We all see patients with diabetes. Many of us see more than one a day. Doing a better job of managing patients with diabetes is a great place to start your quest to change your practice from primary eye care to primary health care.
This common disease is considered a chronic health problem in America and, in spite of the host of treatment options, is one of the most undermanaged problems we face. Comprehensive diabetes care is one of the key elements of the 2013 Healthcare Effectiveness Data and Information Set (HEDIS) measurements.
Part of this measurement is assuring that all diabetics have an annual dilated eye examination. Unfortunately, many factors in the medical community have reduced this to a simple question: “Retinopathy? Yes or no.” Some primary care physicians have even suggested that a nonmydriatic fundus camera in the PCP office with photos read by an off-site retina specialist is equivalent to a dilated eye examination.
Recently, I had a conversation with a managed care executive that was suggesting this model to improve his plan’s HEDIS scores. To me, this demonstrates the failure of primary care optometrists to convey the information they gather in the diabetic eye examination to the primary care physician and the health plan.
To participate in the management of patients with diabetes, there are several elements that the primary care optometrist must look to improve. First, to satisfy your license requirements, consider taking courses on systemic diabetes. Learn more about the current management of this disease and all of the medical options for treatment. Learn about each of the medicines used in diabetic management, how they work, how they are used together and the related side effects. Armed with this knowledge, your patient’s medical history will become more meaningful. You will query your patient with diabetes about their hemoglobin A1c and their daily fasting blood sugar results. You will ask about diet and probe your patient’s understanding of their disease and their own role in its effective management.
The examination of the patient with diabetes will be much better with an understanding of their relative sugar control. You will look more closely at the tear film, cornea and anterior segment. You may recognize early cataracts related to poor diabetic control. A close look at the retina with a slit lamp fundus lens may reveal early vascular changes that might not show up on photography. Refractive shifts may have a new meaning, as will reduced visual acuity.
The most important aspect of a diabetic eye exam happens at the end. (See my previous blog: The ‘doctoring’ of the eye examination.) Even when the eye findings are negative, a discussion about diet, exercise and the daily management of diabetes is critical. Your patient needs to understand that the day-to-day control of their diabetes will affect their long-term visual outcome. Uncontrolled diabetes often affects the eye at multiple levels, from mild symptoms such as dry eye and fluctuating vision to devastating problems such as optic neuropathies and retinopathies that can lead to blindness. Stress the importance of the annual comprehensive dilated examination as well as interim visits as needed to address ocular symptoms.
Lastly, and certainly an issue critical to your role on the primary care team (see my previous blog: The new team for optometry in health care reform), is the communication with the primary care physician. This should never be just “Retinopathy? Yes or no,” but a detailed report of your examination including your counseling session and your overall impression of the patient’s understanding of their disease and willingness to actively participate in their own management.