Disparities in ophthalmology exist whereby racial and ethnic minority individuals receive less eye care compared to nonminority individuals.¹ For example, Black patients are less likely to receive recommended glaucoma testing than non-Hispanic White patients.² In diabetic retinopathy care, advanced retinal imaging is superior to fundoscopic examination alone in detecting vision-threatening disease.³ However, physician comfort in ordering and interpreting such imaging can depend on subspecialty training and practice location.⁴ The purpose of this study was to evaluate whether racial and ethnic differences in the receipt of different types of advanced retinal imaging among patients with diabetes exist and whether these differences could be explained by physician characteristics.

This retrospective cohort study examined adult patients (aged ≥18 years) with diabetes who had 2 or more office visits at the Wilmer Eye Institute from April 3, 2013, to March 30, 2022,⁵ with data analysis performed from July 2022 to January 2023. The Johns Hopkins institutional review board approved the study and waived the requirement for informed consent, as the study was considered secondary research. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology () reporting guidelines.

The outcome of interest was receipt of retinal imaging, including fundus photographs, fluorescein angiography or indocyanine green angiography, and optical coherence tomography (Table). The main explanatory variable was self-reported patient race and ethnicity via the electronic health record.⁶ We adjusted for age, sex, insurance status and type, the 2019 US national Area Deprivation Index of the patient’s residential block group (a measure of neighborhood-level socioeconomic deprivation), and other ocular characteristics.^5,6 Multivariable conditional logistic regression models were used, clustered by eye care professional to examine the association between patient race and ethnicity and receipt of retinal imaging, controlling for confounding by patient-level variables and eye care professional specialty by location variables. This method estimated the effects of race and ethnicity by comparing imaging rates across subgroups among patients who received care from the same eye care professional. Two-tailed P values were generated, with significance set at P < .05. Statistical analysis was performed in R version 4.3 (R Foundation) and Python version 3.8.5 (Python Software Foundation).

In the study period, 30 086 patients were seen by 614 eye care professional at the Wilmer Eye Institute (Table). Mean (SD) patient age was 61.7 (13.0) years, and 15 596 patients (51.8%) were female. In total, 5929 patients (19.7%) received any retinal imaging (183 Hispanic patients [13.7%], 2440 non-Hispanic Black patients [22.5%], 2839 non-Hispanic White patients [19.4%], and 467 patients in the other race category [14.4%]). Non-Hispanic Black patients had 6% lower composite odds of any imaging (odds ratio [OR], 0.94; 95% CI, 0.86-1.03) than non-Hispanic White patients with the same eye care professional (P = .18) (Figure). Compared to non-Hispanic White patients, Hispanic patients had 32% lower odds of any imaging (OR, 0.68; 95% CI, 0.55-0.83; P < .001), and other race patients had 35% lower odds of any imaging (OR, 0.65; 95% CI, 0.57-0.73; P &±ô³Ù; .001).

In this cohort study, racial and ethnic disparities were found in the receipt of advanced retinal imaging for diabetic retinopathy among patients with diabetes at a tertiary care academic institution. Compared with non-Hispanic White patients, Hispanic patients and patients of other races and ethnicities with diabetes had lower odds of receiving retinal imaging, even when seen by the same eye care professional, while non-Hispanic Black patients had similar odds. These differences were not fully explained by insurance differences, eye care professional specialty, and office location, which could have limited the type of imaging technology available, or by differences in underlying diabetic retinopathy severity or other ophthalmic conditions. Limitations of this study included its retrospective nature, its conduct at a single institution, and the inability to include all ocular confounders (eg, visually significant cataracts). Strengths included the inclusion of multiple patient and eye care professional characteristics. Further examination should consider potential root causes of these apparent racial and ethnic disparities in receipt of retinal imaging and the role of social risk factors, patient preferences, and other aspects of the patient-physician relationship.

Accepted for Publication: August 12, 2024.

Published Online: October 10, 2024. doi:10.1001/jamaophthalmol.2024.4120

Corresponding Author: Cindy X. Cai, MD, MS, Wilmer Eye Institute, Johns Hopkins School of Medicine, 1800 Orleans St, Room 711, Baltimore, MD 21287 (ccai6@jhmi.edu).

Author Contributions: Dr Cai 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: Zeger, Cai.

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

Drafting of the manuscript: Schein, Tran, Zeger, Cai.

Critical review of the manuscript for important intellectual content: Wang, Tran, Crews, Zeger, Cai.

Statistical analysis: Schein, Wang, Tran, Zeger.

Obtained funding: Cai.

Administrative, technical, or material support: Tran.

Supervision: Cai.

Conflict of Interest Disclosures: Dr Crews reported grants from Baxter and Somatus outside the submitted work. Dr Cai reported grants from Regeneron Pharmaceuticals and equipment from Optomed outside the submitted work. No other disclosures were reported.

Funding/Support: This project was supported by a Career Development Award to Dr Cai from Research to Prevent Blindness, a K23 award from the US National Institutes of Health (NIH)/National Eye Institute (NEI) (K23EY033440) to Dr Cai, a K24 award from the NIH/National Heart, Lung, and Blood Institute (K24HL148181) to Dr Crews, and an unrestricted grant to the Wilmer Eye Institute from Research to Prevent Blindness. Dr Cai is the Jonathan and Marcia Javitt Rising Professor of Ophthalmology. This project was also supported by the Wilmer Eye Institute Ophthalmology Research and Innovation award to Dr Schien.

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.

Data Sharing Statement: See Supplement 1.