Nonophthalmic health professionals

PR I NC I PLES FOR ORGAN I Z I NG EYE HEALTH SYSTEM FOR THE CARE OF D I ABETI C RETI NOPATHY

having to see yet another doctor (an ophthalmologist) presents an additional burden (59). Thus, being able to see just one doctor for comprehensive diabetes care enhances the continuity of care and thus the ability to receive higher quality care. General practitioners are usually best paced to situate the rsk for vision loss for each patent as part of the overall care strategy for diabetes, as the known rsk factors for retinopathy are among the conditions managed by the general practitioner or endocrinologist.

Awh, Coupes & Javitt (66) conducted pre- and post-educational assessments of 10 university-affiliated physicians (five in family practice, three internists and two endodcrmologists), who examined 20 patients. I n the pre-test, 80% found that pupil dilatation for direct ophthalmoscopy was both unfamiliar and uncomfortable, and only one physician could name a medication used for dilatation. The mean score on a written examination on eye conditions and diabetes was 49%; 30% were familiar with the schedule for eye examinations, and 43% recommended delayed referrals for patents with retinopathy. The score in the pre-test on a nine-point scale for detecting any retinopathy was 6.6. The performance of these physicians for detecting and referrmg eyes with pre-proliferative or proliferative retinopathy (sight-threatening) was only 40%.

I n a study in Glasgow, Scotland, among junior physicians with no specialized education or training, one-third made appropriate referrals to a diabetic retinopathy clinic, but only 30% gave a 'correct' diagnosis (67). I n a pre-test based on photographs among general practitioners in New South Wales, Australia, 44% made a correct diagnosis (68). Endocrinologists were able to identify microaneurysms correctly in 80% of patients, macular oedema in none, neovascularization on the disc in about 50% and neovascularization elsewhere in 30% (69). An important issue for diabetes eye care is the referral period or interval for additional eye care based on the findings of the screening or detection system. I n this study of whether appropriate referral perods were determined relative to the results of analysis by the gold standard 7 field photographic system, diabetologists made appropriate referral recommendations 64% of the time, ophthalmologists 56%, and nonmydratic photographs 69% of the time. I nterestingly, the varous provders more often recommmended later follow-up than indicated by the 7 field photographs, with rates of 24% for diabetologists, 23% for non-mydriatic photographs, and 41% for ophthalmologists.

Published studies thus indicate that non-eye care professionals who are interested in the eye care of patients with diabetes and who conduct such examinations without additional education or training perform somewhat more poorly than eye care providers. When examinations are not performed, referral patterns vary, with room for improvement in most settings. The overall performance of care for most chronic diseases by prmary care provders is less than 50% (39).

Awh and colleagues (66) reported that failure to detect sight-threatening retinopathy fell from 60% to 15% and that for maculopathy fell from 83% to 16%, with improved familiarity and use of dilating drops, after a 4 hours course with post-testing 12 days later. The scores for accuracy of classification of severity of disease rose only sightly, however, from 6.6 to 7.0 (on a nine-point scale). Bibby et al. (67) noted that physicians who received 40-50 h of special instruction and outpatient training in a diabetic retinopathy clinic were subsequently able to make more appropriate referrals (65% versus 33%), fewer incorrect diagnoses (5% versus 25%) and more correct diagnoses (67% versus 30%). Confos, Frith & Mitchell (68) found that the accuracy of interpretation of photographs increased from 44% to 53% 6 weeks after a workshop on diabetic retinopathy, while the reported use of clinical examinations with a direct ophthalmoscope increased from 41% to 69%. Gil et al (70) found that, while education can enhance sensitivity for detecting retinopathy, it can be associated with lower specificity (more referrals).

None of the studies reported on the persistence of the benefits of education in the long term. On the basis of the results of studies in other areas of medicine, it might be expected that practitioners who care regularly for a sizeable number of patents with diabetes and who continue to practice in the way recommended in the educational intervention are likely to continue to practice at a higher level (71). It is less dear, however, how these practitioners would fare i new recommendations for care and use are made on the basis of new findings. As eye care is not the prmary activity of general physicians, any significant change in eye care for patents with diabetes will be unlikely to be translated quickly into changed practice, and new educational efforts will be needed to bring general practitioners up to date.

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