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Brief Report
May 27, 2021

Racial/Ethnic Disparities and Barriers to Diabetic Retinopathy Screening in Youths

Author Affiliations
  • 1Division of Pediatric Endocrinology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 2Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison
  • 3Johns Hopkins School of Medicine Biostatistics, Epidemiology and Data Management (BEAD) Core, Baltimore, Maryland
  • 4Wilmer Eye Institute at the Johns Hopkins School of Medicine, Baltimore, Maryland
  • 5Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City
  • 6Digital Diagnostics, Coralville, Iowa
  • 7Iowa City VA Medical Center, Iowa City, Iowa
JAMA Ophthalmol. 2021;139(7):791-795. doi:10.1001/jamaophthalmol.2021.1551
Key Points

Question  Are there racial/ethnic disparities in access to the diabetic eye examination in patients with pediatric diabetes?

Findings  In this cohort study of 149 participants, minority youths were less likely to report a previous diabetic eye examination (non-White individuals, 46% vs White individuals, 85%), yet more likely to have diabetic retinopathy (15% vs 3%).

Meaning  This study suggests that implementation of point-of-care diabetic retinopathy screening in the diabetes care setting can improve access to and mitigate racial/ethnic disparities for the diabetic eye examination.


Importance  Diabetic retinopathy is a major complication of diabetes for which regular screening improves visual health outcomes, yet adherence to screening is suboptimal.

Objective  To assess disparities in diabetic eye examination completion rates and evaluate barriers in those not previously screened.

Design, Setting, and Participants  In this cohort study at a single academic center (Johns Hopkins Hospital pediatric diabetes center in Baltimore, Maryland) from December 2018 to November 2019, youths with type 1 or type 2 diabetes who met criteria for diabetic retinopathy screening and were enrolled in a prospective observational trial implementing point-of-care diabetic retinopathy screening were asked about prior diabetic retinopathy screening.

Main Outcomes and Measures  Demographic and clinical characteristics were compared between those who did and did not have a previous diabetic eye examination and stratified according to race/ethnicity, using t tests and χ2 tests. Multivariate logistic regression was used to analyze the association between race/ethnicity, screening, and other social determinants of health. A questionnaire assessing barriers to screening adherence was administered.

Results  Of 149 participants (76 male patients [51.0%]; mean [SD] age, 14.5 [2.3] years), 51 (34.2%) had not had a prior diabetic eye examination. These individuals were more likely than those who had prior diabetic eye examinations to be non-White youths (38 [75%] vs 31 [32%]; P < .001) and have type 2 diabetes (38 [75%] vs 10 [10%]; P < .001), Medicaid or public insurance (43 [84%] vs 31 [32%]; P < .001), lower household income (annual income ≤$25 000, 21 [41%] vs 9 [9%]; P < .001), and parents with education levels of high school or less (29 [67%] vs 22 [35%]; P < .001). The main barriers reported included not recalling being recommended to obtain a diabetic eye examination (19 [56%]), difficulty finding time for an additional appointment (10 [29%]), and transportation issues (7 [20%]). Minority youths were less likely to have a previous diabetic eye examination (non-White, 34 [46%] vs White, 64 [85%]; P < .001) and more likely to have diabetic retinopathy (11 [15%] v 2 [3%]; P = .008). Minority youths were less likely to get diabetic eye examinations even after adjusting for insurance, household income, and parental education level (odds ratio, 0.29 [95% CI, 0.10-0.79]; P = .02).

Conclusions and Relevance  In this cohort study, non-White youths were less likely to undergo diabetic eye examinations yet more likely to have diabetic retinopathy compared with White youths. Addressing barriers to diabetic retinopathy screening may improve access to diabetic eye examination and facilitate early detection.

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