Diabetic retinopathy screening in incident diabetes mellitus type 2 in Germany between 2004 and 2013 - A prospective cohort study based on health claims data

Objective: To assess factors associated with diabetic retinopathy (DR) screening uptake following a diagnosis of type 2 diabetes mellitus (type 2 diabetes) in Germany. Materials and methods: A nationally representative prospective sample of individual-level health claims data for 250,000 members from Germany’s largest public insurance provider in 2004–2013 was assessed. In the sample, 26,560 persons with incident type 2 diabetes were identified. Factors associated with subsequent DR screening were assessed using descriptive statistics, Kaplan-Meier estimator, and Cox regression analysis. Results: On average 27.6 visits to an ophthalmologist per 100 person-years in persons with incident type 2 diabetes occurred. Half of all incident cases (Kaplan-Meier estimator) had not seen an ophthalmologist after more than two years (2.25 years) following their diabetes diagnosis. In the multivariate analysis, an older age (from hazard ratio HR(70–74) = 0.93 [95%-CI: 0.89–0.97] to HR(90+) = 0.50 [95%-CI: 0.42–0.60] compared to persons aged 50–69 years) and a higher disability level (i.e. HR(disability level 3) = 0.30 [95%-CI: 0.25–0.36]) were associated with a lower likelihood, while female sex (HR = 1.12 [95%-CI: 1.08–1.15]), six or more comorbidities (HR = 1.26 [95%-CI: 1.15–1.37]), moderate (HR = 1.51 [95%-CI: 1.46–1.56]) or severe type 2 diabetes (HR = 1.53 [95%-CI: 1.45–1.61]) as well as being enrolled in a type 2 diabetes disease management program (HR = 1.78 [95%-CI: 1.69–1.87]) were associated with a higher likelihood of DR screening. Conclusions: A high proportion of newly diagnosed persons with type 2 diabetes did not follow current German recommendations for DR screening, impeding timely detection and management of potential complications. This was more apparent among persons who were men, older or had a disability. The uptake of screening was considerably greater among those enrolled in a diseases management program. These factors need to be considered when planning DR screening services and/or referrals.