Most PCPs Forgo Fundoscopic Exams for Diabetic Retinopathy in T2D Patients


An analysis from Duke University School of Medicine suggests few PCPs were performing fundoscopy to identify diabetic retinopathy in patients with type 2 diabetes and even those who did were often accurate just 63% of the time.

An earlier version of the article was published on

Ailin Song, MHS

Ailin Song, MHS

Fundoscopic examinations for diabetic retinopathy (DR) are not often utilized by primary care professionals (PCP) and are largely ineffective when used, according to a new study from the Duke University School of Medicine.

An analysis of more than 2000 encounters among a cohort of 767 adult patients with diabetes, results of the study demonstrate PCPs performed a documented fundoscopic examination for just 12.1% of patients with the sensitivity of PCP-performed fundoscopy for detecting disease at 0.0%.

"To our knowledge, this is the first study to report on clinical practice patterns of fundoscopic examination for DR screening in primary care," wrote investigators. "Our finding complements the existing literature reporting low rates of DR screening: approximately 40% of patients in this study did not receive a screening examination from either an eye care professional or their PCP, suggesting that current primary care systems are insufficient to fill gaps in eye care for patients with diabetes."

The Lack of Access to Eye Care

Primary care physicians are critical in diabetic retinopathy screenings, particularly where there is limited access to specialty eye care.

However, there is also limited data on current diabetic retinopathy screening practice patterns within the primary care setting. With this in mind, a team, led by Ailin Song, MHS, of Duke University School of Medicine, assessed the practice patterns of fundoscopic examination for diabetic retinopathy screening in a large primary care network and evaluated the sensitivity and accuracy of PCP fundoscopy for detecting the disease.

In the retrospective cohort study, the investigators used a random sampling and manual review of electronic health records for PCP fundoscopic examination documentation. The team compared this data with documentation of an examination performed by either an ophthalmologist or optometrist within 2 years before and after primary care visits.

The Network

The data was derived from a network of 28 clinics with 7449 adult patients with diabetes seen by at least one primary care network in 2019. Investigators also obtained data from 2001 encounters from the electronic health record for a random sample of 767 patients.

The primary outcome of interest for the study was the frequency of PCPs performing fundoscopy at least once in the calendar year for patients with diabetes. They also identified patient, clinician, and clinic factors linked to PCPs performing fundoscopy at least once in the calendar year using univariate and multivariable logistic regression analyses.

Finally, they compared the PCP examination results with diagnoses made by eye care professionals to assess the sensitivity and accuracy of the findings from the PCP examinations.

Underutilized Fundoscopic Examinations

The results show primary care professionals documented a fundoscopic examination for 12.1% (n = 93) of this patient population. All of these results were classified as normal. After using eye care examination results as a reference standard, the accuracy of PCP fundoscopic examination was 62.7% (95% CI, 50.0%-73.9%). There was also a sensitivity for detecting disease of 0.0% (95% CI, 0.0%-14.9%).

In addition, patient demographics and clinical characteristics were not associated with PCPs performing fundoscopy. However, after conducting a multivariable logistic regression analysis, the investigators connected the number of PCP years in practice with a greater odds of patients receiving fundoscopy at least once in the year (aOR per 10 years in practice, 1.26; 95% CI, 1.01-1.59; P = .04).

Nurse practitioner credentials was also linked to a lower odds of receiving fundoscopy (aOR, 0.23; 95% CI, 0.04-0.79; P = .049; compared with having physician credentials), after adjusting for rural clinical location, clinic location in a primary care shortage area, and documentation of an up-to-date eye care professionals examination by a PCP in the study year.

“In this cohort study, fundoscopic examination was rarely performed and was not sensitive for detecting DR in primary care practice,” the authors wrote. “Because the rate of DR screening by eye care professionals remains low, research to explore and break down barriers to the implementation of effective primary care–based DR screening strategies, such as teleretinal imaging, is needed to prevent vision loss from undiagnosed DR.”

The study, “Practice Patterns of Fundoscopic Examination for Diabetic Retinopathy Screening in Primary Care,” was published online in JAMA Network Open.

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