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P.P. Lee, F. Sloan, Z. Feldman, J. Osterman, D.S. Brown; Longitudinal Rates of Annual Eye Exams Among Patients with Diabetes Mellitus and Glaucoma . Invest. Ophthalmol. Vis. Sci. 2003;44(13):169.
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Purpose: To understand the longitudinal utilization patterns of patients with diabetes mellitus and glaucoma to assess the continuity of care for these chronic diseases. Methods: Enrollees in the National Long-Term Care Survey (NLTCS) are a representative sample of the Medicare population aged 65 and older in the United States, re-balanced every 5 years. We analysed the cohort of patients who were at least age 65 in 1991 through to their death or the end of the analysis period in 1999, eliminating those who could not be matched to Medicare files and those enrolled in an HMO for more than 6 months.. Data are available from 7 medicare claims files, including parts A and B, skilled nuring, home health, and hospice. The outcome indicator was an exam claim by an optometrist or ophthalmologist in consecutive 15 month time periods from January 1, 1999, indicative of at least an "annual" exam for these conditions in that time period. A time period without an eye exam was considered a "gap" in the continuity of follow-up. Results: From a base sample of 21, 644 enrollees, there were 2193 with diabetes without eye findings, 161 with background retinopathy (BDR), 22 with macular edema (ME), and 67 with proliferative disease (PDR). There were 410 glaucoma suspects, 1026 with open-angle glaucoma, 231 with narrow angle, and 137 with other types of glaucoma. For those followed for 4 or more consecutive time periods (a total of at least 60 months), only 12% of those with diabetes and no eye findings had no gaps in visits, while 37% of those with PDR or ME had no gaps. Almost two-thirds of those with diabetes without eye findings had 3 or more gaps in this same time period, compared to 40% with BDR, 36% with ME, and 27% with PDR. Among those with open-angle glaucoma followed for at least 4 time periods, 50% had at least one gap, but only 20% had 3 or more gaps. Only 20% of suspects had no gaps, with 45% having 3 or more gaps with longitudinal follow-up of 4 or more periods. Conclusions: Longitudinal analysis of utilization in a representative sample of the Medicare population with diabetes and glaucoma reveal major shortfalls in the continuity of care for both diseases, using even minimal standards. Among those with diabetes, more severe eye disease is associated with better continuity, but the overall rate remains disconcertingly high. Those with glaucoma appear to have somewhat more regular care, but with still high levels of discontinuity of care. The results of this longitudinal analysis point out an even more concerning picture of care than has been obtained to date with cross-sectional and lmited longitudinal studies.
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