If you are like many primary care physicians, you may refer your patients with diabetes to an eye care specialist for an annual eye exam, but most of those patients never go or go less frequently than requested. According to the American Academy of Ophthalmology (AAO), over 50 percent of patients with diabetes, when asked by their primary medical provider, don’t end up scheduling or attending the follow up eye exam after their primary care visit.[i] Additionally, studies show compliance rates may be as low as 15% in patients with type 2 diabetes.[ii]
These low compliance rates are especially problematic given that diabetic retinopathy (DR) is the leading cause of blindness in American working-age adults, with nearly 24,000 patients going blind from DR complications each year.[iii] [iv] Yet DR is a highly treatable disease for which early diagnosis and treatment is essential to prevent vision loss and address manageable symptoms before damage is irreversible.
There are a number of reasons patients don’t follow through on their eye care referrals. Patients cite finances as a major barrier, with the cost of overall diabetes care overshadowing concerns about eye disease.[v] Low rates of retinal exam compliance are also associated with limited access to eye care specialists in many cases.[vi]
To overcome these barriers to compliance, it is important to provide patients with options, including options that increase their access to testing for DR. Providing or coordinating education about what the patient can expect during the exam process can also be of benefit.
The Traditional Eye Exam
The most common method primary care physicians use to get patients tested for DR is to refer them for a comprehensive eye exam at an eye care specialist’s office.
Dr. Stephen Russell, an ophthalmologist at University of Iowa Health Care, said, “A typical ocular evaluation runs 45 minutes to an hour, especially for a new patient exam. Then, in general if abnormalities are identified, additional testing may be required which would extend the duration of the evaluation.”
According to Dr. Russell, “An eye care provider looks at general characteristics of vision like vision manifest refraction, as well as assessing glasses requirements, and conducting visual field, pupillary, eye movement, biomicroscopic exams, and so on. Then the eyes are dilated so the examiner can look at the back of the eye for evidence of DR, which is the most common complication of diabetes in the eyes.”
Patients who receive a DR diagnosis may not have symptoms, as the early stages of DR tend to be asymptomatic.
“The majority of patients have DR in an early disease state that does not require intervention,” said Dr. Russell. “However, it is important a patient’s DR continues to be monitored in the event it progresses to a more advanced stage that does require treatment.”
If DR is severe enough to require treatment, Dr. Russell said, “treatment could range from increased attention to blood sugar levels, to injections in the eye, to minor eye surgery.”
With DR, the sooner the disease is directed, the less invasive treatment needs to be.”
An accessible way for patients to complete their DR exam
With new advances in technology, patients now have the option of receiving their DR exam in their primary care provider’s office with an autonomous AI diagnostic tool called IDx-DR.
An advantage of this approach is that no additional scheduling or visits are necessary, and dilation of the eye may not be required. This option is far more convenient for patients under the control of a primary care physician and increases the likelihood the patient will complete their exam on an annual basis. Patients who have an IDx-DR exam are only referred to an eye care specialist if the exam indicates they have more than mild diabetic retinopathy. By enabling earlier disease detection through testing in primary care offices, patients may be able to avoid potential vision loss.
“It has been shown in a number of studies that the earlier you get treated, the more effectively we can preserve the patient’s vision. We can’t always recover all of the vision that’s been lost, so for that reason we try to intervene before the vision deteriorates significantly,” said Dr. Russell.
This is why the IDx-DR approach, which is to move the evaluation closer to annual patient contact by putting it in the primary care office, has a lot of potential benefit.”
An exam with IDx-DR
An IDx-DR exam adds, on average, less than ten minutes to a patient’s diabetes checkup visit. The patient has two images taken of each eye by a trained operator, usually without the need for dilation. The AI based diagnostic software then analyzes the images for signs of diabetic retinopathy. In less than a minute, a diagnostic report is generated that indicates whether the patient has more than mild diabetic retinopathy and should be referred to an eye care specialist, or whether the patient’s eyes are negative for more than mild diabetic retinopathy and can be retested in twelve months.
As the primary care physician, the instant results of IDx-DR allow you to provide a more comprehensive view regarding the end organ effects of diabetes management to patients during their diabetes exam. If further intervention is necessary, you have the data needed to advise them about the benefits of making and keeping referral follow up appointments.
An IDx-DR exam allows for a patient to have easier access to the diagnostic they need, at an affordable rate, in their primary care office. There is no additional wait time or follow-up needed as the system is an instantaneous DR diagnostic while the patient is in the office.
This new DR diagnostic has the potential to reduce the number of people with diabetes who go undiagnosed, while simultaneously reducing the unnecessary referral of patients who don’t have DR. This approach also has the potential to reduce the strain on eye care specialists’ schedules and allow for shorter wait times for those who are in need of treatment.
“Part of what makes IDx-DR unique is that it is specifically for people who are not currently under an ophthalmologist’s care for a complication of the eye caused by diabetes,” said Dr. Russell.
IDx-DR is not a replacement for an eye care specialist, but rather a powerful diagnostic tool that aims to reduce vision loss by making a high-quality diagnostic assessment more accessible to patients who may never have been seen otherwise.
[i] Sixty Percent of Americans with Diabetes Skip Annual Sight-Saving Exams [Internet]. American Academy of Ophthalmology. 2016 [cited 2019May13]. Available from: https://www.aao.org/newsroom/news-releases/detail/sixty-percent-americans-with-diabetes-skip-exams
[ii] Benoit SR, Swenor B, Geiss LS, Gregg EW, Saaddine JB. Eye Care Utilization Among Insured People With Diabetes in the U.S., 2010-2014 [Internet]. Diabetes care. U.S. National Library of Medicine; 2019 [cited 2019Jun7]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30679304
[iii] Watch Out for Diabetic Retinopathy | Features | CDC [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2018 [cited 2019May13]. Available from:https://www.cdc.gov/features/diabetic-retinopathy/index.html
[iv] Economic Studies|Vision Health Initiative (VHI) [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2017 [cited 2019May17]. Available from: https://www.cdc.gov/visionhealth/projects/economic_studies.htm
[v] Hartnett ME. Perceived Barriers to Diabetic Eye Care [Internet]. Archives of Ophthalmology. American Medical Association; 2005 [cited 2019May17]. Available from: https://jamanetwork.com/journals/jamaophthalmology/fullarticle/416929
[vi] Lee DJ, Kumar N, William J Feuer C-FC, Rosa PR, Schiffman JC, Morante A, et al. Dilated eye examination screening guideline compliance among patients with diabetes without a diabetic retinopathy diagnosis: the role of geographic access [Internet]. BMJ Open Diabetes Research & Care. BMJ Specialist Journals; 2014 [cited 2019May17]. Available from: https://drc.bmj.com/content/2/1/e000031