Understanding Barriers to Diabetic Eye Care for Alabama’s Underserved Patients

ABSTRACT

Objectives: Underserved populations often have difficulty accessing care for diabetic eye disease, including screening, referral, and treatment. Although barriers to diabetes care management have been well documented, less is understood about barriers specific to rural and underserved populations. In this study, we interviewed health care professionals to identify barriers to and facilitators of screening for diabetic eye disease and specialty care among underserved patients in Alabama.

Methods: We conducted 12 semistructured interviews with experts in ophthalmology, diabetes care management, and primary care in Alabama between November 2023 and January 2024. We used the Health Equity Implementation Framework to code interviews and identify key themes related to access barriers and other obstacles to care, as well as opportunities to improve access to screening and treatment.

Results: Factors associated with access barriers for underserved populations include limited services in rural areas, insufficient referrals, cost, transportation, limited patient knowledge about diabetes and eye health, inadequate information provided during clinical encounters, and mistrust of clinicians. Several innovative approaches were identified to improve access to eye care services at the health system level and during clinical encounters.

Conclusions: Experts have suggested groundbreaking ways to improve access to care across several domains, including clinic mobility, teleophthalmology, and improved information dissemination to patients on disease. Further research is needed to establish an evidence base for additional innovations aimed at improving access to diabetic eye care and expanding their scope through quantitative research efforts, both in Alabama and nationwide.

Am J Manag Care. 2026;32(Spec. No. 9):SP254-SP263

doi:10.37765/ajmc.2026.90017

Diabetic macular edema (DME) is a common manifestation of diabetic retinopathy (DR) and is a leading cause of legal blindness in patients with type 2 diabetes.^1,2 Approximately 500,000 individuals in the United States have clinically significant DME, with an annual incidence of 75,000; this number is projected to rise with the increasing prevalence of diabetes.³ Unlike proliferative DR, in which photocoagulation remains the standard treatment to significantly reduce the risk of vision loss, DME may require alternative interventions such as anti-VEGF therapy, steroids, or focal/grid macular laser therapy to avoid vision loss.³ The risk of vision loss can be further exacerbated by inadequate screening; screening rates are lowest among underserved non-White populations and those living in rural regions.⁴

Vision health disparities are consistent with data from the national Vision and Eye Health Surveillance System (VEHSS) platform launched in 2018, which was established to analyze data to estimate the prevalence of eye disorders and disabilities, utilization of eye health services, and disparities in visual health treatment and outcomes.⁵ According to the VEHSS data, non-Hispanic Black and North American Native populations exhibit the highest prevalence of vision loss from diabetic eye disease, and North American Native populations have the lowest screening claims compared with any other racial or ethnic group.⁶

Although VEHSS data provide a comprehensive estimate of the prevalence of eye disorders and disabilities, utilization of eye health services, and disparities in visual health treatment and outcomes, a clear gap in evidence exists because of the absence of referral pathway data within VEHSS. Notably, Alabama, which has a high prevalence of diabetes (13.9%),⁷ has a higher prevalence of DR than the national average (3.06% vs 2.89%).⁶ Screening for diabetic eye disease enables early detection and treatment, helping to prevent irreversible vision loss.⁸ However, the frequency of diabetic eye screening in the US remains suboptimal, with reported rates ranging from 15% to 26%.⁹ Given the wide variability in reported diabetic eye screening rates, it is crucial to understand the referral pathway to address gaps in care and identify factors contributing to why some patients do not receive timely screenings. Rural populations face greater challenges in obtaining diabetic eye screening, and they are less likely to receive guideline-concordant care, while also experiencing more severe DR than those in urban areas.¹⁰

This study sought to increase understanding about access to eye care screening, treatment for diabetic eye diseases in specialty care, barriers that underserved patients in Alabama experience in receiving care, and opportunities to connect those patients to care.

METHODS

Study Design and Setting

This qualitative study consisted of 12 1-on-1, semistructured virtual interviews with experts in eye care (eg, ophthalmologists, retina specialists, optometrists, optometry students), diabetes care management, and primary care in Alabama between November 2023 and January 2024.

Health Equity Implementation Framework

To ground our approach through an equity and implementation science lens, we used the Health Equity Implementation Framework (HEIF) (Figure), a conceptual framework that depicts multiple factors at the individual, organizational, community, and policy levels, which interact and influence health and health equity.¹¹ The framework enables prospective and retrospective assessment of the ways in which evidence-based practices are incorporated into clinical settings to improve uptake of innovations. Furthermore, HEIF helps researchers ensure that health care innovations and practices are adopted in a manner that addresses disparities in health care access, quality, and outcomes across different populations. Although this study did not test an innovation in care, we used HEIF to organize our data in a meaningful way that accounts for the multilevel factors that influence health disparities.¹¹

Study Participants

We used a combination of purposive and snowball sampling strategies to identify participants with insight into the context of the local Alabama eye care health system.^12,13 Coauthors (SK, DT, and BW) developed a list of contacts with expertise and experience in screening and treatment for diabetic eye care in Alabama, with an emphasis on Birmingham and the surrounding area. A coauthor (CN) emailed contacts to share details about the study and assess their interest in participating. We recruited eye care specialists (ophthalmology and optometry), primary care providers, and others involved in care for patients with diabetes at risk for eye disease (eg, diabetes educators, vision therapists, dietitians, and care managers) to understand care from a variety of health care professional perspectives. During interviews, we asked participants to recommend additional contacts whom they believed were knowledgeable and could provide further insight into health care systems in the context of diabetic eye disease within the state of Alabama. Most experts had more than 9 years of experience in diabetic eye care and working with underserved communities.

Although the study successfully engaged 12 participants, 22 potential contacts either declined to participate due to lack of interest or time constraints or did not respond to the recruitment efforts. However, this study reached saturation as the data from the 12 participants addressed all research questions and objectives. The final sample ensured a diverse range of perspectives on diabetic eye care delivery and barriers to access across Alabama.

Interview Protocol Development and Conducting Interviews

We developed a semistructured interview guide with questions to elicit information on access to care for patients at risk for or with diabetic eye disease. The interview protocol included open-ended questions about diabetic eye care screening and treatment focused on knowledge, awareness, strategies to improve awareness, and challenges and facilitators of access. The interview protocol also included questions about the participants’ professional background and experience with diabetic eye care in Alabama and the demographic characteristics of the patients they serve.

Before each interview began, researchers received verbal informed consent from each participant. Each interview lasted approximately 30 minutes and was video- and audio-recorded via Zoom with permission from participants. Researchers made field notes during the interviews. Participants received a $75 gift card as an incentive to take part in interviews.

Interview Codebook Development and Transcript Analysis

We used deductive and inductive approaches to guide codebook development. First, a set of deductive codes was developed based on HEIF; then, additional inductive codes were added throughout the coding process, as necessary. We established face validity by aligning the interview protocol and coding process with HEIF and ensuring expert review of the study design and methodology to confirm that the data collection and analysis accurately captured the intended constructs related to access barriers and opportunities in diabetic eye care.

A member of the research team (CN) transcribed the interviews before analysis. The analysis team consisted of a primary (VK) and a secondary coder (RL). As a consequence of the small sample size, all transcripts were double coded to ensure consensus on coded data. Both coders reviewed and coded each transcript independently using NVivo 14 software (Lumivero). After double coding was complete, the coders reviewed data to agree on the final set of codes. The research team discussed any disagreements until the team reached consensus about the final interview coding. The research team then reviewed the final set of coded transcripts for themes based on patterns and concepts that surfaced in the data. The frequency of codes was reviewed to determine which codes were used most often within and across interviews. Commonalities across participants and relationships within the data were sought using a qualitative
content analysis.

RESULTS

Our final sample included 12 participants practicing across Alabama: 5 eye care professionals, 2 primary care providers, 2 certified diabetes educators, 1 dietitian, 1 care manager, and 1 vision therapist. Of the eye care professionals, 1 was an ophthalmologist, 1 was a retina specialist, 2 were optometrists, and 1 was an optometry student. Although 1 interviewee was an optometry student at the time, the interviewee had 9 years of clinical eye care experience in Alabama, providing valuable insights. Their inclusion was further supported by a referral from another expert interviewee. We present the main findings from the study, organized by barriers to access and opportunities to improve access. We include exemplar quotations from participants to illustrate key themes.

Barriers to Screening and Treatment

The Table summarizes the barriers and opportunities associated with HEIF described by interviewees. A number of themes emerged in the coded data related to barriers to access and treatment for diabetic eye disease. Themes were organized by factors within HEIF from outermost to innermost influences. The data did not identify barriers for every factor within HEIF. We started at the level of societal influences—specifically, physical structures—and then moved to the context of care. Barriers related to the context of care included those at the local level. Next, we described the themes related to barriers that emerged based on patients’ social determinants and perceived knowledge. Finally, we addressed barriers at the level of the clinical encounter itself.

Physical Structures

Access to available eye care services is an obstacle for rural and underserved communities in Alabama. Participants mentioned that there is a lack of eye care professionals in rural and underserved communities, which makes it difficult for patients to access screening or treatment. One diabetes dietitian said that rural patients often must travel to a more populated city to receive care. An ophthalmologist noted that eye care professionals are not located in rural areas of Alabama.

“Because we have a bunch of rural areas where there aren’t hospitals and clinics that they can get to within
5 minutes, they normally have to drive to the nearest, more populated city in order to get that kind of care.” (Diabetes Dietitian)

“Some of it has to do with social determinants of health and having assets in order to go to the doctor, but a lot of it is people are living in more rural areas where eye care providers aren’t located.” (Ophthalmologist)

Local

Primary care clinics are not referring patients often enough to eye care specialists. Interviewees mentioned that primary care clinics have challenges referring patients to eye care specialists. One retina specialist explained that primary care providers are aware that patients with diabetes need annual eye examinations, but are not making the referrals. A diabetes educator said that patients are not receiving needed referrals to eye care specialists.

“I think the primary care doctors are aware of it and they’re aware that the patient should be getting an annual diabetic eye exam. But they’re unfortunately not getting it, and for whatever reason, they’re not being referred for an eye exam…. And so, we’re still getting these [patients with diabetes] too late when they’ve already lost a lot of their vision.” (Retina Specialist)

“[Patients are] not getting those referrals. [Patients are] not getting their education, and a lot of them aren’t even aware that it’s [an issue connected to] their diabetes.” (Diabetes Educator)

Patient Factors: Social Determinants

Competing priorities, cost of service, and transportation challenges limit the ability of some patients to schedule or attend eye care appointments. Interviewees mentioned that patients have competing priorities, concerns about cost, and transportation challenges that may affect whether they receive necessary screening or specialty care treatment. One care manager mentioned that patients may have challenges scheduling appointments when they cannot get time off work. A primary care provider and an optometrist stated that cost and transportation are the 2 limitations they most often hear about when scheduling or following up with referrals for patient screening or specialty eye care.

“Whenever they’re trying to get an appointment, depending on their employment type, they may not be able to take off in the middle of the day or during the day.” (Care Manager)

“I think there [are] a number of factors, and we’ve actually done focus groups with African American [individuals] in Alabama. Both [in] rural areas and urban areas, I think cost is one. People don’t always readily have insurance that covers it.” (Primary Care Provider)

“It could be maybe 2 hours away. And they don’t have a reliable car. So it’s great to say, ‘Go to the doctor,’ but they’ve got to pay somebody, and they don’t have the money. So those are some of your limitations in those areas.” (Optometrist)

Patient Factors: Perceived Patient Knowledge

Many patients have limited knowledge about diabetes and eye health or how to manage diabetes. A primary care provider and a diabetes educator shared that patients are not knowledgeable about diabetes and eye health and that overall knowledge about diabetes is low. This lack of knowledge reduces the likelihood that patients will seek care when confronted with competing priorities or barriers to access because they are unlikely to recognize the importance of early diagnosis and treatment for diabetic eye disease to preserve their vision.

“I don’t think patients are knowledgeable at all. Not until they start coming on a regular basis.” (Primary Care Provider)

“And honestly, for a lot of them, I would say one of the biggest barriers is their overall knowledge of diabetes. For some of them, they think, ‘This is just what happens with diabetes,’ like there’s nothing that [they] can do about it. ‘My grandma had diabetes, my mom had diabetes. This is just the route of how things go.’” (Diabetes Educator)

Clinical Encounter

Patients are not receiving adequate information about diabetes, eye health, and diabetes management during the clinical encounter in primary care. Interviewees mentioned that primary care clinicians need to share additional resources with patients about diabetes, eye health, and diabetes management. A vision therapist and a diabetes educator shared that people with DR often lack knowledge about glucose and diabetes management. Competing demands, such as other important health topics, may overshadow the sharing of information about the risks of diabetes on eye health.

“I have learned [about] or have experience with people with diabetic retinopathy. A lot of times there are things like talking glucose monitors and things of that nature that the health care providers don’t inform them of, and then some people may have trouble with drawing their insulin, not being able to get the right amount of blood on their strips, and I haven’t experienced any health care providers that provide training to people [who] are blind or have low vision.” (Vision Therapist)

“They’re just trying to rush you in and out of that room so that they can move on to the next patient, and they’re not taking the time to fully explain to the patients exactly what is needed to be in control of diabetes, including eye care.” (Diabetes Educator)

“But in real time, if there are other things that come up, I think it’s easy to forget to go back over it…. There’s a lot of competing demands on things that you want to go over in the list, particularly in primary care.” (Primary Care Provider)

Underserved patients in Alabama frequently lack rapport with clinicians. Interviewees mentioned that patients often have difficulty in trusting non-Black clinicians because of the racial discrimination and injustices that Black people have faced historically in Alabama. One primary care physician said there are not many Black eye care professionals who practice in Alabama.

“I think the point is that fear in Alabama, and this is from [the USPHS Untreated Syphilis Study at Tuskegee]. We simply don’t trust. It’s not like we have a whole list of Black ophthalmologists that you can just go to. I don’t know any Black ophthalmologists in this town. We know Black optometrists. It’s OK she sent me to a White doctor, but there are a lot of trust issues.” (Primary Care Provider)

“Alabama as a state, you’ve heard of the Tuskegee syphilis study. There are issues with trust. And so, you have to build trust up as well. I think those are the big barriers for receiving routine eye care, particularly for patients with diabetes.” (Ophthalmologist)

Opportunities to Improve Access to Care and Treatment

After exploring barriers to screening and treatment within our coded data, we analyzed the data for opportunities to improve access to care. Next, these opportunities were discussed and organized from the outermost context to the clinical encounter. Similar to our study findings on barriers, our data did not contain opportunities at all levels and factors of HEIF. The opportunities that were identified pertained to innovations within the clinical encounter, organizational level of the health system, and patient access to eye care services.

Innovations to Improve Patient Access to Eye Care Services

Interviewees suggested several ways to improve eye care services for underserved patients in Alabama. One primary care provider shared that mobile vans are being used to improve access to eye care services in rural Alabama for community outreach to patients.The mobile vans provide an additional means of access outside the traditional provider’s office, eliminating transportation or distance barriers. One care manager explained that expanding clinic hours outside of regular office hours may address challenges that patients experience in reaching the clinic during traditional working hours. Patients often have inflexible work schedules or cannot afford to take time off work to attend a doctor’s appointment; expanded appointment times enable patients to access care at times that do not interfere with their workday. To reduce the challenges patients experience when scheduling follow-up screening visits, a retina specialist suggested screening patients in the primary care setting.

“I know that there are mobile units, mobile vans, that will go down to...the rural area of Alabama periodically and do screenings and checkups.” (Primary Care Provider)

“Whenever they’re trying to get an appointment, depending on their employment type, they may not be able to take off in the middle of the day or during the day. So, if we were able to have after-hours eye screening, after traditional hours, or a Saturday eye screening, that could...be beneficial to have more availability for those patients.” (Care Manager)

“I started a company where we are basically putting cameras in the primary care office where we do the screening right where the patient is at, so they don’t have to send them anywhere. They can take a picture of the retina. And then we can, from telemedicine, diagnose this patient if they have problems or not. So, we’re trying to solve it in a different way because that way they don’t have to be referred. We can make it easy on the patient, the primary care team.” (Retina Specialist)

Innovations at the health System’s organizational level

Interviewees mentioned that calling or texting patients who miss appointments and following up before appointments may help improve the process of connecting underserved patients to eye care services. A primary care provider and a diabetes educator emphasized the importance of these communications in ensuring that patients have the connections they need.

“And then the other thing we’re trying is follow-up phone calls with folks who’ve missed their visit to ophthalmology, to try and better understand the barriers to making it to those visits so that we can figure out whether or not there are system-level or patient-level interventions that we could try that would help those folks overcome those barriers and get them back into clinic.” (Primary Care Provider)

“I think it’s having that communication, especially when the referral process is happening on what that follow-up is going to look like. So if I have a patient [who] is coming in, and I know that they need to be referred to an ophthalmologist, some sort of recordkeeping as to whether or not that referral was handled or if that ophthalmologist did reach out to the patient to schedule appointments [is helpful].” (Diabetes Educator)

Innovations Within the Clinical Encounter

Interviewees shared that establishing trust with patients can improve access to eye care for underserved populations in Alabama. One retina specialist said that more Black physicians are needed to garner trust from the community because of the distrust created by the racial discrimination and injustices that Black people historically have experienced. One primary care provider mentioned that being truthful, up-front, and caring with patients about the status and prognosis of their disease is a strategy that can build trust.

“A lot of the affected population is African American in Alabama. I think that there’s some history with the Tuskegee study. Trials, issues, and other things where we didn’t do the right thing. I’d love to see more African American physicians be in this market because I think that’s automatic trust. If you have other retina specialists [who] are African American and of the same minority, I think that would be helpful.” (Retina Specialist)

“So this is how I approach it; it is very, very up-front. A lot of that is going back to having that loving space with the patient and having a family approach and hoping that what I am saying, she will trust. Then she’ll not only see me as somebody doing no harm but that I want them to live a longer, healthier life.” (Primary Care Provider)

Specifically, interviewees mentioned that clinics and primary care providers can share information about the effects of diabetes on eye health and about diabetes management before, during, and after the clinical encounter. One primary care provider noted that clinics could have literature about diabetes and eye health available in their waiting rooms to help educate patients. Providing information in waiting rooms can also help patients feel more comfortable discussing diabetes and eye health with their primary care provider. One vision therapist said that health care professionals could improve how patients manage their diabetes and eye health by sharing information about the health services available to patients while they are in the clinic. In addition, a retina specialist described how public awareness campaigns raise awareness about diabetes, eye health, and diabetes management.

“I think having literature in the [waiting] room helps. [Patients] can come in the room and they may have something already in their hand. Like, ‘Oh, I got this; I was reading about this.’ So they have 20 topics in there with the pamphlets…so it opens up the room to have the conversation.” (Primary
Care Provider)

“But I do know that most of the time they are not aware that the services we provide are available to individuals with that disability to help them.” (Vision Therapist)

“Like the smoking commercials that are done, where those are very impactful…. I hate to be that dramatic, but something along those lines where somebody that looks like you and your age group is saying, ‘I’m blind.’ ” (Retina Specialist)

DISCUSSION

We identified a mix of social, economic, and environmental barriers and opportunities at the patient and clinical encounter levels that influence access to eye care for underserved patients with diabetes in Alabama. These patients experience access to care barriers due to the limited availability of health care professionals in underserved communities, along with the competing demands related to social determinants of health. There is also ongoing mistrust of clinicians, which often leads underserved patients to delay care.

Knowledge gaps in diabetic eye care were another important access barrier identified, as patients are not fully informed about the connection between diabetes management and their eye health. These patient knowledge gaps are also affected by health care professionals who are not consistently sharing adequate information about eye health and diabetes management, particularly during primary care visits. The innovations we identified that are currently in use in Alabama seek to address these barriers to equitable access to diabetic eye care. We found that those who care for patients with diabetes in Alabama are implementing changes to the clinical encounter, such as using mobile vans, offering expanded hours for care, and improving how information about diabetes and eye health is communicated to patients.

Overall, access barriers identified in Alabama are similar to health equity barriers documented in the literature in other therapeutic areas.¹⁴ This includes the following factors: (1) patients, such as their lack of rapport with clinicians; (2) the clinical encounter, including all communication during that visit; and (3) the health care system, such as the lack of a system to improve quality in the delivery of health care services.¹¹Improving clinical encounters by expanding the roles of nurses and diabetes educators could give primary care providers more time for diabetic eye care. Additionally, implementing a system to enhance the quality of health care services would ensure that diabetic eye care is not overlooked due to time constraints in primary care settings. Collectively, these strategies highlight fundamental barriers to care identified in our study and provide actionable insights for designing future interventions to improve referral follow-through and eye care completion.

Among the innovations discussed by Alabama experts to improve access to care, mobile clinics and teleophthalmology visits appear to be effective strategies. Mobile clinics have been shown to be a cost-effective approach to improve screening for diabetic eye disease and follow-up with ophthalmologists, and mobile vans used for teleophthalmology provide convenient remote screening and diagnosis.^15,16 Artificial intelligence–based screening also offers a low-cost, point-of-care tool for DR detection and has been shown to improve the completion rate of diabetic eye exams.¹⁷ These approaches can improve access to care for rural and underserved communities. Beyond access, it is critical to address mistrust of health care professionals, particularly among African American patients. Patient empowerment strategies, such as education, self-advocacy, and building self-efficacy, can increase trust in providers.¹⁸ Promoting the enrollment and employment of diverse health care professionals, including Black physicians and nurse practitioners, further enhances trust through shared lived experiences.¹⁸ Collectively, these interventions that expand access and strengthen trust through patient empowerment and representative health care teams may be effective in reducing disparities in eye care.

Access barriers to diabetic eye care are also being measured through public-private partnerships among patient advocacy groups and private organizations, which provide quantifiable evidence to support interventions that improve access to care and clinical outcomes.^19,20 These innovative approaches not only offer feasible solutions to current access challenges but also set the stage for broader efforts to improve diabetic eye care access across Alabama. It is crucial to build an evidence base for additional innovations aimed at improving access to diabetic eye care by leveraging this work and expanding its scope through quantitative research efforts.¹⁵

HEIF demonstrated strong usability in assessing barriers and opportunities to diabetic eye care in Alabama, with physical structures and clinical encounter emerging as the most relevant constructs. Physical structures, such as the limited number of health care professionals in rural and underserved communities, highlighted systemic access challenges, whereas the clinical encounter revealed gaps in patient education and health care professionals’ communication about diabetic eye care. The insights gained by using HEIF can guide the further implementation of innovations such as mobile clinics and teleophthalmology, promote expanded clinic hours, and foster improved education and trust-building efforts to address disparities and enhance access to diabetic eye care across Alabama.

Despite the insights gained from our study and the strengths of our approach, there are several limitations. To explore perspectives on access barriers, we chose a qualitative approach, which provides for depth of response by interviewees and offers the opportunity to explore rich contextual factors. Use of an established framework ensured a rigorous, valid, and reliable approach. HEIF provided us with theoretical and conceptual grounding with which to analyze our results. Because of the smaller scope of our study, we targeted specific domains within HEIF and did not collect quantitative data. The small sample size, focused on experts and health care professionals, may limit the generalizability of our findings. However, it is important to note that our sample included individuals across various facets of care delivery, including eye care professionals, primary care providers, and those involved in diabetes care management, thereby offering a diverse perspective on the topic. We did not collect racial demographic data from our participants. Similarly, the geographical concentration of our interviewees primarily in the Birmingham metropolitan area of Alabama could limit the generalizability of our findings on a national level, as health care dynamics may differ across other urban, suburban, and rural regions of the United States. Finally, interviews are needed with other key stakeholders, such as patients and policy makers, to further explore and validate the findings.

CONCLUSIONS

Our study identified a mixture of social, economic, and environmental factors influencing access to eye care for underserved patients with diabetes in Alabama. We have identified a multitude of barriers at both the patient and clinical encounter levels, ranging from limited availability of health care professionals in underserved communities to knowledge gaps regarding diabetic eye care among patients. Additionally, the persistent mistrust of clinicians among underserved populations further exacerbates these challenges, highlighting the need for targeted interventions, in which retina specialists collaborate with primary care physicians in screening and treatment. Despite several barriers identified, our research data also suggest promising innovations to address access disparities. Particularly, mobile clinics, teleophthalmology exams and assessments, and improved patient educational material seem feasible strategies, offering efficient and economical solutions to improve screening, diagnosis, and treatment of diabetic eye disease. These innovative approaches not only offer practical solutions to current access challenges but also lay the groundwork for broader efforts to enhance diabetic eye care access across the country. For future research, this highlights the importance of establishing an evidence base for additional innovations, thereby ensuring equitable access to eye care for all patients in the United States. Our study provides insights into the barriers and opportunities in diabetic eye care access, laying a foundational work for future research and interventions aimed at improving health equity in Alabama and beyond.

Author Affiliations: Genentech, Inc. (SK, DT, BW), South San Francisco, CA; American Institutes for Research (MK, VK, RL, SM, CN), Arlington, VA; University of California San Francisco Institute for Health & Aging (KJ), San Francisco, CA

Source of Funding: This work was supported by Genentech, Inc, South San Francisco, CA, which developed the study concept, as well as analysis review, decision to publish, and manuscript preparation support.

Author Disclosures: Dr Ko reports employment at Genentech and stock ownership in Roche. Dr Tabano reports being an employee with Genentech and stock ownership in Genentech. Dr Wilson reports being a part of the American Diabetes Association’s Louisiana Community Leadership Board and owning stock in Genentech as an employee.

Authorship Information: Concept and design (SK, DT, MK, KJ, VK, SM, BW ); acquisition of data (VK, RL, SM, BW); analysis and interpretation of data (SK, DT, MK, KJ, VK, RL, SM, CN); drafting of the manuscript (SK, DT, MK, SM, CN); critical revision of the manuscript for important intellectual content (SK, DT, MK, KJ, SM, BW); statistical analysis (DT); obtaining funding (DT, SM, BW); administrative, technical, or logistic support (DT, MK, RL, SM, CN, BW); and supervision (DT, MK, SM, BW).

Address Correspondence to: David Tabano, PhD, Genentech, Inc, 350 DNA Way, South San Francisco, CA 94080. Email: tabano.david@gene.com

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