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Interprofessional diabetes care improves with communication, regular screening
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Optometrists who interact with other providers more than once a year on behalf of patients with diabetes were more satisfied with their health care role and more likely to believe that team-based care makes a difference in patient outcomes, according to survey results from Kierstyn Napier-Dovorany, OD, FAAO, associate professor at the College of Optometry at Western University of Health Sciences, and her team.
“In the different practice situations in which I have worked, the interprofessional interaction has been dramatically different,” Napier-Dovorany said in an interview with Primary Care Optometry News. “I have always wondered if the theory of interprofessional interaction taught in optometry school does not align with most interprofessional interactions in practice.”
The email-based survey was sent to 9,600 U.S. optometrists, and researchers received 668 responses from ODs who currently see patients with diabetes. According to the results, 96.7% of respondents interact with other providers at least once a year.
She found a subgroup that interacts with non-eye care providers on an ongoing basis more than once per year. The characteristics that separated them from the rest of the optometrists include: practicing in a rural or urban area over suburban practice, seeing more ocular disease and diabetes patients, having residency training and practicing a greater number of years.
Napier-Dovorany said she and her colleagues are considering focusing on other disease processes, such as hypertension and rheumatological disease, in the future to compare optometrists’ practices to the interprofessional habits of other specialties, as well as investigating how to improve the interprofessional interaction between providers.
Diabetes remains the seventh leading cause of death in the U.S. and the leading cause of new blindness in those younger than 70 years, and 7.7 million people with diabetes have diabetic eye disease, according to the National Eye Institute during its recent Eye on Diabetes Twitter Chat. About one in three U.S. adults, or 84.1 million people, have prediabetes.
As the prevalence of diabetes increases, and as technology for routine refractive and wellness care becomes more kiosk- and web-based, Scott A. Edmonds, OD, FAAO, co-director of the Low Vision/Contact Lens Service at Wills Eye Hospital in Philadelphia, sees opportunity for optometry in systemic disease.
“Optometrists getting more involved in systemic medical problems that affect the eye, like diabetes, is really the future of the profession. We will better serve the profession and the public in this endeavor than trying to fight the online suppliers of optical goods,” he told PCON.
Optometrists can get more involved by finding out hemoglobin A1c (HbA1c) levels, as this number is critical to the care management plan, Edmonds added.
“Opening up communication with primary care should be what we are working on with electronic charts, but it is taking much longer than expected to achieve this,” he said. “In addition to us providing eye examination information to the PCP, it’s also critical for us to get systemic health information from the PCP. I think that the communication must be a two-way street.”
Guidelines on dilated exams
The American Diabetes Association (ADA) recently redefined its screening recommendations for diabetic retinopathy to ensure that those who need dilated exams the most receive them more frequently.
If there is no evidence of diabetic retinopathy at a comprehensive annual exam, exams every 2 years may be considered, based on Diabetic Retinopathy: A Position Statement by the American Diabetes Association, according to Sherrol A. Reynolds, OD, FAAO, an associate professor at Nova Southeastern University and clinical attending in the diabetes and macular clinic.
“The use of newer imaging technologies, such as OCT angiography (OCT-A), which aids in the detection of early diabetic retinopathy complications such as microaneurysms before they are clinically evident, may impact this recommendation,” she said in an interview.
“The 2-year schedule may make economic sense as long as there is no evidence of retinopathy at one or two exams and if the patient is well controlled and compliant with medications and management,” Reynolds said. “Also, if there is no retinopathy detected on OCT-A imaging.”
Patients who have risk factors for retinopathy, such as longer duration of the disease, poor glycemic control and concomitant diseases such as hypertension and hypercholesterolemia, should be checked with a dilated exam on an annual basis, she continued. Other risk factors, such as obesity, sleep apnea and concomitant retinal diseases such as AMD should be considered.
The ADA screening recommendation suggests that adults with type 1 diabetes should have a comprehensive eye exam within 5 years of disease onset, and that those with type 2 should have an exam at the time of diagnosis. Pregnant women with type 1 or type 2 should have a dilated exam before pregnancy or in the first trimester and be monitored every trimester and 1 year postpartum.
If a patient has no retinopathy and good metabolic control with an HbA1c less than 7%, shorter duration of diabetes and reasonably controlled blood pressure, that patient does not necessarily require an annual dilated exam, A. Paul Chous, MA, OD, FAAO, who specializes in diabetes eye care and education at his private practice in Tacoma, Wash., added.
Telemedicine debate
Much debate exists over telemedicine, its limitations, its advantages and how it fits into the diabetes care continuum.
In a retinal screening setting, the quality of the image is one of the most important components, according to Chous. Pupil size and media opacity greatly impact image quality, he told PCON.
Also, the camera matters. “A standard fundus camera captures a 30° to 45° field of the retina, and you’ll miss people that have retinopathy in the periphery,” he said. “Predominantly peripheral retinopathy lesions are associated with a higher risk of significant retinopathy progression.”
He believes an ultra-widefield device or montage fundus photography would be best.
Chous sees value in a system where patients are examined by an actual provider on a schedule of every other year.
“It’s kind of a fail-safe,” he said. “Severe and, hopefully, mild to moderate retinopathy is going to be caught by a reasonably good telemedicine program, and people with milder retinopathy aren’t likely to progress in a year, but it’s possible. Some patients with diabetic macular edema, the leading cause of vision loss in diabetes, will be missed without stereoscopic fundus examination or use of OCT. I think a stop-gap measure would be to alternate dilated exams with high-quality retinal imaging.”
He added that the images must be secure, with qualified readers who go through extensive training with certification and utilize high-quality instrumentation in the primary care or endocrinology office.
Chous supports primary care physicians, endocrinologists and eye doctors partnering “to form a collaborative consortium of patient care so that patients are getting screened for complications from the disease and receive mutually reinforcing messages.
“It’s also important to remember that there are reasons for routine eye care in diabetes other than the detection of sight-threatening retinopathy,” he added, “including detection of myriad other eye conditions and ongoing patient education as the care of diabetes evolves.”
Retinal screening clinics successful
One example of organized retinal screening for patients with diabetes is clinics spearheaded by Rajeev S. Ramchandran, MD, MBA, a retinal specialist at the Flaum Eye Institute, University of Rochester, New York.
He said many of his retinal screening clinics in the state doubled their patient screening rate for diabetic retinopathy. A few clinics screened 80% of their patient population within the first year. Furthermore, many of the patients went on to see an eye doctor because they were motivated to do so by learning that eye care is important by visiting the clinic.
Ramchandran told PCON that he first saw telemedicine at work in rural areas in India while in medical school. When he finished his residency, he was determined to keep patients from end-stage disease while promoting wellness through camera-based screening and linking with primary care. He worked with a local foundation to establish clinics that worked with an existing reading center to receive images.
The nonmydriatic cameras screen for vision-threatening retinopathy with sensitivity and specificity rates of over 85% to 90%, he said.
“The images of one’s own eye and retina are powerful tools to drive home the point of preserving eyesight through improved glycemic and blood pressure control to avoid potentially blinding damage to retinal blood vessels seen in these photographs,” Ramchandran said. “Eye care providers can work with primary care providers and staff to help teach patients how managing their diabetes well preserves good sight. If you do this enough and track people who then take better care of their sugars, you can help decrease retinopathy, people will save their sight, and diabetic retinopathy won’t be the leading cause of blindness in the U.S. or Canada anymore.”
Such a system also helps triage patients with the greatest need, he said.
“If you can understand who is at risk, perform interventions to mitigate that risk, keep people well, triage folks who need urgent care in a more appropriate manner and reach out to patients, we will promote wellness and health by reaching people before they become patients with eye disease,” Ramchandran said.
He also said a big part of setting up a screening center is finding the right interprofessional fit.
“You are imposing a screening strategy that must be on primary care’s terms; you have to find the right partners who are ready to champion the cause and get patients through the camera screening ... and they have to be motivated to follow up on these patients,” Ramchandran said.
The optometrist or ophthalmologist will read the images and give recommendations on follow-up, but the primary care physician will be the one to actually encourage the patient to follow up with an optometrist or ophthalmologist, he said.
“In a full exam you’re measuring IOP; examining for cataract, glaucoma and other eye issues; as well as assessing for glasses, things not done during screening,” Ramchandran said. “While a screening is not as complete as a full eye exam, performing a camera-based screening regularly every year can allow for a comprehensive dilated eye exam for the diabetic population probably once every 3 years for eyes without known or identified eye disease. This would free up eye care resources, especially to reach people who otherwise would not seek timely preventive eye care.
“Optometrists and ophthalmologists may be concerned that camera screening programs may reduce fee-for-service collections,” Ramchandran continued. “But in a value-based system when we are given a standard amount of money to care for a population over time, techniques such as remote camera-based screening are going to be the way to screen for vision-threatening retinopathy and eye disease in a safe, effective and efficient manner to care for a larger share of the population.”
Eye care providers should not run from screening; “they should be involved with it and driving it,” he said.
Best practices for comanagement
It is estimated that primary care providers receive an eye exam report for about 10% to 20% of patients with diabetes who get a dilated exam, Chous said.
“That’s pathetic,” he said. “It’s on us as a profession to help get those numbers substantially elevated.”
Many of our experts recommend sending a report immediately after seeing a patient. Letters can be faxed or mailed. Edmonds suggests keeping letters to one page and not using optometry-specific acronyms or lingo, which might be unknown to a primary care physician.
Mandeep Brar, MD, an endocrinologist in Glendale, Ariz., said that failure to send consultation or progress notes to the care team is a barrier to better comanagement.
“Another barrier is lack of a unified care plan that all providers are conveying to the patient, such as a hemoglobin A1C goal for a single patient, which can vary between different providers,” Brar told PCON.
In addition to sending a summary report of the patient’s eye findings to the primary care physician or endocrinologist, Reynolds gives a copy to her patients to deliver, allowing them to participate in their care. She also inquires about the forms at the follow-up appointments to ensure they were delivered.
She said she also gives all diabetic and pre-diabetic patients – even those with no retinopathy – a summary report so their treating physicians are aware that they are getting a dilated eye examination.
If Brar has specific recommendations that she wants discussed with another provider, she explains them to the patient and includes written instructions that are part of the patient’s clinic visit summary. She communicates urgent recommendations over the phone to the other providers. She also recommends providing patients with an updated medication list at each visit, especially if a new therapy is initiated.
“By optometrists knowing more about the diagnostic criteria of diabetes and prediabetes and the medications available – we will serve as educators for our patients to better manage their condition,” Chous said. – by Abigail Sutton
- References:
- Napier-Dovorany K, et al. Journal of Interprofessional Education & Practice. 2018;doi.org/10.1016/j.xjep.2017.10.003.
- Solomon SD, et al. Diabetes Care. 2017;doi.org/10.2337/dc16-2641.
- Story PP, et al. Retina. 2016;doi.org/10.1097/IAE.0000000000000652.
- For more information:
- Mandeep Brar, MD, can be reached at: mandeep.brar@gmail.com.
- A. Paul Chous, MA, OD, FAAO, can be reached at: dr_chous@diabeticeyes.com.
- Scott A. Edmonds, OD, FAAO, is a Primary Care Optometry News Editorial Board Member. He can be reached at: scott@edmondsgroup.com.
- Kierstyn Napier-Dovorany, OD, FAAO, can be reached at: knapier@westernu.edu.
- Rajeev S. Ramchandran, MD, MBA, can be reached at: rajeev_ramchandran@URMC.Rochester.edu.
- Sherrol A. Reynolds, OD, FAAO, is a PCON Editorial Board Member. She can be reached at sreynold@nova.edu.
Disclosures: Brar, Chous, Napier-Dovorany and Reynolds report no relevant financial disclosures. Edmonds is medical director for MARCH Vision Care. Ramchandran is a consultant for EyePACS and Google within an artificial intelligence project. He serves on the national scientific advisory council for Prevent Blindness.