Up to 95 percent of the more than 6, 000 to 24, 000 new cases of blindness and the ten thousands of cases of visual impairment due to diabetes each year in the United States can be prevented. Most efforts to reduce the visual loss have focused upon raising the 50 percent rate of annual eye exams on the assumption that patients entering the eye care system will subsequently do well. However, new qualitative and quantitative data indicate that significant deficiencies exist in the competency (diagnostic accuracy and treatment patterns) and technical process quality of care (history taking and examination elements) of eye care providers. Community-Based optometrists and general ophthalmologists correctly staged the severity of retinopathy in our pilot study about a third of the time, while roughly 40 percent of both groups reported performing at least 60 percent of the recommended history and examination elements on patient visits. Our proposed study is a randomized controlled trial that seeks to compare to a control group the efficacy of two levels of structured interventions that directly address both competency and technical process quality. One intervention will be """"""""low technology"""""""" with paper-based aids (posters with standard reference photos and structured visit forms). The Second """"""""high technology"""""""" intervention uses similarly structured aids in a digital tool (PDA). The control group will be exposed to usual and customary continuing professional education and educational feedback. The proposed measures are readily implemented and are accepted by providers. Because the study encompasses both general (comprehensive) ophthalmologists and optometrists, it includes the major community providers of eye care for patients. Retina specialist will be excluded, since they provide the level of care that is the goal of improvement to be attained with these interventions. The insights from the study results should be applicable to other areas of diabetes care and health care in general.
