Are your patients adhering to diabetes self-care standards? Here's how you can help

Daily self-monitoring of blood glucose, foot checks, cholesterol checks and annual, dilated eye examinations—patients are advised these practices done in conjunction can help fend off diabetes-related complications, researchers say.

Yet, adherence to these standards was below average among patients with diabetes, say authors of a study published Jan. 19, 2021, in BMJ Open Diabetes Research & Care.

Among the 30,780 participants studied, only about 30% abided by all four diabetes care practices, they found. Further, cost-related variables, such as having health insurance and/or a personal doctor, “were positively associated with diabetes care practices, with the strongest association observed for adherence to more costly practices (annual eye examination and cholesterol check) vs. less costly ones (daily blood glucose check, daily foot check).”

Assessing variations in diabetes self-care practices and factors linked with differences in adherence was the purpose of the study. Data from the 2017 Behavioral Risk Factor Surveillance System survey was used.

Among the findings:

• Adherence concurrently to all four diabetic care practices was low (30%), though a higher percentage of study participants complied with individual, not all, practices.
• Daily foot checks were not as common (60%) and annual eye examinations more common (69% vs. 62%) in 2017 compared to 2010 data.
• Risk factors for adherence were linked to individual care practices for diabetes. Practices more closely related to cost and access to care, such as eye exams, showed lower adherence compared with less costly, home-based practices, such as foot checks.

The authors conclude the study by offering potential solutions for increasing adherence.

“These findings suggest that stronger adherence may require diabetes care practice-specific strategies, such as improved accessibility or more comprehensive insurance coverage for clinic-based practices, and targeted early education for home-based practices,” the researchers say.

“Encouraging early adherence may reduce complications and unnecessary future costs, particularly in high-risk subgroups,” they add. “Given that the highest adherence was observed for annual cholesterol checks, adherence to the remaining diabetes care practices could be reinforced at the same time that a health care provider orders a cholesterol test.”

Education among keys to adherence, doctors say

Diane Russo, O.D., MPH, associate professor of optometry at the New England College of Optometry, teaches several courses in patient care. Dr. Russo finds grounds for hope and concern in the study.

“For optometrists, I think it's encouraging to see that there has been an increase in eye exams for patients with diabetes compared to the same survey results from 2010, which means we're trending in the right direction,” she says.

“However, there was also evidence that patients with less severe disease were less likely to adhere to the diabetes care practices,” she adds. “This is something doctors can keep in mind for implementing the ‘targeted early education’ discussed in the article.”

To increase adherence, Dr. Russo says, doctors can include education of all four diabetes care practices as part of their diabetes patient education. But one challenge highlighted in the study was that patients with less severe disease in particular are less likely to follow the four practices all together.

Further, the study identifies “a very real barrier” to care—a lack of health insurance that can cover the cost of an annual eye exam, Dr. Russo notes. According to the study, the lowest percentage of patients following the care practices (16.4%) were those without health care coverage.

“Expanding access to health insurance is an important step in providing access to needed eye care services to all patients, but patients with diabetes specifically based on this study,” she says. “Doctors could be participating in advocacy work to expand access to care in the form of health insurance for all.”

Paula Newsome, O.D., M.S., practices in North Carolina, where she manages a program called “KNOC out Diabetes™.” The program emphasizes patients’ self-management of their disease, including nutrition, counseling and eye health.

Doctors of optometry, Dr. Newsome says, can make a real difference to patients with diabetes because of their geographic diversity. Ninety-nine percent of Americans live in a county with a doctor of optometry. More than 90% of U.S. Medicare beneficiaries live within 15 minutes of a doctor of optometry.

“As optometrists, who are found all over the country and are widely disbursed throughout the country, we may be the only or most convenient doctor our patients see,” Dr. Newsome says.

“We should be, and need to be, included in their health care team to ensure our patients are getting the information that they need,” she says. “I truly believe when people know better, they do better. It is incumbent upon doctors of optometry to expand their knowledge and become patient advocates in the management of their disease.”

Expand your knowledge

Read “Integrating Models of Diabetic Eye Care” in the November/December 2020 edition of AOA Focus.

Access the AOA’s Evidence-based Clinical Practice Guideline: Eye Care of the Patient with Diabetes Mellitus, Second Edition and listen to a podcast.

Educate your community

Find an infographic that you can use to educate your community on the importance of regular, dilated eye exams from a doctor of optometry.

Advocate for patients

Expanding access to health insurance is an important step in providing access to needed eye care services to all patients. Access the AOA’s Action Center to contact your federal lawmakers and agency officials.