“They Relied on A Single Test Result”

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A new NPR  article reporting on diabetes and public health offers the perfect opportunity to revisit important issues relative to health and screening. The study lead by researchers at the Johns Hopkins Boomberg School of Public Health (Disclosure:  I’m a proud JHSPH alum & former Hopkins faculty/medical staff) analyzed how estimates were calculated differently between epidemiological and clinical studies, and discusses why relying on one test (which often works for informing on historical trends, etc.) doesn’t work when focusing on global impacts of undiagnosed diabetes and the burden of this disease.

NPR’s lead off sentence states “Undiagnosed diabetes may not be as big of a public health problem as thought” and grabs one’s attention (also another good example of why words matter).  While the authors state the U.S is finding and diagnosing diabetes, they also report the number of people with undiagnosed diabetes was likely to have been overreported because of the reliance on a “single positive test result.”  Their findings showed the prevalence of diabetes in the U.S. rose from 5.5% in 1988-1994 to 10.8% in 2011-2014 while the proportion of undiagnosed cases of diabetes dropped 16.3% over the same period.  So there is now additional evidence to better understand diabetes population-level details.  Think of everything we have discovered and experienced over the past decade – the facts/figures, the evidence systematically reviewed and shared with the public through the AOA’s diabetes clinical practice guideline, the economic and population health outcomes associated with diabetes – and pair that with front line statistics like the over 320,000 people with findings of diabetes first detected and diagnosed through eye examination in 2016 by doctors of optometry – and it’s clear that diabetes remains a significant public health and health care problem.

From the study, several take-homes are offered for consideration:

  • the authors state that public health efforts should target people who are most likely to have undiagnosed diabetes with a specific focus on:
    • people who are obese
    • racial or ethnic minorities
    • people without health insurance or regular health care
    • the undiagnosed group of overweight/obese younger adults with high A1C levels who “are likely not engaged with the health care system”.
  • they offer more evidence showing that differences in how research is conducted impacts downstream actions – for example, when resulting data is used to develop clinical care recommendations, assess funding proprities, and conduct health economic analyses.
  • when clinical investigation teams include health services research – i.e., a focus on key upstream factors like determinants of health and clearly defined variables (see the recent National Academies of Science, Enginnering and Medicine (NASEM) report on recommendations for needed standardization of language in the U.S. regarding chronic visual impairment and eye-related factors), and areas including cost effectiveness, disease burden, risk factors (like obesity and high cholesterol), potential/realized access, and specified health outcomes, they create the opportunity to realize findings that are more nuanced and specific.

I offer four additional recommended eye & health-related take-homes:

  • Public health efforts in the U.S. should focus directly on facilitating access to, and uptake of, readily available eye care to reach undiagnosed populations.  This follows directly from the authors’ recommendations for diabetes, and is relevant across the health spectrum.  Eye care in the U.S. remains readily available.  Data shows the workforce is there – doctors of optometry remain accessible, but sadly, not fully utilized. Accessing readily available eye care in the U.S. begins with comprehensive eye examination, resulting in the desired outcomes of improved early intervention and proper disease management, and reduced disease burden and negative health impacts that include chronic visual impairment.
  • In eye care, there is no single test, assessment, metric, or ‘screen’ that rules in or rules out a healthy visual system.  The evidence clearly shows the value of comprehensive eye examination is crtical to overall health and achieving desirable population health outcomes.  An eye examination is a series of clinical procedures, examinations, tests, and assessments based on the patient and their presentation that utilizes the clinical decision making of the eye doctor to best determine individualized patient diagnosis, treatment, and management, and includes eye/vision as well as systemic health considerations.
  • As highlighted by the authors, looking at “a single test” (as is often the basis of what is called an “eye or vision ‘screen’ or ‘test’ “) is just not good enough in 2017 for the discovery of needed eye and health-related evidence, for surveillance, and for population health.  Epidemiologic data, while valuable, cannot alone answer our questions regarding health care and its delivery – examples include evidence on eye care relative to comparative effectiveness, clinical decision science, and health information technology applications.  The “single test result” concept does a disservice to health in that is does not accurately represent the population-based approach to eye health & eye care as related to overall care.  It also diminishes subsequent reporting on health outcomes and any recommendations and policy to improve health that are developed from these data (see AOA CPGs, also see NASEM report  where eye examination is ‘standard of care’ for improving nation’s health, also see U.S. states that require eye examination prior to entering school).
  • From a population health perspective, it is critical to first accurately represent targeted health outcomes of groups of individuals and then properly assess the distribution of outcomes within targeted groups.  When compared to the availability and utilization of the eye examination process in the U.S. as the recognized standard for improving the nation’s health, a “single test” approach cannot meet requirements for informing on eye and vision-related quality measurement and outcomes, nor should it be acceptable to do so.

The U.S. Department of Health and Human Services (DHHS) listened to the public health message of the AOA, looked at the evidence, and chose to mandate comprehensive eye examination – and necessary treatment including prescription glasses – as part of pediatric essential health benefits (EHBs) for a reason.  The complexity of the eye and visual system mandates this:  effective, quality health care that values the visual system and our sense of sight must reflect evidence that is more than just “a single test result”.  DHHS policy for pediatric eye examination as an EHB is an example of good health policy for the absolute BEST reasons – to facilitate a lifetime of optimum eye health and vision for all children beginning as early as possible and serving to improve overall health and related outcomes.

EPILOGUE:  I truly value writing in this forum and sharing perspectives as a way to inform and engage, and to let folks out there know my network of colleagues and I will continue the hard work of raising awareness, sharing knowledge, and expanding opportunities for best health for people of all ages across the U.S. spectrum of clinical care, research, and health policy.


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