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Disparities in Retinal Detachment Surgery for Women

Aug 19 2020

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20/20 Blog

Palo Alto, CA — Retinal detachment surgery is an emergency procedure that prevents blindness, but research from Stanford’s Byers Eye Institute shows women may be treated differently than men.

As a vitreoretinal surgery fellow, Natalia Callaway M.D., M.S. examined 133 million records in the largest outpatient insurance database to find out if men and women receive the same surgical care for retinal detachments. Among over 60,000 cases, Dr. Callaway found that women were 34% less likely to receive surgical intervention.

Vinit Mahajan M.D., Ph.D., associate professor of ophthalmology at Stanford and a co-author on the paper, said, “Disparities in our healthcare system need to be identified and corrected. If you asked retina surgeons if they manage retinal detachments in men and women differently, they would say no. The surprising results from this study bring to light issues we weren’t even aware exist in our clinics and operating rooms."

He added, “Dr. Callaway’s work using big data is especially significant right now as we are putting medicine under a magnifying glass to understand disparities in COVID-19 morbidity and mortality.”

Dr. Mahajan’s interview with Dr. Callaway:

What made you think that women may not be getting the same care for retinal detachments as men?

I wasn’t sure if there would be a difference, but I felt it warranted investigation based on research in other fields that showed disparities in numerous healthcare treatments and outcomes. I walked into the research hoping I would not find a difference. There is data from cardiology, neurology, and general medicine that shows that women are less likely to receive emergency cardiothoracic surgery, get a prompt diagnosis for life-threatening conditions like stroke and myocardial infarction, and receive fewer prescriptions. Comprehensive investigations for reported symptoms such as abdominal pain are less often undertaken for women. In each of these fields, as you mentioned, most likely the specialists in the field would not expect any disparity, and yet there were differences. These fields not only identified healthcare treatment and outcome disparities but have made efforts towards addressing them.

A great example is the difference in myocardial infarction presentation between men and women and how treatment, even within my medical training, has changed. When I was in school a “heart attack” photo in textbooks showed an elderly man hunched over grabbing his chest reporting pain and pressure that may radiate to his left arm. This is a presentation of myocardial infarction, but the disparities research in cardiology for women revealed that women are much more likely than men to present with vague symptoms including abdominal pain and nausea. Now when we look at the cardiology education through their main professional societies and here at the Stanford School of Medicine, we find that medical students are educated on possible differences in symptom presentation and physical signs of myocardial infarction in order to better identify women with a heart attack in a timely manner. These initiatives helped better identify heart attacks in women and as a result saved lives.

To address disparities in healthcare, we must first know what they are and then work to correct them. This is the first study in the field of retina to determine if there are differences in surgical intervention rates for a potentially blinding emergency.

What is the significance of your findings?

The findings demonstrate that ophthalmology is not immune to disparities in healthcare delivery. Women are not getting to the operating room as often as men and this is a huge problem. Here, I found that after adjusting for all available risk factors insured women were 34% less likely to receive surgery for a retinal detachment, a blinding condition, than insured men. I suspect this disparity is even greater in uninsured populations.

There were also differences in how retinal detachments were repaired between women and men, when they were repaired, and the reoperation rates. These findings require further research into the reason for these differences in order for us to better serve our patients. The study deficit is also very significant because we calculate that 7,029 women during the study period did not receive surgery, based on the most recent U.S. Census data, and may now be blind. We need to do better. To do that we must first identify the problem.

Why do you think there are differences in the surgical repair of retinal detachments for women and men?

I can’t say for certain, but I suspect it is multifactorial. Women carry a tremendous unspoken weight in our society at every stage of life. Women are more often caregivers for children, parents, spouses at every stage of their lives and this informal responsibility carries with it a significant physical and emotional burden. The stress of caregiving has been associated with an increased rate of depression, anxiety, burnout, and delays or avoidance of seeking medical care. 

Surveys of female cancer caregivers report delays in seeking interventional treatment for their own medical needs because of fear of complication that would limit their ability to care for their dependent family member. In retinal detachment repair, where vision may be decreased for weeks due to a gas or oil tamponade, women may delay or not undergo surgery to preserve vision and fulfill their caretaker responsibilities. The caretaker role and fear of complications may also contribute to the differential surgical selection seen in this study as scleral buckle and laser barricade are less likely to have the same temporary visual reduction as a vitrectomy with tamponade.

In addition to their role as caretakers, women may be less likely to voice concerns or challenge authority, here the physician, related to the procedure or timing of surgery, and this may result in “no-shows” on the date of surgery. Women also tend to outlive their husbands and are more likely to be widowed, so they may not have the support to travel to the numerous appointments associated with surgery. Studies in other fields have also reported differences in work-up and timing of symptom reporting between women and men so perhaps when women report symptoms of retinal detachment it is not being triaged the same way due to unconscious biases in the healthcare system. Finally, provider bias cannot be excluded as a possibility for the difference in receipt of repair.

What impact do you think your findings will have as surgeons make decisions about patient care?

I hope that this study spurs further research into the area to better understand these healthcare disparities for women. Beyond being surgeons, we have committed to being doctors and advocating for the welfare of our patients. This study demonstrates that there is a huge group of our patients that require more advocacy from our profession. First, institutions should review their own data and determine if there are points of potential improvement to get women to the operating room: are they being scheduled at the same time for the same symptoms as men? Are they presenting in a different way? Do they have more concerns about co-pays or time off of work? Are they the sole provider for children and can’t be face down for weeks at a time? Do they require more flexibility with scheduling or procedure intervention because of their work, household, and other demands? These are all possible obstacles to women receiving care.

Surgeons should consider these findings when they are discussing surgical interventions and options with their female patients. Female patients may benefit from a shared decision-making model that offers flexibility of scheduling, transportation, and prescription delivery services. Openly discussing any hesitations during the initial visit may enable a physician to engage social work, transportation services, request prior authorizations to overcome whatever is limiting the patient’s ability to get to the operating room.

How do you think these disparities can be corrected?

First, we need to better understand the problem. Follow-up studies to determine where the point of potential intervention along the diagnosis to operating room path need to be conducted. Then these points need to be understood – why are women not getting to surgery after they are diagnosed? The intervention could be as simple as offering more flexibility with scheduling or reviewing options for surgical intervention. But we can’t solve the problem without knowing what it is first. This work is the first research on this topic, but I hope it opens up many more studies on this and other classically underserved groups to get them the best healthcare outcomes.
Everyone deserves the best healthcare regardless of sex, race, religion, or orientation.

Do you think unconscious bias plays a role in the treatment plans for men and women?

Yes, unconscious bias plays a role in everything we do. Countless studies from all fields, including those beyond medicine, demonstrate the power of unconscious bias. We as humans make immediate judgements and decisions about individuals within seconds of meeting them, and these are based on our historical references and emotions – not necessarily logic. Although we would like to believe we are perfectly rational, countless areas of research suggest we are not perfectly objective – even as physicians. Knowing this, however, and raising awareness of these issues is the first step in mitigating them. Here unconscious bias could play into many different obstacles related to women getting to the operating room and needs to be better understood.

How can women better advocate for themselves when seeing an eye surgeon, or any other kind of doctor?

First, I think the responsibility to the patient falls on the healthcare system. I believe as healthcare professionals we should be advocates for our patients and this requires understanding the unique individual circumstances each patient faces.

If some of my hypotheses on difficulty with scheduling dates are true, then perhaps women raising concerns could address this issue. I say this hesitantly, however, because many studies have found that women are less likely to challenge authority, and I worry that if this is the plan that means we have no plan. Society has shaped women to be more “agreeable” and less contrarian for centuries. Saying that women should suddenly change their personality when they come from cultures where they have all their lives been told not to speak up feels like a “heal thyself” solution. 

The healthcare system has failed these women and it is time for the system and all the players in it to acknowledge the disparity and take ownership of its responsibility to deliver the best care to every patient regardless of sex, race, religion, or orientation. Identifying the problem is the first step, and I’m grateful for your support, Dr. Mahajan, as well as the entire research team, in helping me shed light on this disparity in our field of retina and ophthalmology.

 

Mahajan said, “It was a great privilege for all of us to mentor Dr. Callaway. Her groundbreaking research will make a difference in how we care for women with retinal disease. I expect her to make significant contributions to our field.”

This work was presented at the Association of Vision Research, Women in Ophthalmology where it was selected as a “Top Research Poster” and will be presented at the upcoming Retina Society in September.

Dr. Callaway’s paper, “Sex Differences in the Repair of Retinal Detachments in the United States,” was recently published in the Journal of American Ophthalmology. Co-authors on the manuscript include Daniel Vail, Ahmad Al-Moujahed, Cassie Ludwig, Marco H Ji, Vinit B Mahajan, Suzann Pershing, and Darius M Moshfeghi.