·Investigation·
Knowledge
and practices of primary care physicians on the current referral system of
diabetic retinopathy in Islamabad and Rawal-Pindi, Pakistan
Muhammad Shakaib Anwar1, Baila Shakaib1,
Waseem Akhtar1, Erum Yusufzai1, Maham Zehra1,
Hajira Munawar2, Kinza Azhar2
1Department of Ophthalmology, Rawal
Institute of Health and Sciences, Islamabad 44000, Pakistan
2Medical College, Rawal Institute of
Health and Sciences, Islamabad 44000, Pakistan
Correspondence to: Baila Shakaib. Department of
Ophthalmology, Rawal Institute of Health and Sciences, Islamabad 44000,
Pakistan. bailashakaib@gmail.com
Received:
Abstract
AIM: To assess the current knowledge and practices in diabetic eye care and
referral system regarding diabetic retinopathy (DR) in health centers of
Islamabad and Rawal-Pindi.
METHODS: A cross-sectional study was carried out in 4
government and private health centers in Rawalpindi-Islamabad from May 2018 to
Oct. 2018. A total of 38 Primary Care Physicians (general practitioners, family
physicians, and internists) were recruited out of which data for 2 were either
not returned, or were missing partially. Data were collected through a 27-item
consented & validated, multiple-choice questionnaire based on physician
characteristics, knowledge and practice of diabetic eye care and challenges
faced due current DR referral system. Descriptive analyses for all variables
were performed including, mean and standard deviation. Analytical analyses were
also conducted to study association between different study variables.
RESULTS: Mean scores of knowledge for general practitioners,
family physicians, and internists were 41.7%, 42.0% and 46.6% respectively. A
lack of knowledge, and suboptimal practices were observed regarding signs,
symptoms, screening, testing, evaluation and referral of DR regardless of
physicians’ specialty, or years in practice. Lack of expertise regarding direct
ophthalmoscopy, interpretation of findings, and referral to an ophthalmologist
were noted. Physicians who performed consultation and counselling according to
patients’ needs referred more patients to an ophthalmologist than those who
restricted their consultation to a fixed amount of time and had more patients
per unit time (P=0.01). Physicians who had taken care of less than 5
number of patients with DR marked less incorrect answers with no significantly
greater number or correct answers compared to physicians who had taken care of
more than 5 number of patients with DR (P=0.044). An association of more
than 5 patients with DR taken care of with more need based patient consultation
and counselling was also noted (P=0.017). An evaluation of the current
referral system for DR revealed major loopholes in the health care
infrastructure, proper guidelines, properly functioning equipment, check and
balances, and lack of guidance to physicians regarding acquiring and updating
knowledge regarding DR.
CONCLUSION: Lack of updated and adequate knowledge, practices
among primary care physicians, and suboptimal diabetic eye care and referral
system have contributed to late presentation of DR. Interventions are needed to
improve current diabetic eye care, and knowledge and practices of primary care
physicians.
KEYWORDS: diabetic retinopathy; referral of
diabetic retinopathy; diabetic retinopathy guidelines; primary care physicians
DOI:10.18240/ijo.2019.12.11
Citation:
Anwar MS, Shakaib B, Akhtar W, Yusufzai E, Zehra M, Munawar H, Azhar K.
Knowledge and practices of primary care physicians on the current referral
system of diabetic retinopathy in Islamabad and Rawal-Pindi, Pakistan. Int J Ophthalmol 2019; 12(12):1885-1892
INTRODUCTION
Diabetes mellitus (DM) is one of the
world’s fastest growing chronic diseases[1]. World
health organization (WHO) has estimated that the total number of people with
diabetes would reach 366 million by 2030[2].
Diabetic retinopathy (DR), a specific microvascular complication of DM, is the
fifth most common cause of acquired visual loss worldwide, and the leading
cause of visual impairment among working aged adults, thereby having a
significant socio economic impact[3-4].
The prevalences of DR due to
diabetes mellitus type 1 (DM1) and diabetes mellitus 2 (DM2) were reported as
10% to 50% and 25.2% respectively[5].
Approximately 93 million people with non-proliferative diabetic retinopathy
(NPDR), 17 million with proliferative diabetic retinopathy (PDR), 21 million
with diabetic macular edema (DME) and 28 million with vision threatening
diabetic retinopathy (VTDR) exist worldwide[6].
Patients with DR may lose sight as a result of development of DME and/or PDR[7].
Because DR has few symptoms until
visual loss develops and the present treatments, photocoagulation and
anti-vascular endothelial growth factor (VEGF) injections, are only effective
at slowing the progression of retinopathy and reducing visual loss, but not
restoring lost vision[8], regular DR screening
becomes critical[9]. Two gold standard methods
recognized for DR screening are comprehensive dilated eye slit lamp ophthalmic
examination by a trained health professional (e.g., ophthalmologist)[10] and stereoscopic 7-field fundus photography by a
trained photographer with image interpretation by an experienced grader[11]. Both methods require the specialist equipment and
professionals from specialist clinics[12] and, in
most health care systems, is preceded by screening by non-ophthalmologists.
To facilitate timely screening and
appropriate treatment, American Diabetes Association (ADA) has established a
comprehensive set of guidelines[13]. It
recommends an initial dilated and comprehensive eye examination by an
ophthalmologist or optometrist within 3-5y after the onset of diabetes for DM1,
repeated annual examinations by an experienced and knowledgeable
ophthalmologist or optometrist for both DM1 and DM2 and prompt treatment for
severe macular edema, NPDR and PDR. Women with preexisting diabetes planning
pregnancy should have comprehensive eye examinations in the first trimester
with subsequent follow ups for macular edema[14].
Although visual loss due to DR can
be reduced by 60% if treated timely, the proportion of blindness due to DR
ranges from 3% to 7% in the Southeast Asia and Western Pacific regions, and is
as high as 15%-17% in developed regions such as the Americas and Europe. In
2010, WHO declared that DR accounts for approximately 4.8% of cases of
blindness (37 million) worldwide[15]. Out of
above 35% blind and 40% with visual impairment due to DR[6]
belonged to South Asia. Factors such as socio-economic status, young age, low
income, lack of education, less comorbidity, insulin use, high specialists’
fee, lack of patient cooperation, and not enough education on diabetes have
been shown to lead to patients’ non-adherence to eye examinations, timely
follow up , and guidelines.
It has been proven that
patient-physician relationship is a two way street[16].
Improving physician’s compliance with guideline-recommended care remains a
challenge; timely referral of DR for evaluation is facing one of such
challenges. Furthermore, busy primary care practices lacking organizational
support and computerized tracking systems, telecommunication, sustainability,
outstripped capacity and resources for implementation of DR eye care further
increases the burden of DR eye care on health care system and economy[17]. With a limited health care budget and growing
morbidity due to DR, it is vital to delve into issues surrounding physicians’
knowledge and practices and current health care system for DR.
The present study, to the best of
our knowledge, is the first of its kind to be carried out in the area to assess
the knowledge and practices of primary care physicians regarding DR as they are
mostly the first physicians whom patients with diabetes come in contact with.
The study also analyzed the challenges surrounding the current diabetic eye
care system and referral of patients with DR to an ophthalmologist.
SUBJECTS AND METHODS
Ethical Approval Ethical approval was obtained from
Rawal Institute of Health and Sciences Ethical Approval Committee. A consent
form was provided to each physician prior to participation in study, indicating
the purpose of the study, benefits of participation and the right to withdraw.
A serial number was assigned to each participant to maintain confidentiality.
Data was accessible only to the members of the research team.
Study Population and Setting A cross-sectional study was carried
out in 4 government and private health centers of Rawalpindi-Islamabad from May
2018 to Oct. 2018. Primary care physicians[1]
holding MBBS degree and license from Pakistan Medical and Dental Council and
having completed one year of house job were recruited through purposive
sampling. Physicians who had treated and properly followed up at least 5
patients with diabetes were included. While a total of 38 physicians were
recruited for the study, only 36 physicians were included for statistical
analyses as data for 2 was either not returned, or was missing partially.
Data Collection Data were collected through a
27-itemed, consented & content validated, questionnaire created by the
research team. A member of the research team trained specially for the purpose
by the primary investigator was given the task to collect data and instructed
the participants to answer the questions without referring to internet, or any
textbook or colleague. The questionnaire contained 4 sections: the first
section was based on demographics and physician characteristics including years
in practice and number patients with DM and DR taken care of. The second
section contained questions regarding knowledge about DR as a disease, its
screening evaluation, treatment, knowledge regarding referral and relevant
physical examination and its findings. The third section comprised of questions
regarding physicians’ practices with respect to examination of DR, screening
and referral practices, patient education regarding DR, and updating
physician’s knowledge about DR. The fourth and last section was a survey
containing questions regarding DR screening, evaluation, referral systems and
infrastructure of current health care system in Islamabad and Rawal-Pindi.
Data Analysis Data were entered and analyzed using
SPSS version 20. Scores were displayed in form of percentages and analyzed
using mean and standard deviation as measures of central tendency. Analysis of
variance (ANOVA) and t-test for independent samples were used to
evaluate differences in means of scores obtained by general practitioners,
family physicians, and internists. A Chi-square test of independence was used
to analyze whether the difference in knowledge and practice was dependent on
years in training, specialty or number of patients with DM taken care of. A
P value of <0.05 was set throughout the analysis to define a result as
statistically significant.
To evaluate knowledge and practices,
scoring of the questionnaire was done by awarding plus one for a correct answer
and zero for a “not sure”, wrong, or missing answer. The final scores for knowledge
and practices were calculated out of 100. The wrong answers regarding knowledge
and practices were, however, counted and coded for separately form missing of
“not sure” answers while entering and analyzing data.
RESULTS
Participant Characteristics Totally 64% of participants were
women while the remaining 36% were men. Majority of the participants, 75% (n=27)
were general practitioners (Table 1). Ages ranged from 25 to 65y with a mean
age of 33.10±11.2y. Most of the participating physicians, 61% (n=22) had
spent less than 5y in practice. The 64% (n=23) of the participants had
taken care of more than 30 patients with DM during their practice, and only 6%
(n=2) had taken care of less than 5, and 10-15 patients with DM, each,
during their practice. Most of the participants, 44% (n=16), had not
taken care of any patient with DR during their practice, and only 14% (n=5)
had taken care of more than 5 patients with DR during their practice. Although
the questionnaire was distributed to include equal number of participants from
each category of specialty, a number of forms were never returned. Mean scores
of knowledge for general practitioners, family physicians, and internists were
41.7%, 42.0% and 46.6% respectively. The mean percent incorrect responses were
13.5%, 13.3% and 12.4% respectively.
Table 1 Physician demographics and
background characteristics n (%)
|
Category |
Physicians (n=36) |
|
Sex |
|
|
Male |
13 (36) |
|
Female |
23 (64) |
|
Specialty |
|
|
General practitioner |
27 (75) |
|
Family physician |
2 (6) |
|
Internist |
7 (19) |
|
Years in practice |
|
|
<5y |
22 (61) |
|
6-10y |
5 (14) |
|
11-15y |
2 (6) |
|
16-20y |
2 (6) |
|
>20y |
5 (14) |
|
Number of patients with DM taken
care of |
|
|
5 |
2 (6) |
|
10-15 |
2 (6) |
|
15-20 |
4 (11) |
|
20-25 |
5 (14) |
|
>30 |
23 (64) |
|
Number of patients with diabetic
retinopathy taken care of |
|
|
Less than 5 |
11 (31) |
|
More than 5 |
5 (14) |
|
None |
16 (44) |
|
Not sure |
4 (11) |
Knowledge For the best initial screening exam
for DR most physicians, 80% correctly chose comprehensive dilated fundus
examination (Table 2). Although most physicians recognized long duration of
diabetes, and uncontrolled glycemic levels as risk factors for DR, 20% knew
that blood lipid levels were one of the three main predictors of progression of
DR including hypertension and diabetic kidney disease (Table 3). Only 30%
rightly considered pre-existing diabetes in pregnant woman a risk factor for DR
while 35% incorrectly recognized gestational diabetes as risk factor. Only 9%
of physicians correctly understood that DR presents with no symptoms in very
early stages. An overall lack of knowledge was observed regarding time for
initial screening for DR in DM1 and DM2 (Table 3).
Table 2 Knowledge regarding best
first line test for diagnosis of retinopathy deemed appropriate by physicians
|
Test |
Physicians (%) |
|
Comprehensive dilated fundus
examination |
80.0 |
|
Handheld ophthalmoscope |
5.0 |
|
Fundus fluorescein angiography |
10.0 |
|
I don’t know |
5.0 |
Table 3 Knowledge of percentage of
physicians regarding screening of DR in terms of time for initial dilated
comprehensive fundus examination for both type 1 and type 2 DM, and lab
investigations that could help predict progression of DR
|
Time of initial dilated
comprehensive fundus examination |
Physicians (%) |
Lab investigations that could help predict
prognosis of diabetic retinopathy |
Physicians (%) |
|
|
DM1 |
DM2 |
|||
|
At the time of diagnosis |
45 |
40 |
Serum lipid levels |
20 |
|
One year after diagnosis |
10 |
10 |
Blood pressure monitoring |
30 |
|
Within 3-5y of diagnosis |
40 |
35 |
HbA |
70 |
|
On developing visual disturbance |
5 |
5 |
Fasting blood sugar |
75 |
|
I am not sure |
0 |
10 |
|
|
Very few physicians had detected
signs of DR on ophthalmoscopy correctly (Figure 1) and knew the right time of
referrals for DM1 and DM2 (Table 3). These included both internists and general
practitioners (GPs). Only 8% of the physicians knew that panretinal
photocoagulation is treatment modality of DR, while 40% knew about intravitreal
corticosteroids, 45% knew about anti-VEGF, and only 25% knew about vitrectomy
as being treatment modalities for DR.
Figure 1 Responses regarding being
able to detect signs of DR and the referral accordingly.
While most of the physicians claimed
to have always consoled their patients regarding raised blood lipid levels and
their risk factors (85%), very few (20%) actually ordered lab tests for them; counselling
itself was considerably fair. Although 75% of the physicians claimed that they
updated their knowledge on DR regularly, as opposed to 25% who did not update
their knowledge at all, through mentioned sources --which were internet and
social media, journals, guidelines, conferences, pamphlets, and books (Table 4)
—the responses to questionnaire revealed that either the knowledge was not
properly updated, unreliable resources were being used, or rationale behind the
guidelines was not adequately understood.
Table 4 Practices of primary health
care physicians in terms of performance of ophthalmoscopy and updating
knowledge regarding DR by primary health care physicians
|
Regarding performing
ophthalmoscopy in clinics |
Percent (%) |
Update on knowledge regarding diabetic retinopathy |
Percent (%) |
|
I perform it regularly in my
clinic with pupil dilation |
5.0 |
I don’t, I continue with what I know |
25.0 |
|
I can perform it but do not
perform regularly |
55.0 |
Internet and social media |
55.0 |
|
I do not know how to perform it
well and do not perform it |
40.0 |
Journals, guidelines, conferences |
50.0 |
|
|
|
Pamphlets |
30.0 |
|
|
|
Books |
40.0 |
A t-test for independent
samples was performed to analyze whether the number of patients with DR taken
care of had a significant impact on physicians’ responses to the questionnaire
regarding DR. The result revealed that physicians who had taken care of less
than 5 number of patients with DR marked less incorrect answers than those who
had taken care of more than 5 patients and the difference was statistically
significant (P=0.044) with no significant relation with the number of
correct responses (P=0.210). This could be due to limited knowledge and
exposure, and thus more responses were left blank. Physicians’ years in
practice, age and gender did not display any statistically significant
difference in knowledge and practice.
Practice Only 5% of the physicians knew how
to do direct ophthalmoscopy and performed it regularly (Table 4), 55% claimed
they knew how to perform it but did not perform it regularly, and the remaining
40% neither knew how to perform ophthalmoscopy properly, nor performed it
regularly, irrespective of their specialty, years in practice or number of
patients with DM or DR taken care of. Only 45% of the physicians referred
patients both with DM1 and DM2 for screening and regular follow up (Table 5).
While 50% followed up patients after their visit to ophthalmologist, 25%
believed it was solely ophthalmologists’ responsibility.
Table 5 Practices of primary health
care physicians in terms of referral to an ophthalmologist and follow up of
patients with DR
|
Patients referred to an
ophthalmologist by the physician |
Physicians (%) |
Patients with diabetic retinopathy followed up by the physician |
Physicians (%) |
|
All diabetic patients only if they
have visual disturbances |
35 |
Yes always |
50.0 |
|
All diabetic patients |
45 |
Only patients who may require treatment from an
ophthalmologist |
25.0 |
|
Patients with DM2 for screening
and routinely follow ups |
5 |
No, it’s ophthalmologists’ responsibility |
25.0 |
|
Never referred a patient |
15 |
|
|
An analysis of variance (ANOVA) was
performed to assess the difference between the mean number of ophthalmological
referrals made by physicians who tailored their consultation and counselling
according to patients’ needs without any particular time limit in mind,
physicians who restricted their consultation and counselling to less than 5min,
5-15min, and 15-30min separately. The results revealed that the physicians
whose consultation and counseling times were based on the patients’ needs made
significantly more referrals for DR to an ophthalmologist (P=0.01).
A Chi-square test for categorical
variables confirmed a significant association between time required for
consultation and counselling and number of patients with DR seen throughout
career (χ2=24.77, P=0.003). Physicians who had seen
less than 5 number of patients with DR averaged a consultation with counselling
around 15min while those who had seen more than 5 number of patients with DR
tailored their consultation and counselling time according to patients need and
took more time. Those physicians who took more time for consultation and
counselling, referred more patients (χ2=20.19, P=0.017).
Diabetic Retinopathy Referral
System The results displayed multiple
loopholes in the screening and referral system (Table 6). Physicians shared
their fears of causing angle closure glaucoma, patients not willing to be
dilated and lack of properly functioning ophthalmoscopes. Patients’
unwillingness to pay for ophthalmologists’ appointments, lack of trained staff
and deficiencies in referral system were also noted. Most of the physicians
believed that there was a need for proper training and teaching sessions for
physicians. Totally, 90% of the physicians agreed there was a need to improve
their practice or knowledge, or both. Although their scores revealed lack of
knowledge regarding DR and suboptimal practice, the remaining 10% were content
with their content with their current knowledge and practice (Table 7).
Table 6 Physicians responses to the
survey regarding current diabetic eye care
|
Challenges faced in clinic during
screening of diabetic retinopathy |
% |
Challenges faced with respect to
diabetic eye care and referral system |
% |
Methods of referral to an
ophthalmologist |
% |
|
I cannot detect signs of DR
properly on direct ophthalmoscopy |
10 |
Not sure |
30 |
Through an automatic hospital
referral system that does not function well |
5 |
|
Patients do not want to be dilated |
35 |
No proper referral system |
10 |
Ask patients to take an
appointment themselves to see an ophthalmologist themselves as they please. |
10 |
|
No dilating drops available |
25 |
No follow up system |
25 |
Ask patients to take an
appointment themselves to see an ophthalmologist and follow up |
15 |
|
Ophthalmoscope is either not
charged or not working properly |
15 |
Lack of log registers for
maintaining record |
25 |
Using a referral form which they
use to get appointment |
30 |
|
I fear dilating drops may cause
angle closure glaucoma |
30 |
Lack of staff to schedule referral |
35 |
Using a referral form and after
their appointment I follow them ups |
60 |
|
No ophthalmoscopes available |
20 |
Lack of reminder system |
35 |
|
|
|
If I detect, I don’t know how to
manage those signs of DR |
25 |
Lack of diabetic guideline
pamphlets |
15 |
|
|
|
|
|
Lack of counselling for diabetic
eye care by physician or nurse |
15 |
|
|
|
|
|
Patients not willing to bear
expense of ophthalmologist’s appointment |
20 |
|
|
|
|
|
Poor clinic and hospital
management |
10 |
|
|
|
|
|
Lack of feedback sessions to
improve quality care |
30 |
|
|
|
|
|
Lack of regular training and
teaching sessions for physicians and staff regarding diabetic eye care |
35 |
|
|
Section 4 of the questionnaire
contained a brief survey containing questions with “select all that apply”
statements as responses regarding the current health care infrastructure and
referral system pertaining to DR. The table displays answers opted for by
percentage of physicians in response to challenges faced in clinic during
screening of DR, challenges faced with respect to diabetic eye care and
referral system, and current methods of referral to an ophthalmologist.
Table 7 Physicians’ opinions on the
need to improve their knowledge and practice regarding diabetic eye care
|
Physicians’ opinions |
Percent (%) |
|
No, I think I know enough, and my
practice is appropriate |
10 |
|
I think I do not need to improve
my knowledge, but I have to improve my practice |
10 |
|
I think I need to improve my
knowledge, but my practice is fine |
5 |
|
I think I need to improve both my
knowledge and practice |
75 |
DISCUSSION
Primary physicians are mostly the
first in line to provide diabetic care. The present study revealed that
although there is lack of knowledge and suboptimal practices regarding DR among
primary health care physicians, the means to fill these loopholes are also
suboptimal. While a greater percentage of physicians is keen to improve their
current knowledge and practices, over evaluation of one’s knowledge and
practices also exist amongst physicians.
A recent survey in urban Indonesia
reported that less than 50% of the patients with diabetes were informed the
need for eye examinations by their physicians[18].
Kraft et al[19], in their study,
reported that 45% percent of the physicians surveyed responded with high
chances of referring all of their patients with DM1 to an eye care specialist
annually as did 35% of the physicians for referring their patients with DM2. As
comparable to the results of present study, fewer physicians reported high
chances of routine in-office fundus examination.
Another study reported that even
though both ophthalmologists and optometrists received and read the National
Health and Medical Research Council (NHMRC) guidelines, Australia, very few
demonstrated statistically significant or clinically relevant changes in
professional behavior; implementation of guideline reminder systems was
considered a solution[20]. This finding is
comparable to that of the present study where the physicians claimed to have
acquired knowledge form different
sources of information but that information did not translate into their
applicable knowledge and practices .This could be due to lack of awareness of
the rationale behind the guidelines, time for communication, reimbursement,
resources, computerized tracking systems, organizational support and limited
education about effective communication during continued medical education
programs[16].
Streja and Rabkin[21]
carried out a retrospective chart audit for patients and a retroactive
questionnaire for physicians to evaluate physician characteristics associated
with implementation of measures for preventive care in patients with DM. They
discovered that physician practice style was the most common physician
characteristic impacting physicians’ decision for ophthalmology referral, along
with serum high-density lipoprotein, cholesterol measurement and urinalysis.
Physicians with high number of patient encounters per unit time showed a lower
level of implementation of outcomes. Only few were to be referred to an
ophthalmologist for a dilated fundus examination. These findings were similar
to those of our study where the physicians who tailored their consultation and
counselling according the needs of the patients ended up referring more
patients to an ophthalmologist compared to those who restricted their
consultation to a set amount of time or encountered more patients per unit time
as a result of less time spent per consultation.
Physicians also overestimated the
percentage of referrals advised, and level of care offered, thus forming a poor
correlation between physicians’ stated belief and performance, as also revealed
by the present study where physicians were content with their current knowledge
and performance even though they displayed lack of knowledge regarding DR and
suboptimal practice[22]. A mini clinic setting,
with more time for patient care was considered to be associated with improved
level of care and screening for patients with DR.
Furthermore, as previous studies
observed, the lack adherence to instructions, untimely referral and false
positive diagnoses by non-ophthalmologists appears to be linked to lack of
adequate expertise and understanding of ophthalmic diseases, screening
equipment and imaging[23] --such as screening in
the presence of inadequate pupil dilation, lack of dilating eye drops,
ophthalmoscopes with suboptimal functioning, and single field photography.
Conversely, some photographers without specialist training have been found to
report false positive results and subsequent unnecessary referrals to
ophthalmologists[12]. The reason for this could
be, according to the present study, lack of proper knowledge and practice
regarding observation of signs of DR on the fundus and what intervention and
time of referral they call for. However, with adequate training improvement in
sensitivity, specificity and accuracy of family physicians for DR evaluation
has been observed[10].
The last section of the
questionnaire focused on the current health care infrastructure and referral
system for DR. Generally, multiple modifiable loopholes in the current health
care system exist including no proper system for referral, suboptimal
practicing environment, unavailability or improperly functioning equipment,
lack of checks and balances, and lack of ongoing updated training session. This
reveals lack of funds, proper utility of funds, policy making and proper
guidance regarding practices and update of knowledge for future physicians.
It was the first of its kind
in-depth study to assess knowledge and practices of primary care physicians in
the region along with evaluating referral system. The methods employed to
assess knowledge had been guided through previous studies carried out in other
parts of the world.
The study has a small sample size
and a larger sample size would have allowed a better correlation.
Generalizability is also limited. Most of the participants were GPs. Equal
numbers of family physicians and internists would have accentuated any
significant results.
In conclusion, knowledge and
standard of diabetic eye care are well below optimal, regardless of the
physicians’ specialty, practice size or years of experience. Although
physicians claim to update their knowledge, the results reflect that the
knowledge is not being updated regularly or the resources being unreliable (e.g.,
social media, some internet sources). This could also be due to lack of
awareness of the rationale behind the guidelines, lack of time for
communication. There is, thus, a dire need to improve screening and referral
system through reducing cost and training physicians and staff. Our study
proves that the late presentation of DR is not only due to non-compliant
patients, rather physicians and healthcare system are also responsible.
Preparation of DR guidelines should
be as an authentic and verified source of knowledge for understanding DR and
its proper referral and follow up. We recommend annual or 2-yearly symposia
with assessments should be made mandatory. Teaching and training sessions
should be conducted regularly in health care centers and should be made
mandatory. Trained optometrists should be employed in primary health care
clinics for screening to reduce cost and missed follow ups.
ACKNOWLEDGEMENTS
Conflicts of Interest: Anwar MS, None; Shakaib B, None; Akhtar
W, None; Yusufzai E, None; Zehra M, None; Munawar H,
None; Azhar K, None.
REFERENCES