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Editors Selection IGR 17-4

Miscellaneous: Socioeconomic factors impacting glaucoma diagnosis

Comment by Steve Mansberger & Erin Boese on:

66749 Impact of Socioeconomic Status on the Diagnosis of Primary Open-Angle Glaucoma and Primary Angle Closure Glaucoma: A Nationwide Population-Based Study in Taiwan, Ko YC; Hwang DK; Chen WT et al., PLoS ONE, 2016; 11: e0149698

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Understanding the risk factors for glaucoma is important to design effective interventions in the future. This study examines how socioeconomic status (SES) alters the diagnosis of primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG). The authors utilize the National Health Insurance Research Database (NHIRD), a national registry comprised of the 98% of Taiwan's population.

The National Health Insurance Research Database (NHIRD), a national registry comprises of the 98% of Taiwan's population

The authors found that patients with high SES were more likely to be diagnosed with POAG, while patients with lower SES were more likely to be diagnosed with PACG. The study suggests that these findings may allow more targeted approaches for screening and education.

The authors acknowledge the discrepancy between prevalence and diagnosis of disease, which may partially contribute to the study's relatively low rates of glaucoma. For example, POAG and PACG only occurred in 0.36% and 0.42%, respectively in subjects over 70 years, which is at least 30 times less frequent than results from prevalence studies.

This low rate of disease may be related to the definition of POAG and PACG including a diagnosis code for four or more visits per year. Only those most compliant with their visits would be considered 'glaucoma', and the study indicates that those with lower SES were less likely to utilize the health care system. A sensitivity analysis with different cut-offs for 'glaucoma' would be informative. A similar bias may occur if cataract surgery is more common in those of higher SES since they would be less likely to develop angle closure glaucoma. Interestingly, while the study focuses on how SES influences the rate of diagnosis, age was a much greater risk factor with those of older age having glaucoma at ten times the risk when compared to comparisons based on SES.

POAG and PACG only occurred in 0.36% and 0.42%, respectively in subjects over 70 years, which is at least 30 times less frequent than results from prevalence studies

While interesting, we do not anticipate the study results to significantly influence population screening because the study does not examine intervention to decrease undiagnosed glaucoma. A potential next study could include a step-wise multivariate model to determine the most important characteristics of a population at risk for undiagnosed glaucoma using this same database (including effect of age). Furthermore, it would be interesting to see how these correlations hold up in other populations.

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