Community-Based Retinopatny Clinics

The value of annual ophthalmologic examination of virtually all diabetic patients has been clearly established. This standard of care -derived from the Diabetic Retinopathy Study (DRS; 1), was promulgated by the National Diabetes Advisory Board (2,3) and has recently been incorporated into the clinical practice recommendations for diabetes care by the American Diabetes Association (4). Diabetes' grim statistic as the leading cause of new blindness in adults can be changed; the diagnostic and therapeutic tools to do so are available and have been for more than a decade. Because a substantial portion of blindness due to diabetes can be prevented or delayed, the Public Health Service and the Institute of Medicine set a target for the year 2000 of reducing the incidence of this condition from 5,800 to 4,000 (5). This goal should be achievable; however, there is much to be done within the system that delivers care to the diabetic patient before this goal is reached. Despite the existence of clear guidelines for monitoring the ophthalmologic health of the diabetic patient, there is a sizeable gap between ideal and actual application of these guidelines. Only 59% of randomly selected community-based diabetic individuals in Michigan reported that they had ever seen an ophthalmologist (for any reason), and only 54% had done so within the past 2 yr (6). To address this and similar diabetes-care issues, the Michigan Diabetes Research and Training Center (MDRTC) formed communitybased diabetes advisory councils in six Michigan communities; council members include physicians with a special interest in diabetes, nurse educators, dietitians, social workers, patients, and family members. Councils function by reviewing the status of diabetes care and education within their community, comparing their local standards with regional and national standards for diabetes care, and mounting local efforts to correct identified discrepancies. Three of these councils identified lack of regular ophthalmologic examinations for diabetic patients as a problem. Council members and MDRTC staff considered ways to increase the number of diabetic patients receiving appropriate ophthalmologic examination. Several barriers were identified, including: primary-care physician unawareness of the standard of yearly ophthalmologic examinations for patients with diabetes, patient unawareness of the importance of this examination, absence of an ophthalmologist in the local area, cost of the service, patient confusion about optometrists versus ophthalmologists, and primary-care physician belief that their funduscopic examination was sufficient. We were aware of the excellent studies by Klein et al. (7,8), in which funduscopic screening of large numbers of community-based diabetic patients was accomplished with a fundus camera transported to community sites via a van. However, this equipment and that service were not available to the Michigan communities addressing this problem, necessitating an alternative method with available resources. The community-based retinopathy screening clinic provided an alternative that addressed all barriers previously noted. The procedures developed for these clinics and the results of conducting the first 12 clinics are presented in this report. Retinopathy screening clinics were organized by the communitybased diabetes advisory council, with one member of each council serving as a voluntary organizer and coordinator of the clinic activities. Patients were recruited through announcements in the local newspaper, public service announcements on the radio, fliers mailed to known diabetic patients, and requests for referral by their primary-care physicians. Direct recruitment of patients addressed both the barriers of physician and patient unawareness of the need for this service. The patients' participation in the clinic and the report sent to the patients' primary-care physicians served an instructional function for both. A regional ophthalmologist who served the local community was invited to attend the clinic to provide the ophthalmologic exam, which included determination of gross visual acuity, tonometry, and funduscopic examination through a dilated pupil. Ophthalmologists with laser photocoagulation capabilities were willing to provide this service; ophthalmologists who could not provide therapeutic intervention for significant retinal findings were less willing to do so. The willingness of practicing ophthalmologists with laser photocoagulation capability to voluntarily serve in retinopathy screening clinics was the key element of the community clinics that did not have a portable fundus camera. In addition to the ophthalmologic exam, the clinic provided opportunity for the council members who staffed the clinics to perform other diabetes-related assessments, provide patient education related to diabetic eye disease, and establish contact with many area diabetic patients to facilitate future council activities developed to serve these patients. Over 2 yr, 12 clinics were conducted in three communities, and 489 diabetic patients were screened. Of the 489 patients, 64 (13%) had insulin-dependent (type I)