Diabetic retinopathy screening programs are unlikely to meet their goal of promoting patient adherence to recommended follow-up eye examinations, according to this prospective study.
Despite having access to low-cost care, only one-third of patients who received a screening for diabetic retinopathy (DR) at a publicly funded health clinic returned for recommended follow-up visits. Even 2 years later, only half had an eye exam. This study shows that additional research is critical if we are to identify and overcome barriers to care.
Estimates indicate that only two-thirds of individuals with self-reported diabetes receive an annual dilated eye examination. Annual use estimates are even lower among African American individuals with diabetes, with studies indicating that fewer than half of African American adults with diabetes receive an annual examination. These data are concerning because the prevalence of vision-threatening DR is 190% higher among African Americans than among non-Hispanic whites.
Evidence shows that implementation of DR screening programs leads to more persons with diabetes receiving retinal screening, lower rates of sight-threatening DR in the future, and reduced incidence of blindness. But, the key to these programs is whether participants adhere to the timetable of follow-up comprehensive eye care recommended by the screening program.
To learn more about patient adherence, this group of investigators in Alabama implemented a DR screening program using a nonmydriatic camera in a publicly funded county health system that primarily serves African American patients.
Screening was completed in 949 adults with diabetes, of whom 84.5% were African American, 64.5%were women and 71.7% lacked health insurance. Participants ranged in age from 21 to 95 years, with a mean age of 53.9. Mean age at diabetes diagnosis was 44.3, and the mean duration of diabetes was 9.6 years. Only 29.9% returned for follow-up eye care within the recommended time frame. Two years after a participant’s screening date, 50.9% had no record of having received eye care. Older patients and those who knew their glycated hemoglobin level were more likely to return for care.
The authors were surprised by the low adherence rate because the most cited barriers to eye care – access and cost – were minimized. The county clinic had its own ophthalmology service at the same location as the internal medicine service where patients access care for diabetes. Examinations were low cost or free. At this county-operated clinic, no one seeking care is turned away if he or she is a registered patient at the facility, which was the case for every study subject. The screening coordinator even offered assistance in making the appointment.
The authors note that even when the cost of the examination is covered, some aspects of cost, such as lost wages on the day of the follow-up appointment for those employed, remain unaddressed in this study. Younger adults are more likely to be employed and were also less likely to be adherent to interval recommendations for follow-up care. Education is one factor the authors suggest may have contributed to the low-adherence rate. They conclude that it is probably unrealistic to expect DR screening initiatives on their own, without the inclusion of an educational initiative, to lead to high rates of adherence for follow-up care.