This article was originally published in a sponsored newsletter.

In health care today, especially in the discussion of personalized medicine, we often use the buzz phrase social determinants of health (SDOH) to refer to the social, economic and environmental factors that can impact patients’ overall health. Individual SDOH can influence access to health care, disease diagnoses, access to therapies and adherence to treatment plans and follow-up. SDOH are described broadly in Healthy People 2030 (HP2030), a 10-year plan for improving the health and well-being of the U.S. population (https://health.gov/healthypeople). In its fifth iteration of the broader Healthy People initiative, the plan builds on four decades of work to guide national health promotion and disease prevention efforts to improve the health of the nation. There are many vision-related initiatives and goals in HP2030. Some are developmental, while others involve research and improving access to care.

This issue’s abstract and discussion reflect on the impact of SDOH in diagnosing and managing dry eye disease with some interesting findings. For example, our columnists assess geographic differences in access to care, insurance coverage and overall health status. The research findings create more questions for patient care: Are we addressing health care delivery needs in all segments of the population? How can we do better?

In clinical trials, emphasis is being placed on ensuring that study participants’ age, gender and ethnicity are considered during recruitment, but other SDOH are rarely considered. Data sets may also not be large enough (or they do not include enough other SDOH variables of interest) to determine whether the efficacy of potential therapeutics is different in subgroups categorized by SDOH variables. This uncertainty is why post-market approval (FDA Phase 4) studies in different subgroups are critical, especially when they involve factors such as comparisons of different medications or evaluations of access.

As more therapeutics are approved for ocular surface diseases, it will be increasingly important to understand the order in which drugs are prescribed, when they should be added together and what patient characteristics are important when selecting therapeutics. Understanding how we can reach underserved areas of the country, via telehealth visits or other avenues, will continue to be explored. Collecting data to allow insurers to better understand where therapeutics fall in treatment plans and evaluating whether the process is consistent across plans is warranted. So much has been learned and progress has been made in ocular surface disease, but there is much work to be done for the betterment of our patients now, and for those who are yet to be patients in the future.

Kelly K. Nichols, OD, MPH, PhD
Editor

 Managing dry eye and other chronic conditions in underserved populations presents unique challenges. Limitations in access to health care, education and essential resources often create boundaries to patients receiving care. Fortunately, we can take a few simple steps to make a big impact for these patients.

Education

Community outreach is a crucial component to managing dry eye in this population. Education surrounding awareness of dry eye, its symptoms and ways to seek care can help catch patients earlier in the disease process. These programs can be delivered through local clinics, community centers or even mobile health units. Working with local leaders and organizations in the community can help build trust and ensure the message reaches those in need. Additionally, educating local primary care teams on tips for managing dry eye with at-home therapies can benefit patients who have limited access to an eye doctor.

Affordable Treatment Options

Many times, dry eye is exacerbated by patients’ own habits. Education regarding lifestyle and environmental changes can help improve symptoms with little cost to patients. Recommendations can include limits in screen time, cosmetics to avoid, turning fans away from the face at night and getting proper hydration and sleep. Warm compresses are also a mainstay in dry eye treatment, as are inexpensive and reusable heat masks. Although Omega 3 supplements and artificial tears are available over-the-counter, insurance may cover them if you write prescriptions for them.

Cost can still be a burden to patients, even when we send prescription therapies through their insurance. However, many pharmaceutical companies offer patient assistance programs for patients who have trouble meeting these costs. These programs can provide discounts or may even cover the medication entirely.

Telemedicine

Follow-up care is essential for managing dry eye, and we can explore telemedicine options when in-person access to an eye doctor is limited. While we prefer to re-examine the ocular surface in person to gauge improvements, remote follow-ups can be effective in ensuring that patients are taking the appropriate treatment and addressing any burdens they have.

Managing dry eye in underserved populations requires a multifaceted approach that addresses barriers to care and the specific needs of each community. However, even in resource-limited settings, effective dry eye management can be accomplished. Through community outreach, education, affordable treatment options and the use of telemedicine, significant strides can be made in improving the quality of life for those affected by this chronic condition.

 When addressing eye health and related conditions, understanding modifiable risk factors plays a key role in management and prevention. A relatively new addition to modifiable risk factors in eye health are social determinants of health (SDOH), or “the conditions in the environments in which people live, learn, work, play, worship, and age.”¹ According to the Healthy People 2030 framework, the overarching SDOH domains are:¹

1. neighborhood and built environment
2. economic stability
3. social and community context
4. education access and quality
5. health care access and quality

Currently, limited evidence exists regarding the impact of social determinants on disparities for specific eye conditions, including dry eye.

Dry eye is a multifactorial condition that can be asymptomatic or symptomatic, with a wide range of potential symptoms from ocular pain to itching and tearing. The economic burden of dry eye is difficult to estimate because there is such a wide variety of symptoms and levels to which dry eye affects individuals. Dry eye can interfere with a person’s daily functional abilities and negatively affect their psychosocial well-being. Early diagnosis and treatment are crucial, but may be limited by an individual’s access to eye exams and ability to afford the associated costs. Other SDOH domains, such as neighborhood and built environment (e.g., climate or pollution levels) or social and community contexts (e.g., family support), could affect an individual’s predisposition to try available therapies.

The objective of this systematic review was to identify and summarize the current literature concerning the association between SDOH and dry eye in the U.S. population. The literature search mapped SDOH indicators to one of five domains following the Healthy People 2030 framework and categorized dry eye measures into “dry eye diagnosis and care,” “dry eye symptoms” or “ocular surface parameters.” The data were summarized by the worsening, beneficial or null association between SDOH indicators and dry eye.¹

Eighteen studies were deemed appropriate for analysis. From those, 51 SDOH indicators, mostly mapped to the neighborhood and built environment domain, were included. Neighborhood and built environment revealed that the Southern region of the United States is associated with an increased prevalence of dry eye compared with the Northeast region. Social and community context indicators reported that Hispanic participants and participants of “other” racial/ethnic groups, older participants, women and participants who were divorced/separated/widowed were associated with increased odds of a dry eye diagnosis. White or Asian patients with diabetes were more likely to have a dry eye diagnosis compared with other groups, and patients with dry eye had more limitations in daily activities, socioemotional functioning, self-rated pain/discomfort and anxiety/depression symptoms when compared with individuals who did not have dry eye. The education access and quality domain noted that participants with a college degree or higher were more likely to have a dry eye diagnosis. Finally, the health care access and quality domain reported that insured participants were more likely than uninsured participants to receive a dry eye diagnosis.¹

The authors concluded that most SDOH indicators studied were associated with unfavorable dry eye measures, such as a higher disease burden, worse symptoms or delayed referral. One of the main challenges in the analysis was that the investigations between SDOH and dry eye did not use standardized instruments, which made comparison between studies challenging.¹

References:
1. Liu S-H, Shaughnessy D, Leslie L, et al. Social determinants of dry eye in the United States: a systematic review. Am J Ophthalmol. 2024 May;261:36-53. doi: 10.1016/j.ajo.2024.01.015

Social Determinants of Dry Eye in the United States: A Systematic Review

Su-Hsun Liu, Daniel Shaughnessy, Louis Leslie, Kaleb Abbott, Alison G Abraham, Paul McCann, Ian J Saldanha, Riaz Qureshi, and Tianjing Li
Am J Ophthalmol. 2024 May;261:36-53. doi: 10.1016/j.ajo.2024.01.015

PURPOSE: To conduct a systematic review to summarize current evidence on associations between social determinants of health (SDOH) indicators and dry eye in the United States.

DESIGN: Systematic review.

METHODS: We followed a protocol registered on Open Science Framework to include studies that examined associations between SDOH indicators and dry eye. We mapped SDOH indicators to 1 of the 5 domains following the Healthy People 2030 framework and categorized dry eye measures into "dry eye diagnosis and care," "dry eye symptoms," or "ocular surface parameters." We summarized the direction of association between SDOH indicators and dry eye as worsening, beneficial, or null. We used items from the Newcastle Ottawa Scale to assess risk of bias.

RESULTS:Eighteen studies reporting 51 SDOH indicators, mostly mapped to the neighborhood and built environment domain, were included. Thirteen studies were judged at high risk of bias. Fifteen of 19 (79%) associations revealed an increase in the diagnosis of dry eye or delayed specialty care for it. Thirty-four of 56 (61%) associations unveiled exacerbated dry eye symptoms. Fifteen of 23 (65%) found null associations with corneal fluorescein staining. Ten of 22 (45%) associations revealed an increased tear break up time (45%) whereas another 10 (45%) showed null associations.

CONCLUSIONS: Most SDOH indicators studied were associated with unfavorable dry eye measures, such as a higher disease burden, worse symptoms, or delayed referral, in the United States. Future investigations between SDOH and dry eye should use standardized instruments and address the domains in which there is an evidence gap.

When and How to Use Z Codes for Social Determinants of Health

As optometrists, we understand that each patient has a story beyond their review of systems and medication lists that impact their health and outcomes. Many of these factors are captured as social determinants of health (SDOH) and encompass a range of environmental, economic and social conditions that can significantly impact an individual's well-being. To document these factors, health care professionals—including optometrists—can utilize Z codes (Z55 -Z65), which are part of the ICD-10-CM. These codes capture non-medical information that influences health outcomes.

SDOH play a crucial role in shaping health disparities and outcomes. Factors such as socioeconomic status, education, neighborhood and physical environment, employment and social support networks can influence a patient's access to health care, adherence to treatment plans and overall eye health. By recognizing and documenting these factors, optometrists can provide more comprehensive care and contribute to a broader understanding of patient health within the health care system.

Z codes should be used whenever a SDOH is identified during routine eye exams, medical history reviews or patient interactions where relevant social information is disclosed. Situations warranting the use of Z codes include economic stability issues, educational barriers, housing and environment problems, social and community issues, and health care access.

To document Z codes effectively, follow these steps:

1. Access: During patient interactions, actively inquire about social determinants that might influence their eye health. This can be done through direct questioning or standardized screening tools.
2. Identify: Determine which specific Z codes apply to the patient's situation. These codes can be found within the ICD-10 reference, Z55-Z65.
3. Document: Accurately record the relevant Z codes in the patient's electronic health record to ensure that the information is available for future reference and can be used to inform treatment plans.
4. Refer: When appropriate, refer patients to additional resources or services, such as social workers, community organizations or financial assistance programs that can address their social needs.

We have all had patients who, for example, present for glaucoma care but cannot afford the basics of life, much less the overpriced 2.5 ml bottle of vision-saving medication. In these cases, when economic challenges present a real barrier to a patient’s health care needs, using Z59.6 - Low Income in the coding process identifies the SDOH as a nonmedical factor in the health care outcomes of that patient.

Incorporation of these SDOH Z codes allows us to tailor care plans to the unique needs of each patient, which enhances patient care and can lead to better health outcomes. Documenting SDOH also helps build a comprehensive dataset that can inform public health strategies and policy decisions aimed at reducing health disparities. Finally, utilization of Z codes fosters collaboration between optometrists and other health care providers to promote a holistic approach to patient care.

Integrating Z codes for SDOH into our practices is a vital step toward providing holistic and equitable care. By recognizing the broader context of patients' lives, optometrists can contribute to improved health outcomes and play a pivotal role in addressing health disparities.