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Diabetic Eye Screening: Knowledge and Perspectives from Providers and Patients

  • Microvascular Complications—Retinopathy (JK Sun and PS Silva, Section Editors)
  • Published:
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Abstract

Purpose of Review

Diabetic retinopathy remains the leading cause of blindness among working-age US adults even though timely screening and treatment prevent 90% of blindness. We summarize current knowledge and perspectives to better understand why diabetic eye screening rates remain low and future directions towards preventing blindness from diabetes.

Recent Findings

Significant advancements in the past 10 years include primary care and patient-oriented interventions as well as the use of teleophthalmology. In England, diabetic eye disease is no longer the leading cause of certifiable blindness following the implementation of a national teleophthalmology program for diabetic retinopathy.

Summary

Multiple workflow and systems-level barriers affect providers. Patient barriers include a limited understanding of screening and lack of access to care. Interventions have been developed, but new barriers exist towards sustaining their impact. More research is needed to identify and implement the best practices to increase diabetic eye screening rates long-term.

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References

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  1. Zheng Y, He M, Congdon N. The worldwide epidemic of diabetic retinopathy. Indian J Ophthalmol. 2012;60(5):428–31. doi:10.4103/0301-4738.100542.

    Article  PubMed  PubMed Central  Google Scholar 

  2. World Health Organization Western Pacific Region. Diabetic retinopathy. In: Blindness prevention and control. http://www.wpro.who.int/blindness prevention control/topics/diabetic retinopathy/en/. Accessed 4/15/17.

  3. National Eye Institute. Facts about diabetic eye disease. https://nei.nih.gov/health/diabetic/retinopathy. Accessed 8/15/17.

  4. •• Scanlon PH. The English National Screening Programme for diabetic retinopathy 2003-2016. Acta Diabetol. 2017; doi:10.1007/s00592-017-0974-1. Summary of the national teleophthalmology program for diabetic eye screening in England

  5. Holman GT, Beasley JW, Karsh BT, Stone JA, Smith PD, Wetterneck TB. The myth of standardized workflow in primary care. J Am Med Inform Assoc. 2016;23(1):29–37. doi:10.1093/jamia/ocv107.

    Article  PubMed  Google Scholar 

  6. Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209–14. doi:10.1370/afm.310.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635–41.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Holley CD, Lee PP. Primary care provider views of the current referral-to-eye-care process: focus group results. Invest Ophthalmol Vis Sci. 2010;51(4):1866–72. doi:10.1167/iovs.09-4512.

    Article  PubMed  Google Scholar 

  9. Hartnett ME, Key IJ, Loyacano NM, Horswell RL, Desalvo KB. Perceived barriers to diabetic eye care: qualitative study of patients and physicians. Arch Ophthalmol. 2005;123(3):387–91. doi:10.1001/archopht.123.3.387.

    Article  PubMed  Google Scholar 

  10. • Hipwell AE, Sturt J, Lindenmeyer A, Stratton I, Gadsby R, O'Hare P, et al. Attitudes, access and anguish: a qualitative interview study of staff and patients' experiences of diabetic retinopathy screening. BMJ Open. 2014;4(12):e005498. doi:10.1136/bmjopen-2014-005498. Semi-structured interviews were conducted to better understand patient perspectives in the English teleophthalmology program for diabetic eye screening. Knowledge of diabetic retinopathy and screening were patient facilitators, while work commitments, the use of dilating drops, and travel concerns were identified as barriers to patient participation

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Willard-Grace R, Chen EH, Hessler D, DeVore D, Prado C, Bodenheimer T, et al. Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial. Ann Fam Med. 2015;13(2):130–8. doi:10.1370/afm.1768.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Reiss-Brennan B, Brunisholz KD, Dredge C, Briot P, Grazier K, Wilcox A, et al. Association of integrated team-based care with health care quality, utilization, and cost. JAMA. 2016;316(8):826–34. doi:10.1001/jama.2016.11232.

    Article  PubMed  Google Scholar 

  13. Maclennan PA, McGwin G Jr, Searcey K, Owsley C. A survey of Alabama eye care providers in 2010–2011. BMC Ophthalmol. 2014;14:44. doi:10.1186/1471-2415-14-44.

    Article  PubMed  PubMed Central  Google Scholar 

  14. •• Silva PS, Aiello LP. Telemedicine and eye examinations for diabetic retinopathy: a time to maximize real-world outcomes. JAMA Ophthalmol. 2015; doi:10.1001/jamaophthalmol.2015.0333. Overview of current challenges in teleophthalmology for diabetic eye screening

  15. Kilmer G, Bynum L, Balamurugan A. Access to and use of eye care services in rural Arkansas. J Rural Health. 2010;26(1):30–5. doi:10.1111/j.1748-0361.2009.00262.x.

    Article  PubMed  Google Scholar 

  16. Conlin PR, Fisch BM, Cavallerano AA, Cavallerano JD, Bursell SE, Aiello LM. Nonmydriatic teleretinal imaging improves adherence to annual eye examinations in patients with diabetes. J Rehabil Res Dev. 2006;43(6):733–40.

    Article  PubMed  Google Scholar 

  17. Whited JD, Datta SK, Aiello LM, Aiello LP, Cavallerano JD, Conlin PR, et al. A modeled economic analysis of a digital tele-ophthalmology system as used by three federal health care agencies for detecting proliferative diabetic retinopathy. Telemed J E-Health. 2005;11(6):641–51. doi:10.1089/tmj.2005.11.641.

    Article  PubMed  Google Scholar 

  18. Ellish NJ, Royak-Schaler R, Passmore SR, Higginbotham EJ. Knowledge, attitudes, and beliefs about dilated eye examinations among African-Americans. Invest Ophthalmol Vis Sci. 2007;48(5):1989–94. doi:10.1167/iovs.06-0934.

    Article  PubMed  PubMed Central  Google Scholar 

  19. • Sheppler CR, Lambert WE, Gardiner SK, Becker TM, Mansberger SL. Predicting adherence to diabetic eye examinations: development of the compliance with annual diabetic eye exams survey. Ophthalmology. 2014;121(6):1212–9. doi:10.1016/j.ophtha.2013.12.016. A survey instrument was developed to assess predictors of adherence with diabetic eye screening. Factors associated with obtaining screening included insurance coverage, consideration of screening as a priority, the belief that eye disease could be detected, lower hemoglobin A1c levels, and longer duration of diabetes

    Article  PubMed  Google Scholar 

  20. • Zangalli CS, Murchison AP, Hale N, Hark LA, Pizzi LT, Dai Y, et al. An education- and telephone-based intervention to improve follow-up to vision care in patients with diabetes: a prospective, single-blinded, randomized trial. Am J Med Qual. 2016;31(2):156–61. doi:10.1177/1062860614552670. This prospective study evaluated the effectiveness of a multipronged intervention to improve adherence with diabetic eye exams. The intervention group had significantly increased rates of scheduling and obtaining diabetic eye exams

    Article  PubMed  Google Scholar 

  21. Thom DH, Ghorob A, Hessler D, De Vore D, Chen E, Bodenheimer TA. Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. Ann Fam Med. 2013;11(2):137–44. doi:10.1370/afm.1443.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Fong DS, Aiello LP, Ferris FL 3rd, Klein R. Diabetic retinopathy. Diabetes Care. 2004;27(10):2540–53.

    Article  PubMed  Google Scholar 

  23. National Diabetes Statistics Report. Estimates of diabetes and its burden in the United States, 2014. In: prevention. CfDCa, editor. U.S. Department of Health and Human Services: Atlanta; 2014.

    Google Scholar 

  24. Early Treatment Diabetic Retinopathy Study Research Group. Early photocoagulation for diabetic retinopathy: ETDRS report number 9. Ophthalmology. 1991;98(5):766–785. doi: 10.1016/S0161-6420(13)38011-7

  25. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States A. GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2011.

    Google Scholar 

  26. Lee PP, Feldman ZW, Ostermann J, Brown DS, Sloan FA. Longitudinal rates of annual eye examinations of persons with diabetes and chronic eye diseases. Ophthalmology. 2003;110(10):1952–9. doi:10.1016/S0161-6420(03)00817-0.

    Article  PubMed  Google Scholar 

  27. Hatef E, Vanderver BG, Fagan P, Albert M, Alexander M. Annual diabetic eye examinations in a managed care Medicaid population. Am J Manag Care. 2015;21(5):e297–302.

    PubMed  Google Scholar 

  28. Munoz B, O'Leary M, Fonseca-Becker F, Rosario E, Burguess I, Aguilar M, et al. Knowledge of diabetic eye disease and vision care guidelines among Hispanic individuals in Baltimore with and without diabetes. Arch Ophthalmol. 2008;126(7):968–74. doi:10.1001/archopht.126.7.968.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Maclennan PA, McGwin G Jr, Heckemeyer C, Lolley VR, Hullett S, Saaddine J, et al. Eye care use among a high-risk diabetic population seen in a public hospital's clinics. JAMA Ophthalmol. 2014;132(2):162–7. doi:10.1001/jamaophthalmol.2013.6046.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Owsley C, McGwin G Jr, Lee DJ, Lam BL, Friedman DS, Gower EW, et al. Diabetes eye screening in urban settings serving minority populations: detection of diabetic retinopathy and other ocular findings using telemedicine. JAMA Ophthalmol. 2015;133(2):174–81. doi:10.1001/jamaophthalmol.2014.4652.

    Article  PubMed  PubMed Central  Google Scholar 

  31. 10. Microvascular complications and foot care. Diabetes Care. 2017;40(Suppl 1):S88–s98. doi:10.2337/dc17-S013.

  32. NCQA.org (2017). HEDIS Publications: Overview. [online] Available at: http://www.ncqa.org/HEDISQualityMeasurement/HED. [Accessed 2 Aug.2017].

  33. NCQA.org. (2017). 2015 NCQA Health Plan Accreditation Requirements. [online] Available at: hhttp://www.ncqa.org/Portals/0/Programs/Accreditation/HPA/2015%20HPA%20SGs.pdf?ver=2017-01-21-153207-313. [Accessed 2 Aug. 2017].

  34. Rein DB. Vision problems are a leading source of modifiable health expenditures. Invest Ophthalmol Vis Sci. 2013;54(14):Orsf18–22. doi:10.1167/iovs.13-12818.

    Article  PubMed  Google Scholar 

  35. Rowe S, MacLean CH, Shekelle PG. Preventing visual loss from chronic eye disease in primary care: scientific review. JAMA. 2004;291(12):1487–95. doi:10.1001/jama.291.12.1487.

    Article  CAS  PubMed  Google Scholar 

  36. Wiggins MN, Landes RD, Bhaleeya SD, Uwaydat SH. Primary care physicians' knowledge of the ophthalmic effects of diabetes. Canad J Ophthalmol. 2013;48(4):265–8. doi:10.1016/j.jcjo.2013.03.011.

    Article  Google Scholar 

  37. Delorme C, Boisjoly HM, Baillargeon L, Turcotte P, Bernard PM. Screening for diabetic retinopathy. Do family physicians know the Canadian guidelines? Can Fam Physician. 1998;44:1473–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  38. Davidson JA. The increasing role of primary care physicians in caring for patients with type 2 diabetes mellitus. Mayo Clin Proc. 2010;85(12 Suppl):S3–4. doi:10.4065/mcp.2010.0466.

    Article  PubMed  PubMed Central  Google Scholar 

  39. American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology. 2016. Available at: www.aao.org/ppp.

  40. American Optometric Association Evidence-based Optometry Guideline Development Group. Eye Care of the Patient with Diabetes Mellitus. St. Louis, MO: American Optometric Association. 2014 Available at: https://www.aoa.org/Documents/EBO/EyeCareOfThePatientWithDiabetesMellitus%20CPG3.pdf

  41. Dansky KH, Dirani R. The use of health care services by people with diabetes in rural areas. J Rural Health. 1998;14(2):129–37.

    Article  CAS  PubMed  Google Scholar 

  42. Sloan FA, Yashkin AP, Chen Y. Gaps in receipt of regular eye examinations among Medicare beneficiaries diagnosed with diabetes or chronic eye diseases. Ophthalmology. 2014;121(12):2452–60. doi:10.1016/j.ophtha.2014.07.020

  43. Krishna S, Gillespie KN, McBride TM. Diabetes burden and access to preventive care in the rural United States. J Rural Health. 2010;26(1):3–11. doi:10.1111/j.1748-0361.2009.00259.x.

    Article  PubMed  Google Scholar 

  44. Lindenmeyer A, Sturt JA, Hipwell A, Stratton IM, Al-Athamneh N, Gadsby R, et al. Influence of primary care practices on patients' uptake of diabetic retinopathy screening: a qualitative case study. Br J Gen Pract. 2014;64(625):e484–92. doi:10.3399/bjgp14X680965.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Odom JV. Vision, visual needs, and quality of life of older people in rural environments: a report and synthesis of a meeting. J Rural Health. 2001;17(4):360–3.

    Article  CAS  PubMed  Google Scholar 

  46. Halbert RJ, Leung KM, Nichol JM, Legorreta AP. Effect of multiple patient reminders in improving diabetic retinopathy screening: a randomized trial. Diabetes Care. 1999;22(5):752–5.

    Article  CAS  PubMed  Google Scholar 

  47. Jiwani A, Himmelstein D, Woolhandler S, Kahn JG. Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence. BMC Health Serv Res. 2014;14:556. doi:10.1186/s12913-014-0556-7.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Tozer K, Woodward MA, Newman-Casey PA. Telemedicine and diabetic retinopathy: review of published screening programs. J Endocrinol Diabetes. 2015;2(4) doi:10.15226/2374-6890/2/4/00131.

  49. Cavallerano AA, Cavallerano JD, Katalinic P, Blake B, Rynne M, Conlin PR, et al. A telemedicine program for diabetic retinopathy in a Veterans Affairs Medical Center—the Joslin Vision Network eye health care model. Am J Ophthalmol. 2005;139(4):597–604. doi:10.1016/j.ajo.2004.10.064.

    Article  PubMed  Google Scholar 

  50. Garg S, Zimmer-Galler I. Telemedicine and remote imaging for diabetic retinopathy evaluation: an update. Retin Physician. 2013:49–51.

  51. Mansberger SL, Sheppler C, Barker G, Gardiner SK, Demirel S, Wooten K, et al. Long-term comparative effectiveness of telemedicine in providing diabetic retinopathy screening examinations: a randomized clinical trial. JAMA Ophthalmol. 2015;133(5):518–25. doi:10.1001/jamaophthalmol.2015.1

  52. Murchison AP, Friedman DS, Gower EW, Haller JA, Lam BL, Lee DJ, et al. A multi-center diabetes eye screening study in community settings: study design and methodology. Ophthalmic Epidemiol. 2016;23(2):109–15. doi:10.3109/09286586.2015.1099682.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Silva PS, Cavallerano JD, Tolson AM, Rodriguez J, Rodriguez S, Ajlan R, et al. Real-time ultrawide field image evaluation of retinopathy in a diabetes telemedicine program. Diabetes Care. 2015;38(9):1643–9. doi:10.2337/dc15-0161.

    Article  CAS  PubMed  Google Scholar 

  54. Aiello LP, Ayala AR, Antoszyk AN, Arnold-Bush B, Baker C, Bressler NM, et al. Assessing the effect of personalized diabetes risk assessments during ophthalmologic visits on glycemic control: a randomized clinical trial. JAMA Ophthalmol. 2015;133(8):888–96. doi:10.1001/jamaophthalmol.2015.1312.

    Article  PubMed  Google Scholar 

  55. Frank RN. Can ophthalmologists achieve better blood glucose control in their diabetic patients? JAMA Ophthalmol. 2015;133(8):897–8. doi:10.1001/jamaophthalmol.2015.2258.

    Article  PubMed  Google Scholar 

  56. Vijan S, Fagerlin A. Diabetes risk assessment and glycemic control. JAMA. 2015;314(17):1861–2. doi:10.1001/jama.2015.11518.

    Article  CAS  PubMed  Google Scholar 

  57. Looker HC, Nyangoma SO, Cromie DT, Olson JA, Leese GP, Philip S, et al. Predicted impact of extending the screening interval for diabetic retinopathy: the Scottish diabetic retinopathy screening programme. Diabetologia. 2013;56(8):1716–25. doi:10.1007/s00125-013-2928-7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Taylor-Phillips S, Mistry H, Leslie R, Todkill D, Tsertsvadze A, Connock M, et al. Extending the diabetic retinopathy screening interval beyond 1 year: systematic review. Br J Ophthalmol. 2016;100(1):105–14. doi:10.1136/bjophthalmol-2014-305938.

    Article  PubMed  Google Scholar 

  59. DCCT/EDIC Research Group, Nathan DM, Bebu I, Hainsworth D, Klein R, Tamborlane W, et al. Frequency of evidence-based screening for retinopathy in type 1 diabetes. N Engl J Med. 2017;376(16):1507–16. doi:10.1056/NEJMoa1612836.

  60. Rein DB, Wittenborn JS, Zhang X, Allaire BA, Song MS, Klein R, et al. The cost-effectiveness of three screening alternatives for people with diabetes with no or early diabetic retinopathy. Health Serv Res. 2011;46(5):1534–61. doi:10.1111/j.1475-6773.2011.01263.x.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Rosenberg JB, Tsui I. Screening for diabetic retinopathy. N Engl J Med. 2017;376(16):1587–8. doi:10.1056/NEJMe1701820.

    Article  PubMed  Google Scholar 

  62. Centers for Disease Control and Prevention. Self-management education: learn more. Feel better. https://www.cdc.gov/LearnMoreFeelBetter/. Accessed 8/15/17.

  63. Li HK, Horton M, Bursell SE, Cavallerano J, Zimmer-Galler I, Tennant M, et al. American Telemedicine Association Diabetic Retinopathy Telehealth Practice Recommendations Working Group. Telehealth practice recommendations for diabetic retinopathy, second edition. Telemed J E Health. 2011;17:814–837 . doi:10.1089/tmj.2011.0075.pmid:21970573.

  64. Daskivich LP, Vasquez C, Martinez C Jr, Tseng CH, Mangione CM. Implementation and evaluation of a large-scale teleretinal diabetic retinopathy screening program in the Los Angeles County Department of Health Services. JAMA Intern Med. 2017; doi:10.1001/jamainternmed.2017.0204.

  65. Walton OB, Garoon RB, Weng CY, Gross J, Young AK, Camero KA, et al. Evaluation of automated teleretinal screening program for diabetic retinopathy. JAMA Ophthalmol. 2016;134(2):204–9. doi:10.1001/jamaophthalmol.2015.5083.

    Article  PubMed  Google Scholar 

  66. Keenum Z, McGwin G Jr, Witherspoon CD, Haller JA, Clark ME, Owsley C. Patients’ adherence to recommended follow-up eye care after diabetic retinopathy screening in a publicly funded county clinic and factors associated with follow-up eye care use. JAMA Ophthalmol. 2016;134(11):1221–8. doi:10.1001/jamaophthalmol.2016.3081.

    Article  PubMed  Google Scholar 

  67. Soliman AZ, Silva PS, Aiello LP, Sun JK. Ultra-wide field retinal imaging in detection, classification, and management of diabetic retinopathy. Semin Ophthalmol. 2012;27(5–6):221–7. doi:10.3109/08820538.2012.708812.

    Article  PubMed  Google Scholar 

  68. Goh JK, Cheung CY, Sim SS, Tan PC, Tan GS, Wong TY. Retinal imaging techniques for diabetic retinopathy screening. J Diabetes Sci Technol. 2016;10(2):282–94. doi:10.1177/1932296816629491.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Hansen MB, Abramoff MD, Folk JC, Mathenge W, Bastawrous A, Peto T. Results of automated retinal image analysis for detection of diabetic retinopathy from the Nakuru study, Kenya. PLoS One. 2015;10(10):e0139148. doi:10.1371/journal.pone.0139148.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Zhang W, Nicholas P, Schuman SG, Allingham MJ, Faridi A, Suthar T, et al. Screening for diabetic retinopathy using a portable, noncontact, nonmydriatic handheld retinal camera. J Diabetes Sci Technol. 2017;11(1):128–34. doi:10.1177/1932296816658902.

    Article  PubMed  Google Scholar 

  71. Rajalakshmi R, Arulmalar S, Usha M, Prathiba V, Kareemuddin KS, Anjana RM, et al. Validation of smartphone based retinal photography for diabetic retinopathy screening. PLoS One. 2015;10(9):e0138285. doi:10.1371/journal.pone.0138285.

    Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Yao Liu.

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Yao Liu and Rebecca Swearingen declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Yao Liu is supported by NIH/NEI K23 EY026518 and by an institutional grant from Research to Prevent Blindness, Inc.

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This article is part of the Topical Collection on Microvascular Complications—Retinopathy

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Liu, Y., Swearingen, R. Diabetic Eye Screening: Knowledge and Perspectives from Providers and Patients. Curr Diab Rep 17, 94 (2017). https://doi.org/10.1007/s11892-017-0911-2

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