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Children, Adolescents With Diabetes Might Be Missing Out on Retinopathy Screenings

Race, socioeconomic status thought reasons behind lack of adherence to the recommendations.

As the youth population continues to experience an increased prevalence of obesity, the incidence of type 2 diabetes in children and adolescence is also on the rise, with roughly 45% of all new adolescent diagnoses consisting of T2D, where previously most cases of juvenile diabetes were type 1.

Estimates extrapolated from U.S. Census data suggest that by 2050, the rate of type 1 diabetes in youth will triple, and the rate of type 2 in the same population will quadruple.  Along with this unsettling picture, the associated risk of diabetic retinopathy is expected to rise as well. Because DR can lead to blindness, early screening for DR remains important. Screening guidelines are established for TD1 patients, generally supporting retinal exam at 5-6 years from initial diagnosis, while recommending initial screening takes place coincident with diagnosis of T2D.  Previous studies report that only 33% of youth with T1D and 50% with T2D obtained eye examinations according to guidelines.  This may reflect concerns about younger age, diagnosis of T2D versus T1D, and shorter duration of diabetes in this population. Not surprising is that most studies have been done in adults, and very few of the youth studies looked at other demographic factors that may contribute to the lack of adherence to the guideline recommendations.  In the recent issue of JAMA Ophthalmology, a study was presented looking at retinopathy screening rates in youth with diabetes.

Data from 5,453 youth with T1D and 7,233 with T2D were collected from a nationwide managed care network from January 2001 through December 2014. Inclusion criteria were uninterrupted enrollment in the medical plan for at least 3 years and at least 2 diagnoses of diabetes on separate dates. Children who had never filled a prescription for insulin or an oral hypoglycemic, and those with pre-existing diabetes (diagnosed prior to 12 months in the medical plan) were excluded. Those children whose data lacked socioeconomic information were also excluded. The primary outcome was documentation of an eye exam as defined by Current Procedural Terminology.  Timing from initial diagnosis to initial eye exam in both T1D and T2D were compared using the log-rank test.

Multivariable Cox proportional hazards regression were used to evaluate the effects of diabetes type and sociodemographic factors on the proportion of those screened.

In those with T1D, the median age at diagnosis was 11 year (interquartile range 8-15 years), while in T2D, the median was 19 years (IQR 16-22 years).  The median time in the medical plan for both types was 2.1 years.  In the T2D subset, most patients were female (83.5%).  Of the T1D patients, 82.6% were white, 8.2% were black, 7.2% Latino, and 2% were Asian, while T2D patients were 69.9% white, 14.6% Latino, 12.8% black, and 2.8% Asian. Survival analysis showed that by 6 years after initial diagnosis, patients with T1D had a higher rate of eye examination than did those with T2D (HR 2.14; 95% CI 1.97-2.33).  Whites and Asians had a higher rate of exam (54.7% and 57.3% respectively) than did blacks and Latinos (44.6% and 41.6%).  Economic data showed the likelihood of an eye exam increased as household income increased (net worth ≥ $500,000 vs < $25,000, HR 1.50; 95% CI 1.34-1.68). Stratified for type of diabetes, analysis showed that type 2 patients were less likely to be examined the farther they were from initial diagnosis, whereas type 1 patients were unaffected. Considering race, utilizing the prevalence of white patients who were screened as the reference point, blacks and Latinos were less likely to be screened (11%, p=0.04 and 18%, p<0.001) respectively, whereas Asians were 9% (NS) more likely to be screened.

Overall, 64.9% of T1D and 42.2% of T2D youths had received an eye examination within six years of their initial diagnosis. This study is considered to be the first to account for race and socioeconomic factors in the youth population, and suggests that existing barriers to DR screening may include lack of understanding on the parts of both the patient and the provider, patient financial barriers such as lack of health insurance, non-acceptance of the diagnosis, and even an aversion to pupillary dilation. While the study was strong in the number of patients analyzed, and available of records to confirm performance of eye exams (versus relying on patients self-reporting), the algorithm used to determine presence of diabetes may have allowed inclusion of misclassified diagnoses, such as use of metformin for prediabetes or insulin resistance. This may have led to underestimating the time of onset to first eye exam, and overestimation of the numbers who were actually screened within 6 years.  The general conclusion that youth with diabetes are considerably under-screened for retinopathy is supported, suggesting that practitioners revaluate their approach to screening in this population.

Practice Pearls:

  • Diabetic retinopathy is a serious potential complication in the diabetes population, regardless of age.
  • A remarkably high percentage of youth with diabetes are not screened for retinopathy as recommended by accepted guidelines.
  • Potential barriers to screening may be predicted by factors such as race and socioeconomic status of the patients’ families.

References:

Wang SY, Andrews CA, Gardner TW, Wood M, Singer K, Stein JD. Ophthalmic Screening Patterns Among Youths With Diabetes Enrolled in a Large US Managed Care Network. JAMA Ophthalmol. 2017. Epub 2017/03/23. doi: 10.1001/jamaophthalmol.2017.0089. PubMed PMID: 28334336.

 

Mark T. Lawrence, RPh, PharmD Candidate, University of Colorado-Denver, School of Pharmacy NTPD