Optometry and Diabetes: Beyond the Exam Room

A multidisciplinary approach is needed to address this growing public health problem.

By Leon Nehmad, OD, MSW

Diabetes. Worldwide epidemic. Disease affecting multiple organs. Prominent cause of death. Consumer of resources. Major cause of blindness.

Optometrists have long played a key role in diagnosing and managing diabetes. To underscore its importance, the American Optometric Association recently published its "Evidence-Based Clinical Practice Guideline: Care of the Patient with Diabetes."1 Advances in eye care have increased the number of clinical tools at the disposal of the practitioner. The emergence of optical coherence tomography imaging and the availability of intravitreal vascular endothelial growth factor inhibitors have made it easier for clinicians to diagnose and manage diabetes.2

But the eye is not the only part of the body affected. Diabetes represents a major problem to the overall health of the individual, and it is a huge consumer of public health resources. Manifestations of diabetes in the eye are markers for its impact on the body as a whole. As primary health care providers, optometrists have a crucial part to play in the management of the disease beyond the exam room.

SCOPE OF THE DISEASE

Diabetes is defined by the American Diabetes Association as “a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.”3 Without insulin, the body’s cells cannot absorb glucose, which is needed for energy. The result is hyperglycemia.3 In the case of type 1 diabetes, typically occurring in childhood and accounting for only about 10% of all diabetes, the body’s immune system attacks the beta cells of the pancreas that make insulin. The more common type 2 diabetes, characterized by the body’s inadequate response to insulin, typically occurs in adulthood. Genetic factors, diet, sedentary lifestyle, and obesity play a large part in the development of type 2 diabetes.

Major complications and comorbid conditions associated with diabetes include hypertension, dyslipidemia, cardiovascular disease, stroke, kidney disease, and neuropathies. Diabetes is associated with the failure of multiple organs including the eyes, kidneys, nerves, heart, and blood vessels.

In 2014, according to the American Diabetes Association, 29.1 million Americans, or 9.3% of the population, had diabetes, of whom 8.1 million were undiagnosed. In 2012, 86 million people, approximately one-third of all Americans age 20 and older, had prediabetes, a condition associated with increased risk of heart disease and stroke.

Diabetes is the seventh leading cause of death in the United States in 2010, although it is thought to be underreported.4 Its prevalence is growing at an alarming rate: From 1980 to 2014, the number of adults in the United States aged 18 to 79 years with newly diagnosed diabetes more than tripled, from 493,000 to more than 1.4 million.5 Worldwide, according to the World Health Organization’s global report on diabetes in 2016, the number of people with diabetes rose from 108 million in 1980 to 422 million in 2014.6 Most of this is due to type 2 diabetes.

In terms of its impact on the visual system, diabetes is one of the leading causes of blindness in the world. It can cause visual impairment through multiple means, including retinopathy, cataract development, and optic neuropathy. It was estimated that, of a total 32.4 million blind and 191 million visually impaired individuals in 2010, 8 million were blind and 3.7 million severely visually impaired due to diabetic retinopathy. This was an increase of 37% and 64%, respectively, since 1990. Diabetic retinopathy alone accounted for 2.6 % of all the world’s blindness and 1.9% of all visual impairment in 2010.7

Given the breadth and multidimensional aspect of the disease, it is clear that eye care providers cannot act independently in addressing the size of the problem. Partnering with other health care providers is essential.

THE HEALTH CARE NETWORK

Many professionals are involved in the care of the diabetic patient. The primary care physician (PCP) may be a family practice doctor, internist, or endocrinologist. Other providers may also work in the same practice with the PCP, including nurse practitioners and physician assistants. Diabetic patients who need medication counseling also require the help of a pharmacist. Because diet is crucial in the management of the disease, people with diabetes frequently need the services of a dietitian. Those with lower limb problems will need the care of a podiatrist. Problems of activities of daily living can be addressed by a physical or occupational therapist. A higher prevalence of dental problems necessitates close dental care. A social worker or psychologist may be needed to help deal with psychological aspects of the disease.

Being able to educate patients and collaborate with the diversity of practitioners involved in the care of diabetes is crucial in the management of the disease. Because of the number of practitioners involved, it is helpful to have a specialist in coordinating care. Certified diabetes educators (CDEs), who may come from a variety of professions, are trained to perform this function.8 CDEs work as part of the patient’s health care network to engage the patient and his or her providers in informed, shared decision-making. They help patients learn to manage the day-to-day aspects of diabetes care. They may refer a patient with diabetes to any number of specialists to address the multidimensional problems of the disease. Optometrists may receive referrals from CDEs for eye exams for patients with diabetes. Correspondingly, an optometrist who identifies diabetic eye disease in a patient may refer that patient to a CDE to coordinate multidisciplinary care for the patient’s diabetes.

Optometrists who practice in settings such as health maintenance orgainzations, Veterans Affairs hospitals, and other such interdisciplinary settings may find it easier to partner with other professions than do those who work in private practice. Federal programs such as the US National Diabetes Education Program (NDEP) may be of help to providers who do not practice in an interdisciplinary setting. NDEP, a program established under the US National Institutes of Health and Centers for Disease Control and Prevention in 1997, works with more than 200 community partners to “improve the treatment and outcomes for people with diabetes, promote early diagnosis, and prevent or delay the onset of type 2 diabetes.”9

The NDEP targets key professions providing diabetes care: pharmacy, podiatry, optometry, and dentistry (PPOD). It has published a guide, "Working Together to Manage Diabetes," aimed at these groups. The guide describes in detail how these professions can work collaboratively and with members of other health care professions such as PCPs, physician assistants, nurse educators, and community health workers in their efforts to treat or prevent diabetes.10

The guide is an excellent resource for health care professionals who work with people with diabetes. It includes recommendations for communicating with patients, networking with other PPOD providers and local professional associations, conducting diabetes classes and consultations at local clinics, participating in public screenings, and partnering with other providers in and outside of one’s specialty. It also provides tips on practice promotion within network partnerships; creating presentations for PPOD conferences, local hospitals, or medical societies; and creating custom materials and websites for member practices and local associations.

The profession of optometry has increasingly recognized the need to treat diabetic patients with an interprofessional approach. In 2014, the Association of Schools and Colleges of Optometry (ASCO) formed an interprofessional education task force, subsequently named the Interprofessional Education and Collaborative Practice Committee. Following guidelines from ASCO, optometry schools have increased the interprofessional educational component of their curriculums.

The Council on Optometric Practitioner Education offers a continuing education course to update participants regarding the role of the optometrist in caring for patients with diabetes. The “Diabetes Nation” course educates optometrists on recent advances and the current state of diabetes and optometric diabetes care. It is now available on EyeLearn, the American Optometric Association’s online learning resource.11

THE OPTOMETRIST IN TELEMEDICINE

Patient education delivered through a multidisciplinary protocol, including optometry, pharmacy, and endocrinology, has been found to increase patient knowledge regarding diabetic eye care.12 Still, many patients with diabetes do not attend eye exams on a consistent basis. It has been estimated that 95% of individuals with diabetic retinopathy could avoid vision loss if referred in time for treatment. Unfortunately, fewer than 50% of patients with diabetes undergo an annual eye exam, and only about 60% receive vision-saving treatments.13 In uninsured populations, the number of diabetic patients who receive an annual eye exam can be as low as 25%.14

One way of reaching underserved populations is by bringing the eye exam to the patient through telemedicine. In this way, patients who live in underserved areas, homebound patients, and those unable to get to a doctor’s office because of physical or cognitive limitations may still gain access to care. In point-of-care testing, patients seen at their PCP’s office can have retinal photos taken and sent to a remote trained eye doctor for reading. In the event of abnormal findings, the patient can then be referred for a full eye examination.

A report by the American Academy of Ophthalmology found that, as a tool to detect sight-threatening retinopathy, single-field fundus photography has a sensitivity ranging from 38% to 100% and specificity ranging from 75% to 100%, compared with a dilated fundus exam. The report concluded that, although retinal photography is not a substitute for a comprehensive ophthalmic examination, there is level 1 evidence that it can serve as a screening tool to detect diabetic retinopathy.15

Telemedicine is a broad and expanding practice. There is compelling evidence for its use in diabetes care. In a 2015 review of more than 70 research articles on diabetes and telemedicine from 2005 to 2015, Bashshur and colleagues found that there were “positive effects of telemonitoring and telescreening in terms of glycemic control, reduced body weight, and increased physical exercise.”16

Telemedicine is not a substitute for a face-to-face doctor-patient interaction, but it is a pragmatic tool to enable care that might not otherwise be rendered. A recent study found that patients’ attitudes toward telemedicine in comparison with traditional care were variable.17 Patients who were receptive to telemedicine were found to have more comorbidities and appreciated the value of convenience. Patients who were less receptive tended to have had the disease for longer durations and placed a higher value on the doctor-patient relationship.

Telemedicine relies on nonprofessionals who are trained to operate instrumentation outside the eye doctor’s office. Because information is gathered outside the optometrist’s exam room, without the direct supervision of the doctor, it is imperative that the physician participating in a telemedicine program verify the quality of data, accuracy of interpretation, and adequacy of staff training.

FUTURE GENERATIONS: THE TEAM APPROACH

Professional optometry has an obligation to train future generations in order to ensure that the public can maintain the best eye health care. New developments must become incorporated into practice to ensure that the highest standard of care is met. This includes expanding the scope of optometric practice as part of the health care team.

The Interprofessional Diabetes Education and Awareness (IDEA) program at Nova Southeastern University is an example of training optometric students in interprofessional diabetes care through service to the community. In the IDEA program, interprofessional teams of students from a wide variety of health care professions, including optometry, osteopathic medicine, dentistry, pharmacy, and physical therapy, are led by faculty members in conducting community workshops aimed at educating at-risk groups on the prevention and management of diabetes. Settings for these workshops can include schools, health fairs, and community medical centers.

The program helps students learn how to manage diabetes from a real-world interprofessional perspective. Optometry students learn about the roles of other professions in diabetes care, and vice versa. Exposing students to an interdisciplinary approach early in their careers enables them to incorporate it into their mode of practice in the future. Several hundred individuals in the optometric community have been educated in the program since IDEA was started 4 years ago.18

Several studies have looked at the effects of interprofessional training on practitioners. After participants underwent a series of training activities, Yamani found an increase in knowledge and teamwork on the Team Climate Inventory test, a commonly used questionnaire designed to measure team function in health care organizations.19 In a study in which diabetes specialists designed an education tool to educate health care professionals, Herring and colleagues found that the training program improved provider confidence and knowledge.20

Use of an interprofessional approach has also been found to improve patient outcomes in diabetes. Janson et al compared care provided by a team of internal medicine residents, nurse practitioner students, and pharmacy students with that provided by internal medicine residents only.21 Patients who received team care were more likely to utilize health care services, including general medical exams, blood glucose assessments, blood pressure testing, lipid evaluations, and foot care exams.

In a multicenter study in Mexico, investigators compared the care given by providers who received high intensity communication training and providers using a conventional approach. They observed statistically significant improvements in patients’ blood glucose levels and in the proportion of patients achieving quality improvement goals in those who received care from the trained providers compared with the conventional practice providers.22

SUMMARY

Diabetes is a vast health care problem that requires an expansive, multidisciplinary approach. In order to fully address this condition, the practice of contemporary optometry requires doctors to extend their interventions beyond the exam room to collaborate with a broad range of providers within the health care network. When this is achieved, eye care providers will be able to serve patients in a more comprehensive fashion. This will make an impact on the prevention and treatment of the disease and enhance the health of the population at large.

1. Eye Care of the Patient with Diabetes Mellitus. Evidence-Based Clinical Practice Guidelines. American Optometric Association. 2014. https://www.aoa.org/Documents/EBO/EyeCareOfThePatientWithDiabetesMellitus%20CPG3.pdf. Accessed October 24, 2017.

2. Colagiuri R. The optometrist's role in the multidisciplinary diabetes team: towards a more holistic approach. Clin Exp Optom. 1999;82(2-3):55-58.

3. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33 Suppl 1:S62-69.

4. Fast Facts - Data and Statistics About Diabetes. American Diabetes Association. 2017. https://professional.diabetes.org/content/fast-facts-data-and-statistics-about-diabetes. Accessed October 24, 2017.

5. New CDC report: More than 100 million Americans have diabetes or prediabetes [press release]. Centers for Disease Control and Prevention. July 18, 2017. https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html. Accessed October 24, 2017.

6. Diabetes Fact Sheet. World Health Organization. July 2017. http://www.who.int/mediacentre/factsheets/fs312/en/. Accessed October 24, 2017.

7. Leasher JL, Bourne RR, Flaxman SR, et al; Vision Loss Expert Group of the Global Burden of Disease Study. Global estimates on the number of people blind or visually impaired by diabetic retinopathy: a meta-analysis from 1990 to 2010. Diabetes Care. 2016;39(9):1643-1649.

8. Burke SD, Sherr D, Lipman RD. Partnering with diabetes educators to improve patient outcomes. Diabetes Metab Syndr Obes. 2014;7:45-53.

9. About the National Diabetes Education Program. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-communication-programs/ndep/about-ndep/Pages/index.aspx. Accessed October 24, 2017.

10. Working together to manage diabetes: a guide for pharmacy, podiatry, optometry, and dentistry. National Diabetes Education Program. January 2014. https://www.cdc.gov/diabetes/ndep/pdfs/ppod-guide.pdf. Accessed October 24, 2017.

11. EyeLearn: AOA’s Online Learning Resource. https://www.aoa.org/optometrists/education-and-training/eyelearn?sso=y. Accessed October 24, 2017.

12. Wagner H, Pizzimenti JJ, Daniel K, Pandya N, Hardigan PC. Eye on diabetes: a multidisciplinary patient education intervention. Diabetes Educ. 2008;34(1):84-89.

13. Zhang W, Nicholas P, Schuman SG, et al. Screening for diabetic retinopathy using a portable, noncontact, nonmydriatic handheld retinal camera. J Diabetes Sci Technol. 2017;11(1):128-134.

14. Shi L, Wu H, Dong J, Jiang K, Lu X, Shi J. Telemedicine for detecting diabetic retinopathy: a systematic review and meta-analysis. Br J Ophthalmol. 2015;99(6):823-831.

15. Williams GA, Scott IU, Haller JA, Maguire AM, Marcus D, McDonald HR. Single-field fundus photography for diabetic retinopathy screening: a report by the American Academy of Ophthalmology. Ophthalmology. 2004;111(5):1055-1062.

16. Bashshur RL, Shannon GW, Smith BR, Woodward MA. The empirical evidence for the telemedicine intervention in diabetes management. Telemed J E Health. 2015;21(5):321-354.

17. Valikodath NG, Leveque TK, Wang SY, et al. Patient attitudes toward telemedicine for diabetic retinopathy. Telemed J E Health. 2017;23(3):205-212.

18. Dunbar SB, Feldman HA, Nelson TM, et al. The Interprofessional Diabetes and Education Awareness (IDEA) community program. J Interprof Educ Pract. 2017;7:75-77.

19. Yamani N, Asgarimoqadam M, Haghani F, Alavijeh AQ. The effect of interprofessional education on interprofessional performance and diabetes care knowledge of health care teams at the level one of health service providing. Adv Biomed Res. 2014;3:153.

20. Herring R, Pengilley C, Hopkins H, et al. Can an interprofessional education tool improve healthcare professional confidence, knowledge and quality of inpatient diabetes care: a pilot study? Diabet Med. 2013;30(7):864-870.

21. Janson SL, Cooke M, McGrath KW, Kroon LA, Robinson S, Baron RB. Improving chronic care of type 2 diabetes using teams of interprofessional learners. Acad Med. 2009;84(11):1540-1548.

22. Barceló A, Cafiero E, de Boer M, et al. Using collaborative learning to improve diabetes care and outcomes: the VIDA project. Prim Care Diabetes. 2010;4(3):145-153.

Leon Nehmad, OD, MSW
• Professor at Nova Southeastern University, College of Optometry, Fort Lauderdale, Fla.
lnehmad@aol.com
• financial disclosure: none relevant