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Improving Eye Care for Persons with Diabetes Mellitus -- Michigan
Since 1984, the Michigan Department of Public Health Diabetes Control Program (MDCP) has conducted a statewide project to prevent vision loss by improving detection and treatment of diabetic retinopathy. Guidelines stressing the importance of routine annual examinations by ophthalmologists have been developed and widely distributed among physicians, patient educators, and persons with diabetes mellitus (1). Patient and provider surveys to determine eye care and referral practices have also been conducted to provide a baseline for assessing the impact of the project.
A mail survey of practicing ophthalmologists was conducted between August and October 1984 to describe ophthalmologist utilization patterns for diabetic and nondiabetic persons. The survey obtained information from ophthalmologists and their patients over a 5-day period. Ophthalmologists were identified from the membership roster of the Michigan Ophthalmological Society (MOS) and were selected from urban and rural regions of the state.
Questionnaires were sent to 51 general ophthalmologists and 21 retinal specialists; the response rates were 49% and 29%, respectively. Completed questionnaires were obtained from 12% of practicing general ophthalmologists and 27% of the practicing retinal specialists who were members of the MOS.
Of the 3,923 patients who visited the responding ophthalmologists during the 5-day survey periods, the MDCP obtained data on 3,325 (85%). Approximately 10% and 17% of the patients examined by the general ophthalmologists and retinal specialists, respectively, had diabetes.
In the general ophthalmologists' practices, 14% of diabetic patients were visiting for the first time, and in the retinal specialists' practices, 19%. Similarly, 20% and 25% of nondiabetic persons were having initial eye examinations by the general ophthalmologists or retinal specialists.
Individuals receiving their initial ophthalmologic examinations were asked to identify the person who recommended the visit. Diabetic individuals reported that the most important stimulus was their physician (Table 1); the second most important professional person was their optometrist. The most important source of nonprofessional encouragement for the diabetic individuals was self-referral, which accounted for 18% of initial visits to general ophthalmologists and 8% of initial visits to retinal specialists. Collectively, relatives and friends stimulated 30% of referrals to general ophthalmologists and approximately 20% of referrals to retinal specialists.
To allow evaluation of the impact of the 1984 Diabetic Retinopathy Guidelines, a survey was conducted during May 1985 to document baseline referral patterns for eye care for persons with diabetes. The survey was sent to members of the Michigan Organization of Diabetes Educators (MODE), the principal professional organization for diabetes educators in Michigan. Each MODE member actively involved in patient education was asked to complete a questionnaire and have up to seven patients also complete a questionnaire before beginning instruction.
Seventy (31%) of the 228 MODE members and 202 diabetes patients completed the survey. The patient educators who responded included 52 registered nurses, 15 registered dietitians, and four other health professionals. MODE's members include 142 registered nurses, 42 registered dietitians, and 38 other health professionals (six unknown).
Responses from the diabetes educators determined that 80% always or almost always recommended that their diabetic patients have routine eye examinations. Sixty-one percent of these educators recommended an eye examination by an ophthalmologist at least every 12 months. Among the 29% of educators who had already read Michigan's guidelines, 80% indicated their practices were in accord with the guidelines, compared to 54% for those who had not read the guidelines.
Seventy-five percent of the registered nurses made patient-referral recommendations consistent with the state's recommendations, compared to 17% of the other health professionals. For example, three of the 11 registered dietitians who indicated they advised their patients regarding eye care provided recommendations equivalent to those in the guidelines.
According to the guidelines, 177 (88%) of the 202 diabetic respondents should have received an eye examination through dilated pupils by an ophthalmologist during the previous 12 months. Only 76 (43%) received such care.
When asked about professional advice provided by physicians, nurses, or health educators, 81 (46%) of the 177 diabetic individuals reported they were told to have their eyes examined at least annually, and 71 (40%) were told to go to an ophthalmologist. Only 46 (26%) of 177 were told the complete recommendations in Michigan's guidelines. Diabetic individuals who received advice consistent with the guidelines were twice as likely to have visited an ophthalmologist during the past year as those who had not received such advice (67%, compared with 34%).
Self-reported "eye problems" seemed to influence the decision of a diabetic person to have an ophthalmologic exam, but these conditions did not appear to influence whether a diabetic person followed the guidelines. Among patients who were not advised about the guidelines, 44% of those with self-reported eye problems visited ophthalmologists within the past 12 months, compared to 25% of those without problems. Among individuals who were advised, 70% of those with eye problems and 63% of those without eye problems reported visiting an ophthalmologist within the past 12 months. Reported by W Herman, MD, University of Michigan, Ann Arbor, M Halpern, PhD, BE Pack, MPH, J Beasley, MA, C Callaghan, MPH, Diabetes Control Program, Center for Health Promotion, Michigan Dept of Public Health; Div of Diabetes Control, Center for Prevention Svcs, CDC.
Editorial Note: Diabetic retinopathy accounts for at least 10% of new cases of legal blindness in the United States each year and is the leading cause of new cases of legal blindness in adults aged 20-74 years (2). Proliferative diabetic retinopathy, the most severe form, is generally asymptomatic in its most treatable stages. In a university setting, 52% of internists and 33% of diabetologists missed the diagnosis of proliferative retinopathy, while fewer than 10% of ophthalmologists missed this diagnosis (3). A recent study, however, found that 37% of persons with earlier onset and 50% of persons with later onset of diabetes had not received an ophthalmological exam within the past 2 years (4).
In Michigan, public health officials are working to improve the level of diabetic care. They have developed referral guidelines for the detection of diabetic retinopathy, and they are disseminating these guidelines to physicians, diabetes educators, and other primary health-care providers. In addition, they are using media coverage to inform diabetic persons of the need for annual ophthalmologic examinations.
Surveys conducted in Michigan have attempted to document the current referral practices of providers and the care-seeking behavior of diabetic individuals and suggest that considerable improvements should be made in ophthalmologic utilization, patient and professional education, and patient-referral recommendations. Because these surveys had low response rates, caution must be used when making inferences from these findings. Additional information was not available to address the issue of selection bias. Subsequent surveys will be designed to improve response rates and collect information on nonrespondents.
Survey information from Michigan, thus far, is encouraging. For example, appropriate changes in patient behavior are occurring. Patients who did not report eye problems but who received recommendations consistent with Michigan's guidelines were much more likely to visit ophthalmologists than patients with eye problems who did not receive the guidelines. Further evaluation will be necessary to determine the impact of Michigan's Diabetic Retinopathy Guidelines. It will be necessary to document changes in retinopathy referral patterns and care-seeking behavior of the diabetic individual.
In an effort to prevent blindness associated with diabetic eye disease, CDC continues to support retinopathy projects in Georgia, Michigan, and Mississippi and is initiating eye-care projects for diabetic persons in the following states: Colorado, Florida, Kansas, Kentucky, Maryland, Massachusetts, Minnesota, New York, Ohio, and West Virginia. The program provides for examination of diabetic persons at high risk for retinopathy. These include persons who have noninsulin-dependent diabetes mellitus or postpubertal individuals with insulin-dependent diabetes mellitus of 5 or more years duration. Participants will also be examined for glaucoma, cataracts, and impaired visual acuity and for hypertension that can be associated with the development of retinopathy. Patients identified with treatable conditions will be assured access to care, and all participants will be referred for annual eye examinations. Those requesting further information should contact the state health departments in the states listed above or the Division of Diabetes Control, Center for Prevention Services, CDC.
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