11Nov

Decreasing the Risk of Diabetic Retinopathy in a Type 2 Diabetes Study: Part 4

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Case management may also have played a role in attendance at sessions when the photographs were taken and the immediate feedback that nonmydriatic photography can give to the health care team and thus facilitate the follow-up of patients with documented retinopathy. Whether it is the support associated with case management and the resultant adherence to nonglycemic targets such as hypertension that led to the improved retinal status, independent of improved glycemic control, cannot be addressed by this study. However, perhaps because case management clearly improves glucose control in a Medi-Cal–type population and is associated with decreased risk of new-onset retinopathy, comprehensive case management may be justified in similar health care settings.

Limitations of this study include the fact that it was not of sufficient duration to address whether case management may have also prevented progression of previously recognized retinopathy, which may have required more time or larger numbers to see an effect. Another limitation is the fact that we only used a single field for evaluation of the retina rather than the seven fields used in other studies of retinopathy, although in previous reports, this technique for diabetic retinopathy screening has been shown to be effective. In this way, minimal retinopathy may have been missed in the periphery at baseline and at the follow-up study. However, since both baseline and follow-up retinal fields were identical, it is most likely that our findings reflect a clinically meaningful decrease in the development of retinopathy over the 2-year time span that was tested. Furthermore, seven-field photography was not practical in this case management setting. Although all participants were urged to visit an ophthalmologist, those subjects with evidence of any retinopathy on the photograph were personally followed by the case management team to facilitate the consultation.

Although other studies show that improved glycemic control decreases the risk of retinopathy, this study is the first to show that even a relatively short duration of improved control (?2 years) instituted before the onset of clinically identifiable retinopathy can decrease the risk of developing new retinopathy. This study also underscores the risk of retinal disease in type 2 diabetes in that progression of retinopathy occurred within a relatively short time when glycemic control was not achieved. Further studies are necessary to determine whether early intervention to achieve glycemic control in established diabetes has a greater effect to reduce diabetic retinopathy than its introduction at a later stage of the disease.

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11Nov

Decreasing the Risk of Diabetic Retinopathy in a Type 2 Diabetes Study: Part 3

FILED IN Type 2 Diabetes No Comments

This report is the first evidence that intensive case management reduces risk of new-onset retinopathy in people with established type 2 diabetes. The U.K. Prospective Diabetes Study first demonstrated the effects of improved glycemic control on retinopathy in type 2 diabetes, but the subjects who participated in that landmark study were all newly diagnosed, whereas the patients without retinopathy in this study had a mean duration of diabetes of 7.5 years by the time the case management intervention was begun. Although the number of subjects with established retinopathy in this study was not sufficient to draw conclusions about progression of retinopathy compared with those who had none at baseline, the response observed in the latter suggests that early intervention with case management is an effective approach to reducing the burden of retinopathy in patients with type 2 diabetes. This conclusion is reinforced by the finding that even when case management is maintained for a short duration (mean <2 years), it is sufficient to diminish the risk of retinopathy.

The mechanisms for the effect of case management on reduction in the development of new-onset retinopathy may be related to any of the different facets of the case management process, although the major factor is likely to be improved glycemic control. Although A1C concentrations were not consistently evaluated at the time the follow-up photographs were taken, in the main trial the case management group showed a persistent improvement in the A1C that was greater than in the standard care group (6), suggesting that the decreased risk of retinopathy is likely due to improvement in glycemia. This study, therefore, confirms the necessity of providing adequate education and follow-up support, as delivered in this trial that utilized case management and frequent intervention, in order to achieve and maintain an A1C improvement over and above the standard care given to this county clinic Medi-Cal population.

However, other elements of the case management approach may well have contributed to the reduction in development of new-onset retinopathy. With adequate surveillance and support, glycemia improves, but, as demonstrated in our primary report, this improvement was associated with significant decreases from baseline to end of study in diastolic blood pressure, LDL cholesterol, and total cholesterol and an increase in HDL cholesterol in the intervention group. Thus, case management not only resulted in improvement of glycemic control but also had an effect on diminishing the risk of microvascular disease, as measured by retinopathy.

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