This column highlights clinical trial data and landmark trials. Information for obtaining trial data and the references to the published articles are provided to facilitate discussion with your patients/colleagues. The trial is identified by the acronym and the National Clinical Trials Identifier. Primary outcome results are summarized.
Study Title: Eye Care Utilization Among Insured People With Diabetes in the U.S., 2010-2014
Study Title Acronym: N/A
ClinicalTrials.gov Identifier: N/A
Reference: Benoit SR, Swenor B, Geiss LS, Gregg EW, Saaddine JB. Eye care utilization among insured people with diabetes in the U.S., 2010-2014. Diabetes Care. 2019;42(3):427-433.
Sponsor: Not stated
Study Design: A retrospective cohort analysis using the IBM MarketScan Research Database of healthcare claims identified patients who were 10 to 64 years of age with a diagnosis of either type 1 or type 2 diabetes (T1D, T2D), and with continuous insurance coverage from January 1, 2010 through December 31, 2014. Using this defined cohort, the study team then reviewed clinical encounter data to determine the frequency of eye examination visits over the 5-year study period, stratified by diabetic retinopathy (DR) status (no DR vs. those with a DR diagnosis at study onset). Data were analyzed relative to diabetes type, diabetes duration, age-group [10 to 19 years (T1D only); 20 to 39 years; 40 to 64 years], sex, and severity of DR [if present: DR vs. Vision-threatening DR (VTDR)].
Primary Outcome: The frequency of eye examination visits, over a 5-year period, among insured patients with either T1D or T2D.
Other Outcomes: The cumulative prevalence and incidence of DR in patients with diabetes who received ≥1 eye exam visit during the study period.
Results: A total of 355,384 unique, continually-insured patients with diabetes (334,047 with T2D; 21,337 with T1D), representing all 50 U.S. states, the District of Columbia, and Puerto Rico (~50% of study population representing Georgia, Michigan, Texas, Ohio, Tennessee and California) were identified. For patients with T2D and no DR at baseline, 48.1% had no eye exam visits during the study period, whereas only 15.3% met American Diabetes Association (ADA) recommendations for an eye exam every 1 or 2 years. For patients with T1D and no DR at baseline (T1D ≥ 5 years duration), 33.6% had no eye exam visits during the study period, whereas only 26.3% met ADA recommendations for eye exam frequency. In either diabetes type, eye exam frequency was lowest among the younger age groups, compared with the 40 to 64 year old patients. As example, ~95% of 20 to 39 year olds with T2D attended no (66.9%) or very infrequent (27.7%) eye clinic visits.
The 5-year prevalence of either DR or VTDR at study onset was 24.4% or 8.3%, respectively, for patients with T2D, compared with 54.0% or 24.3%, respectively, for patients with T1D. As expected, compliance with ADA recommended eye exam frequency was higher among those patients with a DR diagnosis at study onset (50.9% of T2D and 63.5% of T1D patients). The 5-year cumulative incidence of either DR or VTDR was 15.8% or 4.7%, respectively, for patients with T2D, compared with 33.4% or 11.2%, respectively, for patients with T1D. Finally, DR was found to be more common among males, and among the 40 to 64 year age category; in T1D specifically, 30.6% of patients in this oldest age-group had VTDR.
Summary: Results of this analysis suggest that despite being cost-effective, utilization of eye care services for DR screening, even among a cohort of continually insured diabetes patients, was extremely low. The authors acknowledge that accuracy of their data may be compromised by using retrospective diagnosis codes, rather than clinical assessment with fundus photography, to define DR, and by using diagnosis codes along with medication use to define diabetes type. These data suggest that for the prevention of vision-threatening eye disease, a reliance on expected adherence to ADA screening recommendations was insufficient. Instead, the development of interventions to overcome barriers to screening was suggested, such as telemedicine or the use of other remote DR screening technologies in the primary care setting as options to improve eye care.
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About our experts: Kathryn Thrailkill, MD, Professor of Pediatrics, Division of Pediatric Endocrinology, Barnstable Brown Endowed Chair in Pediatric Diabetes Research, Barnstable Brown Diabetes Center, University of Kentucky, Lexington, Kentucky
Derick Adams, DO, Assistant professor, internal medicine, Division of Endocrinology, Endocrinology Fellowship associate program director, Barnstable Brown Diabetes Center, University of Kentucky, Lexington, Kentucky