Benefits unfamiliarity proves barrier to diabetes care

Although many patients with diabetes still don't appreciate the importance of routine dilated eye examinations, it's not the most common reason for neglecting necessary care—it's benefits bewilderment.

Published this past October in the journal American Health & Drug Benefits, a study illustrated that of the multitude of reasons for diabetic patient nonadherence to routine eye examinations, a lack of understanding of insurance benefits proved a greater barrier than insufficient awareness of examination importance.  

In fact, half of participating diabetic patients weren't sure if their routine dilated eye examination was even covered by their current plan, while one-third reported out-of-pocket costs, including co-pays and visits to other specialists, were barriers. A lack of importance of dilated eye examinations and time constraints were equally found to be the next most common reason for noncompliance.  

However, that's not necessarily how doctors viewed things. Interviewed separately from patients, participating doctors—9 ophthalmologists and 9 primary care providers—believed that lack of patient education and the fact that patients with diabetes already had to deal with a lot were the most common barriers for patients. Benefits awareness and out-of-pocket costs were far less likely to be identified as hindrances to routine care.  

The most troubling finding, however, was a lack of patients' sense of urgency for having a routine dilated eye examination, study authors note. It's an observation that highlights a need to better coordinate with primary care providers typically referring patients for examinations.  

"Education delivered by the healthcare provider regarding the importance of the dilated eye examination among patients with diabetes is addressable through patient interventions, but efforts are also needed to ensure that patients fully understand their health insurance benefits, as well as to reduce remaining financial barriers," the study concludes.  

Understanding optometry's role in diabetes care  

Diabetes is the leading cause of new blindness among U.S. adults, aged 20 to 74, and that's why AOA and groups such as the American Diabetes Association recommend patients with diabetes receive annual, dilated comprehensive eye examinations. However, the Centers for Disease Control and Prevention (CDC) shows adherence to this recommendation is subpar at best—nearly 37% of U.S. adults with diabetes forgo yearly examinations. Unfortunately, that means every 15 minutes someone with diabetes loses visual function.

Ideally, a diabetes diagnosis should immediately cue referrals for multidisciplinary care that includes a comprehensive eye examination, yet that's not always the case. Michael Dueñas, O.D., AOA chief public health officer, says although optometry already has come a long way in diabetes care since the late 1980s, optometry can and should do more.  

"From a public health perspective, we have to understand that in an epidemic we must engage the situation differently than we would otherwise," Dr. Dueñas says in the November/December 2016 edition of AOA Focus. "Doctors of optometry are primary care providers, and as such, they have to step up and assume a greater role."  

This expanded role involves a more proactive approach in terms of prevention and early detection of diabetes, notes Joseph Pizzimenti, O.D., full-time faculty member at University of the Incarnate Word, Rosenberg School of Optometry: "It's a transition that goes beyond retinopathy."  

A proactive approach could include administering hemoglobin A1C tests in the office, reviewing patients' glucose log books, educating about the ABCs of diabetes control, directing patients for continued care, or better informing patients about the importance of yearly examinations.  

"Up until now, it's been all about early detection of diabetic eye disease," Dr. Pizzimenti says. "Now, we are moving toward a conversation about what we can do to prevent diabetic eye disease from even happening. Even a quick, 2-minute conversation about the importance of proper nutrition, physical activity, smoking cessation, blood-pressure control or lipid control, all that ties in."  

Read more from the AOA Focus feature, "Eye Care in the Diabetes Age."