PREVENTING “INEVITABLE” BLINDNESS in the DIABETIC PATIENT—AN EVIDENCE-BASED, CLINICAL SUCCESS and REFERRAL ROADMAP for 2021 and BEYOND WEBINAR

January, 20201 - Diabetic Eye Webinar Series - Pre-Program Survey

Survey Instructions

This online pre-program survey is designed to determine the educational effectiveness of this activity, with results from this Phase I survey compared to results from a Phase II survey to be conducted after the program. Please complete the questions below prior to the start of the webinar.

To complete this Pre-Program Performance and Referral Survey, select your answer for each of the questions below. Please select the best single answer for each question.

CMEducation Resources

Current Self-Reported Practice and Referral Patterns for Optometrists, Diabetes Specialists, Primary Care Physicians, or Other HCPs Evaluating Patients with Type 1 or Type 2 Diabetes for Diabetic Retinopathy

1. Based on patient records in your clinical database, please estimate how many patients per week you perform eye screening specifically to detect DR and other diabetic eye conditions, including : *

2. On what percentage of patients in your optometry (or diabetes or primary care) practice do you currently perform dilated eye exams? *

3. Approximately what percentage of your eye exams are performed on patients with diabetes? *

4. Approximately what percentage of your eye exams currently are performed on patients 60 years of age or older? *

5. Do you currently have specific protocols in place in your optometry, primary care or diabetes practice for detecting early signs of DR and making prompt referrals directly to a retina specialist for further evaluation and definitive treatment? *

Yes

No

6. Do you currently have specific protocols in place in your optometry, primary care or diabetes practice for detecting early signs of DR and making prompt referrals directly to a retina specialist for further evaluation and definitive treatment? *

Yes

No

7. Overall, approximately what percentage of your diabetic patients/retina screening require further evaluation for eye pathology of any kind do you refer directly to a retina specialist? *

8. Overall, approximately what percentage of patients that you currently examine and screen in your optometry, primary care, or diabetes practice whom you suspect have or have detected retinal signs or symptoms of early DR that require further evaluation do you refer directly to a retina specialist? *

9. Overall, approximately what percentage of all patients you currently examine and screen in your optometry or diabetes practice whom you suspect have or in whom you have detected retinal signs or symptoms of age-related macular degeneration (AMD) that require further evaluation do you refer directly to a retina specialist? *

10. Currently, in your optometry or diabetes practice, in patients in whom you suspect have or have detected retinal signs, visual tests, or symptoms of diabetic macular edema (DME) that require further evaluation, the following referral pattern best reflects your current practice: *

I typically refer them to an ophthalmologist for further evaluation

I typically refer them to their primary care physician or diabetologist

I typically refer them to a diabetes specialist if they don’t have one

I typically refer them to a retina specialist/retina surgeon skilled in invasive retinal procedures including intravitreal injections

11. Currently, in your optometry or diabetes practice, in patients in whom you suspect have or have detected retinal signs, visual tests, or symptoms of DR that require further evaluation, the following referral pattern best reflects your current practice: *

I typically refer them to an ophthalmologist for further evaluation

I typically refer them to their primary care physician or diabetologist

I typically refer them to a diabetes specialist if they don’t have one

I typically refer them to a retina specialist/retina surgeon skilled in invasive retinal procedures including intravitreal injections

12. Please rate how comfortable you currently feel diagnosing, looking for, detecting, and confirming the likely presence of DR or DME in diabetic patients that you routinely examine in your optometry, primary care or diabetes practice: *

13. Please rate how comfortable you currently feel diagnosing, looking for, detecting, and confirming the likely presence of age-related macular edema (AMD) in patients hat you routinely examine in your optometry, diabetes, or primary care practice *

14. Please rate how knowledgeable you feel you are about the evidence, guidelines, outcomes, and FDA approval status and therapeutic effectiveness of intravitreal anti-VEGF injectable agents for inhibiting progression of, preventing blindness in, and improving visual outcomes in diabetic patients with early non-proliferative diabetic retinopathy (DR)? *

15. Please rate how knowledgeable you feel you are about the evidence, guidelines, outcomes, FDA approval status and therapeutic effectiveness of intravitreal anti-VEGF injectable agents for inhibiting progression of, preventing blindness in, and improving visual outcomes in diabetic patients with DME? *

16. Based on my current referral patterns, if you encounter a diabetic patient in which the diagnosis of non-proliferative diabetic retinopathy (DR) is strongly suspected you will refer the patient promptly and directly to a retina specialist: *

100% of the time

About 75% of the time

About 50% of the time

About 25% of the time

I would most likely refer to a different kind of specialist, i.e. a general ophthalmologist or a diabetologist

17. Based on my current referral patterns, if you encounter a patient in which the diagnosis of the diagnosis of age-related macular degeneration (AMD) is strongly suspected you will refer the patient to a retina specialist: *

100% of the time

About 75% of the time

About 50% of the time

About 25% of the time

I would most likely refer to a different kind of specialist, i.e. a general ophthalmologist or their primary care physician

19. Based on your current referral patterns, about what percentage of diabetic patients with retinal findings suggestive of diabetic retinopathy do your currently refer to an ophthalmologist? Please fill in a number *

20. Based on your current referral patterns, about what percentage of diabetic patients with retinal findings suggestive of diabetic retinopathy do your currently refer to a retina specialist/retina surgeon trained in invasive procedures including intravitreal injections? Please fill in a number *

21. Please indicate your practice type and setting. *

22. Do you think this program has successfully addressed the unmet needs of community optometrists? *

Yes

No

Your Information

Please provide your email address to complete this confidential survey form. Completed surveys will be assigned a de-identifying number that will allow us to process your survey responses and compare pooled pre-program survey results with post-program survey results to measure ongoing, enduring learning. Your email address will not be shared with any third parties. We may use your email addresses to conduct additional surveys and/or to communicate the aggregate final survey results to you. Thank you.

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