How much information do medical practitioners and endocrinologists have about diabetic retinopathy?

Quanta informação os médicos gerais e endócrinologistas tem sobre retinopatia diabética?

CLINICAL SCIENCES

How much information do medical practitioners and endocrinologists have about diabetic retinopathy?

Quanta informação os médicos gerais e endócrinologistas tem sobre retinopatia diabética?

Rony Carlos Preti; Fábio Saraiva; João Artur Trein Junior; Walter Y. Takahashi; Maria Elizabeth Rossi da Silva

Ophthalmology and Endocrinology. University Medical School- São Paulo/SP,Brazil. Email: [e-mail]

ABSTRACT

OBJECTIVE: The objective of this study was to use a questionnaire to evaluate knowledge concerning diabetic retinopathy among the physicians present at the 12th Latin American Congress on Diabetes held in São Paulo, Brazil, September 2004.

METHODS: A questionnaire about their experience and management of patients with diabetes mellitus and the ophthalmologic examination was administered to 168 endocrinologists attending the meeting.

RESULTS: Among the 168 physicians, only 36.9% correctly referred patients with diabetes type 1 to an ophthalmologist, whereas 86.9% referred patients with the type 2 disorder as recommended by the American Academy of Ophthalmology. Regarding the correct indication for screening for diabetic retinopathy, more physicians who had received their degree less than 5 years previously implemented this practice (54.8%), as opposed to those who had received their MD 20 years or more ago (22.6%). Regarding their experience in funduscopy during their specialty training, 52.4% claimed to have experience, but only 21.4% of those interviewed performed this examination on their patients. According to 84.5% of the interviewees, the fundus examination influenced their clinical treatment program.

CONCLUSION: Our study demonstrates that medical knowledge among medical practitioners and endocrinologists on preventive measures and periodicity of diabetic retinopathy examinations appears to be far from ideal for diabetes type 1, but satisfactory for diabetes type 2. Therefore, refresher courses emphasizing the correct management of diabetic patients are necessary, because the social and economic impact of retinopathy is significant.

Keywords: Consumer satisfaction. Diabetic retinopathy. Diabetes. Knowledge. Retina.

RESUMO

OBJETIVO: O objetivo deste estudo foi avaliar através de questionário o conhecimento dos médicos presentes no 12º Congresso Latino Americano de Diabetes Realizado em São Paulo Brasil, Setembro de 2004.

MATERIAIS E MÉTODOS: Através de um questionário aplicado a 168 especialistas em endocrinologia presentes no 12º Congresso Latino Americano de Diabetes realizado São Paulo - Brasil em Setembro de 2004, os autores interrogaram sobre a experiência e conduta em relação à Retinopatia Diabética e ao exame oftalmológico.

RESULTADOS: Dos 168 médicos, apenas 36,9% encaminhavam corretamente ao oftalmologista os pacientes com diabetes do tipo 1, enquanto 86,9% o faziam de acordo com a Academia Americana de Oftalmologia para os diabéticos do tipo 2. Quanto ao correto encaminhamento dos pacientes para exame de fundo de olho: os médicos com tempo de formação inferior a cinco anos foram os que mais realizam esta prática (54,8%), comparados àqueles com 20 ou mais anos (22,1%). Quanto à experiência em fundoscopia durante a especialização, embora 52,40% afirmassem possuir experiência, apenas 21,4% dos entrevistados realizavam fundo de olho em seus pacientes. Para 84,5% dos entrevistados, o exame de fundo de olho influenciava o tratamento clínico sistemico.

CONCLUSÃO: O estudo demonstra que o conhecimento médico das medidas preventivas e de periodicidade do exame da Retinopatia Diabética apresenta-se distante do ideal, para diabéticos tipo 1 e satisfatória para diabéticos tipo 2. Médicos graduados ate 5 anos apresentaram maior porcentagem de correto encaminhamento. A presença de retinopatia diabética no exame de fundo de olho influencia o tratamento clinico sistêmico da maioria dos médicos entrevistados.

Unitermos: Conhecimento, Diabetes, Retina, Retinopatia Diabética.

INTRODUCTION

Diabetic retinopathy is the main cause of reduced visual acuity in the United States.^1,2 It is one of the most common vascular complications of diabetes mellitus (DM) and one of the main causes of new cases of blindness among active people in the workplace.^3-5

The American Academy of Ophthalmology (AAO) recommends that the first fundus examination (FE) in patients with type 1 diabetes should be performed 5 years after diagnosis of the disorder,⁶ because retinopathy is rarely observed before this period.^7,8 However, patients with type 2 diabetes should be examined immediately when they are diagnosed,⁶ because the duration of the disease is uncertain, so some degree of retinopathy may be present at this time.⁹ The findings at this first examination will determine the frequency of subsequent tests.

Multicenter studies have shown that if laser therapy is indicated at the proper time for treatment of diabetic retinopathy, the probability of blindness is considerably reduced.^10-13 Therefore, it is extremely important for endocrinologists and general practitioners to be fully informed about the diagnosis and treatment of this retinopathy, considering its significant social and economic impacts on society.

The objective of this study was to administer a questionnaire designed to evaluate knowledge concerning diabetic retinopathy among physicians present at the 12th Latin American Congress on Diabetes held in São Paulo, Brazil, September 2004.

MATERIALS AND METHODS

A questionnaire with 6 questions was devised and administered to physicians present at the 12th Latin American Congress on Diabetes held in São Paulo, Brazil, September 2004 (^{Appendix 1}).

Statistical analysis comprised the chi-square test with Yates correction for analysis of frequencies among the groups.

The collected data were compared with the recommendations of the American Academy of Ophthalmology, ie, that the first fundus examination (FE) should be performed 5 years after diagnosis of the disorder for patients with type 1 diabetes and at the time of diagnosis for patients with type 2 diabetes.

RESULTS

Out of 500 questionnaires administered, only 168 (33.6%) were completely answered.

The length of time since the physicians present at the Congress had received their degree was divided into 5-year intervals (Table 1), with an average of 17.0 years (± 10.30).

Upon answering the questionnaire, 58 of the 168 physicians (34%) reported correct referral of their patients according to AAO guidelines, without differentiating type 1 from type 2 diabetes, whereas, 110 (65.5%) did this incorrectly. Regarding the type of diabetes, patients with type 1 were correctly referred by 36.9% of the physicians, while those with type 2 were correctly referred by 86.9% (P < .001; Table 2).

The length of time since graduation was not significantly correlated with experience with fundus examination during specialty training (range, 30.8% to 65.0% among the 5 groups; average, 52.4%) or the frequency of performing funduscopy in everyday practice (range, 11.54% to 30%). Physicians who had received their degree less than 5 years previously were significantly more likely to correctly refer patients for fundus examination compared with alumni of over 20 years (P = .003; Table 3 ). Regarding whether they had experience with fundus examination during specialty training, 88 physicians (52.4%) stated they had experience, whereas 80 (47.6%) did not. Only 21.4% of those interviewed stated that they perform the test on their patients (question 3, ^{Appendix 1}).

Concerning correlation of the length of time since graduation with experience with fundus examination during specialty training and with performing fundus examinations in current clinical practice, no significant difference was noted among the groups (Tables 4 and 5).

Similarly, no significant difference was found regarding the relationship between experience with fundus examination during specialty training and the correct referral of patients with type 1 or type 2 diabetes (Table 6) Only 31.8% of the physicians with experience with fundus examination during specialty training referred their patients correctly, which was similar to the group without this experience (37.5%).

When questioned about the effect of the results of the fundus examination on the type of treatment they adopted, 84.5% of the physicians atated that they are influenced, whereas 15.5% are not (P < .001).

DISCUSSION

Studies have shown that treatment of diabetic retinopathy is effective in prevention of blindness,^14,15 and that early detection and follow-up are important for a good prognosis.

Although only 36.9% of doctors referred patients with type 1 diabetes according to AAO guidelines, the incorrect referral of these patients was due mainly to indication before the need to do so. Practically speaking, this does not harm the patient directly; it is more of a matter of inefficient expenditure of public health funds.

When the length of time since graduation was compared to the correct referral of patients, correct referral was more frequent for those who had received their degree less than 5 years previously (54.8%) compared with those who had graduated 20 or more years previously (22.1%); this is probably due to recent guidelines and more adequate specialty training.

The length of time since graduation did not significantly correlate with experience with fundus examination during specialty training or with the frequency of performing funduscopy in everyday practice. Although funduscopy is an important examination, only 21.4% of the total number of physicians stated performing it with their patients, which is in agreement with the 22% observed by Vilela et al,¹⁶ and supportive of the contention that treatment of diabetics may be impaired due to a gap in the physician's knowledge. However, it should be noted that having or not having experience with funduscopy during specialty training did not seem to affect correct referral rates.

It has already been demonstrated that proper metabolic control reduces the risks of development or progression of retinopathy by 76% to 54%. Therefore, it is neither necessary nor suitable to await the result of funduscopy to introduce a stricter dietary regimen. Nevertheless, in our analysis, for most of the physicians interviewed, clinical treatment was influenced by the results of the fundus examination, indicating a lack of adherence to best practices by these health professionals.

CONCLUSIONS

The study confirms that the knowledge, medical performance, guidelines, awareness of preventive measures, and periodicity of diabetic retinopathy examinations in our country appear to be far from ideal regarding patients with type 1 diabetes and are satisfactory for those with type 2 diabetes.

Received for publication on December 05, 2006.

Accepted for publication on January, 17, 2007.

1. WHAT YEAR DID YOU GRADUATE?_____________________ 1. 1) SEX: ( )M ( )F

2. IN YOUR SPECIALTY TRAINING DID YOU RECEIVE ANY EXPERIENCE IN FUNDUS EXAMINATION?

( )YES ( )NO

3. DO YOU PERFORM EYE FUNDUS EXAMINATIONS IN YOUR DIABETIC PATIENTS?

( )YES ( )NO

3.1. IF YES, DO YOU HAVE EXPERIENCE CLASSIFYING DIABETIC RETINOPATHY?

( )YES ( )NO

4. HOW LONG AFTER THE DIAGNOSIS OF TYPE 1 DIABETES DO YOU REFER YOUR PATIENT TO EVALUATION FOR RETINOPATHY?

( )IMMEDIATELY ( ) 2M ( ) 4M ( )6M ( )1y ( )5y

5. HOW LONG AFTER DIAGNOSIS OF TYPE 2 DIABETES DO YOU REFER YOUR PATIENT TO EVALUATION FOR RETINOPATHY?

( )IMMEDIATELY ( ) 2M ( ) 4M ( )6M ( )1y ( )5y

6. IS THE MANAGEMENT CHOSEN INFLUENCED BY THE RESULT OF THE FUNDUS EXAMINATION?

( )YES ( )NO

• 1. Klein R, Klein BEK, Moss SE, Davis MD, DeMets DL. The Wisconsin Epidemiologic Study of Diabetic Retinopathy IV. Diabetic macular edema. Ophthalmology. 1984;91:1464-74.
• 2. Moss, SE, Klein, R, Klein BEK. The 14-year incidence of visual loss in a diabetic population. Ophthalmology. 1998;105:998-1003.
• 3. Klein HA, Moorehead HB. Statistics on blindness in the Model Reporting Area, 1969-1970. Bethesda, Maryland: U.S. Department of Health, Education and Welfare; 1973. DHEW publication no. 73-427 1970.
• 4. National Society to Prevent Blindness, Operational Research Department. Vision Problems in the U.S.: A Statistical Analysis. New York: National Society to Prevent Blindness; 1980. Available from: National Society to Prevent Blindness, 500 East Remington Road, Schaumburg, IL 60173.
• 5. Klein R, Klein BE. Vision disorders in diabetes. In: Diabetes in America: Diabetes Data Compiled 1984. Bethesda, Maryland: U.S. Department of Health and Human Services; 1985: ch. 8:1-2. NIH publication no. 85-1468.
• ⁶
  American Academy of Ophthalmology: Preferred Practice Pattern: Diabetic Retinopathy. San Francisco: American Academy Ophthalmology, 1993.
• 7. Klein R, Klein BEK, Moss SE, Davis MD, DeMets DL: The Wisconsin Epidemiologic Study of Diabetic Retinopathy II: Prevalence and risk of diabetic retinopathy when age of diagnosis is less than 30 years. Arch Ophthalmol. 1984;103:520-6.
• 8. Klein R, Klein BEK, Moss SE, Davis MD, DeMets DL: The Wisconsin Epidemiologic Study of Diabetic Retinopathy IX: Four-year incidence and progression of diabetic retinopathy when age of diagnosis is less than 30 years. Arch Ophthalmol. 1989;107:237-43.
• 9. Klein R, Klen BEK, Moss SE, Davis MD, DeMets DL: The Wisconsin Epidemiologic Study of Diabetic Retinopathy X: Four-year incidence and progression of diabetic retinopathy when age of diagnosis is less than 30 years. Arch Ophthalmol. 1989;107:244-9.
• 10. The Diabetic Retinopathy Study Research Group. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS report no. 8. Ophthalmology. 1981;88:583-600.
• 11. The Diabetic Retinopathy Study Research Group. Four risk factors for severe visual loss in diabetic retinopathy. The third report from the Diabetic Retinopathy Study. Arch Ophthalmol. 1979;97:654-5.
• 12. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Arch Ophthalmol. 1985;103:1796-806.
• 13. Early Treatment Diabetic Retinopathy Study Research Group. Early photocoagulation for diabetic retinopathy: ETDRS report no. 9. Ophthalmology. 1991;98:766-85.
• 14. Indications of photocoagulation treatment of diabetic retinopathy: Diabetic Retinopathy Study Report no. 14. The Diabetic Retinopathy Study Research Group. Int Ophthalmol Cli 1987;103:1796-806.
• 15. Photocoagulation for diabetic macular edema. Early treatment Diabetic Retinopathy Study: Report number 1. Early treatment Diabetic Retinopathy Study research group. Arch Ophthalmol 1985;103:1796-806.
• 16. Vilela MAP, Saadi AK, Pletsch L, Giacomet A. Inquérito entre pacientes e médicos sobre as estratégias aplicadas na prevenção e tratamento da retinopatia diabética. Arq. Brás de Oftalm, 1997;60:152-5.

APPENDIX 1  - QUESTIONNAIRE OPHTHALMOLOGIST/ENDOCRINOLOGIST'S DAILY RELATIONSHIP WITH DIABETIC RETINOPATHY SÃO PAULO

Publication Dates

• Publication in this collection
  18 June 2007
• Date of issue
  2007

History

• Received
  05 Dec 2006
• Accepted
  17 Jan 2007