Elsevier

Ophthalmology

Volume 121, Issue 6, June 2014, Pages 1212-1219
Ophthalmology

Original article
Predicting Adherence to Diabetic Eye Examinations: Development of the Compliance with Annual Diabetic Eye Exams Survey

Presented in part at: Association for Research in Vision and Ophthalmology Annual Meeting, May 2012, Fort Lauderdale, Florida.
https://doi.org/10.1016/j.ophtha.2013.12.016Get rights and content

Objective

To identify variables that predict adherence with annual eye examinations using the Compliance with Annual Diabetic Eye Exams Survey (CADEES), a new questionnaire designed to measure health beliefs related to diabetic retinopathy and annual eye examinations.

Design

Questionnaire development.

Participants

Three hundred sixteen adults with diabetes.

Methods

We developed the CADEES based on a review of the literature, the framework of the Health Belief Model, expert opinion, and pilot study data. To examine content validity, we analyzed participant responses to an open-ended question asking for reasons why people do not obtain annual eye examinations. We evaluated construct validity with principal components analysis and examined internal consistency with Cronbach's α. To assess predictive validity, we used multivariate logistic regression with self-reported adherence as the dependent variable.

Main Outcome Measures

Associations with self-reported adherence (defined as having a dilated eye examination in the past year).

Results

The content analysis showed that CADEES items covered 89% of the reasons given by participants for not obtaining an annual eye examination. The principal components analysis identified 3 informative components that made up 32% of the variance. Multivariate logistic regression modeling revealed several significant predictors of adherence, including beliefs concerning whether insurance covered most of the eye examination cost (P < 0.01), whether there were general barriers that make it difficult to obtain an eye examination (P < 0.01), whether obtaining an eye examination was a top priority (P = 0.02), and whether diabetic eye disease can be seen with an examination (P = 0.05). Lower hemoglobin A1c levels (P < 0.01), having insurance (P = 0.01), and a longer duration of diabetes (P = 0.02) also were associated with adherence. A multivariate model containing CADEES items and demographic variables classified cases with 72% accuracy and explained approximately 24% of the variance in adherence.

Conclusions

The CADEES showed good content and predictive validity. Although additional research is needed before finalizing a shorter version of the survey, our findings suggest that researchers and clinicians may be able to improve adherence by (1) counseling newly diagnosed patients, as well as those with uncontrolled blood glucose, on the importance of annual eye examinations and (2) discussing perceived barriers and misconceptions.

Section snippets

Participants

We recruited adults with diabetes enrolled in an ongoing clinical trial examining the effectiveness of an ophthalmic telemedicine program in 2 primary care clinics.19 We randomized participants to 1 of 2 groups: (1) telemedicine with a nonmydriatic camera or (2) traditional surveillance with an eye care provider. After 2 years of enrollment, we offered telemedicine screenings to those in the traditional surveillance group. At the time the CADEES was administered, all participants had been

Participants

Table 1 presents the demographic characteristics of the sample. Approximately 70% of participants reported a nonwhite race or ethnicity, and one third had no health insurance. The average time diagnosed with diabetes was more than 12 years, and the mean hemoglobin A1c level was almost 8%. Roughly 90% reported having type 2 diabetes, 7% reported having type 1 diabetes, and 3% were unsure of their diagnosis. Fifty-eight percent reported having a dilated eye examination in the past year.

Content Validity

Discussion

We created the CADEES to measure the demographic, clinical, and health belief variables related to adherence with annual eye examination recommendations in patients with diabetes. Our ultimate goal is to help clinicians improve adherence through their interactions with patients, and the tool developed in this study provides an important first step. We found that the CADEES has good content and predictive validity, and its organizational structure supported the presence of a barriers construct.

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    Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

    Supported by the Centers for Disease Control and Prevention, Atlanta, Georgia (Cooperative Agreement no.: 1-U-48-DP-002673 [S.L.M., T.M.B.]); and the Good Samaritan Foundation, Portland, Oregon (S.L.M.). The Centers for Disease Control and Prevention participated in the review of study materials. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Good Samaritan Foundation or the Centers for Disease Control and Prevention.

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