Documentation of Stage of Retinopathy Among Patients With Diabetes Mellitus Among Primary Eye Care Providers

Abstract

Purpose:: Management of diabetic retinopathy requires accurate assessment of its presence and severity. Yet, while several studies have noted opportunities for improvement for accurate recognition of diabetes findings, little is known about the levels of documentation of the severity staging of diabetic eye disease. As such,, we sought to assess the frequency and accuracy of documentation of the stage of retinopathy in the charts of patients with diabetes mellitus cared for by primary eye care providers.

Methods:: The initial 663 chart abstractions of community-based optometrists and comprehensive ophthalmologists in an ongoing study to improve diabetes eye care were assessed for 1) the presence or absence of documentation of the severity (stage) of retinopathy present and 2) whether the assigned stage conformed with the retinal findings described in the chart using the International Classification of Diabetic Retinopathy (ICDR) system.

Results:: The stage of retinopathy was not documented for 11% (65/663) of right eyes and 12% (71/663) of left eyes. In addition, documentation of findings to support an assigned stage of retinopathy were absent in another 13% of right eyes and 15% of left eyes, meaning that one quarter of charts lacked documentation of either specific findings on examination or the stage of retinopathy. In addition, another 8% of eyes did not specify the eye to which a stage of retinopathy was assigned. Staging using the ICDR system was correct in approximately ¾ of eyes in which the stage was documented, using an exact match for the ICDR stages (none, mild NPDR, moderate NPDR, severe NPDR, and PDR).20% of eyes (or 80% of those with an incorrect stage) were staged by the provider as being less severe than the findings documented on the exam that day would indicate.

Conclusions:: Findings suggest that significant opportunities exist to improve both the degree of documentation of the severity of retinopathy and the underlying fundus examination and to more appropriately stage the severity of retinopathy present. Prior studies indicating mis-staging of retinopathy in patients thus probably reflect both challenges in recognizing the findings present and, as shown in this study, synthesizing the recognized findings into an appropriate severity classification.

Keywords: diabetic retinopathy • clinical (human) or epidemiologic studies: health care delivery/economics/manpower