Demographic and clinical characteristics of patients with diabetes presenting to an urban public hospital ophthalmology clinic

Implementation of a Teleophthalmology Screening Program for Diabetic Retinopathy in New York City

Purpose: To examine the implementation of a teleophthalmology program for diabetic retinopathy (DR) screening at a metropolitan hospital system and identify the challenges that the clinical teams encountered using the program. Methods: The study was conducted in 2 parts. The first was a pilot retrospective chart review of 300 consecutive patients screened for DR by the teleophthalmology screening program. The baseline variables, DR capture rate and staging, and continuity of care for those diagnosed with DR were analyzed. The second was a web-based survey identifying the barriers encountered by 36 physicians and clinical staff as they participated in the teleophthalmology screening program. Results: Part 1: Of the patients evaluated, 57 (19.0%) were diagnosed with DR; 42 (73.7%) had mild nonproliferative DR (NPDR), 7 (12.3%) had moderate NPDR, none had severe NPDR, and 8 (14.0%) had PDR. Thirty-one patients (54.4%) with retinopathy diagnoses were referred for an in-person follow-up at the clinic while the rest continued monitoring via the program. Of this subset, 22 (71.0%) completed the follow-up visit. Part 2: The survey respondents comprised 28 physicians (77.8%), 6 licensed nurse practitioners (16.7%), and 2 medical assistants (5.6%). Twenty-two providers (71.0%) preferred initiating referrals for in-person annual examinations over teleophthalmology screening referrals. The most common barriers described were related to workflow interruption, time constraints, and staff shortages. Conclusions: The teleophthalmology DR screening program allowed identification of early or absent DR at clinics in an urban setting (New York City). The findings suggest areas for targeted improvement in the screening program to better complement internal referral practices' workflows.

Telemedicine in an Academic Movement Disorders Center during COVID-19

Objective

Telemedicine has rapidly gained momentum in movement disorder neurology during the coronavirus disease (COVID-19) pandemic to preserve clinical care while mitigating the risks of in-person visits. We present data from the rapid implementation of virtual visits in a large, academic, movement disorder practice during the COVID-19 pandemic.

Methods

We describe the strategic shift to virtual visits and retrospectively examine elements that impacted the ability to switch to telemedicine visits using historical prepandemic in-person data as a comparator, including demographics, distance driven, and diagnosis distribution, with an additional focus on patients with deep brain stimulators.

Results

A total of 686 telemedicine visits were performed over a five-week period (60% of those previously scheduled for in-office visits). The average age of participants was 65 years, 45% were female, and 73% were Caucasian. Men were more likely to make the transition (p = 0.02). Telemedicine patients lived farther from the clinic than those seen in person (66.47 km vs. 42.16 km, p < 0.001), age was not associated with making the switch, and patient satisfaction did not change. There was a significant shift in the distribution of movement disorder diagnoses seen by telemedicine compared to prepandemic in-person visits (p < 0.001). Patients with deep brain stimulators were more likely to use telemedicine (11.5% vs. 7%, p < 0.001).

Conclusion

Telemedicine is feasible, viable and relevant in the care of movement disorder patients, although health care disparities appear evident for women and minorities. Patients with deep brain stimulators preferred telemedicine in our study. Further study is warranted to explore these findings.

Quantification of Retinal Nonperfusion and Neovascularization With Ultrawidefield Fluorescein Angiography in Patients With Diabetes and Associated Characteristics of Advanced Disease

Importance

Quantification of nonperfusion (NP) and neovascularization (NV) in diabetic retinopathy (DR) may identify better biomarkers of disease progression.

Objective

To identify demographic risk factors and markers of advanced DR that are associated with increased areas of NP and NV in eyes with disease ranging from no DR but diagnosed as having diabetes to proliferative DR (PDR) and to calculate a threshold total area of NP that may be associated with an increased risk of PDR.

Design, Setting, and Participants

This retrospective case series was performed on ultrawidefield fluorescein angiography (UWF FA) images from January 2009 to May 2018 at the University of Michigan Kellogg Eye Center. A total of 363 participants (651 eyes) diagnosed as having type 1 or 2 diabetes receiving UWF FA were included. Exclusion criteria included previous panretinal photocoagulation (PRP) and poor-quality images (eg, vitreous hemorrhage and significant cataract).

Main Outcomes and Measures

The surface areas in millimeters squared of the foveal avascular zone; total NP; NP at posterior pole, midperiphery, and far periphery; total NV; NV at posterior pole, midperiphery, and far periphery were measured.

Results

Of 363 patients, most were male (205 patients [56.5%]) and white (247 [68%]) or black (77 [21.2%]). The mean (SD) age was 59.4 (13.7) years. Seventy-six eyes with no DR, 92 with mild NPDR, 144 with moderate NPDR, 101 with severe NPDR, 220 with PDR, and 18 with DR of unknown severity were included. Male sex had a positive association with total NP (difference, 15.72; 95% CI, 4.83-26.61; P = .005); black race/ethnicity with total NV (difference, 2.32; 95% CI, 0.09-4.55; P = .04); and vitreous hemorrhage with total NP (difference, 30.00; 95% CI, 5.26-54.75; P = .02). A threshold total NP area of 77.48 mm2 (95% CI, 54.24-92.66 mm2) was identified, at greater than which patients may have an increased risk of developing PDR (sensitivity of 59.5% and specificity of 73.6%).

Conclusions and Relevance

Our results indicate NP and NV can be quantified on UWF FA. These biomarkers interpreted with demographic risk factors may help predict disease progression. Conclusions are limited by ascertainment and information biases because the results are from retrospective data.

Economic Strain Deteriorates While Education Fails to Protect Black Older Adults Against Depressive Symptoms, Pain, Self-rated Health, Chronic Disease, and Sick Days

Background

A large body of empirical evidence on Minorities' Diminished Returns (MDRs) suggests that educational attainment shows smaller health effects for Blacks compared to Whites. At the same time, economic strain may operate as a risk factor for a wide range of undesired mental and physical health outcomes in Black communities.

Aim

The current study investigated the combined effects of education and economic strain on the following five health outcomes in Black older adults in underserved areas of South Los Angeles: depressive symptoms, number of chronic diseases, pain intensity, self-rated health, and sick days.

Methods

This cross-sectional study included 619 Black older adults residing in South Los Angeles. Data on demographic factors (age and gender), socioeconomic characteristics, economic strain, health insurance, living arrangement, marital status, health behaviors, depressive symptoms, pain intensity, number of chronic diseases, sick days, and self-rated health were collected. Five linear regressions were used to analyze the data.

Results

Although high education was associated with less economic strain, it was the economic strain, not educational attainment, which was universally associated with depressive symptoms, pain intensity, self-rated health, chronic diseases, and sick days, independent of covariates. Similar patterns emerged for all health outcomes suggesting that the risk associated with economic strain and lack of health gain due to educational attainment are both robust and independent of type of health outcome.

Conclusion

In economically constrained urban environments, economic strain is a more salient social determinant of health of Black older adults than educational attainment. While education loses some of its protective effects, economic strain deteriorates health of Black population across domains. There is a need for bold economic and social policies that increase access of Black communities to cash at times of emergency. There is also a need to improve the education quality in the Black communities.

Patients' perspectives on the barriers to referral after telescreening for diabetic retinopathy in communities

OBJECTIVE

To understand the referral completion and explore the associated barriers to the referral after telescreening for diabetic retinopathy (DR) among people with vision-threatening DR (VTDR).

RESEARCH DESIGN AND METHODS

All participants with VTDR after DR telescreening in the communities completed the self-reported questionnaires to assess referral completion and their perspectives on referral barriers. Sociodemographic characteristics and perceived barriers related to incomplete referrals were identified by conducting univariate analysis and multiple logistic regression model. The final model was then built to predict incomplete referral.

RESULTS

Of the 3362 participants, 46.1% had incomplete referral. Old age and lower education level showed significant association with incomplete referral. Almost all participants had at least one barrier during the referral process. Knowledge-related and attitude-related barriers, including 'Too old to want any more treatment', 'Difficulty in getting time to referral', 'No serious illness requiring treatment at present', 'My eyes are okay', 'Distrust the recommended hospital' and 'Have not been diagnosed or treated before', and logistics-related barrier 'Mobility or transportation difficulties' showed significant association with incomplete referral.

CONCLUSIONS

The issue of incomplete referral after DR telescreening is serious among individuals with VTDR, particularly in the elder and low education level population. The negativity of knowledge-related and attitude-related factors might be more prominent than logistic barriers in predicting incomplete referral. Therefore, new strategies to improve the compliance with referral assist in optimizing the referral accessibility, and the ongoing educational support to improve the awareness of disease and increase the effectiveness of physician-patient communication.

Psychometric assessment and application of the Chinese version of the Compliance with Annual Diabetic Eye Exams Survey in people with diabetic retinopathy

AIM

To translate the Compliance with Annual Diabetic Eye Exams Survey (CADEES) into Chinese, allowing assessment of its reliability and validity, and to identify variables that predict attendance at annual eye examinations.

METHODS

People with vision-threatening diabetic retinopathy were recruited from the Shanghai Diabetic Eye Study. The study involved three phases: (1) translation and cross-cultural adaptation, (2) a pilot study (n = 496) to evaluate the psychometric properties of the Chinese-CADEES, and (3) a primary cross-sectional survey (n = 3818) to assess self-reported attendance at annual eye examinations. Factors related to non-attendance were identified using univariate analysis, and then a multiple logistic regression model. Finally, a component model and individual item models were built to predict attendance.

RESULTS

The Chinese-CADEES had satisfactory reliability and validity. The issue of low attendance at annual eye examinations was serious. In addition to 13 health belief items, living in semi-urban suburban areas, shorter duration of diabetes, poor glucose control, lower education level, better presenting visual acuity and milder diabetic retinopathy diagnosis were significantly related to non-attendance. The multivariate predictive model was able to predict, with 64.7% accuracy, whether or not participants were going to attend annual eye examinations and explained ~ 11.3% of the variance in attendance.

CONCLUSIONS

The Chinese-CADEES showed good reliability and validity for predicting attendance at annual eye examinations in people with diabetic retinopathy. Clinicians and researchers can improve attendance by addressing modifiable characteristics and increasing education on diabetic retinopathy and the importance of eye health in people with diabetes.

First Clinical Application of Low-Cost OCT

Purpose

We present the design of a new low-cost optical coherence tomography (OCT) system and compare its retinal imaging capabilities to a standard commercial system through a clinical study.

Methods

A spectral-domain OCT system was designed using various cost-reduction techniques to be low-cost, highly portable, and completely stand-alone. Clinical imaging was performed on 120 eyes of 60 patients (60 eyes of normal volunteers and 60 eyes with retinal disease) using both the low-cost OCT and a Heidelberg Engineering Spectralis OCT. Contrast-to-noise ratio (CNR) was measured from resulting images to determine system performance.

Results

The low-cost OCT system was successfully applied to clinical imaging of the retina. The system offers an axial resolution of 8.0 μm, a lateral resolution of 19.6 μm, and an imaging depth of 2.7 mm for a 6.6-mm field of view in the X and Y directions. Total cost is $5037, a significant size reduction compared to current commercial higher performance systems. Mean CNR value of low-cost OCT images is only 5.6% lower compared to the Heidelberg Spectralis.

Conclusions

The images captured with the low-cost OCT were of adequate resolution and allowed for clinical diagnostics. It offers comparable performance as a retinal screening tool at a fraction of the cost of current commercial systems.

Translational Relevance

Low-cost OCT has the potential to increase access to retinal imaging.

VISUAL AND ANATOMICAL OUTCOMES AFTER DIABETIC TRACTION AND TRACTION-RHEGMATOGENOUS RETINAL DETACHMENT REPAIR

PURPOSE

To evaluate visual and anatomical outcomes of diabetic tractional retinal detachment repaired with pars plana vitrectomy.

METHODS

Operative records were used to retrospectively identify all patients with tractional retinal detachments secondary to proliferative diabetic retinopathy surgically repaired with pars plana vitrectomy between November 1, 2009, and January 1, 2015 at the LAC + USC (Los Angeles County + University of Southern California) Medical Center.

RESULTS

A total of 403 eyes with diabetic tractional retinal detachment in 359 patients were included. Successful reattachment of the retina was achieved in 87.6% of eyes after one surgery and 92.6% of eyes at the final follow-up. Best-corrected visual acuity at the final follow-up improved two or more lines in 56.3% of eyes, was stable in 23.8% of eyes, and decreased two or more lines in 19.9% of eyes. Eyes repaired with 23-gauge and 25-gauge vitrectomy systems had similar success rates as eyes treated with 20-gauge instrumentation (P = 0.73). Eyes receiving silicone oil tamponade had lower single-surgery reattachment rates (77.6% vs. 87.6%; P = 0.013), lower reattachment rates at the final follow-up (85.7% vs. 92.6%; P = 0.048), and higher rates of vision loss (34.7% vs. 19.9%; P < 0.0001) but were more likely to have concurrent rhegmatogenous detachment (47.0% vs. 21.3%; P < 0.0001) and macula involving detachment (74.5% vs. 60.0%; P < 0.0001).

CONCLUSION

In this large, single-center retrospective study of patients with advanced diabetic tractional retinal detachment, vitrectomy achieved excellent anatomical outcome and improved or stabilized vision in 80.1% of eyes. Smaller gauge vitrectomy systems were found to have similar outcomes to 20-gauge instrumentation.

Identification of population characteristics through implementation of the Comprehensive Diabetic Retinopathy Program

Background

Diabetic retinopathy is the most common cause of blindness in working-age adults. Characteristics of patients with diabetes presenting to a retina subspecialty clinic have not been adequately studied, limiting our ability to risk stratify patients with diabetic retinopathy. Our goal is to describe an innovative program that collects structured, longitudinal data on patients with diabetes in a retina clinic, and identifies population characteristics to define patient risk stratification.

Methods

Demographics, body-mass index, blood pressure, hemoglobin A_1c, smoking history, diabetes type, diabetes duration, kidney disease history, and diagnosis codes were collected on all patients with diabetes at the Kellogg Eye Center retina clinic. A mixed effects negative binomial regression was then performed to assess visit frequency as a function of these variables. Visit frequency was used as a marker for cost of care. A subgroup of patients was surveyed about knowledge of diabetes management goals and barriers to better self-management.

Results

There were 2916 patients in the cohort with 1014 in the subgroup. The cohort was predominantly Caucasian (74.5%), with a mean age of 64 years (range 13–99) and a relatively even distribution of sex (53.2% men). The mean maximum hemoglobin A_1c was 8.0% (range 4.3–15.7%), and 57.1% had a diagnosis of diabetic retinopathy. Patients averaged 3.9 visits (range 1–27) during the 18-month study period. Blood pressure and duration of diabetes were positively associated with visit frequency (p < 0.0001, p < 0.0001, respectively). Of the surveyed patients, 87.6% knew their goal hemoglobin A_1c, while only 45.9% identified the correct blood pressure goal. The most common reported barrier to better self-management was “it’s just not working” (47.1%).

Conclusions

Implementation of this program enables the creation of a longitudinal dataset on patients with diabetes. Resulting data can be used to improve quality of care provided to patients at a retina clinic. The findings suggest considerable healthcare resources are being directed to a small patient population. This enhanced understanding of characteristics of patients with diabetes will improve efforts to preserve vision and utilize health system resources efficiently.

Factors influencing patient adherence with diabetic eye screening in rural communities: A qualitative study

Objective

Diabetic retinopathy remains the leading cause of blindness among working-age U.S. adults largely due to low screening rates. Rural populations face particularly greater challenges to screening because they are older, poorer, less insured, and less likely to receive guideline-concordant care than those in urban areas. Current patient education efforts may not fully address multiple barriers to screening faced by rural patients. We sought to characterize contextual factors affecting rural patient adherence with diabetic eye screening guidelines.

Research design and methods

We conducted semi-structured interviews with 29 participants (20 adult patients with type 2 diabetes and 9 primary care providers) in a rural, multi-payer health system. Both inductive and directed content analysis were performed.

Results

Factors influencing rural patient adherence with diabetic eye screening were categorized as environmental, social, and individual using the Ecological Model of Health. Major themes included limited access to and infrequent use of healthcare, long travel distances to obtain care, poverty and financial tradeoffs, trusting relationships with healthcare providers, family members’ struggles with diabetes, anxiety about diabetes complications, and the burden of diabetes management.

Conclusions

Significant barriers exist for rural patients that affect their ability to adhere with yearly diabetic eye screening. Many studies emphasize patient education to increase adherence, but current patient education strategies fail to address major environmental, social, and individual barriers. Addressing these factors, leveraging patient trust in their healthcare providers, and strategies targeted specifically to environmental barriers such as long travel distances (e.g. teleophthalmology) may fill crucial gaps in diabetic eye screening in rural communities.

Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives

The association between socioeconomic position and morbidity and mortality has long been recognized. We evaluate the evidence for an association between multiple aspects of deprivation and ocular health in a global context. This is a systematic review of studies that evaluated deprivation in the adult population in the context of the major acquired causes of visual loss such as cataract, diabetic eye disease, glaucoma, age-related macular degeneration, and ocular trauma. The search strategy identified relevant studies reported between 1946 and August 2016, with randomized control trials, case-control, cohort, and cross-sectional study designs being selected for inclusion. The studies identified in this review from across the world demonstrate the extent to which the common themes such as low educational attainment and low income may be associated with increased incidence of various sight-threatening conditions and may adversely affect access to specialist assessment and delivery of treatment. Health inequality may always persist, but an increased recognition of the importance of the various impacts of deprivation may empower policy makers to target limited resources to the most vulnerable groups in order to deliver the greatest benefit.

Disparities in Adherence to Screening Guidelines for Diabetic Retinopathy in the United States: A Comprehensive Review and Guide for Future Directions

Diabetic retinopathy (DR) is the leading cause of new-onset blindness in American adults aged 20-74 years old. The number of diabetics living with diagnosed DR increased by 89%, from 4.06 million to 7.69 million, between 2000 and 2010. Projected numbers from the Vision Health Initiative by the CDC predict that the rate of DR will triple by 2050, from 5.5 million people living with DR to 16 million. Screening guidelines aim to detect cases early because the treatments for DR can reduce severe vision loss by up to 94%. However, adherence to these guidelines is quite low. It is estimated that more than half of patients with diabetes may fail to receive necessary screening. Risk factors for non-screening discussed in this study include low health literacy, lack of access to care, pregnancy, physician adherence to guidelines, unique factors present in different minority populations, gender and age disparities, and living in rural regions. This paper also aims to address potential interventions that may improve adherence rates.

Diabetic tractional retinal detachment repair by vitreoretinal fellows in a county health system

PURPOSE

To investigate anatomical and functional outcomes of vitreoretinal fellow-performed vitrectomy for tractional retinal detachment secondary to proliferative diabetic retinopathy in a county hospital system.

METHODS

Consecutive retrospective review of patients surgically treated for diabetic tractional retinal detachment at Olive View-UCLA County Medical Center (Sylmar, CA) during a 2-year training period.

RESULTS

Sixty-two eyes of 58 patients met inclusion criteria with a mean age of 48 ± 9 years and preoperative hemoglobin A1c of 8.4 ± 1.9%. Previous panretinal photocoagulation had been performed in 34 eyes (54.8%). Mean surgery duration was 153 ± 54 minutes. There was no significant time difference observed between first-year fellow surgeries (159.5 ± 52.3 minutes) and those performed by second-year fellows (146.8 ± 56.4 minutes, P = 0.35), although there was a trend toward longer first-year surgical times. After a mean follow-up of 11.2 months, successful retinal reattachment was achieved in 56 eyes (90.3%). Overall, mean logMAR visual acuity improved from 2.0 ± 0.5 to 1.4 ± 0.8 (P = 0.0007). Final visual acuity had improved in 33 eyes (53.2%), was unchanged in 11 eyes (17.7%), and decreased in 18 eyes (29%). Postoperative complications encountered included early vitreous hemorrhage in 10 eyes (16.1%), delayed vitreous hemorrhage in 3 eyes (4.8%), secondary rhegmatogenous retinal detachment in 11 eyes (17.7%), and neovascular glaucoma in 5 eyes (8%). Second-year fellows had a lower incidence of rhegmatogenous retinal detachment than first-year fellows (P = 0.016).

CONCLUSION

Patients with diabetic tractional retinal detachment present to county hospitals with more complex retinal pathology, yet surgical outcomes as performed by vitreoretinal fellows compare favorably to previously reported series.

Diabetes eye screening in urban settings serving minority populations: detection of diabetic retinopathy and other ocular findings using telemedicine

IMPORTANCE

The use of a nonmydriatic camera for retinal imaging combined with the remote evaluation of images at a telemedicine reading center has been advanced as a strategy for diabetic retinopathy (DR) screening, particularly among patients with diabetes mellitus from ethnic/racial minority populations with low utilization of eye care.

OBJECTIVE

To examine the rate and types of DR identified through a telemedicine screening program using a nonmydriatic camera, as well as the rate of other ocular findings.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study (Innovative Network for Sight [INSIGHT]) was conducted at 4 urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority and uninsured persons with diabetes. Participants included persons aged 18 years or older who had type 1 or 2 diabetes mellitus and presented to the community-based settings.

MAIN OUTCOMES AND MEASURES

The percentage of DR detection, including type of DR, and the percentage of detection of other ocular findings.

RESULTS

A total of 1894 persons participated in the INSIGHT screening program across sites, with 21.7% having DR in at least 1 eye. The most common type of DR was background DR, which was present in 94.1% of all participants with DR. Almost half (44.2%) of the sample screened had ocular findings other than DR; 30.7% of the other ocular findings were cataract.

CONCLUSIONS AND RELEVANCE

In a DR telemedicine screening program in urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority populations, DR was identified on screening in approximately 1 in 5 persons with diabetes. The vast majority of DR was background, indicating high public health potential for intervention in the earliest phases of DR when treatment can prevent vision loss. Other ocular conditions were detected at a high rate, a collateral benefit of DR screening programs that may be underappreciated.

Self-Declaration of Diabetes and Factors Associated with Having Regular Eye Examinations among Patients with Type 2 Diabetes in Turkey

Purpose

To assess the awareness of diabetic retinopathy (DR), decided by self-declaration of diabetes, and the factors associated with having regular eye examinations among patients with type 2 diabetes in Turkey.

Methods

Between January and June 2014, 3322 adult patients attending an outpatient ophthalmology clinic were screened and 160 patients with type 2 diabetes with a known duration of at least 5 years were included. All patients were asked for their complaints and self-declaration of diabetes was noted. A questionnaire including questions about demographic characteristics, disease process, and follow-up was applied to responders, and all patients underwent a detailed ophthalmologic examination with dilation.

Results

A total of 31.9% of the patients self-declared that they had diabetes and/or requested examination for DR. A total of 29.4% reported that they had regular eye examinations. In regression analyses, factors associated with having regular eye examination were longer duration of diabetes (odds ratio [OR] 2.42; 95% confidence interval [CI] 1.01-5.8; p = 0.049), insulin use (OR 4.45; 95% CI 1.7-10.7; p = 0.001), and self-declaration of diabetes (OR 8.16; 95% CI 3.5-19.2; p<0.001).

Conclusions

The rates of self-declaration of diabetes and having regular eye examinations among patients with type 2 diabetes are low in Turkey. All adults undergoing an eye examination should be questioned for diabetes. Education of both patients with diabetes and the health care stuff dealing with them could improve the rates of patients having regular eye examinations and enhance the early detection of DR.

Eye care use among a high-risk diabetic population seen in a public hospital's clinics

IMPORTANCE

Little is known regarding eye care use among low-income persons with diabetes mellitus, especially African Americans.

OBJECTIVE

To investigate eye care use among patients with diabetes who were seen in a county hospital clinic that primarily serves high-risk, low-income, non-Hispanic African American patients.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study with 2 years of follow-up examined eye care use among adult patients with diabetes seen in 2007 in an outpatient medical clinic of a large, urban county hospital that primarily serves low-income, non-Hispanic African American patients. Patients with a history of retinopathy and macular edema or a current diagnosis indicating ophthalmic complications were excluded. Eye care use was defined dichotomously as whether or not patients had a visit to the eye clinic for any eye care examination or procedure. We estimated crude and adjusted rate ratios (aRRs) and 95% CIs for the association between eye care use and selected clinical and demographic characteristics.

RESULTS

There were 867 patients with diabetes identified: 61.9% were women, 76.2% were non-Hispanic African American, and 61.4% were indigent, with a mean age of 51.8 years. Eye care utilization rates were 33.2% within 1 and 45.0% within 2 years. For patients aged 19 to 39 years compared with those aged 65 years or older, significantly decreased eye care utilization rates were observed within 1 year (aRR, 0.48; 95% CI, 0.27-0.84) and within 2 years (aRR, 0.61; 95% CI, 0.38-0.99).

CONCLUSIONS AND RELEVANCE

Overall eye care utilization rates were low. Additional education efforts to increase the perception of need among urban minority populations may be enhanced if focused on younger persons with diabetes.

Assessment of awareness of diabetic retinopathy and utilization of eye care services among Turkish diabetic patients

AIMS

Raising awareness of diabetic retinopathy (DR) was shown to be a key element for early diagnosis and treatment of this blinding disease. There is very limited data about the knowledge level, attitude, and behavior of diabetic patients regarding DR in Turkey. This study was planned to assess the awareness of DR and the utilization of eye care services among Turkish diabetic patients.

METHODS

Diabetic patients who were under the care of ophthalmologists, endocrinologists, and/or primary care physicians were administered a questionnaire in order to assess their awareness of diabetes and its ocular complications.

RESULTS

A total of 437 patients (51.8% female and 48.2% male) with a mean age of 55.2 ± 11.9 were included in the study. Of the 437 patients, 31.8% had not been educated about diabetes, 88.1% were aware that diabetes can affect the eyes, and 39.8% thought that diabetics with good glycaemic control might suffer from DR. While 86.7% thought that early diagnosis was possible in DR, 77.3% previously had eye examinations, and 41.9% stated that annual eye examinations were necessary for diabetics. An educational level of middle school or higher, duration of DM longer than 5 years, previous DM education, and recruitment from the university (ophthalmology department and endocrinology department) were associated with better awareness of DR. The independent factors associated with visiting an ophthalmologist on a regular basis were DM education, DM duration, and site of recruitment.

CONCLUSION

Although most of the patients know that DM affects the eye, there is a lack of appropriate knowledge and behavior about the management of DR. The importance of better control of DM and regular eye examination in the prevention of DR should be emphasized.

Race/ethnic difference in diabetes and diabetic complications

Health disparities in diabetes and its complications and comorbidities exist globally. A recent Endocrine Society Scientific Statement described the Health Disparities in several endocrine disorders, including type 2 diabetes. In this review, we summarize that statement and provide novel updates on race/ethnic differences in children and adults with type 1 diabetes, children with type 2 diabetes, and in Latino subpopulations. We also review race/ethnic differences in the epidemiology of diabetes, prediabetes, and diabetes complications and mortality in the United States and globally. Finally, we discuss biological, behavioral, social, environmental, and health system contributors to diabetes disparities to identify areas for future preventive interventions.

Lack of awareness of common eye conditions in the community

PURPOSE

Awareness of eye conditions aids health promotion activities and leads to better outcomes. We examined factors influencing the lack of awareness of common eye conditions in a population.

METHODS

The Singapore Malay Eye Study examined 3280 (78.7% response) Malays aged 40-80 years. We included 2112 (64.4%) participants with at least one of five eye conditions: 1504 (71.2%) with cataract, 1013 (47.8%) with myopia, 270 (12.8%) with diabetic retinopathy, 181 (8.6%) with age-related macular degeneration and 150 (7.1%) with glaucoma. Lack of awareness was defined in the questionnaire as not answering "yes" to previously being told by a doctor of having the eye condition.

RESULTS

Among 2112 participants, 83.2% were unaware of at least one of their eye conditions. After controlling for age, sex and socioeconomic factors, participants unaware of their eye condition were older (odds ratio, OR, 1.03, per 1 year, p < 0.001), had better visual acuity (OR 1.32, p = 0.04), lower education (OR 1.89, p < 0.001), poorer literacy (OR 1.44, p = 0.02), lower income (OR 1.73, p = 0.009), higher blood glucose (OR 1.08, per 1 mmol/L, p < 0.001), higher serum cholesterol (OR 1.20, per 1 mmol/L, p = 0.003), lower annual eye examination attendance (OR 2.08, p < 0.001) and were less likely to wear glasses (OR 2.90, p < 0.001) than those who were aware of their condition.

CONCLUSIONS

In this community-based population, 80% of those with common eye conditions were unaware of their condition.

How Do Low-Income Urban African Americans and Latinos Feel about Telemedicine? A Diffusion of Innovation Analysis

Introduction. Telemedicine is promoted as a means to increase access to specialty medical care among the urban underserved, yet little is known about its acceptability among these populations. We used components of a diffusion of innovation conceptual framework to analyze preexperience perceptions about telemedicine to assess its appeal among urban underserved African Americans and Latinos. Methods. Ten focus groups were conducted with African American (n = 43) and Latino participants (n = 44) in both English and Spanish and analyzed for key themes. Results. Both groups perceived increased and immediate access to multiple medical opinions and reduced wait time as relative advantages of telemedicine. However, African Americans expressed more concerns than Latinos about confidentiality, privacy, and the physical absence of the specialist. This difference may reflect lower levels of trust in new health care innovations among African Americans resulting from a legacy of past abuses in the US medical system as compared to immigrant Latinos who do not have this particular historical backdrop. Conclusions. These findings have implications for important issues such as adoption of telemedicine, patient satisfaction, doctor-patient interactions, and the development and tailoring of strategies targeted to each of these populations for the introduction, marketing, and implementation of telemedicine.

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement

OBJECTIVE

The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement.

EVIDENCE

The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society.

CONCLUSIONS

Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

Prevalence of diabetic retinopathy in various ethnic groups: a worldwide perspective

The alarming rise in diabetes prevalence is a global public health and economic problem. Diabetic retinopathy is the most common complication of diabetes and the leading cause of blindness among working-age populations in the Western world. Screening and prompt treatment of diabetic retinopathy are not top priorities in many regions of the world, because the impacts of other causes of preventable blindness remain an issue. Ethnicity is a complex, independent risk factor for diabetic retinopathy. Observations from white populations cannot be extrapolated fully to other ethnic groups. The prevalence of diabetic retinopathy, sight-threatening diabetic retinopathy, and clinically significant macular edema are higher in people of South Asian, African, Latin American, and indigenous tribal descent compared to the white population. Although all ethnic groups are susceptible to the established risk factors of diabetic retinopathy-such as length of exposure and severity of hyperglycemia, hypertension, and hyperlipidemia-ethnic-specific risk factors also may influence these rates. Such risk factors may include differential susceptibility to conventional risk factors, insulin resistance, differences in anthropometric measurements, truncal obesity, urbanization, variations in access to healthcare systems, genetic susceptibility, and epigenetics. The rates of nonproliferative diabetic retinopathy appear to be declining in the United States, supporting the observation that better medical management of diabetes and prompt treatment of sight-threatening diabetic retinopathy substantially improve the long-term diabetic retinopathy incidence; studies from other parts of the world are limited and do not mirror this finding, however. We examine the ethnicity and region-based prevalence of diabetic retinopathy around the world and highlight the need to reinforce ethnicity-based screening and treatment thresholds in diabetic retinopathy.

Lack of Awareness amongst Community Patients with Diabetes and Diabetic Retinopathy: The Singapore Malay Eye Study

Introduction: We assessed awareness of diabetes and diabetic retinopathy in a Singaporean Malay population. We hypothesised that poor awareness is associated with poorer control of diabetic retinopathy risk factors (glycaemic and blood pressure levels) and suboptimal treat-ment with laser therapy. Materials and Methods: A population-based survey of 3280 (78.7% response rate) persons among Singaporean Malays aged between 40 and 80 years old. Diabetes was defined in persons with random glucose ≥11.1mmoL/L, use of diabetic medication, or a previous physician diagnosis. Diabetic retinopathy was graded from retinal photographs fol-lowing the modified Airlie House classification. Patient awareness was assessed via structured interviews. Glycosylated haemoglobin was measured from venous blood. Results: Of the 3280 study participants, 768 had diabetes, of whom 13.2% (n = 101) were unaware of their diabetes status. Participants unaware of their diabetes status had significantly higher mean glycosylated haemoglobin (9.7% vs 8.2%, P <0.001), systolic blood pressure (160.0 mmHg vs 153.7 mmHg, P = 0.01) and diastolic blood pressure (83.5 mmHg vs 78.5 mmHg, P <0.001), compared to participants who were aware. Of the 272 (35.4%) participants detected to have diabetic reti-nopathy, 83.4% (n = 227) were unaware of having retinopathy. Of the 77 with vision-threatening retinopathy, laser treatment had been performed in only 55.6% of those unaware of having retinopathy. Conclusion: In a sample of Malays with diabetes, high proportions were unaware of their disease. Unawareness was associated with poorer control of diabetic retinopathy risk factors. Only half of persons who were unaware that they had vision-threatening diabetic reti-nopathy had received laser treatment. These data highlight room for improvement in diabetic retinopathy prevention through better patient education and screening. Key words: Asia, Epidemiology, Ophthalmology

Pre-experience perceptions about telemedicine among African Americans and Latinos in South Central Los Angeles

This study explores perceptions about telemedicine among urban underserved African American and Latino populations. Telemedicine has been advanced as a vehicle to increase access to specialty care among the urban underserved, yet little is known about its acceptability among these populations. We conducted 10 focus groups with African American and Latino participants (n = 87) in urban Los Angeles in order to explore perceptions about this novel type of care. We found that concerns about telemedicine varied between the two racial/ethnic groups. These findings have implications for important issues such as adoption of telemedicine, patient satisfaction, and doctor-patient interaction. It will be critical to consider perceptions of this healthcare innovation in the development of strategies to market and implement telemedicine among urban, underserved African American and Latino populations.

Psychometric Performance of the National Eye Institute Visual Function Questionnaire in Latinos and Non-Latinos

OBJECTIVE

To compare the psychometric performance of Spanish versions of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) and the NEI VFQ-39 administered to Latino patients with the psychometric performance of the standard English NEI VFQ-25 and NEI VFQ-39 administered to non-Latino patients.

DESIGN

Clinic-based cross-sectional survey.

PARTICIPANTS

Four hundred three patients (160 Latinos and 243 non-Latinos) recruited from general ophthalmology clinics of an urban public hospital over a 6-month period.

METHODS

Structured face-to-face interviews were conducted in Spanish and English to collect data for the NEI VFQ-25 and NEI VFQ-39. We calculated the mean, standard deviation, and percentage of participants having the minimum (floor) and maximum (ceiling) possible score for each item and scale. Internal consistency reliability of the NEI VFQ-25 and NEI VFQ-39 was estimated using the Cronbach alpha and average inter-item correlation. Construct validity for the instruments was assessed by comparing scores for participants classified as having normal versus impaired visual acuity.

MAIN OUTCOME MEASURES

Instrument scales for general health; general vision; ocular pain; near activities; distance activities; vision-specific social functioning, mental health, role difficulties, and dependency; driving; color vision; and peripheral vision.

RESULTS

Internal consistency reliability was significantly lower in the Spanish version than in the English version for 3 scales of the NEI VFQ-25. More importantly, 3 scales in the Spanish version manifested inadequate reliability (alpha< or =0.70), compared with only 1 inadequately reliable subscale in the English version. Reliability coefficients associated with the Spanish NEI VFQ-39 scales exceeded commonly accepted minimum standards. Comparison of reliability coefficients between Latino and non-Latino subgroups demonstrated statistically significant differences for 4 scales: Ocular Pain, Mental Health, Role Difficulties, and Dependency. In each case, the Latino group had the lower internal consistency reliability. However, only for the Ocular Pain subscale was reliability both significantly lower and inadequate (alpha<0.70).

CONCLUSION

Overall performance of the NEI VFQ in Latino populations is adequate. However, in the absence of modifications to improve the reliability of specific Spanish version subscales, comparisons between Latino and non-Latino subgroups using the NEI VFQ must be interpreted with appropriate caution.

A Web-based Telemedicine System for Diabetic Retinopathy Screening Using Digital Fundus Photography

The purpose was to design and implement a Web-based telemedicine system for diabetic retinopathy screening using digital fundus cameras and to make the software publicly available through Open Source release. The process of retinal imaging and case reviewing was modeled to optimize workflow and implement use of computer system. The Web-based system was built on Java Servlet and Java Server Pages (JSP) technologies. Apache Tomcat was chosen as the JSP engine, while MySQL was used as the main database and Laboratory of Neuro Imaging (LONI) Image Storage Architecture, from the LONI-UCLA, as the platform for image storage. For security, all data transmissions were carried over encrypted Internet connections such as Secure Socket Layer (SSL) and HyperText Transfer Protocol over SSL (HTTPS). User logins were required and access to patient data was logged for auditing. The system was deployed at Hubert H. Humphrey Comprehensive Health Center and Martin Luther King/Drew Medical Center of Los Angeles County Department of Health Services. Within 4 months, 1500 images of more than 650 patients were taken at Humphrey's Eye Clinic and successfully transferred to King/Drew's Department of Ophthalmology. This study demonstrates an effective architecture for remote diabetic retinopathy screening.

Ophthalmologic disorders in minority populations

Race- and ethnicity-related differences in prevalence of a number ofophthalmologic disorders have been documented. More importantly, blackand Hispanic Americans share a disproportionate share of morbidity, asmeasured by visual impairment and blindness, when compared with whiteAmericans. The reasons for this health disparity are complex andmultifactorial. If the unequal, individual, and societal burden of avoidable vision lossamong black and Hispanic Americans is to be decreased, it is essential tounderstand the apparent barriers to accessing timely and appropriateophthalmologic monitoring and care for these minority populations. Forthose who do gain access to ophthalmologic care, it is important tounderstand better the determinants leading to different treatment of blackand Hispanic Americans compared with white Americans. Opportunities for decreasing vision-related morbidity caused by cataract,diabetic retinopathy, and glaucoma for these minority groups clearly exist. Strategies for each of these ophthalmologic disorders may differ. Cataract isa reversible cause of visual impairment and removal of cataract improvesquality of life. Cataract surgery should be offered to all who can potentiallybenefit from this treatment. Earlier diagnosis, before the disease hasprogressed to loss of vision, should be a goal in both glaucoma and diabeticretinopathy. Strategies for screening high-risk groups may be particularlyrelevant in this regard. Additionally, with diabetic retinopathy, improvedmanagement of contributing risk factors, such as blood glucose control andblood pressure control, is important. Asian Americans are increasingly becoming a sizable minority group inthe United States. It is projected that by 2070, the Asian population willreach 11% of the total population of the United States. Virtually all of thepopulation-based data relating to ophthalmologic disorders in Asians havebeen performed in Asia. The reported relative proportion of PACG versusPOAG, however, among some Asian populations and of normal-tensionglaucoma versus high-tension glaucoma among the Japanese seems to applyto the United States Asian population. This assertion is based onwidespread clinical impression and analysis of Medicare claims data [56]. Understanding the differences is important for optimal treatment of theseminority populations as the proportion of Asians in the United Statescontinues to grow. The common denominator in all of these diseases is the role of thephysician and patient. Educational programs aimed at the physician tofacilitate cultural competence and at the patient to increase level of knowledgeabout their disease are appropriate and enthusiastically endorsed.

Access to vision care in an urban low-income multiethnic population

OBJECTIVE

This study applied a well-known, recently revised theoretical model of healthcare access and utilization, the Behavioral Model for Vulnerable Populations, to examine the relationship between access to care and utilization of eye care services among a multiethnic, predominately minority sample of residents from low-income public housing.

DESIGN

Population-based, cross-sectional survey of community sample.

SETTING

Urban Public Housing Communities in Los Angeles County, California.

PARTICIPANTS

A geographically defined stratified random sample of 152 residents (86% Latino or African American) 40 years of age and older from three urban public housing communities.

RESULTS

Only 62% of our sample of persons 40 years and older had received an eye examination within the past 2 years. Sixty-one percent of participants reported having vision care coverage. Yet, one out of four respondents claimed that no health care provider had ever told them that they needed an eye-examination. Applying multiple logistic regression and controlling for a number of predisposing, enabling, and need-for-care characteristics, the variables 1) receiving advice from health care providers for eye examination (OR = 3.9, p < 0.01), 2) possessing coverage for eye-care (OR = 3.2, p < 0.01), and 3) having regular and continuity of medical care (OR = 2.4, p < 0.01) remained significant predictors of eye-examination within the past 2 years.

CONCLUSION

This study documents significantly diminished utilization of eye care services relative to recommended guidelines for a low-income, predominately minority sample of residents from public housing communities. We documented no association between presence of diabetes or hypertension and recency of eye examination. Affordability, continuity, and regular sources of care, as well as receiving physician advice, remain the core factors significantly associated with receiving vision care. These results underscore the need for continued efforts to ensure that the medically underserved minority have access to vision care services. These findings also point toward the urgent need for educational and motivational interventions that encourage health care providers serving underserved communities to promote eye examination, particularly among diabetic patients, hypertensive patients, and other individuals at risk for eye-related disease and complications.

Affluence is not related to delay in diagnosis of Type 2 diabetes as judged by the development of diabetic retinopathy

AIM

To determine the relationship between affluence and the presence of diabetic retinopathy at time of diagnosis of Type 2 diabetes.

METHODS

Records of patients held by Southampton Retinal Screening Programme were examined. Patients (n = 1844) newly diagnosed with Type 2 diabetes and subsequently receiving photographic retinal screening within 24 months were selected. Townsend scores for social deprivation were calculated and the patients with and without retinopathy at first screening were then compared.

RESULTS

No significant difference was found in the median Townsend score of those people with (-0.2, interquartile range (IQR) -3.7 to 3.8) and those without (-0.5, IQR -3.3 to 3.6) diabetic retinopathy at first screening after diagnosis of Type 2 diabetes (P = 0.6).

CONCLUSION

The relative affluence of the area in which a person lives, as judged by postcode, does not appear to predict likelihood of diabetic retinopathy at diagnosis of Type 2 diabetes.

Coagulation pathways and diabetic retinopathy: abnormal modulation in a selected group of insulin dependent diabetic patients

AIMS

To investigate whether diabetic retinopathy (DR), already associated with microvascular alterations, ischaemia, and endothelial dysfunction, was also characterised by abnormal modulation of coagulation pathways.

METHODS

Plasma samples, collected from 67 type 1 diabetics comparable for age, duration of disease (DD), and metabolic control (MC), were processed for prothrombin degradation products (F1+2) and factor VII coagulant activity (FVII:c). 50 normal subjects served as a control group. The ETDRS-Airlie House Classification of DR was used.

RESULTS

A significant correlation between FVII:c and F1+2 plasma concentrations was observed (p <0.05). FVII:c (p <0.005) and F1+2 (p <0.0001) levels were higher in diabetics than in controls, especially in patients with proliferative DR (FVII:c p <0.0001; F1+2 p<0.005). However, cases without retinal lesions and healthy subjects did not differ significantly (FVII:c and F1+2 p >0.05).

CONCLUSIONS

These findings pointed out the presence of a hypercoagulable state associated with endothelial dysfunction in patients with insulin dependent diabetes mellitus (IDDM), demonstrated both by increased FVII:c and F1+2 plasma levels. Moreover, the observation of different DR related degrees of procoagulant activity, despite comparable DD and MC, strengthens the hypothesis of multiple risk factors in the pathogenesis of DR.

Ocular manifestations of diabetes mellitus

The ocular complications of diabetes mellitus are numerous and include retinopathy, cataract, uveitis, and neurophthalmic disorders. A review of the current literature shows that the emphasis has changed from the laser and surgical management of pre-existent retinopathy to the development of cohesive multidisciplinary screening and education programs, and to a better understanding of the cellular and molecular mechanisms that underlie disease. The role of associated and potentially modifiable systemic factors is also now recognized. Early intervention with systemic and local therapies may soon provide hope for the better management of diabetic eye disease.

Diabetic retinopathy: are we really doing all we can for our patients?

Although it is now possible to significantly reduce the incidence of blindness secondary to diabetes mellitus, large numbers of diabetic patients still experience visual loss due to retinal complications of the disease. This implies that protocols for the diagnosis and treatment of diabetic retinopathy used in the various multicenter trials have not yet been transferred into routine clinical practice. In countries where ocular complications of diabetes have been managed on the basis of well-codified protocols for several years, the incidence of visual loss among diabetic patients has been significantly reduced. It is absolutely essential to introduce screening and treatment protocols for diabetic retinopathy promptly everywhere. Their application is within the reach of every ophthalmologist. Patients must be informed that it is important to have regular full ophthalmological examinations, before any symptoms occur; the guidelines for screening and management of retinopathy must be known and accepted by the medical community. Spreading this information among primary care physicians, ophthalmologists and diabetologists is a fundamental step in improving the health care of the diabetic patient.