Revealing the Blind Spots: Linked EHRs Associate Racial and Ethnic Inequities in Diabetic Eye Care Testing

PURPOSE: Retinal imaging, including fundus photography (FP) and fluorescein angiography (FA), are more sensitive for monitoring non-proliferative diabetic retinopathy (NPDR) compared to dilated fundus examination. However, the impact of socioeconomic factors on receipt of this retinal imaging is unknown. We evaluate associations between socioeconomic factors and receipt of FP or FA among patients diagnosed with moderate to severe NPDR by linking data across multisite electronic medical records. METHODS: We linked 16 academic electronic record systems and further linked diverse socioeconomic variables. Cox proportional hazards modeling was used to assess factors associated with the main outcome measure of the receipt of FP or FA in 2,082 patients with moderate to severe NPDR. RESULTS: Males (23.3%) were more likely to receive FA or FP compared to females (19.2%) (p < 0.05). Patients with a graduate degree were more likely to receive imaging than those with a bachelor's degree (p < 0.05). Patients in the 2nd-4th income quartiles had higher imaging rates than those in the 1st (lowest) quartile (p < 0.05). Those with "other/unknown" insurance were less likely to undergo imaging (HR, 0.60; 95% CI, 0.45-0.81). CONCLUSION: Differences in retinal imaging for DR exist based on sex, education, income, and insurance status at the tertiary academic centers studied. Patients who were female, low income, had lower educational attainment, or had other/unknown insurance status were less likely to receive imaging. Multisite electronic health record data can be reliably joined for socioeconomic study of DR outcomes for population health and quality reporting. Across 16 United States academic centers, receipt of fluorescein angiography or fundus photography after nonproliferative diabetic retinopathy diagnosis varied by sex, education, income, and insurance status, revealing socioeconomic disparities despite tertiary care access.