In Reply We thank Armstrong and colleagues for their letter. We agree that the underuse of the health care system by persons with diabetes and DME in the United States is concerning in light of recent advances in vision-preserving treatment for DME. The disparity of DR (without DME) and DME by race/ethnicity groups or different educational levels in our article, which is highlighted in the letter by Armstrong and colleagues, may be influenced by potentially confounding factors such as levels of hemoglobin A1C or duration of diabetes and is the subject of a separate article.1 Nevertheless, we agree that people with diabetes who are very sick may be underrepresented in the National Health and Nutrition Examination Survey, as has been reported for end-stage renal disease from this cohort.2 Thus, our estimates of underuse of the health care system by persons with DME from the National Health and Nutrition Examination Survey likely are conservative, and the need to strengthen our efforts in educating patients with diabetes concerning the eye complications of the disease may be even greater than implied by our findings. While we did assess educational level and not socioeconomic levels, the assertion by Armstrong and colleagues that diabetic patients with lower socioeconomic levels have less access to vision-preserving medical care is supported by data from a population-based sample of adult Latino individuals with type 2 diabetes mellitus indicating that lack of insurance is associated with noncompliance with the American Diabetes Association’s guidelines for vision care.3 As Armstrong and colleagues state, we too are hopeful that the goals of the Patient Protection and Affordable Care Act,4 which includes Medicaid expansion in many states, will contribute to solving some of these problems, but we cannot determine from our study whether these programs will lead to greater use of the health care system by persons with DME.
Bressler NM, Varma R, Doan Q. Vulnerable Populations in the Underuse of the US Health Care System by Persons With Diabetes Mellitus and Diabetic Macular Edema—Reply. JAMA Ophthalmol. 2014;132(8):1030–1031. doi:10.1001/jamaophthalmol.2014.2445
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