Health System Size, Location Important in Diabetic Eye Disease Screening


Eye screening varied from 31.8% - 73.0%, with lower screening rates at smaller health systems.

Yao Liu, MD, MS

Yao Liu, MD, MS

Although low screening rates are linked to diabetic eye diseases' role as the leading cause of blindness in the United states, most interventions have emphasized patient education and yielded modest improvement.

Accordingly, a recent study utilized an all-payer, statewide claims database to assess screening variability across health systems in order to determine whether a patient’s health system may be associated with screening receipt.

Led by Yao Liu, MD, MS, Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, the team found health systems may play an important role in diabetic eye disease receipt, with variability based on size and location of the system.


Lin and colleagues deidentified data from the Wisconsin Health Information Organization All-Payer Claims Database, which covered 75% of residents in the state. They included adults (18 - 75 years) with primary medical insurance coverage throughout the baseline (October 2012 - September 2013) and measurement (October 2013 - September 2015) diagnosed with diabetes.

The included patients received guideline-concordant screening if they had a claim billed for an examination with an eye care provider or telemedicine-based retinal imaging during the measurement period.

On the basis of patient-level factors, age, sex, hierarchical condition category risk score, and primary care clinic rurality were collected.

Multivariable logistic regression models were used to assess potential factors associated with screening receipt, including 143 health systems as 1 categorical variable with 101 possible values. Then, investigators used the absolute value of the odds ratio (OR) for each health system to quantify the distribution of the effect of the health system on screening receipt.


A total of 119,347 adults with diabetes from 698 primary care clinics were included in the study. Data show most patients (74.4%) were ≥55 years (mean age, 60.9 years) and 48.7% were women.

In this patient population, the most common insurers were Medicare (58.4%), commercial (30.9%), and Medicaid (10.1%), while 18.6% of patients received their care at a rural primary care clinic.

The team observed eye screening varied from 31.8% - 73.0%, consisting of lower screening rates at smaller health systems. Additionally, the median magnitude of the effect of health systems on the odds of screening receipt was 1.24 (IQR, 1.11 - 1.48).

If health systems were excluded from the model, those who got care from rural primary care clinics were more likely to obtain screening, compared to urban clinics (OR, 1.14; 95% CI, 1.11 - 1.18). Despite this, the association was shown to reverse when health systems were included (OR, 0.94; 95% CI, 0.91 - 0.98).


“Interventions targeting health systems and rural primary care clinics may be important for increasing diabetic eye disease screening rates,” they concluded.

The study, “Analysis of Health System Size and Variability in Diabetic Eye Disease Screening in Wisconsin,” was published in JAMA Network Open.

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