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Many Youths Not Adequately Screened for Diabetic Retinopathy

By Nicola M. Parry, DVM
WebMD Health News

March 27, 2017

Many youths with diabetes did not receive timely eye examinations to screen for diabetic retinopathy (DR), a new study shows.

Sophia Y. Wang, MD, from the University of Michigan Medical School, Ann Arbor, and colleagues published the results of their study online March 23 in JAMA Ophthalmology.

"For youths with type 1 diabetes, for whom there are clear screening guidelines for DR, approximately two-thirds of children and adolescents in our cohort obtained eye examinations to check for DR as recommended by professional societies," the authors write. "Youths with type 2 diabetes were even less likely to undergo screening to check for DR."

Because DR is a serious sight-threatening complication of diabetes, various professional societies provide guidelines for ophthalmic screening to prevent vision loss in patients with diabetes.

The American Academy of Ophthalmology current guidelines encourage DR screening examinations for all patients with type 1 diabetes to begin 5 years after diabetes diagnosis for youths with type 1 diabetes. The American Diabetes Association guidelines suggest initial screening 3 to 5 years after type 1 diabetes onset for patients aged 10 years or older, and the American Academy of Pediatrics recommends the same for those aged 9 years or older. The American Academy of Ophthalmology and American Diabetes Association also encourage screening of youths with type 2 diabetes at the time of initial diagnosis.

However, the rate of obtaining eye examinations among youths with diabetes in accordance with these guidelines has not been established. Studies estimating compliance with clinical guidelines for eye examinations among patients of all ages with diabetes have shown ranges varying widely, from 20% to 82%.

Therefore, Dr Wang and colleagues performed a retrospective, longitudinal cohort study of 12,686 youths, aged 21 years or younger, with newly diagnosed diabetes, who were enrolled in a US managed care network from January 2001 through December 2014.

Among the youths included in the study, 5453 had type 1 diabetes (median age at initial diagnosis, 11 years) and 7233 had type 2 diabetes (median age at initial diagnosis, 19 years).

The researchers found that only 64.9% of those with type 1 diabetes and 42.2% of those with type 2 diabetes had received an eye examination within 6 years after initial diagnosis, in accordance with established clinical guidelines.

Factors such as race and socioeconomic status also influenced the likelihood of youths undergoing screening eye examinations, the researchers write.

They found that 54.7% of white and 57.3% of Asian youths had received an eye examination by 6 years after initial diabetes diagnosis compared with only 44.6% of black and 41.6% of Latino youths.

In a JAMA Ophthalmology audio interview, senior author Joshua D. Stein, MD, from the University of Michigan, notes that "greater proportions of youths with higher household net worth levels underwent eye exams compared to those with lower net worth levels."

Using a multivariable regression model, the findings showed that youths with type 1 diabetes were 114% more likely to undergo an eye examination than those with type 2 diabetes, Dr Stein says.

In addition, compared with white youths, black youths were 11% less likely (hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.79 - 0.99) and Latino youths were 18% less likely (HR, 0.82; 95% CI, 0.73 - 0.92) to receive screening eye examinations.

"Youths coming from families with incomes over $500,000 per year were 50% more likely to undergo an eye exam compared to those with household net worth levels of $25,000 or less [HR, 1.50; 95% CI, 1.34 - 1.68]," adds Dr Stein.

This study highlights the magnitude of the gap in screening for DR in youths with diabetes, but Dr Stein acknowledges that it does not explain underlying reasons why, for example, children from less affluent families are less likely to undergo an eye examination. Moreover, the study's retrospective design and use of medical claims data precluded determination of these factors.

Moving forward, innovative ways to overcome barriers to screening are needed, he says; for example, using teleophthalmology and nonmydriatic fundus photography at the point of care to help improve screening rates.

However, Dr Stein concludes that to be successful, such strategies must be feasible, implementable, and not overly burdensome to patients, as well as being easy to integrate into busy practices and to incentivize both the primary care physician and the eye care professional who might want to participate in them.

In an accompanying editorial, Seema Garg, MD, PhD, from the University of North Carolina at Chapel Hill, commends the study's authors for highlighting the inadequate screening rates of youths with diabetes and the importance of improving adherence to clinical practice guidelines.

Discussing how to address this public health challenge, Dr Garg also agrees that retinal telescreening with remote expert interpretation could help improve DR screening, especially in the primary care setting on a point-of-care basis.

Telemedicine is especially effective as a strategy in reaching patients living in remote and underserved areas and who might be at risk for more advanced disease.

"In our experience, point-of-care retinal telescreening with remote interpretation in the University of North Carolina Family Medicine clinic led to a sizable and sustained improvement in screening rates," she writes.

Telemedicine offers several advantages, she says. Because of the rising prevalence of diabetes, the number of patients who require retinal screening may far exceed the ability of available eye care professionals to perform these examinations. Patients are also more likely to undergo retinal imaging if it is offered in the primary care clinic they already visit each year.

And because most patients with DR are generally asymptomatic, telemedicine may even facilitate ophthalmology referrals for those at risk for vision loss, allowing earlier disease diagnosis. Dr Garg notes that disease detected later is typically more expensive to treat, and adds that targeted referrals for only those patients who need subspecialty care, such as laser photocoagulation, will also lower costs to both the patient and the healthcare system.

Because of the significant burden to youths who lose a lifetime of vision, Dr Garg emphasizes the importance of screening eye examinations for early detection of sight-threatening disease.

"The solution should include a technological partnership between ophthalmologists and primary care physicians to improve the quality of eye health care delivery and outcomes for all," she concludes.

This study was funded by grants received by three of the authors from the National Eye Institute, the W. K. Kellogg Foundation, the National Eye Institute, the Taubman Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, the Taubman Emerging Scholars Program, and a Research to Prevent Blindness Physician Scientist Award. The remaining authors have disclosed no relevant financial relationships. Dr Garg reports serving on the Clinical Advisory Board for Welch Allyn.

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References
SOURCE: Medscape, March 27, 2017. JAMA Ophthalmol. Published online March 23, 2017.

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