Patients’ Adherence to Recommended Follow-up Eye Care After Diabetic Retinopathy Screening in a Publicly Funded County Clinic and Factors Associated With Follow-up Eye Care Use | Diabetic Retinopathy | JAMA Ophthalmology | JAMA Network
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Original Investigation
November 2016

Patients’ Adherence to Recommended Follow-up Eye Care After Diabetic Retinopathy Screening in a Publicly Funded County Clinic and Factors Associated With Follow-up Eye Care Use

Author Affiliations
  • 1Department of Ophthalmology, School of Medicine, The University of Alabama at Birmingham
  • 2Department of Epidemiology, School of Public Health, The University of Alabama at Birmingham
  • 3Wills Eye Hospital, Philadelphia, Pennsylvania
JAMA Ophthalmol. 2016;134(11):1221-1228. doi:10.1001/jamaophthalmol.2016.3081
Key Points

Question  To what extent do patients with diabetes in a diabetic retinopathy screening program in a publicly funded county clinic adhere to the timetable of recommended follow-up eye examinations?

Findings  In this prospective follow-up study, only 29.9% of patients adhered to recommendations to have an eye examination within indicated time frames, even though cost and accessibility were minimized as barriers. Two years later, 50.9% of patients still had not undergone an eye examination.

Meaning  These data suggest that diabetic retinopathy screening programs unlikely meet their goals about adhering to eye care recommendations.


Importance  The public health success of diabetic retinopathy (DR) screening programs depends on patients’ adherence to the timetable of follow-up eye care recommended by the screening program. African Americans are among those at highest risk for DR and have one of the lowest rates of eye care use.

Objectives  To assess the rate of adhering to recommended follow-up eye care in a DR screening program administered in a safety-net health care facility and to examine factors associated with follow-up eye care use.

Design, Setting, and Participants  Prospective follow-up study of persons with type 1 or type 2 diabetes. The setting was an internal medicine clinic of a publicly funded health system in Alabama, serving a population largely uninsured and African American, that had implemented a DR screening program using a nonmydriatic camera for ocular imaging and remote reading centers for evaluation of images. Patients with physician appointments between January 26 and July 24, 2012, were eligible for screening if they had a diagnosis of type 1 or type 2 diabetes and were 19 years or older. Data from the county health system’s administrative database were obtained from January 26, 2012 (date of first enrollee), through May 1, 2015, to establish participants’ eye care use in the ophthalmology clinic after screening.

Main Outcomes and Measures  Adherence to the recommended interval of follow-up eye appointments in the facility’s ophthalmology service as determined by administrative records, as well as factors associated with adherence.

Results  Diabetic retinopathy screening was completed in 949 adults with diabetes, of whom 84.5% (802 of 949) were African American, 64.5% (612 of 949) were women, and 71.7% (680 of 949) lacked health insurance. Participants ranged in age from 21 to 95 years, and their mean (SD) age was 53.9 (10.4) years. The mean (SD) age at diabetes diagnosis was 44.3 (12.5) years, and the mean (SD) duration of diabetes was 9.6 (9.4) years. Across interval recommendation types, 29.9% (284 of 949) adhered to obtaining comprehensive follow-up eye care within the recommended time frame. Two years after a participant’s screening date, 50.9% (483 of 949) had no record of having received eye care. Factors associated with adhering to interval appointments were having an advanced age (odds ratio, 1.02; 95% CI, 1.01-1.04) and knowing one’s glycated hemoglobin level (odds ratio, 2.00; 95% CI, 1.34-2.97). Agreeing to assistance in making a follow-up eye care appointment was associated with nonadherence (odds ratio, 0.67; 95% CI, 0.45-0.99).

Conclusions and Relevance  After a DR screening program in a public clinic largely serving an African American population, only one-third of participants adhered to interval recommendations for follow-up eye appointments, even though cost and accessibility were minimized as barriers to care. Our findings suggest that DR screening programs are not likely to meet their public health goals without incorporation of eye health education initiatives successfully promoting adherence to recommended comprehensive eye care for preventing vision loss.