P
eople with a lower
socio-economic status
(SES) in Canada tend
to present with more
advanced glaucoma, and
are often in a more deteriorated state
with the disease than those with
higher SES—even though both
groups live in a country with a
publicly funded healthcare system.
This problem is being confirmed by
multiple studies trying to get to the
source of apparent inequities between
the rich and poor in the country’s
health care system.
Glaucoma is the second leading
cause of blindness in the world and
presenting late means an increased
risk for blindness, according to
Dr. Yvonne Buys, professor of
ophthalmology at the University
of Toronto. She has published a
series of studies which confirm there
is a tendency for people living in
poorer areas, or who have attained
lower education levels, to present
later with the disease.
But why there is a difference
between people living in poorer or
richer areas accessing services is a
puzzle. Even taking geography and
access issues related to distance, SES
stands out as an independent issue
related to inequities, according to
studies from the Canadian Institute
for Health Information.
It’s also a phenomenon that
happens in other areas of medicine
and in other countries. And Canada
isn’t the only country with socialized
medicine where people with lower
income tend to present late—studies
show the same thing happens in
England and Scotland. Evidence shows
the issue is not limited to just eye
diseases. The reasons are complicated.
“Individual health care attitudes
are complex, but some possible reasons
could be lack of symptoms, poor health
knowledge such as understanding of
the importance of preventative health
care, poor understanding to navigate
a health care system, and cost of taking
time off work for an examination,”
said Dr. Buys.
Yet detecting the disease and
starting treatment early can make a
huge difference.
A study she coauthored in the
Canadian Journal of Ophthalmology
(CJO) in April 2013 was the first to
show that socioeconomic deprivation
in Canada was associated with
glaucoma being more severe when
patients first presented to an eye care
specialist. In the study, researchers
looked at 290 patients from 18 study
centres across Canada who were
newly diagnosed with open-angle
glaucoma. The postal codes of where
patients lived were correlated with
patient age and severity of disease.
Postal codes helped indicate median
household incomes through use of
the 2006 Canadian census data.
Of the patients, 52.1 per cent had
mild disease, 26.9 per cent moderate
and 21 per cent advanced disease at
initial diagnosis. Of those who
presented with late stage glaucoma,
36 per cent were in the highest
income range, and 55 per cent in the
lowest income range. The effect was
even stronger among rich verses poor
among people 65 years of age or older.
“Whatever the cause, our study
provides evidence for a possible
barrier to vision care related to socio-
economic status that contradicts the
fundamental principle of universal
access of the Canadian health care
system,” Dr. Buys said. Another of
her studies found that people with
lower SES were 2.5 times more likely
not to go to have other sorts of vision
problems checked as well, ranging
from uncorrected vision problems to
blindness.
The full and partial delisting of
eye examinations in some of the
provinces likely exacerbates the
problem. In fact, one study from
2012 by researchers from the
University of Toronto show this is
indeed the case in Ontario where
routine eye examinations were
delisted in 2004. Here, researchers
used data from the Canadian
Community Health Survey from the
years 2000 to 2001 (prior to delisting)
and 2007 to 2008 (after delisting) and
compared how many Ontarians went
for eye exams during those years.
They found that among people
aged 40 to 64, there was a drop in eye
exam visits of 7.2 per cent among
people who had not attained a high
school diploma. Of people who had a
high school diploma, eye exam visits
dropped only 0.7 per cent—an order
of significant difference. There was
also a significant drop of just over five
per cent among people with lower
income.
“The disparity in utilization
between those in the highest and
lowest income groups increased
nearly threefold from before delisting
to after delisting,” said Dr. Graham
Trope, professor of ophthalmology at
the University of Toronto, and a
coauthor of the study.
OPTICAL PRISM | NOV/DEC 2013
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