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Contents available at Sciverse ScienceDirect

Diabetes Research
and Clinical Practice
journ al h ome pa ge : www .elsevier.co m/lo cate/diabres

Brief report

Racial disparities in screening for diabetic retinopathy in

youth with type 1 diabetes
Susan M. Dumser a,*, Sarah J. Ratcliffe b, David R. Langdon a,c,
Kathryn M. Murphy a,d, Terri H. Lipman a,d
a

Division of Endocrinology and Diabetes, The Childrens Hospital of Philadelphia, Philadelphia, PA, United States
Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
c
University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
d
University of Pennsylvania School of Nursing, Philadelphia, PA, United States
b

article info

abstract

Article history:

Of 1112 children with type 1 diabetes, dilated eye exams were performed in 717 (64%).

Received 16 July 2012

Children were less likely to be screened for diabetic retinopathy (DR) if they were black

Received in revised form

(OR = 1.6; p = 0.005) or had poorer diabetes control ( p = 0.002). Those at greatest risk for DR

2 January 2013

were least likely to be screened.

Accepted 4 March 2013

# 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Pediatric type 1 diabetes
Retinopathy
Retinopathy screening
Racial differences
Childhood type 1
Adolescents/children
Youth
Complication(s)
Pediatric clinical care
Pediatric diabetes
Pediatrics
Disparities
Disparities research
Childhood diabetes
Guideline development/
implementation

* Corresponding author at: The Childrens Hospital of Philadelphia, 34th & Civic Center Boulevard, 11 Fl/NW Tower, Suite 30, Philadelphia,
PA 19104, United States. Tel.: +1 267 426 7942; fax: +1 215 590 3053.
E-mail address: dumser@email.chop.edu (S.M. Dumser).
0168-8227/$ see front matter # 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.diabres.2013.03.009
Please cite this article in press as: Dumser SM, et al. Racial disparities in screening for diabetic retinopathy in youth with type 1 diabetes. Diabetes
Res Clin Pract (2013), http://dx.doi.org/10.1016/j.diabres.2013.03.009

DIAB-5752; No. of Pages 3

diabetes research and clinical practice xxx (2013) xxxxxx

Diabetic retinopathy (DR), the most common microvascular

complication of type 1 diabetes, is the leading cause of new
cases of blindness in the United States, and has been associated
with duration of diabetes, age, diabetes control, hypertension
and race [14]. Most recently, the prevalence of DR in youth with
type 1 diabetes has been reported at 17% [5]. Black patients with
type 1 diabetes have a higher rate of developing DR [6].
Regular dilated eye examinations remain an effective
screening tool for detecting and treating vision-threatening
DR [7]. Guidelines for DR screening in youth have been published
recommending an initial dilated eye examination once the child
is 10 years of age or has had diabetes for 5 years and then annual
routine follow-up [8]. The purpose of this study was to identify
factors associated with obtaining eye screening and to estimate
the prevalence of DR in our patients with type 1 diabetes.

1.

Methods

The study site was the Diabetes Center for Children (DCC) at
The Childrens Hospital of Philadelphia (CHOP), and the study
was completed through a retrospective review of patient
records. Patients were included if they had a diabetes visit in a
24 month period, were >10 years of age or had diabetes !5
years. Sex, race, mean of all recorded HbA1c over the study
period, duration of diabetes, documented eye exams and type
of insurance were obtained. The diagnosis and severity of DR
were determined by written reports from eye doctors. The
study was approved by the Institutional Review Board.
Prevalence of DR screening was calculated overall, and
stratified by demographic characteristics. Logistic regression
was used to test if the odds of being screened varied by
demographic and/or clinical characteristics. All analyses were
conducted using StataMP 11.1 [9].

2.

Results

A total of 1112 patients with type 1 diabetes were evaluated in

the DCC during a 2 year period; 52% male, 79% white, 14%

black, 2% Hispanic, 1% Asian, 4% other, ages 5.922.5 yr

(mean = 14 yr " 2.9), duration of diabetes 1.0-20.3 yr
(mean = 5.8 yr " 3.7), HbA1c 5.1%-14.0% (mean = 8.7% " 1.7).
Eighty-six percent of children had private insurance and 13%
had public insurance. Black children were 7 times more likely
to have public insurance (OR = 6.65, 95% CI = 4.439.99,
p < 0.001). During their clinic visits, all patients received a
recommendation to obtain eye screening that was then
documented in the medical records.
Only 717 patients (64%) followed up on the recommendation and obtained dilated eye exams. There was no significant
difference in screening by gender, age or duration of diabetes.
There were significant differences by race. White children
were significantly more likely to be screened for DR than black
children (66% vs. 54%, OR = 1.64, 95% CI = 1.162.32, p = 0.005).
While race and insurance status were significant in unadjusted analyses, insurance status was not associated with being
screened in analyses stratified by race. Those who were
screened had lower mean HbA1c levels (8.6% vs. 8.9%,
p = 0.002) (Table 1).
DR was diagnosed in 5 children; 3 male, 2 female, ages
1620 yr (mean = 18.2 yr), duration of diabetes 618 yr
(mean = 12.6 yr), HbA1c 7.012.5% (mean = 9.75%). One black
child (1/84) and 4 white children (4/578) were diagnosed with
DR; conferred prevalences of 1.2% and 0.7% respectively. All
patients had mild DR except one white 18-year-old male,
with a 9-year duration of diabetes, who required laser
treatment.

3.

Discussion

Only 64% of eligible children were screened for retinopathy in

the 24 months studied despite recommendations for yearly
exams to all families. Children who were not screened were
significantly more likely to be black and have poorer diabetes
control. Other studies have shown fewer yearly eye exams in
black adults and those with poor diabetes control [6,10].
However, this is one of a few studies to provide data on
screening rates in children.

Table 1 Comparison of demographic and clinical characteristics in screened and unscreened children with type 1
diabetes. Mean W standard deviation, or n (%) are shown.
Characteristic

Entire sample N = 1112

Screened

p-Value

Yes n = 717

No n = 395

Male

580 (52.2)

379 (52.9)

201 (50.9)

0.531

Race
White
Black
Hispanic
Asian/pacific islander
Other

875 (78.7)
155 (13.9)
21 (1.9)
12 (1.1)
49 (4.4)

578 (87.3)
84 (12.7)

297 (80.7)
71 (19.3)

0.005a

14.0 " 2.9

146 (13.4)
5.8 " 3.7
8.7 " 1.7

13.9 " 2.9

72 (11.1)
5.8 " 3.8
8.6 " 1.6

14.2 " 3.0

57 (15.8)
5.6 " 3.7
8.9 " 1.9

0.116
0.032
0.423
0.002

Age (years)
Public insuranceb
DM duration (years)
Mean HbA1c
a
b

Comparisons of black and white only, due to small numbers in other categories.
N = 1088.

Please cite this article in press as: Dumser SM, et al. Racial disparities in screening for diabetic retinopathy in youth with type 1 diabetes. Diabetes
Res Clin Pract (2013), http://dx.doi.org/10.1016/j.diabres.2013.03.009

DIAB-5752; No. of Pages 3

diabetes research and clinical practice xxx (2013) xxxxxx

A study by Huo et al. recommended limiting eye screening

to children with elevated HbA1c levels as they found no
confirmed cases of DR [11]. However, there were no data, nor
any discussion, related to the children who were not screenedpossibly children at higher risk for the development of
retinopathy. Our prevalence of DR was much lower than
reported by SEARCH [5] likely due to different methodology for
evaluation of DR and less screening in our high-risk population.
There are patient, system, and provider factors that have
been shown to impact the prevalence of screening for DR in
black adults. There may be a patient belief that there is no need
for an eye exam if there are no symptoms [12]. Economic factors
such as lack of insurance and the cost of the eye exam can be a
barrier; however, insurance type was not associated with eye
screening in our population [12]. Provider bias may impact on
screening for DR. When providers were interviewed about their
impressions of the attitudes of black patients regarding eye
care, 74% had negative comments and voiced frustration that
black patients did not place a priority on eye care [13].
We did not collect data related to reasons for racial
disparities in eye screening. We must acknowledge that
although yearly eye screening is a component of our screening
guidelines, providers may present the importance of eye
screening differently based on the race of the patient. In an
attempt to decrease racial disparities in screening for
retinopathy, clinicians should address confusion related to
refractory error and diabetes eye disease, educate patients and
families regarding the lack of symptoms with early DR, and
stress the value of early detection through screening. To
improve access to diabetes eye exams, the use of fundus
photography during a diabetes clinic visit warrants further
exploration [14]. Data have shown that fundus photography,
interpreted by trained readers, is a screening tool that can be
used to identify patients with DR [14].
Our data demonstrated that racial disparities in screening
for DR in children were not due to differences in SES. It is
critical to note that the children most at risk for DR were least
likely to be screened. Efforts to improve communication and
cultural competency of providers may help to improve the
number of patients with diabetes who receive recommended
eye screening [15].

Conflict of interest
The authors declare that they have no conflict of interest.

Acknowledgements
The authors thank and gratefully acknowledge the technical
assistance of Emily Watts, University of Pennsylvania School
of Nursing.

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Please cite this article in press as: Dumser SM, et al. Racial disparities in screening for diabetic retinopathy in youth with type 1 diabetes. Diabetes
Res Clin Pract (2013), http://dx.doi.org/10.1016/j.diabres.2013.03.009