Factors Associated with Poor Adherence to Diabetic Eye Screening Guidelines in an Inner-city Emergency Department Population C. Ellis Wisely, MD, MBA Transitional Year Resident May 5, 2017

Background Diabetic Retinopathy (DR) Leading cause of new blindness among Americans ages 20- 741 Associated healthcare costs more than $500 million annually2,3 >4 million Americans >40 have DR Prevalence of DR is expected to increase4 Glucose and blood pressure control, early detection, and treatment can prevent or mitigate visual loss5,6 Note: cost savings from mid-90’s and don’t account for lost work productivity ©2016 Trinity Health - Livonia, Mich.

Background Screening for DR Relevance to the Emergency Department (ED) The American Academy of Ophthalmology recommends annual dilated fundus exam (DFE) Overall adherence is low, around 60%7 Screening rates are significantly lower in minority populations and populations with limited access to care8,9 Relevance to the Emergency Department (ED) ~62 million Americans have inadequate primary care access10 ED becomes safety net Eye exam rates based on data from early 90’s 2014 data about poor access to primary care, describing this not on the basis of insurance but on the basis of PCP shortage ©2016 Trinity Health - Livonia, Mich.

Purpose Estimate the proportion of urban ED patients with diabetes and limited primary care access who adhere to annual eye screening Identify stated reasons for non-adherence Analyze factors (demographic and diabetic health- related) associated with non-adherence ©2016 Trinity Health - Livonia, Mich.

Study Population Mt. Carmel West ED, Columbus OH Jun. 2016 - Jan. 2017 DM1 or DM2 diagnosis in EMR 188 patients ©2016 Trinity Health - Livonia, Mich.

Methods Survey questionnaire developed to assess adherence with screening guidelines and reasons for non- adherence Survey conducted verbally during ED visit Demographic data and diabetic health parameters collected via chart review Bivariate analysis and multiple logistic regression determined factors associated with non-adherence statisticians/epidemiologists: Prefer to simplify model by only having the relevant variables in the model. Bivariate analysis first, to find the variables that have the strongest likelihood of being related to the outcome and including those in the model.  There are a couple of problems with including all possible variables in the model: 1) for lack of a better word, it might make the model "go haywire" and return nonsensical (or perhaps even no) results because you don't have enough patients to handle all of those variables; and 2) the more variables you add to a model, the wider the standard error around the point estimates for the odds ratio/relative risk.  If these additional variables don't have an association with the outcome or with the main factors in your model, then all they are doing is making the confidence intervals wider and potentially causing some important variables to become statistically non-significant.  So they don't really have a good purpose in the model except to make it less precise and possibly increase errors in the interpretation. ©2016 Trinity Health - Livonia, Mich.

Results: Adherence & Reported Explanation 49.5% without DFE in last year; 20% never had DFE 46% gave a financially motivated reason ©2016 Trinity Health - Livonia, Mich.

Results: Bivariate Analysis of Adherence Predictors Thus, Predictors of Non-Adherence Include: Younger age Diagnosis of neuropathy in EMR Elevated HbA1c Any DM complications and hyperglycemia trending toward significance, would make intuitive sense as they are related to A1c and poor control Medicare patients were more adherent, presumably because of better access, no significant at p<.05 for this sample size Expected PCP utilization would play a bigger role, as PCP often making eye exam referrals ©2016 Trinity Health - Livonia, Mich.

Results: Multiple Logistic Regression of Adherence Predictors Thus, Predictors of Non-Adherence Include: Younger age Diagnosis of neuropathy in EMR HbA1c drops out A1c drops out, meaning it is related to neuropathy and neuropathy has stronger association? ©2016 Trinity Health - Livonia, Mich.

Conclusions and Future Directions Nearly half of diabetic patients were non-adherent Demographic and Diabetic Health Red Flags: Non-Medicare Insurance Younger age Diagnosis of Neuropathy Elevated HbA1c Future Intervention: Recognize ED may be only healthcare contact Identify and target high-risk ED patients for referrals Implement nurse navigator intervention for high-risk patients Measure effectiveness of linkage program ©2016 Trinity Health - Livonia, Mich.

References Klein BE. Overview of epidemiologic studies of diabetic retinopathy. Ophthalmic Epidemiol2007;14:179–183 Javitt JC, Aiello LP, Chiang Y, Ferris FL III, Canner JK, Greenfield S. Preventive eye care in people with diabetes is cost-saving to the federal government: implications for health-care reform. Diabetes Care. 1994; 17(8):909–917. Rein D, Zhang P, Wirth K, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol. 2006; 124:1754–1760. Zhang X, Saaddine JB, Chou CF, Cotch MF, Cheng YJ, Geiss LS, Gregg EW, Albright AL, Klein BE, Klein R. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA. 2010 Aug 11;304(6):649-56. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998; 317(7160):703–713. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993; 329(14):977–986. Saaddine JB, Engelgau MM, Beckles GL, Gregg EW, Thomspson TJ. A diabetes report card for the United States: quality of care in the 1990s. Ann Intern Med. 2002; 136:565–574. MacLennan PA, McGwin G Jr, Heckemeyer C, et al. Eye care utilization among a high-risk diabetic population seen in a public hospital’s clinics. JAMA Ophthalmol. 2014; 132:162–167. Chou C-F, Sherrod CE, Zhang X, et al. Barriers to eye care among people aged 40 years and older with diagnosed diabetes, 2006-2010. Diabetes Care. 2014; 37:180–188. http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/affordable-care-act/access- primary-care-remains-challenge-62-million- ©2016 Trinity Health - Livonia, Mich.

Contact Information Mt. Carmel Health System, Columbus, OH Research study conducted at Mt. Carmel West Hospital Research Team: Dr. Alan Gora (Emergency Department), Dr. Anantha Padmanabhan (Transitional Year PD), Dr. Lynn Shaffer (Statistician), Usama Awan (Medical Student Assistant), Sheliya Brooks (Clinical Research Nurse) Email: Clayton.Wisely@mchs.com Phone: (614) 234-1079 ©2016 Trinity Health - Livonia, Mich.