Geographic variation in diabetic retinopathy screening within the Veterans Health Administration

Aims Diabetic retinopathy (DR) remains the leading cause of vision impairment among working-age adults in the United States. The Veterans Health Administration (VA) supplemented its DR screening efforts with teleretinal imaging in 2006. Despite its scale and longevity, no national data on the VA's screening program exists since 1998. Our objective was to determine the influence of geography on diabetic retinopathy screening adherence. Methods Setting: VA national electronic medical records. Study Population: A national cohort of 940,654 veterans with diabetes (defined as two or more diabetes ICD-9 codes (250.xx)) without a history of DR. Exposures: 125 VA Medical Center catchment areas, demographics, comorbidity burden, mean HbA1c levels, medication use and adherence, as well as utilization and access metrics. Main Outcome Measure: Screening for diabetic retinopathy within the VA medical system within a 2-year period. Results Within a 2-year time frame 74 % of veterans without a history of DR received retinal screenings within the VA system. After adjustment for age, gender, race-ethnic group, service-connected disability, marital status, and the van Walraven Elixhauser comorbidity score, the prevalence of DR screening varied by VA catchment area with values ranging from 27 % to 86 %. These differences persisted after further adjusting for mean HbA1c level, medication use and adherence as well as utilization and access metrics. Conclusions The wide variability in DR screening across 125 VA catchment areas indicates the presence of unmeasured determinants of DR screening. These results are relevant to clinical decision making in DR screening resource allocation.