Uveitis and health disparities: results from the National Inpatient Sample

Epidemiology of Uveitis from a Tertiary Referral Hospital in Bulgaria over a 13-Year Period

Objectives: The aim of this study was to establish the etiology of uveitis and to examine its relationship with anatomical localization, age, and gender. Methods: A prospective study on patients with uveitis was conducted over a 13-year period at the Department of Ophthalmology, University Hospital "St. George", Plovdiv, Bulgaria. Each case was diagnosed based on a comprehensive eye examination, a review of the systems, and additional laboratory and specialized examination methods. Patients were categorized into four groups based on the location of inflammation: anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis. Results: A total of 606 patients with uveitis were included in the study. The mean age of the study group was 46.5 ± 18.6 years. There was no statistically significant difference in gender distribution (p = 0.329). Anterior uveitis was the most dominant anatomical localization (p < 0.001). Cases with clarified etiology were significantly prevalent (p < 0.001). The most frequently identified etiology was HLA B27-associated uveitis (32.5%), followed by viral uveitis (16.8%). A significant correlation between etiology and anatomical localization was found (p < 0.001). The highest proportion (93%) of cases with clarified etiology was associated with posterior uveitis, while the lowest (39.7%) was linked to intermediate uveitis. Conclusions: We found that anterior uveitis was the most common anatomical localization, followed by intermediate uveitis. The disease is rare in childhood, while in elderly patients, there is an increase in idiopathic and viral uveitis cases. Our results provide valuable information about the most common etiologies of uveitis among the Bulgarian population.

Social Determinants of Health in Uveitis: A Literature Review

BACKGROUND

The uveitides are a group of intraocular inflammatory diseases which can lead to blindness without treatment. It has been shown that socioeconomic status, health literacy, and access to healthcare play a pivotal role in the prevalence, severity, and treatment outcomes in ophthalmic conditions. We review the current literature on the impact of social determinants of health (SDoH) in patients with uveitis.

METHODS

A systematic literature search was conducted utilizing PubMed, Google Scholar, and Embase databases in July 2024. Inclusion criteria included studies written in English, focusing on SDoH in patients with uveitis using the following keywords: "uveitis," "social determinants of health," "socioeconomic status," "education," "access to healthcare," "health literacy," "health disparities," "race/ethnicity," "gender," and "environmental factors." Case reports were excluded.

RESULTS

Fifty two articles were included. Among these, 31 addressed healthcare access (e.g. limited specialist availability, cost/insurance barriers, urban-rural gaps), 23 highlighted economic stability (e.g. low income, out-of-pocket costs, poor medication adherence), 19 discussed environment and community (e.g. higher infectious uveitis rates in resource-limited areas, lack of social support), 18 focused on racial and ethnic disparities (e.g. advanced disease at presentation, worse outcomes for African American, Hispanic, and Indigenous populations), and 15 addressed education and awareness (e.g. low health literacy, inadequate patient education materials). Nine papers examined two domains, and 10 incorporated three or more. Across domains, limited resources and knowledge were associated with delayed diagnosis, suboptimal adherence, and poorer visual outcomes.

CONCLUSION

The current literature shows a correlation between SDoH and an increased incidence and poorer disease outcomes in patients with uveitis. Further research is needed to mitigate disparities in care for patients with uveitis.

Barriers to Health Care Access and Use among Racial and Ethnic Minorities with Noninfectious Uveitis

PURPOSE

To investigate barriers to health care access and use among patients with noninfectious uveitis (NIU) across different racial and ethnic groups.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Participants in the nationwide All of Us Research Program who received a diagnosis of chronic NIU.

METHODS

We analyzed the health care access and use (HCA&U) and social determinants of health (SDoH) surveys. Racial and ethnic groups were defined as non-Hispanic White, non-Hispanic Black, Hispanic, and other. Multivariable logistic regression models adjusted for age, sex, education, insurance type, and income were used to assess disparities.

MAIN OUTCOME MEASURES

Financial and nonfinancial disparities in health care access among racial and ethnic groups.

RESULTS

Of 2452 patients with NIU, 810 patients (33%) responded to the HCA&U survey and 607 patients (24.7%) responded to the SDoH survey. Non-Hispanic Black participants reported significantly more experiences of being treated with less courtesy (adjusted odds ratio [aOR], 2.6; 95% confidence interval [CI], 1.4-5; P = 0.003) and respect (aOR, 2.6; 95% CI, 1.4-4.8; P = 0.003), as well as receiving poorer services (aOR, 3.6; 95% CI, 1.9-6.9; P < 0.001) compared with non-Hispanic White participants. Individuals categorized as belonging to other minority groups were more likely to delay seeking medical care because of out-of-pocket costs (aOR, 3.4; 95% CI, 1.6-7.1; P = 0.001) and concerns over medical bills (aOR, 2; 95% CI, 1.05-3.8; P = 0.04). Additionally, they experienced significant delays in care because of living in rural areas with limited access to health care providers (aOR, 7.1; 95% CI, 1.4-35.6; P = 0.02).

CONCLUSIONS

Racial and ethnic minorities with NIU face significant barriers to health care use and quality, underscoring the need for targeted interventions to address disparities and improve health equity in uveitis management.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Reggio Emilia (Northern Italy) Interdisciplinary Uveitis Clinic: What We Have Learned in the Last 20 Years

PURPOSE

To analyze the referral patterns and the clinical and therapeutic features of patients diagnosed with uveitis in an Italian tertiary referral center to provide a comparison with previously published series from the same center.

METHODS

Retrospective retrieval of data on all new referrals to the Ocular Immunology Unit in Reggio Emilia (Italy) between November 2015 and April 2022 and comparison with previously published series from the same center.

RESULTS

Among the 1557 patients, the male-to-female ratio was 1:1.27. Anterior uveitis was the most common diagnosis (53.7%), followed by posterior (21.6%), pan- (18.5%), and intermediate (6.2%) uveitis. The most identifiable specific diagnoses were anterior herpetic uveitis (18.4%), Fuchs uveitis (12.8%), and tuberculosis (6.1%). Infectious etiologies were the most frequent (34.1%) and were more diffuse among non-Caucasian patients (p < 0.001), followed by systemic disease-associated uveitis (26.5%), and ocular-specific conditions (20%). Idiopathic uveitis accounted for 19.4% of cases. Fuchs uveitis presented the longest median diagnostic delay (21 months). Immunosuppressants were administered to 25.2% of patients. Antimetabolites, calcineurin inhibitors, and biologicals were prescribed to 18.4%, 3%, and 11.4% of cases, respectively. Compared to our previous reports, we observed a significant increase in foreign-born patients and in infectious uveitis, a decrease in idiopathic conditions, and an increasing use of non-biological and biological steroid-sparing drugs.

CONCLUSIONS

The patterns of uveitis in Italy have been changing over the last 20 years, very likely due to migration flows. Diagnostic improvements and a more widespread interdisciplinary approach could reduce the incidence of idiopathic uveitis as well as diagnostic delay.

Adalimumab to treat noninfectious pediatric chronic anterior uveitis: a case series

PURPOSE

Evaluate the response to adalimumab (ADA) in pediatric chronic anterior uveitis (pCAU).

METHODS

Retrospective chart review of pCAU patients treated with ADA. Outcomes evaluated included the proportion of patients achieving zero ocular inflammation and discontinuation of topical corticosteroids, visual outcomes, and incidence of uveitis recurrences after ≥ 12 months of prescribing ADA. Incidence and risk factors for developing anti-adalimumab antibodies (AAAs) were also evaluated.

RESULTS

Of 27 children aged 11 years, 16 (59%) were Caucasian and 6 (22%) African Americans. Thirteen (48%) patients had idiopathic pCAU, 12 (44%) had juvenile idiopathic arthritis (JIA) related pCAU, and 2 (7%) had tubulointerstitial nephritis and uveitis syndrome. At baseline, African American children had worse visual acuity (p = 0.026). At 1 year, 21 (78%) children achieved zero ocular inflammation (remission). Risk factors associated with non-remission were being African American (20% vs. 94%, p = 0.003) and experiencing ≥ 1 episode of uveitis recurrence (100% vs. 0%, p < 0.001). Six episodes of uveitis recurrence were documented in five children, four of whom were African American. Topical corticosteroids were discontinued in 83% of children, and visual acuity remained stable for 1 year. Twelve children were tested for AAAs due to arthritis or uveitis flare-ups, with five (42%) being positive. No significant factors were associated with the development of AAAs.

CONCLUSIONS

We found that ADA is effective in controlling inflammation, reducing the need for topical corticosteroids, and maintaining visual acuity in pCAU. There appears to be racial differences in African American children who had worse baseline disease and poorer outcomes. Studies are necessary to understand better and address these disparities.

Factors influencing treatment and time spent with physicians in patients with uveitis compared to other ophthalmology subspecialties in the National Ambulatory Medical Care Survey

BACKGROUND

Cases of uveitis can necessitate long-term treatment resulting in recurrent follow-up appointments. Analysing the demographic distribution and patient factors influencing treatment and time spent with physicians in this population compared to other subspecialties of ophthalmology using the National Ambulatory Medical Care Survey (NAMCS) has not previously been studied.

METHODS

Data were extracted from the NAMCS database, a large, nationally representative survey of office-based specialists, entered between 2012-2016 and 2018. Demographics, time with physician, and payor types were compared between patients with a uveitis-related diagnosis codes versus all other ophthalmic subspecialty diagnoses.

RESULTS

Overall, 12,870 ophthalmic patients were included of which 300 had uveitis-related diagnosis codes. Uveitis patients were more likely to be non-Caucasian (p < 0.0001 to p = 0.022), visiting the physician's office due to flare of or treatment for a chronic medical problem (p < 0.0001 to p = 0.022). Adjusted for age, sex, race, and ethnicity, uveitis patients spent a significantly longer time (mean 27.5 min) compared to comprehensive ophthalmology patients (mean 25.5 min) with their physician (p = 0.0041). Among the uveitis patient population, African American patients (p = 0.0053), Hispanic or Latino (p = 0.034), and Medicaid (p = 0.035) patients had increased office visit times.

CONCLUSIONS

Those with uveitis spent more time with the physician than comprehensive patients. Race, ethnicity, payor type, and the major reason for the visit all significantly impacted uveitis office visit times. In order to manage their schedules, providers should be aware of the additional support and time needed by these patients during office visits.

Understanding Health Care Disparities Based on Medicare Use for Inflammatory and Infectious Eye Diseases

Purpose

Inflammatory and infectious eye diseases are an important cause of visual impairment in patients older than 65 years of age. Health care disparities for eye care are present for general eye care. However, there is lack of national data on health disparities regarding eye care use for inflammatory and infectious eye diseases. Our study examines the effect of gender and race on eye care in patients with inflammatory and infectious eye diseases who are equal or greater than 65 years of age.

Methods

We have used Medicare data to examine the effect gender and race on use of eye care services in patients with inflammatory and infectious eye diseases for 2014 to 2018. Medicare is a national insurance program administered by the government of United States to insure people age 65 years or older. Owing to its high enrollment, those in Medicare are representative of the U.S. population aged 65 and older.

Results

We found that females have higher use for Medicare for inflammatory and infectious eye diseases across all races from 2014 to 2018. On examining the effect of race, African Americans have lower use as compared with Whites. People of Asian descent have the highest use, followed by Hispanic people.

Conclusions

Health care disparities exist for eye care use for inflammatory and infectious eye diseases for patients 65 years of age and older. Future studies are required to address these disparities to provide equitable eye care.

Translational Relevance

Identification of eye care disparities is the first step to addressing these disparities.

Managing a patient with uveitis in the era of artificial intelligence: Current approaches, emerging trends, and future perspectives

The integration of artificial intelligence (AI) with healthcare has opened new avenues for diagnosing, treating, and managing medical conditions with remarkable precision. Uveitis, a diverse group of rare eye conditions characterized by inflammation of the uveal tract, exemplifies the complexities in ophthalmology due to its varied causes, clinical presentations, and responses to treatments. Uveitis, if not managed promptly and effectively, can lead to significant visual impairment. However, its management requires specialized knowledge, which is often lacking, particularly in regions with limited access to health services. AI's capabilities in pattern recognition, data analysis, and predictive modelling offer significant potential to revolutionize uveitis management. AI can classify disease etiologies, analyze multimodal imaging data, predict outcomes, and identify new therapeutic targets. However, transforming these AI models into clinical applications and meeting patient expectations involves overcoming challenges like acquiring extensive, annotated datasets, ensuring algorithmic transparency, and validating these models in real-world settings. This review delves into the complexities of uveitis and the current AI landscape, discussing the development, opportunities, and challenges of AI from theoretical models to bedside application. It also examines the epidemiology of uveitis, the global shortage of uveitis specialists, and the disease's socioeconomic impacts, underlining the critical need for AI-driven approaches. Furthermore, it explores the integration of AI in diagnostic imaging and future directions in ophthalmology, aiming to highlight emerging trends that could transform management of a patient with uveitis and suggesting collaborative efforts to enhance AI applications in clinical practice.

Incidence and risk factors of postoperative delirium following hepatic resection: a retrospective national inpatient sample database study

BACKGROUND

Postoperative delirium (POD) is a common complication after major surgery and can cause a variety of adverse effects. However, no large-scale national database was used to assess the occurrence and factors associated with postoperative delirium (POD) following hepatic resection.

METHODS

Patients who underwent hepatic resection from 2015 to 2019 were screened using the International Classification of Diseases (ICD) 10th edition clinical modification code from the National Inpatient Sample (NIS) Database. Peri-operative factors associated with delirium were screened and underwent statistical analysis to identify independent predictors for delirium following hepatic resection.

RESULTS

A total of 80,070 patients underwent hepatic resection over a five-year period from 2015 to 2019. The overall occurrence of POD after hepatic resection was 1.46% (1039 cases), with a slight upward trend every year. The incidence of elective admission was 6.66% lower (88.60% vs. 81.94%) than that of patients without POD after hepatic resection and 2.34% (45.53% vs. 43.19%) higher than that of patients without POD in teaching hospitals (P < 0.001). In addition, POD patients were 6 years older (67 vs. 61 years) and comprised 9.27% (56.69% vs. 47.42%) more male patients (P < 0.001) compared to the unaffected population. In addition, the occurrence of POD was associated with longer hospitalization duration (13 vs. 5 days; P < 0.001), higher total cost ($1,481,89 vs. $683,90; P < 0.001), and higher in-hospital mortality (12.61% vs. 4.11%; P < 0.001). Multivariate logistic regression identified hepatic resection-independent risk factors for POD, including non-elective hospital admission, teaching hospital, older age, male sex, depression, fluid and electrolyte disorders, coagulopathy, other neurological disorders, psychoses, and weight loss. In addition, the POD after hepatic resection has been associated with sepsis, dementia, urinary retention, gastrointestinal complications, acute renal failure, pneumonia, continuous invasive mechanical ventilation, blood transfusion, respiratory failure, and wound dehiscence / non-healing.

CONCLUSION

Although the occurrence of POD after hepatic resection is relatively low, it is beneficial to investigate factors predisposing to POD to allow optimal care management and improve the outcomes of this patient population.

Epidemiology of Pediatric Uveitis

Uveitis is uncommon in children and its diagnosis and treatment are challenging. Little is known of the epidemiology of pediatric uveitis. Indeed, population-based studies in the literature are rare. However, there are many tertiary referral center reports that describe the patterns of uveitis in childhood, although few are from developed countries, and their comparison presents some issues. Anterior uveitis is the most frequent entity worldwide, especially in Western countries, where juvenile idiopathic arthritis is diffuse. Most cases of intermediate uveitis do not show any association with infectious or noninfectious systemic diseases. In low- and middle-income countries, posterior uveitis and panuveitis are prevalent due to the higher rates of infectious etiologies and systemic diseases such as Behçet disease and Vogt-Koyanagi-Harada disease. In recent decades, idiopathic uveitis rate has decreased thanks to diagnostic improvements.

A new look into uveitis in Colombia: changes in distribution patterns and clinical characteristics over the last 25 years

PURPOSE

To describe the distribution patterns and clinical characteristics of patients diagnosed with uveitis at a specialized uveitis center in Bogotá, Colombia, from 2013 to 2021 and compare these patterns with the previously reported between 1996 and 2006.

METHODS

We performed an observational descriptive cross-sectional study systematically reviewing clinical records of patients attending between 2013 and 2021. Data were analyzed and compared with previous reports.

RESULTS

Of the 489 patients with uveitis, 310 were females (63.4%). The mean age of onset was 38.7, with a range between 1 and 83 years. Bilateral (52.8%), anterior (45.8%), non-granulomatous (90.8%), and recurrent (47.6%) were the most common types of uveitis found in our population sample. The most common cause of uveitis in this study was idiopathic, followed by toxoplasmosis and HLA-B27 + associated uveitis, which differs from the previous Colombian study where ocular toxoplasmosis was the most frequent cause. This highlights a significant shift from infectious etiologies to more immune-mediated processes as the cause of uveitis in Colombia nowadays.

CONCLUSION

The results of this study provide a comparison between the clinical patterns of presentation of uveitis from 1996 to 2006 and the patterns observed from 2013 to 2021, enhancing awareness about the changing dynamics of uveitis in Colombia to guide a better understanding of the diagnosis, classification, and correlation with other systemic conditions of the disease.

Epidemiology of Uveitis in Olmsted County, Minnesota: A Population-Based Follow-Up Study

PURPOSE

To update the incidence of uveitis in a Midwestern U.S. county population.

METHODS

Retrospective population-based cohort study. All Olmsted County, Minnesota residents diagnosed with uveitis from January 1, 2006 to December 31, 2015 were identified via the Rochester Epidemiology Project. Diagnoses were confirmed by a uveitis specialist.

RESULTS

There were 371 incident uveitis cases, yielding an overall age- and sex-adjusted incidence rate of 26.9 per 100,000 per year (95% CI: 24.1-29.7). Females accounted for 202 (54.4%) cases, 306 (82.5%) were White, and 299 (80.6%) were anterior uveitis. Highest incidence was observed in patients ≥65 years old. No difference in incidence existed between sexes (p = .17). Incidence rates increased with age for uveitis overall (all anatomic subtypes) (p < .001), anterior uveitis (p < .001), and posterior uveitis (p < .001). Idiopathic uveitis accounted for 168 (45.3%) cases, more frequently diagnosed in females (50.0%) than males (39.6%) (p = .05).

CONCLUSION

Uveitis incidence increased 1.6-fold over a 50-year span in this predominately White U.S. Midwestern county population.

Disparities in Vision Health and Eye Care

Significant disparities in vision health and eye care exist. To achieve health equity, we must understand the root causes and drivers of health disparities and inequities, including social determinants of health and systemic racism.

Diagnosis and Management of Idiopathic Persistent Iritis after Cataract Surgery (IPICS)

PURPOSE

To investigate the diagnosis and management of patients with idiopathic persistent iritis after cataract surgery (IPICS).

DESIGN

Retrospective interventional case series.

METHODS

Patients diagnosed with IPICS were evaluated for demographic and clinical characteristics and immune blood markers. Those with more than 6 months of follow-up were evaluated for treatment efficacy to achieve remission (ie, absence of inflammation for 3 months), with either exclusive slow tapering of topical steroids or the need for systemic immunosuppression.

RESULTS

Forty-five patients presented with IPICS. Most were African American (39, 86.7%) or female (33, 77.3%). Antinuclear antibodies were present in 23 (69.9%) of patients. Main complications were steroid dependency (38,84.4%), glaucoma (24,53.5%), and macular edema (11,37.5%). Thirty two patients presented treatment follow up. On these,the proposed treatment strategy achieved remission in 30 (93.8%) of cases in a mean of 6.1 months via tapering of topical steroids in 15 (46.9%) of patients. However, in 17 (53.1%) of cases, adjuvant anti-inflammatory systemic medication was indicated. Meloxicam use was associated with remission in 11 (64.7%) of these patients and, in a minority with persistent iritis, treatment was escalated to methotrexate, which was successful in 4 (100%) of the cases.

CONCLUSIONS

IPICS is a distinct clinical anterior uveitis most common in African American and female patients, characterized by an unexpected onset of iritis after cataract surgery and high rates of steroid dependency, glaucoma, and macular edema. It is best treated with an initial slow taper of topical steroids; although adjuvant systemic anti-inflammatory therapy may be necessary to obtain remission and avoid complications.

Health Literacy, Medication Adherence, and Quality of Life in Patients With Uveitis

Purpose: To evaluate health literacy, medication adherence, and quality of life (QOL) in uveitis patients.Methods: Cross-sectional quality improvement study using questionnaires of health literacy (Short Assessment of Health Literacy), adherence (Beliefs about Medicine Questionnaire), and QOL (12-item Short Form Health Survey).Results: Sixty patients were surveyed: 57% women, 80% identified as Black, and 42% with schooling beyond high school. Forty-three percent of the patients had poor health literacy, with lower scores among those with less schooling (p < .01). Necessity scores were higher for multiple providers (p = .02). Necessity (p = .03) and Concerns (p < .01) scores were higher for patients seeing a rheumatologist. Patients had lower physical (p < .01) and mental QOL (p < .01) than the general US population.Conclusions: Uveitis patients reported many barriers to care. Despite strong perceptions of treatment necessity, there were significant concerns, especially among patients seeing a rheumatologist. We recommend multidisciplinary care, individualized education, and counseling regarding medication safety and the necessity to improve adherence.