If current trends continue, between one in five and one in three adults in the United States will have diabetes by 2050, according to current estimates. “Diabetes is the leading cause of new cases of blindness among adults aged 20 to 74,” says Chiu-Fang Chou, DrPH. “About 29% of people with diabetes have diabetic retinopathy.” In addition, reports have shown that blindness due to diabetes costs the U.S. approximately $500 million annually in healthcare and associated costs.
“The efficacy and effectiveness of screening for diabetic retinopathy among patients with diabetes is well established,” Dr. Chou says. Clinical guidelines recommend annual eye examinations for people with type 2 diabetes beginning at the time of diagnosis or after 5 years of diagnosis for those with type 1 diabetes. In the U.S., Medicare covers an annual eye examination for those with diabetes, and most health insurance covers medical eye examination and treatment for eye diseases, such as diabetic retinopathy, cataracts, and glaucoma. However, studies show that nearly 24% of people with diabetes report not having an eye examination in the past year.
“We need to better understand why people with diabetes do not seek eye care in order to increase the use of preventive services,” Dr. Chou says. In an effort to estimate the prevalence of not having an eye examination in the preceding 12 months, Dr. Chou and colleagues analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS). The study, published in Diabetes Care, also used BRFSS data to describe the reasons that patients did not seek eye care and to identify factors associated with these reasons.
According to the findings, one in four people with diabetes aged 40 and older had not received eye care in the past year. Data from the BRFSS also indicated that 40% of those with diabetes who did not receive eye care reported “no need” as a main reason for not doing so (Table). In addition, about one-third reported cost or lack of health insurance coverage as their main reason for not seeking eye care. People reporting barriers to eye care were highly associated with:
- Poorer sociodemographic factors.
- Lack of health insurance coverage.
- Longer time since a diagnosis of diabetes.
- Taking any diabetes medication.
- Vision impairment.
“We were surprised that ‘no need’ was reported as the main reason for not seeking eye care among people with diabetes because these individuals are at increased risk of developing vision impairment or blindness,” Dr. Chou says. “The underlying reasons for reporting ‘no need’ are not known, but it may be that people with diabetes are unaware that their disease affects vision. These patients may also not know that annual eye examinations are recommended to prevent vision loss.”
Dr. Chou says it was also surprising that nearly 12% of people who reported having diagnosed diabetes for 15 years or longer and did not have an eye exam reported ‘no eye doctor/transportation/appointment’ as their main reason for not seeking eye care. “Furthermore, only about 5% of people with diagnosed diabetes for less than 5 years and did not have an eye exam reported ‘no eye doctor/travel/appointment’ in our study,” she says. She adds that the likelihood of developing diabetes-related complications, including vision problems, increased with time after a diabetes diagnosis.
Assessing the Implications
Findings of the study illustrate the importance of developing strategies to overcome barriers for patients who do not perceive a need to address eye care as well as issues with costs and lack of insurance. “By addressing these barriers, we might be able to increase annual eye examinations among people with diabetes,” Dr. Chou says. Physicians and other healthcare providers should consider paying more attention to these factors and reminding people with diabetes to obtain annual eye examinations.
“Diabetes education is an opportunity to increase awareness,” says Dr. Chou. “We might receive fewer ‘no need’ responses among people who participate in diabetes education. Increasing the amount of information about the need for regular comprehensive eye care during diabetes education might further increase awareness.”
Although the study helped identify some of the primary reasons why people with diabetes do not seek eye care, Dr. Chou notes that more research is necessary. “Future studies should aim to help shape the development of targeted interventions and increase dissemination of effective public health messages to promote better eye care in patients with diabetes,” she says. “Ultimately, our priorities should be to increase annual eye examinations, reduce vision impairment, and improve quality of life among people with diabetes. Reminding patients with diabetes to have an annual eye examination could go a long way toward preventing vision impairment in this patient population.”
Readings & Resources (click to view)
Chou C, Sherrod CE, Zhang X, et al. Barriers to eye care among people aged 40 years and older with diagnosed diabetes, 2006-2010. Diabetes Care. 2014;37:180-188. Available at: http://care.diabetesjournals.org/content/37/1/180.full.
Fong DS, Aiello L, Gardner TW, et al.; American Diabetes Association. Retinopathy in diabetes. Diabetes Care. 2004;27(Suppl):S84-S87.
Zhang X, Saaddine JB, Chou CF, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA. 2010;304:649-656.
Chou CF, Zhang X, Crews JE, Barker LE, Lee PP, Saaddine JB. Impact of geographic density of eye care professionals on eye care among adults with diabetes. Ophthalmic Epidemiol. 2012;19:340-349.
Owsley C, McGwin G, Scilley K, Girkin CA, Phillips JM, Searcey K. Perceived barriers to care and attitudes about vision and eye care: focus groups with older African Americans and eye care providers. Invest Ophthalmol Vis Sci. 2006;47:2797-2802.