Ophthalmic Screening Patterns Among Youths With Diabetes Enrolled in a Large US Managed Care Network

Abstract

IMPORTANCE Ophthalmic screening to check for diabetic retinopathy (DR) is important to prevent vision loss in persons with diabetes. The American Academy of Ophthalmology recommends that ophthalmic screening for DR occur beginning at 5 years after initial diabetes diagnosis for youths with type 1 diabetes; the American Diabetes Association recommends screening of youths with type 2 diabetes at the time of initial diagnosis. To our knowledge, it is unknown to what extent youths with diabetes obtain eye examinations in accordance with these guidelines.OBJECTIVE To assess the rate of obtaining ophthalmic examinations and factors associated with receipt of eye examinations for youths with diabetes. DESIGN, SETTING, AND PARTICIPANTSThis retrospective, longitudinal cohort study examined youths 21 years or younger with newly diagnosed diabetes enrolled in a US managed care network from January 1, 2001, through December 31, 2014. MAIN OUTCOMES AND MEASURES Kaplan-Meier survival curves estimated the time from initial diabetes diagnosis to first eye examination by an ophthalmologist or optometrist. Multivariable Cox proportional hazards regression models identified factors associated with receiving an ophthalmic examination after initial diabetes diagnosis. RESULTS Among 5453 youths with type 1 diabetes (median age at initial diagnosis, 11 years; interquartile range, 8-15 years; 2972 male [54.5%]; 4505 white [82.6%]) and 7233 youths with type 2 diabetes (median age at initial diagnosis, 19 years; interquartile range, 16-22 years; 1196 male [16.5%]; 5052 white [69.9%]), 64.9% of patients with type 1 diabetes and 42.2% of patients with type 2 diabetes had undergone an eye examination by 6 years after initial diabetes diagnosis. Black youths (1367 [10.8%] of the sample) had an 11% and Latino youths (1450 [11.4%] of the sample) had an 18% decreased hazard of undergoing an eye examination by 6 years compared with white youths (black youths: adjusted hazard ratio [HR], 0.89; 95% CI, 0.79-0.99; Latino youths: HR, 0.82; 95% CI, 0.73-0.92). As household net worth increased, youths were increasingly more likely to undergo an eye examination by 6 years after initial diabetes diagnosis

Effect of a tailored leaflet to promote diabetic retinopathy screening among young adults with type 2 diabetes: a randomised controlled trial.

“…The moderate effect size observed is consistent with those found elsewhere in behavioural medicine (26) The low overall sample size combined with a high baseline screening rate (72%) resulted in a lack of power to detect change in the primary outcome. Although similar to the general diabetes population screening rate in Australia (78%, 11) national and international data suggest that the true younger adult screening rate is closer to 50% (9,10), indicating that the current study is likely to have experienced recruitment bias. Possible explanations for recruitment bias, which favors high selfreported screening rates, include: self-selection bias and social desirability and recall bias (34).…”

“…Guidelines recommend screening for DR at T2D diagnosis, repeated periodically thereafter (5)(6)(7). Despite this, young adults with T2D have lower screening uptake in comparison with other groups (8,9). In Australia, screening rates in this priority population are estimated to be 55%, compared with 78% in the general diabetes population (10,11).…”

ISPAD Clinical Practice Consensus Guidelines 2018: Microvascular and macrovascular complications in children and adolescents

“…Severe retinopathy or macular oedema was present in 2% and the youngest patient with PDR was age 6 years. Lower rates of screening uptake were found in those with lower family income and this group had higher rates of retinopathy, suggesting that the actual rate may be even higher …”

“…84,85 In the T1D Exchange Registry in the United States, less than 1% of 12 235 patients reported treatment for retinopathy 86 were found in those with lower family income and this group had higher rates of retinopathy, suggesting that the actual rate may be even higher. 87,88 Initial worsening of diabetic retinopathy can occur with the initiation of improvement in glycemic control as occurred in the DCCT but such worsening did not result in clinically significant visual loss and over time, intensive therapy continued to be superior to standard therapy. This initial worsening of diabetic retinopathy with improvement of glycemic control also occurred in patients with growth failure due to severe under-insulinization.…”

Vulnerabilities in diabetic eye screening for children and young people in England

“…The National Pediatric Diabetes Audit (NPDA), which uses data reported routinely by pediatricians caring for children living with diabetes, reported that only 66% of the UK's eligible children were reported to have undergone screening in 2015/2016, with uptake ranging from 0% to 100% by unit (median: 74%; IQR: 65‐81%) . Similar low screening attendance has been reported in the US where 66% of children and young people (CYP) living with type 1 and 42% of those living type 2 diabetes had undergone retinal examination by 6 years following diagnosis . Uptake of DR screening decreases during adolescence, especially during transition to adult services, a period when non‐adherence to glycaemia control measures.…”