In 2018, approximately 3.5 million Canadians had diabetes and this prevalence is only expected to increase.
- Hooper P
- Boucher MC
- Cruess A
- et al.
Excerpt from the Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of diabetic retinopathy.
Diabetic retinopathy (DR) is the leading cause of blindness in the working age population.
- Kempen JH
- O'Colmain BJ
- Leske MC
- et al.
The prevalence of diabetic retinopathy among adults in the United States.
However, DR in its early and late stages is treatable. Anti-vascular endothelial growth factor (anti-VEGF) injections, intraocular steroid injections, laser treatments, and surgical options are available for different stages of DR. The onset and prevention of sight-threatening DR involves tight glycemic control
- Boyd SR
- Advani A
- Altomare F
- Stockl F.
Clinical Practice Guidelines. Retinopathy.
and since early stages of DR are asymptomatic, regular DR screening is essential for early detection of treatable disease. Alas, DR screening rates among people with diabetes remain suboptimal. For example, in Ontario, screening rates have remained below 60% since 2006.
- Kiran T
- Kopp A
- Moineddin R
- et al.
Unintended consequences of delisting routine eye exams on retinopathy screening for people with diabetes in Ontario, Canad.
In this issue, Ballios and colleagues report on their cross-sectional study to investigate the relationship between DR screening rates in Ontario with demographic and geographic factors.
- Ballios BG
- Park T
- Chaudhary V
- Hurley B
- Kosar S
- Sheidow T
- Cruess A
- Brent MH
- Glazier R
- Wong DT.
Identifying gaps in patient access to diabetic screening eye examinations in Ontario: a provincially representative cross-sectional study.
Data was obtained using Ontario Health Insurance Plan (OHIP) records, Ontario Diabetes Database, and Canadian census data. Between 2011 and 2013, Ballios et al. identified 1 146 000 people over 19 years of age with diabetes in Ontario, 35.4% of which (405 967) had not received DR screening. People in the highest income quintile had slightly lower rates of unscreened individuals compared to those in the lowest income quintile (34.4% vs. 36.9%) and more patients with immigrant status were unscreened compared to nonimmigrants (44.5% vs. 34.6%). 74.1% of all unscreened patients in the study lived in large cities, particularly within the Greater Toronto Area. Large areas of the Toronto Central Local Health Integration Network (LHIN) correlated for low examination rates and low income.
Interestingly, despite urban areas having the greatest concentration of ophthalmologists and optometrists compared to rural areas,
Geographic distribution of ophthalmologists in Ontario: a 10-year review.
Ballios and colleagues found DR screening rates are still lowest in the large cities. There must exist additional barriers to screening that are more complex than simply the availability of eye care providers. Indeed, previous literature has identified some of these barriers, including lack of awareness of the need for DR screening, transportation and time constraints, and the influence of socioeconomic status.
- Orton E
- Forbes-Haley A
- Tunbridge L
- Cohen S.
Equity of uptake of a diabetic retinopathy screening programme in a geographically and socio-economically diverse population.
After OHIP-funded eye examinations were delisted for Ontarians 40-65 years old, there was a decrease in routine eye examinations for healthy adults. While eye examinations by optometrists for patients with diabetes are still insured, there may be confusion regarding what is covered. One study showed decreased use of eye care providers among those with lower socioeconomic status after this change.
- Jin YP
- Buys YM
- Hatch W
- Trope GE.
De-insurance in Ontario has reduced use of eye care services by the socially disadvantaged.
Eye examinations by ophthalmologists were unaffected by delisting.
Poor DR screening rates in Ontario need to be improved. Ophthalmologists often seen a higher degree of DR pathology, and for patients without DR or at low risk of DR, recommend regular screening with optometry instead. It should be made clear to patients with diabetes that DR screening with optometrists are also OHIP-covered, an especially important consideration for patients of lower socioeconomic status. Working together with optometry as well as primary care physicians, endocrinologists, and diabetic nurse educators is paramount to ensure continuity of care and reducing the number of patients who remain unscreened or lost to follow-up. Tele-ophthalmology for DR screening is also emerging as a promising modality for bridging DR screening rate gaps, providing more equitable access to screening for underserviced areas or where transportation and time concerns may be an issue.
Diabetes and its complications are and will continue to be a growing epidemic. This study by Ballios and colleagues effectively identifies disparities in DR screening rates in Ontario, which emphasizes the importance of resource allocation measures and technological solutions to address such disparities.