12 ways to provide better care for patients with prediabetes and diabetes
Trend No. 1: The U.S. Preventive Services Task Force recommended in March that, given such risk factors as obesity, age, family history and a sedentary lifestyle, at-risk Americans should be screened for prediabetes and type 2 diabetes starting at age 35. The American Diabetes Association recommends age 45.
Trend No. 2: According to a National Institutes of Health study published in August, the number of cases of diabetes among youth in the U.S. surged between 2001 and 2017. During that period, the number of people under age 20 with type 1 diabetes—the most common diabetes in youth—increased by 45%, and those with type 2 diabetes jumped by 95%.
Both trends are headed in the wrong direction.
“Increases in diabetes are always troubling—especially in youth. Rising rates of diabetes, particularly type 2 diabetes, which is preventable, has the potential to create a cascade of poor health outcomes,” said Giuseppina Imperatore, M.D., Ph.D., chief of the Surveillance, Epidemiology, Economics, and Statistics Branch in the Division of Diabetes Translation of the Centers for Disease Control and Prevention. “Compared to people who develop diabetes in adulthood, youth are more likely to develop diabetes complications at an earlier age and are at higher risk of premature death.”
As the nation’s primary eye care providers, what can doctors of optometry do to reverse these trends?
Plenty. And they have.
In 2019, they detected an estimated 431,000 cases of diabetes in patients who did not even know they had the disease.
“We have a huge opportunity,” says David Masihdas, O.D., who has dedicated a large portion of his practice for the past 25 years to the treatment of patients with prediabetes, type 1 and type 2 diabetes. “Optometry has the technology, knowledge and facility to provide that huge service.”
Says Michael Dueñas, O.D., AOA chief public health officer: “We should be practicing preventive care more, diagnosing prediabetes and type 2 diabetes, working with endocrinology toward effective glycemic control and not just referring out.”
Here are 12 things doctors of optometry and paraoptometrics can do today to enhance diabetes care.
1. Engage, educate, encourage
“Prevention is still better than a cure,” Dr. Masihdas says. “If you get a 10-year-old who has type 1 diabetes in the habit of getting their eyes examined on an annual basis, as a monitoring mechanism, it sets them up for better behavior as they get older. That’s where we are missing out right now.”
Even for youngsters, frank and informative conversations are needed and can be provided by doctors of optometry. “I tell them that what happens depends on how well they control their blood sugar and consequently their A1C,” Dr. Masihdas says.
“I also talk to them about getting into good habits (self-management) early. By that, I mean exercise and a good diet,” he says. “You might ask, ‘What types of exercise are you doing? How long are you doing them?’ When I talk to them about their diets, I tell them that ‘white bread, white rice, white flour, white pasta and anything that is sweet is not good for you.’ Very simple. If they cut those out, I tell them, there is a good likelihood they can live a very happy life for a long time without any serious complications. We need to encourage kids to be active, to stay away from screen time and watch their diets,” he says.
“We need to steer them back to their primary care doctors so they can discuss these things with them.”
2. Access patient education resources
The AOA has developed, in conjunction with doctors of optometry, a series of helpful patient education materials, including one-page fact sheets and trifold brochures on diabetes. Visit AOA Marketplace to find a two-sided fact sheet on diabetes retinopathy (in English and Spanish), a pamphlet with a Q&A on diabetes (in English and Spanish), nutrition resources, chairside resources on diabetes retinopathy and management of diabetes retinopathy, plus a diabetes health card for patients titled “Taking charge of your diabetes!” and a gallery print.
3. Optimize your EHR
Use your EHR to run reports on how many diabetes patients you have and who they are, says Jeffrey Michaels, O.D. For instance, though doctors might not be able to customize the fields in their EHRs, they can run a report on patients under 18 years of age who haven’t had a comprehensive eye exam within the past 12 to 15 months, Dr. Michaels says.
Its use in supporting clinical decision-making and help in identifying at-risk populations is cited in the AOA evidence-based clinical practice guideline Eye Care of the Patient with Diabetes Mellitus, Second Edition. The American Diabetes Association (ADA) recommends annual exams for children 10 years or older with type 1 diabetes.
“I would use my EHR report to query all my pediatric patients who have a diagnosis of diabetes who have not been in for an exam in a year or so. I can make sure they come in for an appointment,” Dr. Michaels says. “I could also query patients who have retinopathy or make sure that I use ‘recall’ within my EHR on all my kids with diabetes and especially those who have retinopathy to make sure they are getting reminders to come back at the time frame I thought they needed.”
4. Know the A1C goal for kids
Do you know the A1C for children? “A1C goals must be individualized and reassessed over time,” the ADA says in its 2020 Standards of Care recommendations on glycemic control.
“An A1C of <7% (53 mmol/mol) is appropriate for many children.” But that goal may vary, for instance, if a patient has a history of hyperglycemia. The previous version of the ADA’s Standards of Care, published in January 2019, recommended a goal of 7.5% for most children.
5. Make a reading list
- Eye Care of the Patient with Diabetes Mellitus, Second Edition
- Comprehensive Adult Eye and Vision Examination
- Comprehensive Pediatric Eye and Vision Examination
- ADA’s Standard of Medical Care in Diabetes—2020 (abridged)
The AOA Health Policy Institute (HPI) paper Timing of Comprehensive Eye Examination is Vital to Reducing Diabetes Complications
6. Provide point-of-care tests
Be open to point-of-care testing in your practice by becoming certified as a laboratory director under the Clinical Laboratory Improvement Amendments (CLIA) program.
Says Dr. Dueñas: “Real-time bloodwork results can help doctors better identify poor glycemic control among patients and illustrate the importance of self-monitoring, which can be beneficial for reconnecting suboptimally controlled patients with their primary care providers.”
7. Be a good teammate
We say it often—doctors of optometry are an integral part of the health care team. For a doctor of optometry, what does being a good teammate look like? Are you consistently communicating post-examination—via letters or EHR notes—with diabetes patients’ primary care physicians?
At University of Alabama-Birmingham School of Optometry (UAB), the notification to primary care physicians includes whether glasses or contact lenses were prescribed, and if a referral to a vision therapist or medication was made. Going forward, was the doctor of optometry recommending a routine or special “recall” schedule to monitor the patient’s progress? Then there are the diabetes-related findings.
“An optometrist is a very important part of the pediatric diabetes team,” says Katherine Weise, O.D., MBA director of the Pediatric Optometry Service in the UAB clinic. “Diabetes affects the small vessels of the body, so doctors who care for feet, kidney, heart and eyes are critical. Specialists who actively communicate and coordinate that care can propel the health and well-being of the child exponentially.” The notifications also serve to underscore the expert care provided by doctors of optometry and their very real contributions to the overall care team.
8. Get to know your PPOD—and the endocrinologist
A program of the CDC and National Institutes of Health identified a collaborative approach to managing diabetes. That approach involved collaboration between pharmacy, podiatry, optometry and dental—which make up the PPOD—because they all care at some point for patients with diabetes and are in position to work together to deliver consistent messages about that care.
“It’s a team disease,” says Dr. Dueñas, noting the urgency due to studies linking diabetes and COVID-19. “Communication should go both ways.”
9. Ask good questions
Does your family history form ask the right questions about patients’ history of diabetes? “We ask about family history of diabetes, which of course can increase the risk,” says Dr. Weise, whose UAB Pediatric Optometry Service was enlisted this year to provide eye care for patients at Children’s of Alabama’s Division of Pediatric Endocrinology and Diabetes.
“Also, early puberty can put you at risk for type 2 diabetes, independent of BMI (body mass index) or adiposity. We also ask open-ended questions, such as ‘what do you like to do for movement?’”
10. Become an authority on diabetes care
Last year, the National Certification Board for Diabetes Education changed its name to Certification Board for Diabetes Care and Education to truly reflect the role of certified diabetes care and education specialists (formerly certified diabetes educators) today. The aim is the same—to certify health care professionals who “educate and support people affected by diabetes.” Doctors of optometry are eligible for the certification, provided they meet additional criteria.
11. Learn from the experts
Available in the AOA’s EyeLearn Professional Development Hub, the course “AOA Diabetes Masters Class: Diabetes Guideline,” presented by A. Paul Chous, O.D., Steven Ferrucci, O.D., Jeffry Gerson, O.D., Mohammad Rafieetary, O.D., and James Thimons, O.D., is a “springboard to action,” says moderator Dr. Dueñas.
12. Join InfantSEE®
InfantSEE®, a program of Optometry Cares®—The AOA Foundation, is designed to ensure that eye and vision care become an integral part of infant wellness to improve a child’s quality of life. Under this program, AOA member doctors provide a no-cost comprehensive eye and vision assessment for infants 6-12 months old regardless of a family’s income or access to insurance coverage.
The 15th century polymath Leonardo da Vinci quipped, “the eyes, the window of the soul.” He couldn’t know the half of it. Only now, with 21st century technology, are researchers unlocking the secrets of the retina—and the brain. The search for retinal biomarkers of neurocognitive disorders is returning results, and optometry may hold a piece of the puzzle.
The AOA HPI offers information about providing integrated, person-centered diabetes self-management care and education through partnerships with community opportunities and other specialists.