau. Published 2012. Accessed May 12, 2021. https://www.census.gov/history/pdf/c2010br-10.pdf

[eoi210080r2] 2.Jones DS. The persistence of American Indian health disparities. Am J Public Health. 2006;96(12):2122-2134. doi: 10.2105/AJPH.2004.054262 [DOI] [PMC free article] [PubMed] [Google Scholar]

[eoi210080r3] 3.US Centers for Disease Control and Prevention . National diabetes statistics report 2020. Published 2020. Accessed May 10, 2021. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

[eoi210080r4] 4.Heron M. Deaths: leading causes for 2017. National Vital Statistics Reports. US Centers for Disease Control and Prevention. Published 2019. Accessed April 21, 2021. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf

[eoi210080r5] 5.Benjamin EJ, Muntner P, Alonso A, et al. ; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee . Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528. doi: 10.1161/CIR.0000000000000659 [DOI] [PubMed] [Google Scholar]

[eoi210080r6] 6.US Centers for Disease Control and Prevention . CDC and Indian country working together. Published 2017. Accessed May 12, 2021. https://www.cdc.gov/chronicdisease/pdf/CDC-indian-country.pdf

[eoi210080r7] 7.Indian Health Service . Disparities fact sheets. https://www.ihs.gov/newsroom/factsheets/disparities/. Published 2019. Accessed May 1, 2021.

[eoi210080r8] 8.Haymes SA, Leston JD, Ferucci ED, Etzel RA, Lanier AP. Visual impairment and eye care among Alaska Native people. Ophthalmic Epidemiol. 2009;16(3):163-174. doi: 10.1080/09286580902738167 [DOI] [PMC free article] [PubMed] [Google Scholar]

[eoi210080r9] 9.Lee ET, Russell D, Morris T, Warn A, Kingsley R, Ogola G. Visual impairment and eye abnormalities in Oklahoma Indians. Arch Ophthalmol. 2005;123(12):1699-1704. doi: 10.1001/archopht.123.12.1699 [DOI] [PubMed] [Google Scholar]

[eoi210080r10] 10.Mansberger SL, Romero FC, Smith NH, et al. Causes of visual impairment and common eye problems in Northwest American Indians and Alaska Natives. Am J Public Health. 2005;95(5):881-886. doi: 10.2105/AJPH.2004.054221 [DOI] [PMC free article] [PubMed] [Google Scholar]

[eoi210080r11] 11.Butt AL, Lee ET, Klein R, et al. Prevalence and risks factors of age-related macular degeneration in Oklahoma Indians: the Vision Keepers Study. Ophthalmology. 2011;118(7):1380-1385. doi: 10.1016/j.ophtha.2010.11.007 [DOI] [PMC free article] [PubMed] [Google Scholar]

[eoi210080r12] 12.US Centers for Disease Control and Prevention . The vision and eye health surveillance system. Published 2019. Accessed May 1, 2021. https://www.cdc.gov/visionhealth/vehss/index.html

[eoi210080r13] 13.Kaiser Family Foundation . Uninsured rates for the nonelderly by race/ethnicity. Accessed May 16, 2021. https://www.kff.org/uninsured/state-indicator/nonelderly-uninsured-rate-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

[eoi210080r14] 14.Artiga S, Arguella R, Duckett P; Kaiser Family Foundation . Health coverage and care for American Indians and Alaska Natives. Accessed May 19, 2021. https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-and-care-for-american-indians-and-alaska-natives/

[eoi210080r15] 15.Boccuti C, Swoope C, Artiga S. The role of Medicare and the Indian Health Service for American Indians and Alaska Natives: health, access and coverage. Published 2014. Accessed April 11, 2021. https://www.kff.org/report-section/the-role-of-medicare-and-the-indian-health-service-for-american-indians-and-alaska-natives-health-access-and-coverage-report/

[eoi210080r16] 16.Murphy-Barron C, Pyenson B, Ferro C, Emery M. Comparing the demographics of enrollees in Medicare advantage and fee-for-service Medicare. Published 2020. Accessed October 24, 2021. https://bettermedicarealliance.org/wp-content/uploads/2020/10/Comparing-the-Demographics-of-Enrollees-in-Medicare-Advantage-and-Fee-for-Service-Medicare-202010141.pdf

[eoi210080r17] 17.Wittenborn J, Rein D, Dougherty M, Phillips E. Claims and registry data analysis plan: Vision & Eye Health Surveillance System. Published 2018. Accessed December 21, 2020. https://www.norc.org/PDFs/VEHSS/VEHSservice conditionlaimsRegistryAnalysisPlan.pdf

[eoi210080r18] 18.Williams R. Using the margins command to estimate and interpret adjusted predictions and marginal effects. Stata J. 2012;12(2):308-331. doi: 10.1177/1536867X1201200209 [DOI] [Google Scholar]

[eoi210080r19] 19.Frean M, Shelder S, Rosenthal MB, Sequist TD, Sommers BD. Health reform and coverage changes among Native Americans. JAMA Intern Med. 2016;176(6):858-860. doi: 10.1001/jamainternmed.2016.1695 [DOI] [PubMed] [Google Scholar]

[eoi210080r20] 20.Martino service condition, Elliott MN, Hambarsoomian K, et al. Disparities in care experienced by American Indian and Alaska Native Medicare beneficiaries. Med Care. 2020;58(11):981-987. doi: 10.1097/MLR.0000000000001392 [DOI] [PubMed] [Google Scholar]

[eoi210080r21] 21.Kruse CS, Bouffard S, Dougherty M, Parro JS. Telemedicine use in rural Native American communities in the era of the ACA: a systematic literature review. J Med Syst. 2016;40(6):145. doi: 10.1007/s10916-016-0503-8 [DOI] [PMC free article] [PubMed] [Google Scholar]

[eoi210080r22] 22.Mansberger SL, Gleitsmann K, Gardiner S, et al. Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial. Telemed e-Health. 2013;19(12):942-948. doi: 10.1089/tmj.2012.0313 [DOI] [PMC free article] [PubMed] [Google Scholar]

[eoi210080r23] 23.United States Government Accountability Office . Indian Health Service: health care services are not always available to Native Americans. Published 2005. Accessed January 10, 2021. https://www.gao.gov/products/gao-05-789

[eoi210080r24] 24.Hilton GF, Richards WW. Retinal detachment in American Indians. Am J Ophthalmol. 1970;70(6):981-983. doi: 10.1016/0002-9394(70)92479-7 [DOI] [PubMed] [Google Scholar]

[eoi210080r25] 25.Schwab IR, Dawson CR, Hoshiwara I, Szuter CF, Knowler WC. Incidence of cataract extraction in Pima Indians. Diabetes as a risk factor. Arch Ophthalmol. 1985;103(2):208-212. doi: 10.1001/archopht.1985.01050020060020 [DOI] [PubMed] [Google Scholar]

[eoi210080r26] 26.Maberley DAL, Hollands H, Chang A, Adilman S, Chakraborti B, Kliever G. The prevalence of low vision and blindness in a Canadian inner city. Eye (Lond). 2007;21(4):528-533. doi: 10.1038/sj.eye.6702257 [DOI] [PubMed] [Google Scholar]

[eoi210080r27] 27.Pensyl CD, Harrison RA, Simpson P, Waterbor JW. Distribution of astigmatism among Sioux Indians in South Dakota. J Am Optom Assoc. 1997;68(7):425-431. [PubMed] [Google Scholar]

[eoi210080r28] 28.van Rens GH, Arkell SM. Refractive errors and axial length among Alaskan Eskimos. Acta Ophthalmol (Copenh). 1991;69(1):27-32. doi: 10.1111/j.1755-3768.1991.tb01986.x [DOI] [PubMed] [Google Scholar]

[eoi210080r29] 29.Caban AJ, Lee DJ, Gómez-Marín O, Lam BL, Zheng DD. Prevalence of concurrent hearing and visual impairment in US adults: the National Health Interview Survey, 1997-2002. Am J Public Health. 2005;95(11):1940-1942. doi: 10.2105/AJPH.2004.056671 [DOI] [PMC free article] [PubMed] [Google Scholar]

[eoi210080r30] 30.Spanakis EK, Golden SH. Race/ethnic difference in diabetes and diabetic complications. Curr Diab Rep. 2013;13(6):814-823. doi: 10.1007/s11892-013-0421-9 [DOI] [PMC free article] [PubMed] [Google Scholar]

[eoi210080r31] 31.Young TK. Diabetes mellitus among native Americans in Canada and the United States: an epidemiological review. Am J Hum Biol. 1993;5(4):399-413. doi: 10.1002/ajhb.1310050405 [DOI] [PubMed] [Google Scholar]

[eoi210080r32] 32.Daley CM, Hale JW, Berryhill K, et al. Diabetes self-management behaviors among American Indians in the midwestern United States. ARC J Diabetes Endocrinol. 2017;3(1):34-41. doi: 10.20431/2455-5983.0301005 [DOI] [PMC free article] [PubMed] [Google Scholar]

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PERMALINK

Assessing Eye Health and Eye Care Needs Among North American Native Individuals

Maria A Woodward, MD, MSc

Kathleen Hughes, MBA

Dena Ballouz, MD

Richard A Hirth, PhD

Josh Errickson, PhD

Paula Anne Newman-Casey, MD, MSc

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Interventions

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Table 1. Simplified Study Methodology.

Data Abstraction From VEHSS

Computing Claim Rates

Statistical Analysis

Matching Eye Conditions With Eye Services

Results

Table 2. Demographic Characteristics of the 2017 US Vision and Eye Health Surveillance System12 Medicare Fee-for-Service Cohort.

Table 3. Ophthalmic Condition Claim Rates in North American Native Individuals vs Non-Hispanic White Individuals in the 2017 US Vision and Eye Health Surveillance System12 Medicare Fee-for-Service Cohort.

Table 4. Ophthalmic Service Claim Rates in North American Native Individuals vs Non-Hispanic White Individuals in the 2017 US Vision and Eye Health Surveillance System12 Medicare Fee-for-Service Cohort.

Figure. Difference in Claim Rates for Ophthalmic Conditions and Ophthalmic Services Between North American Native Individuals and Non-Hispanic White Individuals in the Vision and Eye Health Surveillance System Medicare Fee-for-Service 2017 Beneficiary Cohort.

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases

Table 2. Demographic Characteristics of the 2017 US Vision and Eye Health Surveillance System¹² Medicare Fee-for-Service Cohort.

Table 3. Ophthalmic Condition Claim Rates in North American Native Individuals vs Non-Hispanic White Individuals in the 2017 US Vision and Eye Health Surveillance System¹² Medicare Fee-for-Service Cohort.

Table 4. Ophthalmic Service Claim Rates in North American Native Individuals vs Non-Hispanic White Individuals in the 2017 US Vision and Eye Health Surveillance System¹² Medicare Fee-for-Service Cohort.