Ethnic background has an impact on glaucoma outcomes

A recent study¹ carried out in the UK found that patient ethnicity is associated strongly with the patients’ perceptions about important health outcomes.

Wide discrepancies have already been recognised in health outcomes^2-4 and quality of life (QoL) among ethnic groups across the globe,⁵ and gaining an understanding of the reasons is important.^6,7 Some factors may be socioeconomic status, access to care and the healthcare experience,^8-10 according to a recent study led by first author Atika Safitri, PhD, and colleagues. She is from the National Institute for Health and Care Research Moorfields Biomedical Research Centre, and the Institute of Ophthalmology, University College London, both in London.

“Beyond social determinants, possible explanations for disparities in health outcomes by ethnic group include differential susceptibility to disease and differential responses to treatment. These issues are exemplified by glaucoma, a chronic disease that is the leading cause of irreversible blindness and accounts for approximately 80% of blindness globally,” the investigators commented. ^11,12 They explained that glaucoma is more prevalent in Black patients, who develop the disease much earlier than Caucasian patients and are 15 times more likely to become visually impaired.^13-15 The investigators also pointed out some inherent problems, in that underscoring race as a risk factor for disease may be a form of structural racism and considering ethnicity in diagnostic/treatment algorithms may result in unsuitable treatment.^7,16,17

One observation is that ethnic groups perceive aspects of QoL differently because they respond differently to instruments that measure it.¹⁸ However, there is little evidence showing that individual patients have different priorities for health outcomes and, if so, how ethnicity affects those priorities, according to Dr Safitri and colleagues.

In light of this, they conducted a cross-sectional observational study to determine if members of minority ethnic groups have different perceptions about the QoL outcomes that matter most to them.

Study methods

The study ran from July 2021 to February 2022 in the UK and included a highly diverse population of patients (n = 511) diagnosed with primary open-angle glaucoma and ocular hypertension. The main outcome was the participants’ self-reported priorities for health outcomes. The patients were grouped based on their Best-Worst Scaling score, which shows the relative importance of outcomes.

Analysis findings

Table. Association of clusters with significant predictors.

*The reference cluster is: 1 (vision).
†Reference group.

The investigators reported that the participants formed four clusters with different priorities for health outcomes: cluster 1, vision, that included 181 patients; cluster 2, drop freedom, that included 98 patients; cluster 3, IOP and vision, that included 192 patients; and cluster 4, one-time treatment and vision, that included 103 patients.

In these clusters, Dr Safitri and colleagues reported, “Ethnicity was the strongest determinant of cluster membership after adjusting for potential confounders.”

They found that compared with White patients whose priority was vision alone, “the odds ratio [OR] for Black/Black British patients was 7.31 (95% confidence interval [CI] 3.43-15.57, P < .001) for prioritising drop freedom; 5.95 (2.91-12.16, P < .001) for IOP; and 2.99 (1.44-6.18, P = .003) for 1-time treatment.”

Compared with White patients, among Asian/Asian British patients, the OR was 3.17 (1.12-8.96, P = .030) for prioritising IOP as highly as vision. In addition, other ethnic minority groups chose other health outcomes over vision, with ORs of 4.50 (1.03-19.63, P = .045) for drop freedom and 5.37 (1.47-19.60, P = .011) for IOP.

In commenting on their findings, Dr Safitri and colleagues said, “We found that patients with glaucoma have different priorities for the outcomes of their care. We identified major racial and ethnic disparities in personal priorities, showing for the first time that minority ethnic groups may have differing expectations of the outcomes of care [than] their White counterparts. These differences need to be considered if racial disparities in health outcomes are to be understood and hence equitably addressed.” Per the investigators’ recommendation, “an individualised and ethnically inclusive approach is needed when selecting and evaluating treatments in clinical and research settings.”

References

1. Safitri A, Konstantakopoulou E, Gazzard G, et al. Priorities for health outcomes in glaucoma in an ethnically diverse UK cohort: an observational study. BMJ Open. 2024;14:e081998. doi:10.1136/bmjopen-2023-081998

2. Cunningham TJ, Croft JB, Liu Y, et al. Vital signs: racial disparities in age-specific mortality among Blacks or African Americans—United States, 1999–2015. MMWR Morb Mortal Wkly Rep. 2017;66:444-456.

3. Benjamins MR, Silva A, Saiyed NS, et al. Comparison of all-cause mortality rates and inequities between Black and White populations across the 30 most populous US cities. JAMA Netw Open. 2021;4:e2032086.

4. Lee KK, Norris ET, Rishishwar L, et al. Ethnic disparities in mortality and group-specific risk factors in the UK Biobank. PLOS Glob Public Health. 2023;3:e0001560.

5. Watkinson RE, Sutton M, Turner AJ. Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey. Lancet Public Health. 2021;6:e145-e154.

6. American College of Physicians. Racial and ethnic disparities in health care. Ann Intern Med. 2004;141:226.

7. Chew M, Das P, Aujla M, et al. Advancing racial and ethnic equity in science, medicine, and health: a call for papers. Lancet. 2021;398:1287-1289.

8. Nazroo JY, Falaschetti E, Pierce M, et al. Ethnic inequalities in access to and outcomes of healthcare: analysis of the Health Survey for England. J Epidemiol Community Health. 2009;63:1022-1027.

9. Whittle J, Conigliaro J, Good CB, et al. Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med. 1993;329:621-627.

10. Butterfield JT, Golzarian S, Johnson R, et al. Racial disparities in recommendations for surgical resection of primary brain tumours: a registry-based cohort analysis. Lancet. 2022;400:2063-2073.

11. Tham YC, Li X, Wong TY, et al. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. 2014;121:2081-2090.

12. GBD 2019 Blindness and Vision Impairment Collaborators, Vision Loss Expert Group of the Global Burden of Disease Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the right to sight: an analysis for the global burden of disease study. Lancet Glob Health. 2021;9:e144-e160.

13. Salowe R, Salinas J, Farbman NH, et al. Primary open-angle glaucoma in individuals of African descent: a review of risk factors. J Clin Exp Ophthalmol. 2015;6:450.

14. Wormald RP, Basauri E, Wright LA, et al. The African Caribbean eye survey: risk factors for glaucoma in a sample of African Caribbean people living in London. Eye (Lond). 1994;8:315-320.

15. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in East Baltimore. N Engl J Med. 1991;325:1412-1412.

16. Cerdeña JP, Plaisime MV, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. Lancet. 2020;396:1125-1128.

17. Selvarajah S, Corona Maioli S, Deivanayagam TA, et al. Racism, xenophobia, and discrimination: mapping pathways to health outcomes. Lancet. 2022;400:2109-2124.

18. Pagano IS, Gotay CC. Ethnic differential item functioning in the assessment of quality of life in cancer patients. Health Qual Life Outcome. 2005;3:60.

Atika Safitri, PhD | E: atika.safitri@ucl.ac.uk

Safitri is a clinical research fellow at the National Institute for Health and Care Research Moorfields Biomedical Research Centre, and the Institute of Ophthalmology, University College London (UCL), both in London. She is originally from Indonesia and completed PhD at the UCL, focusing on glaucoma and patient-reported outcome measures. She has no financial interest in this subject matter.