Asel Ryskulova, MD, MPH Richard Klein, MPH Mary Frances Cotch, PhD Use of Vision Rehabilitation and Adaptive Devices among Adults with Visual Impairment, U.S. 2002 Asel Ryskulova, MD, MPH Richard Klein, MPH Mary Frances Cotch, PhD Good morning! Today I am going to talk about use of rehabilitation services and adaptive devices among adults with visual impairment. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics National Institutes of Health, National Eye Institute

Public Health Importance Visual impairment (VI) – frequent cause of disability in the US 1.1 million people legally blind Annual economic and social costs: $67 billion Prevalence of age-related eye diseases is projected to double by 2020 Use of visual rehabilitation improves quality of life Vision is an essential part of everyday life. Vision affects development, learning, communicating, working, health, and quality of life. Visual impairment is 1 of the 10 most frequent causes of disability in the United States. An estimated 1.1 million Americans are legally blind. The main cause of VI is age related eye diseases such as DR, cataract, glaucoma, and MD. According to NEI the prevalence of age related eye diseases is expected to double by year 2020. The projection is driven largely by the fact that the prevalence of visual impairment increases sharply in persons older than 65 years, and this age group is the fastest-growing segment of the US population and will reach approximately 27 million by the year 2025. While important strides have been made in the prevention and treatment of eye disease, there is no cure for many causes of vision loss. People with low vision often cannot perform daily routine activities, such as reading the newspaper, preparing meals, or recognizing faces of friends. The inability to see well affects functional capabilities and social interactions and can lead to a loss of independence. While nothing medically can be done for patients with low vision, their quality of life can be greatly improved. Many low vision services and devices are available to help patients maintain their independence.

Healthy People 2010 Vision Goal Improve the visual health of the Nation through prevention, early detection, treatment, and rehabilitation. Reflecting the importance of visual health, 10 vision objectives have been included in Healthy People 2010 for the first time. The national healthy vision goal is to improve the visual health of the Nation through prevention, early detection, treatment, and rehabilitation. Healthy People 2010 is a shared responsibility of the Federal Government, States, local governments, health care providers, community leaders, and the American public. Healthy People 2010 goals are to increase the quality and years of healthy life and eliminate health disparities. There are more than 450 national health objectives in 28 focus areas.

Healthy People 2010 Vision Objectives: 28-10. Increase visual rehabilitation 28-10a. Increase the use of rehabilitation services by visually impaired persons aged 18 years and older 28-10b. Increase the use of visual and adaptive devices by visually impaired persons aged 18 years and older One of the HP2010 objective 28-10 is: 28-10. Increase visual rehabilitation. 28-10a. Use of rehabilitation services by visually impaired persons aged 18 years and older 28-10b. Use of visual and adaptive devices by visually impaired persons aged 18 years and older Generally, devices fall into two categories: visual and adaptive. Visual devices use lenses or combinations of lenses to provide magnification. They include such aids as magnifying spectacles, hand-held magnifiers, stand magnifiers, computer monitors with large type, and closed-circuit televisions. Adaptive devices include large-print reading materials (books, newspapers), check writing guides, and high-contrast watch dials. Also in this latter category are auditory aids, such as talking computers.

Objective of the Study To estimate the reported use of visual rehabilitation services and adaptive devices Assess gender, race/ethnicity, education differences among persons who used visual rehabilitation services and adaptive devices The objective of the present study is to provide national self-reported data on use of visual rehabilitation and adaptive devices and to establish whether there are race, gender, and socioeconomic differences by presenting the analysis of 2002 National Health Interview Survey (NHIS) data.

Data Source 2002 National Health Interview Survey (NHIS) Conducted annually since 1957 Nationally representative sample of civilian, non-institutionalized population Computer-assisted in-person interview Over-samples black and Hispanic persons 2002 NHIS vision health supplement The NHIS, conducted by the National Center for Health Statistics, has been the major source of national health data on the civilian non-institutionalized household population of the United States since the 1950s. The NHIS obtains information on a variety of health measures, including medical conditions, access to health care, and health risk factors. Data are collected in a centralized manner by the US Bureau of the Census via in-person interviews. NHIS over-samples Blacks and Hispanics. When Healthy People objectives were first published, only 2 of them had data. So, under the request of NEI, Vision supplement was included into 2002 NHIS.

Study Population Adults ages 18 and over Response rate – 74.3%, sample size – 31,044 NHIS questions on visual impairment, use of visual rehabilitation services and adaptive devices Number of visually impaired persons: 3,301 In 2002 the response rate for children was 74.3% for adults Information was collected on 31,044 adults. 2002 NHIS included questions on visual impairment, use of visual rehabilitation services and adaptive devices. Number of visually impaired persons: 3,301.

NHIS Questions Do you have any trouble seeing, even when wearing glasses or contact lenses? Do you use any vision rehabilitation services, such as job training, counseling, or training in daily living skills and mobility? Do you use any adaptive devices such as telescopic or other prescriptive lenses, magnifiers, large print or talking materials, closed circuit TV (CCTV), white cane, or guide dog? The VI question was defined based on question: Do you have any trouble seeing, even when wearing glasses or contact lenses? To collect the data on use of services and devices the respondents were asked the following questions: Do you use any vision rehabilitation services, such as job training, counseling, or training in daily living skills and mobility? Do you use any adaptive devices such as telescopic or other prescriptive lenses, magnifiers, large print or talking materials, CCTV, white cane, or guide dog?

Analytic Methods SUDAAN software Data were weighted to the US population Estimates were age-adjusted Reliability of estimates determined by relative standard error (RSE) RSE > 30% = unreliable estimates Test of significance at 0.05 level All percentages and associated standard errors were generated using SUDAAN, a software designed to account for a complex sample design. All estimates were weighted to represent the U.S. civilian non-institutionalized population Data were age adjusted to the year 2000 U.S. standard population. Reliability of estimates was determined by RSE, estimates with RSE higher than 30% were considered unreliable. The estimates were compared using two-tailed statistical tests.

Leading Causes of Visual Impairment, 2002 Prevalence of eye diseases among an estimated 205 million US civilian, non-institutionalized adults 18 years and older:   % Number Cataract 8.9 17 million Diabetic retinopathy* 0.7 1.3 million Glaucoma 2.1 4.1 million Macular degeneration 1.2 2.1 million Eye injury 4.4 8.5 million This slide shows the burden of age related eye diseases. Among an estimated 205 million US civilian, non-institutionalized adults 18 years and older: The prevalence of cataract is 8.9%, glaucoma is 2.1%, macular degeneration – 1.2%. Prevalence of diabetic retinopathy among total population – 0.7% and among adults with diabetes - 7.9%. Almost 8.5 million had an occupational eye injury at some point of their life. * Prevalence of diabetic retinopathy among adults with diabetes is 7.9%. Source: National Health Interview Survey, CDC, NCHS.

Visual Impairment in Adults, 2002 Total Female Male AI/AN Asian Black White Hispanic < High school High school >High school This slide shows the self-reported VI among adults 18 years and over. Women had a higher prevalence of visual impairment than men. A smaller proportion of Asian adults have VI compared with other race/ethnic groups. American Indian/Alaska Natives and Blacks have the greatest proportion of people reporting VI. VI is inversely related to years of education. People with diabetes have the most trouble. With diabetes Without diabetes 5 10 15 20 25 Percent Note: Data are age adjusted to the 2000 standard population. Except for education levels, data are for adults 18 years and over; education-level data are for adults 25 years and over. AI/AN - American Indian and Alaska Native. Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race. I is 95% confidence interval. Source: National Health Interview Survey, CDC, NCHS.

Visual Impairment in Adults, 2002 Percent Female Total The prevalence of VI increases dramatically with age. The prevalence increases significantly with age, from 5.7% among persons ages 18-44 to 17.9% among those ages 75-84 and 32.8% among persons 85 and over. Male 18-44 45-54 55-64 65-74 75-84 85+ Source: National Health Interview Survey, CDC, NCHS.

Selected Characteristics of Adults with and without Visual Impairment (VI), 2002   Adults with VI Adults without VI Age 45-74 years 75+ years 50.9% 16.8% 39.0% 6.5% Female 59.4% 51.3% Black 13.1% 11.0% White 73.5% 72.6% Hispanic 7.9% 11.3% Income below 200% of FPL 40.5% 28.1% Education less than high school 25.8% 14.8% Persons with diabetes 15.8% 5.7% This table presents the selected characteristics of adults with and visual visual impairment. Persons with VI were likely to be female, have income below FPL and education less than high school. The percentage of persons with diabetes was almost 3 times higher among those with VI. Note: FPL – Federal Poverty Level Source: National Health Interview Survey, CDC, NCHS.

Use of Visual Rehabilitation Services: Adults with Visual Impairment, 2002 Total Female Male AI/AN * Asian * Black * White Hispanic * < High school * High school >High school Only 1.4 percent of visually impaired adults reported the use of rehabilitation services. Use of rehabilitation services was very low. Our numbers are too small to get comprehensive national estimates for many subpopulation groups. There was no significant difference between men and women. Data were statistically reliable only for white and persons without diabetes. With diabetes * Without diabetes 2 4 6 8 10 Percent Note: Data are for adults 18 years and over who reported visual impairment. Data are age adjusted to the 2000 standard population, education-level data are for adults 25 years and over. AI/AN - American Indian and Alaska Native. Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race. I is 95% confidence interval. *Data are statistically unreliable. Source: National Health Interview Survey, CDC, NCHS.

Use of Visual and Adaptive Devices: Adults with Visual Impairment, 2002 Total Female Male AI/AN * Asian * Black White Hispanic <High school High school >High school In contrast visual devices were used more frequently: 22% – or between 4.8 – 4.9 million adults - reported use of adaptive devices. No significant difference was found among different race, education groups and persons with and without diabetes history. With diabetes Without diabetes 10 20 30 40 50 Percent Note: Data are age adjusted to the 2000 standard population. Data are for adults 18 years and over who reported visual impairment; education-level data are for adults 25 years and over. AI/AN - American Indian and Alaska Native. Black and white exclude persons of Hispanic origin. Persons of Hispanic origin may be any race. I is 95% confidence interval. *Data are statistically unreliable. Source: National Health Interview Survey, CDC, NCHS.

Use of Visual and Adaptive Devices: Adults with Visual Impairment, 2002 Total Age group 18-44 45-54 55-64 65-74 75+ Health insurance No Yes Income Below 200% of FPL Older people with VI were more likely to use adaptive devices than adults of age 18 to 44 years. Above 200% of FPL 10 20 30 40 50 Percent Note: Data are for adults 18 years and over who reported visual impairment. Except for age group, all data are age adjusted to the 2000 standard population. FPL – Federal Poverty Level. I is 95% confidence interval. Source: National Health Interview Survey, CDC, NCHS.

Limitations Vision questions are not asked on a regular basis (vision health supplement) Based on self-reports Excludes institutionalized population Unreliable data on small minority U.S. populations Some limitations of the study should be noted. First, vision questions are not asked on regular basis. It is a supplement. Next limitation: NHIS data are based on self-reports and were not validated. This may result in considerable underreporting, or over-reporting. The accuracy of report is, therefore, unknown. NHIS excludes institutionalized persons, a population at high risk for illness and disability, the results might underestimate the prevalence of visual impairment. Some studies reported that there were about 4 million people in nursing homes with a prevalence of visual impairment of about 27%. Data on small minority U.S. populations are unreliable.

Conclusions NHIS provides national data for HP 2010 vision objectives 19 million adults are visually impaired Low rates of rehabilitation services and adaptive devices use Some population groups with higher rates of visual impairment have lower use of visual rehabilitation Next NHIS vision supplement in 2008 Some conclusions: The 2002 NHIS survey represents the most recently available national data for HP 2010 vision objectives. The study revealed significant under-use of rehabilitation services and adaptive devices: As only 1.4% of adults used rehabilitation services and 22% - adaptive devices Some population groups with higher rates of visual impairment have lower use of visual rehabilitation Next NHIS vision supplement will be included in 2008.