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Original Investigation | Clinical Sciences

Underuse of the Health Care System by Persons With Diabetes Mellitus and Diabetic Macular Edema in the United States

Neil M. Bressler, MD1; Rohit Varma, MD2; Quan V. Doan, PharmD3; Michelle Gleeson, PhD3; Mark Danese, PhD3; Julie K. Bower, PhD4; Elizabeth Selvin, PhD4; Chantal Dolan, PhD5; Jennifer Fine, ScD5; Shoshana Colman, PhD5; Adam Turpcu, PhD5
[+] Author Affiliations
1Wilmer Eye Institute, Johns Hopkins University School of Medicine and Hospital, Baltimore, Maryland
2Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois College of Medicine, Chicago
3Outcomes Insights, Inc, Westlake Village, California
4Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
5Genentech, Inc, South San Francisco, California
JAMA Ophthalmol. 2014;132(2):168-173. doi:10.1001/jamaophthalmol.2013.6426.
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Importance  Thickening of the center of the retina, diabetic macular edema (DME), is the most common cause of visual loss due to diabetes mellitus. Treatment of DME has improved dramatically, and the prompt diagnosis of DME and referral of these patients have become more critical. Nonetheless, awareness of and care for DME in the US population is uncharacterized.

Objective  To characterize eye care and awareness of eye disease among persons with DME in the general US population.

Design, Setting, and Participants  Cross-sectional analysis of data from participants in the 2005 to 2008 National Health and Nutrition Examination Survey 40 years or older with diabetes mellitus and fundus photographs.

Main Outcomes and Measures  Among persons with DME, (1) awareness that diabetes has affected their eyes; (2) report on the last time they visited a diabetes specialist; (3) report on their last eye examination with pupil dilation; and (4) prevalence of visual impairment.

Results  In 2010, only 44.7% (95% CI, 27.0%-62.4%) of US adults 40 years or older with DME reported being told by a physician that diabetes had affected their eyes or that they had retinopathy; 46.7% (95% CI, 27.5%-66.0%), that they had visited a diabetes nurse educator, dietician, or nutritionist for their diabetes mellitus more than 1 year ago or never; and 59.7% (95% CI, 43.5%-75.9%), that they had received an eye examination with pupil dilation in the last year. Among persons with DME, 28.7% (95% CI, 12.7%-44.7%) were visually impaired (defined as visual acuity worse than 20/40 in the eye with DME) based on visual acuity at the initial examination and 16.0% (95% CI, 2.5%-29.4%) based on best-corrected visual acuity.

Conclusions and Relevance  Many persons with diabetes mellitus in the United States are not getting care that can prevent visual impairment and blindness. Strategies to increase awareness are warranted, especially given the recent availability of improved therapies for DME.

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Figures

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Figure 1.
Awareness of Eye Diseases Among Study Participants With Self-reported Diabetes Mellitus

Participants 40 years or older were asked, “Have you been told by a doctor that diabetes has affected your eyes or that you had retinopathy?” Unknown responses were not reported. Error bars represent 95% confidence intervals. DME indicates diabetic macular edema; DR, diabetic retinopathy.

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Figure 2.
Self-reported Last Visit to a Diabetes Mellitus Specialist Among Study Participants With Diabetes

Participants 40 years or older were asked, “When was the last time you saw a diabetes nurse educator or dietitian or nutritionist for your diabetes?” The total for each cohort equals 100%. If not, the difference represents participants who responded “don't know” to this question (not shown). Error bars represent 95% confidence intervals. DME indicates diabetic macular edema; DR, diabetic retinopathy.

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Figure 3.
Self-reported Last Examination With Pupil Dilation Among Study Participants With Diabetes Mellitus

Participants 40 years or older were asked, “When was the last time you had an eye examination in which the pupils were dilated?” The total for each cohort equals 100%. If not, the difference represents participants who responded “don't know” to this question (not shown). Error bars represent 95% confidence intervals. DME indicates diabetic macular edema; DR, diabetic retinopathy.

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Figure 4.
Percentage of Study Participants With Presenting or Best-Corrected Visual Acuity (VA) Worse Than 20/40

Participants 40 years or older included those with diabetes mellitus, diabetes mellitus and diabetic retinopathy (DR) but no diabetic macular edema (DME), and diabetes mellitus with DME. Responses of “unknown” were not reported. Error bars represent 95% confidence intervals.aStandard error is more than 30% of the estimate; estimate may be unreliable.

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