Indian Health Service Diabetes Program Lowered Rates of Diabetic Retinopathy

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American Indian and Alaska Native had increased access to diabetes treatment services, which lowered hyperglycemia and blood lipid levels, as well as diabetic retinopathy incidence.

Over the last 30 years, diabetic retinopathy incidence and progression among American Indian and Alaska Native have decreased and are now comparable with estimates from other populations, according to a recent study published in JAMA Ophthalmology.

Investigators said this is a result of programs implemented by the Indian Health Service (IHS) implemented programs, including the Special Diabetes Program for Indians (SPDI) and the American Telemedicine Association Category 3 teleophthalmology program. The Special Diabetes Program for Indians increased access to diabetes treatment services and reduced hyperglycemia, blood lipid levels, and kidney failure. The teleophthalmology program itself conducted examinations of 120,075 patients between Jan. 1, 2000, and Oct. 31, 2021.

Because substantial changes in diabetes medications have occurred in the past 25 years, investigations in the JAMA Ophthalmology study wanted to examine the incidence and progression of diabetic retinopathy in American Indian and Alaska Native people.

Stephanie J. Fonda, Ph.D.

Stephanie J. Fonda, Ph.D.

Led by Stephanie J. Fonda, Ph.D., vice president of research at Estenda Solutions, a healthcare software and consulting company in Wayne, Pa., they conducted a retrospective cohort study of adults with diabetes initially examined by Indian Health Service in 2015. Patients were reexamined at least one time during the 2016 to 2019 period through the Indian Health Service teleophthalmology program for diabetic eye disease.

Investigators included in their analysis 8,374 people who had a mean hemoglobin A1c level of 8.3% (2.2%) in 2015. Of these, 4,775 were women (57.0%). Investigators used deidentified medical record data obtained during routine clinical operations of the IHS teleophthalmology program at 75 primary care clinics distributed among 20 states.

They found that of patients with no diabetic retinopathy in 2015, 18.0% had mild diabetic retinopathy or worse in 2016 to 2019. The incidence rate from no diabetic retinopathy to any retinopathy was 69.6 cases per 1,000 person-years at risk. A total of 6.2% of participants progressed from no diabetic retinopathy to moderate disease or worse. Of patients with mild diabetic retinopathy in 2015, 27.2% progressed to moderate disease or worse in 2016 to 2019, and 2.3% progressed to severe disease or worse.

One limitation, the authors said, is that this study focused on diabetic retinopathy, omitting diabetic macular edema, another leading cause of vision loss in people with diabetes. “Thus, this study likely underestimated the overall burden of diabetic eye disease incidence for American Indian and Alaska Native patients,” investigators wrote. “However, we believe that the underestimate is modest. Omission of DME in this study may have underestimated the incidence of diabetic eye diseases overall by approximately 1.6% to 2.0%. The percentage might be lower still because some patients with incident DME may have also had incident DR and were already counted in the estimate.”

Another limitation is that 38.8% of the total patients initially evaluated in 2015 were not reexamined from 2016 to 2019.

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