Improving eye care follow-up adherence in diabetic patients with ocular abnormalities: the effectiveness of patient contracts in a free, pharmacy-based eye screening

Implementing pharmacist-led diabetic digital retina scan services at a federally qualified health center

BACKGROUND

Due to low national and local rates for annual eye exams in patients with diabetes, a pharmacist-led chronic care clinic creates a unique opportunity for pharmacists to provide digital retina scans in the primary care setting.

OBJECTIVES

The primary objective is to assess the impact of a pharmacist-led digital retina scan service on rates of annual eye exams among patients with diabetes.

PRACTICE DESCRIPTION

KC CARE Health Center, a federally qualified health center in Kansas City, Missouri, offers healthcare services to any member of the community regardless of insurance status. Pharmacists work in this setting to assist with management of chronic disease under a collaborative practice agreement.

PRACTICE INNOVATION

A pharmacist developed a workflow process to provide digital retina scans in the primary care setting for patients with diabetes who had not had an eye exam in the past 12 months. Images of each eye are captured using a RetinaVue 700 Imager and these images are submitted to an ophthalmologist for review.

EVALUATION METHODS

Rates of annual eye exams among patients with diabetes seen in the primary care clinic before and after retina scan service implementation were analyzed using a chi-squared test with an a-priori alpha of 0.05. Survey data of patient-reported barriers to follow-up were reported using descriptive statistics.

RESULTS

There was a 5% increase in the annual eye exam rate of patients with diabetes seen at the clinic during the study period. The increase in rate of annual eye exam from before the intervention to after was statistically significant (P < 0.001).

CONCLUSION

Implementing a pharmacist-led retina scan program in the primary care setting improved the rate of annual diabetic eye exams and demonstrated the benefit that pharmacists can have in enhancing accessibility to preventative care services.

Factors Associated with Utilization of Teleretinal Imaging in a Hospital-Based Primary Care Setting

Regular eye examinations to screen for the initial signs of diabetic retinopathy (DR) are crucial for preventing vision loss. Teleretinal imaging (TRI) offered in a primary care setting provides a means to improve adherence to DR screening, particularly for patients who face challenges in visiting eye care providers regularly. The present study evaluates the utilization of TRI to screen for DR in an outpatient, hospital-based primary care clinic. Patients with diabetes mellitus (DM) but without DR were eligible for point-of-care screening facilitated by their primary care provider, utilizing a non-mydriatic, handheld fundus camera. Patient demographics and clinical characteristics were extracted from the electronic medical record. Patients who underwent TRI were more likely to be male, non-White, and have up-to-date monitoring and treatment measures, including hemoglobin A1c (HbA1c), microalbumin, and low-density lipoprotein (LDL) levels, in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. Our findings demonstrate that TRI can reduce screening costs compared to a strategy where all patients are referred for in-person eye examinations. A net present value (NPV) analysis indicates that a screening site reaches the break-even point of operation within one year if an average of two patients are screened per workday.

Follow-Up Adherence After Community Health Vision Screening Programs: A Review of the Literature

Objective  Although the purpose of community eye screening programs is to reduce health care disparities, the effectiveness of these programs is limited by the follow-up adherence of their participants. The aim of this review is to investigate factors that may promote or hinder participants from attending follow-up ophthalmological exams after community eye screenings and identify interventions to increase follow-up rates. Methods  For literature review, PubMed, Web of Science, Embase, Proquest/Global Health Library, and Google Scholar databases were searched to identify studies of community eye screenings published between January 2000 and May 2023. Data from these articles were analyzed to identify barriers and facilitators of follow-up adherence after community eye screenings in the United States and to examine strategies used to increase follow-up rates. Only published manuscripts were included. We excluded studies of school screenings and clinic-based screenings. Results  A total of 28 articles were included. Follow-up rates ranged from 12.5 to 89%. Nineteen articles reviewed facilitators and barriers to follow-up. Eighteen articles were non interventional and seven (see Table 1 and 2 , respectively) articles described interventions that were tested to improve follow-up rates after screening. Interventions included prescheduled appointments, transportation assistance, patient education, and patient navigators. Conclusion  Several interventions are promising to increase follow-up adherence in community eye screenings, but more evidence is needed. Future research should focus on randomized trials of isolated interventions to improve follow-up adherence of disadvantaged populations, although this may be limited given ethical considerations and documented lack of follow-up after screening.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Prevalence of Diabetic Eye Diseases in American Indians and Alaska Natives (AI/AN) as Identified by the Indian Health Service's National Teleophthalmology Program Using Ultrawide Field Imaging (UWFI)

PURPOSE

Estimates of diabetic eye disease in American Indian and Alaska Natives (AI/AN) vary over time, region, and methods. This article reports recent prevalence of diabetic retinopathy (DR) and diabetic macular edema (DME) in AI/AN served by the Indian Health Services' (IHS) teleophthalmology program, as identified using ultrawide field imaging (UWFI).

METHODS

This was a retrospective analysis of 2016-2019 clinical data (n = 53,900). UWF images were acquired by certified imagers using a validated protocol, and graded by licensed, certified optometrists supervised by an ophthalmologist. Graders evaluated the extent/severity of retinal lesions in comparison to standard photographs. DR lesions predominantly in any peripheral field were considered "predominantly peripheral lesions" (PPL). The analyses calculated prevalence of any DR, any DME, DR and DME severity, sight-threatening disease, and PPL.

RESULTS

Patients averaged 56 years of age with a 68 mmol/mol A1c and 55% had had diabetes for 5+ years. Prevalence of any DR, any DME, and sight-threatening disease was 28.6%, 3.0%, and 3.0%. In patients with mild nonproliferative DR, PPL was seen in 25.3%. PPL suggested a more severe level of DR in 8.7% of patients. DR increased with age. DME decreased with age. Males and patients in the Nashville IHS area had more diabetic eye disease.

CONCLUSION

AI/AN have a high burden of diabetes and its complications. The IHS is resource-constrained, making accurate disease estimates necessary for resource allocation and budget justifications to Congress. These data update the estimates of diabetic eye disease in Indian Country and suggest that UWFI identifies early DR.

The Effect of Educational Intervention Based on Health Belief Model on Eye Care Practice of Type II Diabetic Patients in Southern Iran

Background

The ocular complication caused by diabetes is one of the most common reasons of blindness in the world. This study aimed to investigate the effect of educational intervention on eye care practice of type II diabetic patients based on health belief model (HBM) in Fasa city.

Methods

This study was a quasi-experimental study on 100 patients with type II diabetes referred to the diabetes center in Fasa city, Fars province, Iran, in 2019. Data were collected using a valid self-reported questionnaire including demographic variables, knowledge, and HBM (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action), and eye care performance (based on self-report) and the level of HbA1cof both groups were measured before and three months after the educational intervention. The experimental group received training in eight sessions; each session lasted for 50 to 55 minutes. In order to analyze the studied data, SPSS 22 software (SPSS Inc., IBM, Chicago, IL, USA), Chi-square, independent t-test, and paired t-test have been used. P < 0.05 was considered as statistically significant.

Results

The results showed that the mean scores of knowledge (P < 0.001) and HBM components (P < 0.001) in the experimental and control groups after intervention have a significant difference. After the training program, eye care performance in the experimental group was better than that in the control group (P < 0.001). Furthermore, HbA1c (P < 0.001) improved significantly in the experimental group compared to the control group.

Conclusions

Planning and implementing education using the HBM to improve eye care performance in diabetic patients are very effective and beneficial. Moreover, educational programs based on health education and health promotion models for diabetic patients for preventing side effects caused by diabetes should be performed.

Utilization of Remote Diabetic Retinal Screening in a Suburban Healthcare System

Purpose

We conducted a cross-sectional study to assess the utilization of a tele-ophthalmology screening program in a low-risk, suburban population of patients with diabetes.

Methods

A total of 214 diabetic patients without previously documented diabetic retinopathy (DR) underwent point-of-care non-mydriatic fundus photography through their primary care providers at five Beth Israel Lahey Health locations. The characteristics of the patients who received remote screening were compared with those patients who were eligible for screening but did not take part in the program. Time-driven activity-based costing (TDABC) was implemented to examine the cost of screening by tele-ophthalmology compared with in-person examinations.

Results

Tele-ophthalmology screening was more likely to be provided for patients who were younger (OR 0.985; 95% CI 0.973–0.997, p=0.016), who were obese (OR 2.04; 95% CI: 1.47–2.84, p=0.008), who had an HbA1c above 8.0% (OR 1.60; 95% CI: 1.13–2.26, p=0.031), or who had an eye examination in the past year (OR 5.55; 95% CI: 3.89–7.92, p<0.001). Those patients newly diagnosed with DR because of the program were more likely to have diabetic nephropathy (OR 7.79; 95% CI: 1.73–35.05, p=0.007). TDABC identified a health system cost-savings of between $8 and $29 per patient screened by tele-ophthalmology compared with the cost of in-person eye examinations.

Conclusion

Tele-ophthalmology presents an opportunity to reduce the costs of screening patients without prior evidence of DR, especially those who have completed a comprehensive eye examination within the prior year.

Interventions to promote access to eyecare for non-dominant ethnic groups in high-income countries: a scoping review

PURPOSE

People who are distinct from the dominant ethnic group within a country can experience a variety of barriers to accessing eyecare services. We conducted a scoping review to map published interventions aimed at improving access to eyecare for non-Indigenous, non-dominant ethnic groups residing in high-income countries.

METHODS

We searched MEDLINE, Embase and Global Health for studies that described an intervention to promote access to eyecare for the target population. Two authors independently screened titles and abstracts followed by review of the full text of potentially relevant sources. For included studies, data extraction was carried out independently by two authors. Findings were summarised using a combination of descriptive statistics and thematic analysis.

RESULTS

We screened 5220 titles/abstracts, of which 82 reports describing 67 studies met the inclusion criteria. Most studies were conducted in the USA (90%), attempted to improve access for Black (48%) or Latinx (28%) communities at-risk for diabetic retinopathy (42%) and glaucoma (18%). Only 30% included the target population in the design of the intervention; those that did tended to be larger, collaborative initiatives, which addressed both patient and provider components of access. Forty-eight studies (72%) evaluated whether an intervention changed an outcome measure. Among these, attendance at a follow-up eye examination after screening was the most common (n=20/48, 42%), and directly supporting patients to overcome barriers to attendance was reported as the most effective approach. Building relationships between patients and providers, running coordinated, longitudinal initiatives and supporting reduction of root causes for inequity (education and economic) were key themes highlighted for success.

CONCLUSION

Although research evaluating interventions for non-dominant, non-Indigenous ethnic groups exist, key gaps remain. In particular, the paucity of relevant studies outside the USA needs to be addressed, and target communities need to be involved in the design and implementation of interventions more frequently.

Interventions to increase appointment attendance in safety net health centers: A systematic review and meta-analysis

RATIONALE, AIMS AND OBJECTIVES

Missed appointments are a persistent problem across healthcare settings, and result in negative outcomes for providers and patients. We aimed to review and evaluate the effectiveness of interventions designed to reduce missed appointments in safety net settings.

METHODS

We conducted a systematic review of interventions reported in three electronic databases. Data extraction and quality assessment were conducted according to PRISMA guidelines. Eligible studies were analyzed qualitatively to describe intervention types. A random effects model was used to measure the pooled relative risk of appointment adherence across interventions in the meta-analysis.

RESULTS

Thirty-four studies met inclusion criteria for the qualitative synthesis, and 21 studies reported sufficient outcome data for inclusion in the meta-analysis. Qualitative analysis classified nine types of interventions used to increase attendance; however, application of each intervention type varied widely between studies. Across all study types (N = 12 000), RR was 1.08, (95% CI 1.03, 1.13) for any intervention used to increase appointment attendance. No single intervention was clearly effective: facilitated appointment scheduling [RR = 3.31 (95% CI: 0.30, 37.13)], financial incentives [RR = 1.88 (0.73, 4.82)] case management/patient navigator [RR = 1.09, (0.96, 1.24)], text messages [RR = 1.02 (0.96, 1.08)], transportation, [RR = 1.05 (0.98, 1.13)], telephone reminder calls [RR 1.12, (0.87, 1.45)], in-person referrals, [RR = 1.01 (0.90, 1.13)], patient contracts [RR = 0.87 (0.52, 1.46)] or combined strategies, [RR = 1.16 (1.03, 1.32)]. No strategy was clearly superior to others, p interaction = .50.

CONCLUSIONS

Strategies to improve appointment adherence in safety net hospitals varied widely and were only modestly effective. Further research harmonizing intervention delivery within each strategy and comparing strategies with the most potential for success is needed.

Patients' perspectives on the barriers to referral after telescreening for diabetic retinopathy in communities

OBJECTIVE

To understand the referral completion and explore the associated barriers to the referral after telescreening for diabetic retinopathy (DR) among people with vision-threatening DR (VTDR).

RESEARCH DESIGN AND METHODS

All participants with VTDR after DR telescreening in the communities completed the self-reported questionnaires to assess referral completion and their perspectives on referral barriers. Sociodemographic characteristics and perceived barriers related to incomplete referrals were identified by conducting univariate analysis and multiple logistic regression model. The final model was then built to predict incomplete referral.

RESULTS

Of the 3362 participants, 46.1% had incomplete referral. Old age and lower education level showed significant association with incomplete referral. Almost all participants had at least one barrier during the referral process. Knowledge-related and attitude-related barriers, including 'Too old to want any more treatment', 'Difficulty in getting time to referral', 'No serious illness requiring treatment at present', 'My eyes are okay', 'Distrust the recommended hospital' and 'Have not been diagnosed or treated before', and logistics-related barrier 'Mobility or transportation difficulties' showed significant association with incomplete referral.

CONCLUSIONS

The issue of incomplete referral after DR telescreening is serious among individuals with VTDR, particularly in the elder and low education level population. The negativity of knowledge-related and attitude-related factors might be more prominent than logistic barriers in predicting incomplete referral. Therefore, new strategies to improve the compliance with referral assist in optimizing the referral accessibility, and the ongoing educational support to improve the awareness of disease and increase the effectiveness of physician-patient communication.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

[Screening for diabetic retinopathy by non-mydriatic fundus photography: First national campaign in Lebanon]

INTRODUCTION

Diabetic retinopathy (DR) is a leading cause of blindness worldwide. Non-mydriatic fundus photography (NMFP) has been adopted as a screening tool for this disease. We aim to determine the prevalence of DR through this method in Lebanese diabetic patients and to evaluate the impact of such screening in this population.

MATERIALS AND METHODS

This study explores data from an awareness and screening campaign conducted in Lebanon. Diabetic patients from multiple regions were referred by their endocrinologists to undergo NMFP using the Optomed SmartScope^® handheld fundus camera. Photographs were interpreted by a remote observer, and recommendations were given accordingly. The prevalence of DR was calculated, and statistical analyses were performed on the clinical characteristics, fundus findings and number of referrals to ophthalmologists.

RESULTS

The campaign lasted 11 months, during which 2205 patients were examined in 37 screening locations. Out of the 97.41% of patients with type 2 diabetes mellitus, 12.56% had signs of DR, with no significant difference between the regions. 6.28% of the photos were uninterpretable. Positive results were associated with a longer duration of diabetes (P<0.01), treatment with insulin (P<0.01), as well as the presence and chronicity of systemic hypertension (P=0.01). 25% of patients with positive testing were retrospectively asked about their follow-up; only one third had an ophthalmologic examination as per the recommendation, among whom 68.18% underwent treatment for proliferative DR and/or diabetic macular edema.

CONCLUSION

Tele-ophthalmology is useful in mass screening for DR. The importance of dilated fundus examinations still needs to be highlighted for diabetic patients, and better collaboration between endocrinologists and ophthalmologists is required to improve screening outcomes.

Behavioral economics and diabetic eye exams

Diabetic retinopathy is a common microvascular complication of diabetes mellitus and is the leading cause of new blindness among working-age adults in the United States. Timely intervention to prevent vision loss is possible with early detection by regular eye examinations. Unfortunately, adherence to recommended annual diabetic eye exams is poor. Public health interventions have targeted traditional barriers to care, such as cost and transportation, with limited success. Behavioral economics provides an additional framework of concepts and tools to understand low screening rates and to promote regular diabetic eye exams for populations at risk. In particular, behavioral economics outlines biases and heuristics that affect decision-making and underlie pervasive barriers to care, such as not viewing diabetic eye exams as a priority or perceiving oneself as too healthy to need an examination. In this review, we examine the literature on the use of behavioral economics interventions to promote regular diabetic eye exams. From the results of the included studies, we outline how concepts from behavioral economics can improve eye examination rates. In particular, the default bias, present bias, and self-serving bias play a significant role in precluding regular diabetic eye examinations. Potential tools to mitigate these biases include leveraging default options, using reminder messages, providing behavioral coaching, applying commitment contracts, offering financial incentives, and personalizing health messages. When combined with traditional public health campaigns, insights from behavioral economics can improve understanding of pervasive barriers to care and offer additional strategies to promote regular preventive eye care for patients with diabetes.

Interventions to increase attendance for diabetic retinopathy screening

BACKGROUND

Despite evidence supporting the effectiveness of diabetic retinopathy screening (DRS) in reducing the risk of sight loss, attendance for screening is consistently below recommended levels.

OBJECTIVES

The primary objective of the review was to assess the effectiveness of quality improvement (QI) interventions that seek to increase attendance for DRS in people with type 1 and type 2 diabetes.Secondary objectives were:To use validated taxonomies of QI intervention strategies and behaviour change techniques (BCTs) to code the description of interventions in the included studies and determine whether interventions that include particular QI strategies or component BCTs are more effective in increasing screening attendance;To explore heterogeneity in effect size within and between studies to identify potential explanatory factors for variability in effect size;To explore differential effects in subgroups to provide information on how equity of screening attendance could be improved;To critically appraise and summarise current evidence on the resource use, costs and cost effectiveness.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, Web of Science, ProQuest Family Health, OpenGrey, the ISRCTN, ClinicalTrials.gov, and the WHO ICTRP to identify randomised controlled trials (RCTs) that were designed to improve attendance for DRS or were evaluating general quality improvement (QI) strategies for diabetes care and reported the effect of the intervention on DRS attendance. We searched the resources on 13 February 2017. We did not use any date or language restrictions in the searches.

SELECTION CRITERIA

We included RCTs that compared any QI intervention to usual care or a more intensive (stepped) intervention versus a less intensive intervention.

DATA COLLECTION AND ANALYSIS

We coded the QI strategy using a modification of the taxonomy developed by Cochrane Effective Practice and Organisation of Care (EPOC) and BCTs using the BCT Taxonomy version 1 (BCTTv1). We used Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital (PROGRESS) elements to describe the characteristics of participants in the included studies that could have an impact on equity of access to health services.Two review authors independently extracted data. One review author entered the data into Review Manager 5 and a second review author checked them. Two review authors independently assessed risks of bias in the included studies and extracted data. We rated certainty of evidence using GRADE.

MAIN RESULTS

We included 66 RCTs conducted predominantly (62%) in the USA. Overall we judged the trials to be at low or unclear risk of bias. QI strategies were multifaceted and targeted patients, healthcare professionals or healthcare systems. Fifty-six studies (329,164 participants) compared intervention versus usual care (median duration of follow-up 12 months). Overall, DRS attendance increased by 12% (risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14; low-certainty evidence) compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted (RD 0.17, 95% CI 0.11 to 0.22) and general QI interventions (RD 0.12, 95% CI 0.09 to 0.15) were effective, particularly where baseline DRS attendance was low. All BCT combinations were associated with significant improvements, particularly in those with poor attendance. We found higher effect estimates in subgroup analyses for the BCTs 'goal setting (outcome)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients, and 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting healthcare professionals.Ten studies (23,715 participants) compared a more intensive (stepped) intervention versus a less intensive intervention. In these studies DRS attendance increased by 5% (RD 0.05, 95% CI 0.02 to 0.09; moderate-certainty evidence).Fourteen studies reporting any QI intervention compared to usual care included economic outcomes. However, only five of these were full economic evaluations. Overall, we found that there is insufficient evidence to draw robust conclusions about the relative cost effectiveness of the interventions compared to each other or against usual care.With the exception of gender and ethnicity, the characteristics of participants were poorly described in terms of PROGRESS elements. Seventeen studies (25.8%) were conducted in disadvantaged populations. No studies were carried out in low- or middle-income countries.

AUTHORS' CONCLUSIONS

The results of this review provide evidence that QI interventions targeting patients, healthcare professionals or the healthcare system are associated with meaningful improvements in DRS attendance compared to usual care. There was no statistically significant difference between interventions specifically aimed at DRS and those which were part of a general QI strategy for improving diabetes care. This is a significant finding, due to the additional benefits of general QI interventions in terms of improving glycaemic control, vascular risk management and screening for other microvascular complications. It is likely that further (but smaller) improvements in DRS attendance can also be achieved by increasing the intensity of a particular QI component or adding further components.

Screening for Diabetes in a Dental School Clinic to Assess Interprofessional Communication Between Physicians and Dental Students

If a dental student diagnoses a patient in a dental school clinic as being at high risk of prediabetes or diabetes, the patient should be referred to his or her physician for further diagnostic evaluation, and the physician should send back the evaluation results so that the dental team can optimize treatment and health care choices if the diagnosis is confirmed. The primary aim of this study was to evaluate physicians' responses to written and oral requests for information regarding follow-up diabetes testing. A secondary aim was to evaluate patients' compliance with recommendations to seek medical care after being determined to be at high risk of prediabetes or diabetes in the dental clinic. Based on at least one positive risk factor for diabetes, 74 patients in one U.S. dental school's clinic were screened by third- and fourth-year dental students for prediabetes or diabetes and underwent point of care HbA1C (glycalated hemoglobin) blood tests between June 2014 and June 2015. Patients with an HbA1C value of 5.7% or above were referred to their physicians for follow-up testing. The physician was mailed the patient's HIPAA release and a request for updates to the student regarding the patient's diabetes status. If the physician did not provide the requested information, a dental student telephoned him or her to obtain the patient's diabetes status. Of the 74 patients, 34 (46%) tested positive with HbA1C tests and were referred to their physicians. Of those 34 referred patients, 20 (59%) saw their physicians for additional evaluations within six months of referral. None of the 20 physicians responded to the written requests for information on additional diabetes testing. After one or two telephone requests, all 20 physicians provided the test results. This study found that most of the patients (59%) followed their dental practitioner's advice to seek follow-up care with their physician, supporting the value of conducting these tests in a dental clinic. However, the results also suggested that a single written request may be insufficient to prompt physicians to return those results and that follow-up communication in a phone call may be more effective.

Patients' preferences for involvement in the decision-making process for treating diabetic retinopathy

BACKGROUND

To assess factors associated with the preferred role of the attending ophthalmologist in the decision-making processes before treating diabetic retinopathy (DR).

METHODS

Cross-sectional study of 810 adults attending secondary diabetes care centers (NCT02311504). Diabetes patients were classified using a validated questionnaire in an ophthalmologist-dominant decision-making (ODM), shared decision-making (SDM) and patient-dominant decision-making (PDM) style. Multivariate logistic regression was performed to determine factors associated with the decision-making process.

RESULTS

A majority of 74.3% patients preferred SDM between ophthalmologist and patient, 17.4% patients wanted ODM, delegating the decision-making process to the ophthalmologist, 8.3% preferred the autonomous style of PDM. Patients wanting ODM were older (OR = 1.2 per decade, p = 0.013), had a lower level of education (OR = 1.4, p = 0.001) and had a higher frequency of consultations per year (OR = 1.3, p = 0.022). Patients with better basic knowledge in DR and memorizing their HbA₁c level showed a higher propensity for SDM (OR = 1.1, p = 0.037). Patients wanting PDM had a significantly higher education (OR = 1.3, p = 0.036) and a greater desire for receiving information from self-help groups (OR = 1.3, p = 0.015).

CONCLUSIONS

The first evaluation of the general patient wishes for the treatment of DR confirmed the concept of SDM, which was favored by three quarters. In particular, older patients with low educational attainment wanted to delegate the decision-making process to the ophthalmologist. Amelioration of ophthalmologic education in diabetic programs might take up patients' propensity for SDM. Regardless of the decision-making group, nearly all patients wanted the medical and scientific information to be transferred by and shared with the ophthalmologist.

TRIAL REGISTRATION

The study was registered on www.clinicaltrials.gov (identifier: NCT02311504) on December 4th 2014.