Once diabetes mellitus has been diagnosed and patients have had an initial eye assessment, of any kind, they must continue eye care. As there is no cure for diabetes mellitus, prevention of vsion loss requires regular examinations. Nevertheless, there are significant problems in ensurng approprate follow-up. The shortfall in efforts to ensure approprate follow-up is illustrated by studies showing that only 68-85% of patients referred for treatment start the treatment, and only 85% who start treatment compete it (43-45), indicating that 28-42% of patients who are referred for treatment do not receive the necessary care. The fact that over 40% of patients with diabetes who are referred for treatment do not actually compete it has not been addressed in educational and intervention programmes. Merely concentrating on ensurng that patients are examined (and that those examinations are accurate) is not sufficient.
In 1989, Olsen, Kassoff & Gerber (95) reported the results of a survey of ophthalmologists in New York State, United States, at a time when the results of the Early Treatment Diabetic Retinopathy and the Diabetic Retinopathy Study had demonstrated the benefit of laser treatment for both proliierative retinopathy and macular oedema. The study showed that only 63% 'almost always' recommended laser treatment for proliierative retinopathy, and another 31 % 'usually' did so. Laser treatment for macular oedema, even when vsion was significantly compromised, was recommended only 73% of the time, and was recommended only 63% of the time when vsion was mildly compromised. Khadem, Buzney & Alich (96) found that use of the recommended treatment patterns did improve with time but not statistically significantly. A report by Hal, Albrecht & Lee (97) is unique in the United States, in reporting a high degree of conformity with recommended diabetic retinopathy care. Unlike the other studies, which were based on surveys, these authors relied on revewng physician documentation of treatments and follow-up intervals.
McCarty and colleagues at the University of Melbourne, Australia, used a seres of surveys of optometrsts and ophthalmologists to assess the impact of national clinical practice guidelines on clinical practice over time, observing the use of laser photocoagulation and fluorescein angiography and the timing of cataract surgery (98,99). These surveys demonstrated better self-reported conformity over time.
The best reported follow-up rates (higher than 90%) on a recurrng basis have come from Newcastle, England (unpublished data), with the use of vans and trained photograph readers, who used standardized reference photos and provided immediate feedback to patients. By directly addressing the issues of convenience, access and feedback, this system might provide a model for a true 'marketing' approach to patient-centred eye disease detection in diabetes.
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