A multi-institutional study has found that a patient’s wealth is a primary predictor of the quality of care received for newly diagnosed glaucoma, surpassing other factors. The research, published in JAMA Ophthalmology, reveals that individuals in the lowest wealth quartile are substantially less likely to achieve recommended clinical outcomes and are far more likely to be lost to follow-up compared to their wealthier counterparts, highlighting significant disparities in the American healthcare system.
The findings underscore a critical challenge in managing glaucoma, a leading cause of irreversible blindness that affects over 4 million people in the United States. Investigators analyzed nonmedical variables—including wealth, urban or rural residence, and household composition—to understand their impact on care quality. The results show a stark connection between socioeconomic status and adherence to treatment standards, suggesting that financial resources are a more decisive factor than even race in determining patient outcomes. This points to systemic barriers that prevent less affluent individuals from receiving consistent and effective long-term care for the chronic eye disease.
Socioeconomic Status as a Decisive Factor
The study’s most striking conclusion is that wealth stands out as the most significant predictor of whether a patient will receive standard-of-care treatment for glaucoma. According to co-author Dustin French, PhD, a professor of Ophthalmology at Northwestern University Feinberg School of Medicine, while it is commonly known that race is a predictor of health outcomes, this research indicates that wealth and income are more directly tied to the quality of medical care and the likelihood of attending follow-up appointments. This distinction is crucial, as it reframes the conversation around health disparities, shifting focus toward economic barriers that cut across racial and ethnic lines, although the disease disproportionately affects Black patients compared to white patients.
The financial burden of managing glaucoma is a likely contributor to these disparities. Treatment often involves costly prescription eye drops, and more advanced cases may require multiple medications to control intraocular pressure (IOP). The authors of the study speculate that even with insurance coverage, out-of-pocket expenses for long-term medication may be too steep for patients with limited financial means. This can lead to poor adherence, disease progression, and ultimately, a higher risk of vision loss. The study effectively demonstrates that the ability to afford consistent treatment is a major determinant of a patient’s success in managing the condition.
Study Design and Patient Cohort
The retrospective cohort study drew upon a large and diverse patient dataset from academic healthcare systems participating in the Sight Outcomes Research Collaborative (SOURCE) Consortium, of which Northwestern is a member. Researchers analyzed the records of 1,466 patients with a new diagnosis of primary open-angle glaucoma (POAG) between January 2010 and December 2022. The objective was to identify associations between nonmedical factors and two key quality metrics: achieving a significant reduction in intraocular pressure and avoiding loss to follow-up within 12 to 18 months of diagnosis.
The patient population had a mean age of 70 years, and 54% were female. The cohort reflected a diverse racial and ethnic composition, with 57% of patients identified as white, 32% as Black, 7% as Latinx, and 3% as Asian American. This demographic breadth allowed investigators to analyze outcomes across different groups while controlling for various socioeconomic and geographic variables. The inclusion of factors like the affluence of a patient’s residential community and whether they lived in an urban or rural setting provided a more nuanced understanding of the external pressures influencing healthcare outcomes.
Key Clinical Outcomes Measured
The research focused on tangible indicators of care quality to quantify the disparities observed. The primary clinical benchmark was the achievement of a 15% or greater reduction in IOP within 12 to 18 months of diagnosis, a standard recommended by the U.S. National Quality Forum to slow optic nerve damage. The second critical outcome was patient retention, specifically measuring the odds of a patient being lost to follow-up, which is a major risk factor for disease progression.
Intraocular Pressure Reduction
Among the 1,030 patients who had at least one follow-up evaluation within the specified timeframe, 76% successfully achieved the target 15% or higher IOP reduction in one or both eyes. However, the likelihood of reaching this goal was dramatically different across wealth levels. The study found that patients in the lowest wealth quartile had five- to nine-fold lower odds of achieving this essential clinical milestone compared to patients in the higher wealth quartiles. This vast gap indicates that a significant portion of the patient population is not receiving effective enough treatment to mitigate the risk of progressive vision loss, and this failure is directly correlated with their economic status.
Loss to Follow-Up
Consistent medical supervision is critical for managing glaucoma, yet the study found that many patients failed to return for necessary follow-up care. Wealth was again a major determinant. The odds of being lost to follow-up were 61% lower in the wealthiest patient quartile than in the least wealthy group. This suggests that affluent patients are far more likely to remain engaged with their eye care specialists, while those with fewer resources face significant barriers to continued care. These barriers could include the cost of appointments, transportation challenges, or difficulty taking time off from work, all of which are exacerbated by financial instability.
Geographic and Household Influences
Beyond wealth, the study identified other nonmedical factors that influenced glaucoma care outcomes. Patients residing in rural communities were found to be more likely to be lost to follow-up compared to their urban counterparts. This finding points to geographic access as another significant barrier to consistent care. Rural residents often face longer travel times to see specialists and may have fewer local healthcare options, making it more difficult to maintain the regular appointment schedule required for effective glaucoma management. These accessibility issues compound the financial challenges faced by many, creating a dual burden for patients outside of major metropolitan areas.
In a surprising finding, the presence of children in a patient’s household was associated with better clinical outcomes. Patients with children at home experienced an average IOP reduction that was 4 mmHg greater than in households without children. The study’s authors suggest that this may be because other household members can provide crucial support, such as helping administer eye drops, providing reminders to take medication, assisting with pharmacy visits, and offering motivation to adhere to the prescribed treatment regimen. This finding highlights the important role of a strong social and familial support system in managing chronic illness.
Improving Access and Affordability
The conclusions drawn from this study call for systemic changes to make quality glaucoma care more equitable. The strong association between patient wealth and outcomes suggests that addressing financial barriers is paramount. Interventions could include making glaucoma medications more affordable and increasing access to eye care specialists for underserved populations. By focusing on the nonmedical factors that prevent patients from receiving standard care, healthcare systems can work to close the significant gaps identified in this research.
Ultimately, the study serves as a clear indicator that to improve glaucoma care on a national level, the medical community and policymakers must look beyond the clinic. Addressing the socioeconomic and geographic disparities that dictate the quality of care is essential to preventing avoidable vision loss and blindness. The research provides a strong evidence base for creating targeted programs that support less wealthy and rural patients, ensuring that everyone with glaucoma has the opportunity to preserve their sight, regardless of their financial circumstances or where they live.