Disparities in Diabetic Retinopathy Screening Rates Within Minority Populations: Differences in Reported Screening Rates Among African American and Hispanic Patients

Implementation Mapping of the Collaborative University of California Teleophthalmology Initiative (CUTI): A Qualitative Study Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework

Background This study aimed to investigate the rationale, barriers, and facilitators of teleretinal camera implementation in primary care and endocrinology clinics for diabetic retinopathy (DR) screening across University of California (UC) health systems utilizing the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Methodology Institutional representatives from UC Los Angeles, San Diego, San Francisco, and Davis participated in a series of focus group meetings to elicit implementation facilitators and barriers for teleophthalmology programs within their campuses. Site representatives also completed a survey regarding their program's performance over the calendar year 2022 in the following areas: DR screening camera sites, payment sources and coding, screening workflows including clinical, information technology (IT), reading, results, pathologic findings, and follow-up, including patient outreach for abnormal results. Focus group and survey results were mapped to the EPIS framework to gain insights into the implementation process of these programs and identify areas for optimization. Results Four UC campuses with 20 active camera sites screened 7,450 patients in the calendar year 2022. The average DR screening rate across the four campuses was 55%. Variations between sources of payment, turn-around time, image-grading structure, image-report characteristics, IT infrastructure, and patient outreach strategies were identified between sites. Closing gaps in IT integration between data systems, ensuring the financial sustainability of the program, and optimizing patient outreach remain primary challenges across sites and serve as good opportunities for cross-institutional learning. Conclusions Despite the potential for long-term cost savings and improving access to care, numerous obstacles continue to hinder the widespread implementation of teleretinal DR screening. Implementation science approaches can identify strategies for addressing these challenges and optimizing implementation.

One-field, two-field and five-field handheld retinal imaging compared with standard seven-field Early Treatment Diabetic Retinopathy Study photography for diabetic retinopathy screening

BACKGROUND/AIMS

To determine agreement of one-field (1F, macula-centred), two-field (2F, disc-macula) and five-field (5F, macula, disc, superior, inferior and nasal) mydriatic handheld retinal imaging protocols for the assessment of diabetic retinopathy (DR) as compared with standard seven-field Early Treatment Diabetic Retinopathy Study (ETDRS) photography.

METHODS

Prospective, comparative instrument validation study. Mydriatic retinal images were taken using three handheld retinal cameras: Aurora (AU; 50° field of view (FOV), 5F), Smartscope (SS; 40° FOV, 5F), and RetinaVue (RV; 60° FOV, 2F) followed by ETDRS photography. Images were evaluated at a centralised reading centre using the international DR classification. Each field protocol (1F, 2F and 5F) was graded independently by masked graders. Weighted kappa (Kw) statistics assessed agreement for DR. Sensitivity (SN) and specificity (SP) for referable diabetic retinopathy (refDR; moderate non-proliferative diabetic retinopathy (NPDR) or worse, or ungradable images) were calculated.

RESULTS

Images from 225 eyes of 116 patients with diabetes were evaluated. Severity by ETDRS photography: no DR, 33.3%; mild NPDR, 20.4%; moderate, 14.2%; severe, 11.6%; proliferative, 20.4%. Ungradable rate for DR: ETDRS, 0%; AU: 1F 2.23%, 2F 1.79%, 5F 0%; SS: 1F 7.6%, 2F 4.0%, 5F 3.6%; RV: 1F 6.7%, 2F 5.8%. Agreement rates of DR grading between handheld retinal imaging and ETDRS photography were (Kw, SN/SP refDR) AU: 1F 0.54, 0.72/0.92; 2F 0.59, 0.74/0.92; 5F 0.75, 0.86/0.97; SS: 1F 0.51, 0.72/0.92; 2F 0.60, 0.75/0.92; 5F 0.73, 0.88/0.92; RV: 1F 0.77, 0.91/0.95; 2F 0.75, 0.87/0.95.

CONCLUSION

When using handheld devices, the addition of peripheral fields decreased the ungradable rate and increased SN and SP for refDR. These data suggest the benefit of additional peripheral fields in DR screening programmes that use handheld retinal imaging.

Racial, Ethnic, and Socioeconomic Disparities Drive Appointment No-Show in Patients with Chronic Eye Disease

BACKGROUND

Visit no-shows (NS) reduce clinic efficiency and effective resource allocation. Inadequate follow-up among patients with chronic eye disease increases risk of disease progression. Our study identifies demographic, medical, and socioeconomic characteristics that increase odds of NS among patients with chronic eye conditions at high risk of vision-threatening complications.

METHODS

This is a retrospective case-control study of data abstracted over a 5-year period (January 2013-December 2018) in an urban academic ophthalmology practice. Follow-up appointments of patients ≥ 18 years of age with a diagnosis of glaucoma, diabetic retinopathy, or age-related macular degeneration were included. Age, sex, race, ethnicity, language preference, zip code, and relevant medical history were recorded. A multivariate mixed logistic regression model was utilized to determine any association between demographic factors and visit NS.

RESULTS

A total of 106,652 visits for 4,598 unique patients were included in this study. Of these, 13,240 (12.4%) visits were NS. Patient characteristics that increased the odds of NS included Hispanic ethnicity (p < 0.0001), Black race (p < 0.0001), and a history of mental illness (p < 0.0001). Socioeconomic factors that increased the odds of NS included median household income < $40,000 (p = 0.002), Medicare insurance (p < 0.0001), and Medicaid insurance (p < 0.0001).

CONCLUSIONS

Our results highlight the influence of ethnic, racial, medical, and socioeconomic characteristics on appointment NS among patients with chronic eye disease. Future interventions aimed at reducing appointment NS could channel resources to the at-risk populations identified in this analysis to improve access to care for those who need it most.

In a Large Healthcare System in the Bronx, Teleretinal Triaging Was Found to Increase Screening and Healthcare Access for an Underserved Population with a High Incidence of T2DM and Retinopathy

The early treatment of diabetic retinopathy (DR) prevents vision-threatening proliferative retinopathy (PDR) and macular edema (DME). Our study evaluates telemedicine (teleretinal) screening for DR in an inner-city healthcare network with a high ethnic diversity and disease burden. Fundus photographs were obtained and graded in a centralized reading center between 2014 and 2016. Patients with positive screenings were referred to a retina specialist. An analysis of sensitivity and specificity and a subgroup analysis of prevalence, disease severity, and follow-up adherence were conducted. In 2251 patients, the '1-year' and 'Overall' follow-ups were 35.1% and 54.8%, respectively. Severe grading, male gender, and age were associated with better follow-up compliance. The DR, PDR, and DME prevalence was 24.9%, 4.1%, and 5.9%, respectively, and was significantly associated with HbA1c. The sensitivity and specificity for DR, PDR, and DME were 70% and 87%, 87% and 75%, and 37% and 95%, respectively. No prevalence differences were noted between ethnicities. Annual diabetic eye exam adherence increased from 55% to 85% during the study period. Teleretinal triaging is sensitive and specific for DR and improved diabetic eye exam compliance for underserved populations when integrated into large healthcare networks. The adherence to follow-up recommendations was better among older patients and among those with more severe retinopathy.

Ang Ating Mata: Disparities in Eye Health Knowledge, Attitudes and Practices among Older Adult Filipino-Americans in the San Francisco Bay Area Counties

Filipino-Americans are the third largest Asian-American population, with a median age of 44. However, there is limited literature focusing on the group's ophthalmic care engagement. Timely eye examinations and outreach are necessary to reduce visual impairment in this older community. To assess eye care knowledge, attitudes, and practices, we conducted a cross-sectional study surveying Filipino-Americans within the nine San Francisco Bay Area counties. Associations between primary outcomes and sociodemographic factors were analyzed using chi-squared analysis and student's T-test. In our convenience sample of 256 surveys, a majority of participants are receiving appropriate eye care; those that lacked health and eye insurance, immigrated and are lower income did not receive optimal eye care. Study participants also demonstrated a lack of awareness of eye diseases and risk factors. Our results suggest that culturally sensitive eye health education materials are lacking and should be made accessible for this large and rapidly growing population.

Social Determinants of Health and Impact on Screening, Prevalence, and Management of Diabetic Retinopathy in Adults: A Narrative Review

Diabetic retinal disease (DRD) is the leading cause of blindness among working-aged individuals with diabetes. In the United States, underserved and minority populations are disproportionately affected by diabetic retinopathy and other diabetes-related health outcomes. In this narrative review, we describe racial disparities in the prevalence and screening of diabetic retinopathy, as well as the wide-range of disparities associated with social determinants of health (SDOH), which include socioeconomic status, geography, health-care access, and education.

Ranked determinants of telemedicine diabetic retinopathy screening performance in the United States primary care safety-net setting: an exploratory CART analysis

Background

Diabetic retinopathy (DR) is a leading cause of blindness worldwide, despite easy detection and effective treatment. Annual screening rates in the USA remain low, especially for the disadvantaged, which telemedicine-based DR screening (TDRS) during routine primary care has been shown to improve. Screening rates from such programs have varied, however, pointing to inconsistent implementation and unaddressed barriers. This work seeks to identify and prioritize modifiable barriers for targeted intervention.

Methods

In this final phase of an exploratory mixed-methods study, we developed, validated, and administered a 62-item survey to multilevel stakeholders involved with TDRS in primary care safety-net clinics. Survey items were aligned with previously identified determinants of clinic-level screening and mapped to the Consolidated Framework for Implementation Research (CFIR). Classification and Regression Tree (CART) analyses were used to identify and rank independent variables predictive of individual-level TDRS screening performance.

Results

Overall, 133 of the 341 invited professionals responded (39%), representing 20 safety-net clinics across 6 clinical systems. Respondents were predominately non-Hispanic White (77%), female (94%), and between 31 and 65 years of age (79%). Satisfaction with TDRS was high despite low self-reported screening rates. The most important screening determinants were: provider reinforcement of TDRS importance; explicit instructions by providers to staff; effective reminders; standing orders; high relative priority among routine diabetic measures; established TDRS workflows; performance feedback; effective TDRS champions; and leadership support.

Conclusions

In this survey of stakeholders involved with TDRS in safety-net clinics, screening was low despite high satisfaction with the intervention. The best predictors of screening performance mapped to the CFIR constructs Leadership Engagement, Compatibility, Goals & Feedback, Relative Priority, Champions, and Available Resources. These findings facilitate the prioritization of implementation strategies targeting determinants of TDRS performance, potentially increasing its public health impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07915-5.

Awareness of Diabetic Retinopathy: Insight From the National Health and Nutrition Examination Survey

INTRODUCTION

This study determines the prevalence and associated correlates of people unaware of their diabetic retinopathy diagnosis in the U.S.

METHODS

Participants unaware of diabetic retinopathy from the National Health and Nutrition Examination Survey from 2005 to 2008 were identified. The prevalence of those unaware of their diabetic retinopathy diagnosis was determined. Descriptive statistics and logistic regression were used to determine correlates associated with being unaware of one's diabetic retinopathy diagnosis (completed in 2018‒2020).

RESULTS

Among 5,563 participants aged ≥40 years who underwent fundus photography, the prevalence of those unaware of their diabetic retinopathy diagnosis was 10.6% (9.8 million). This included 23.1% of those with self-reported diabetes (2.9 million) and 6.8% of those who reported not having diabetes (6.9 million). Among participants reporting diabetes with photographic evidence of retinopathy, 70.1% were unaware. Among individuals with self-reported diabetes, correlates of being unaware of one's diabetic retinopathy diagnosis included diabetes diaganosis for ≥10 years (OR=3.15, 95% CI=1.78, 5.56), HbA1c ≥6.5% (OR=2.92, 95% CI=1.65, 5.18), and treatment with insulin only (OR=4.04, 95% CI=1.43, 11.39). Self-reported hypertension was associated with decreased odds of undiagnosed diabetic retinopathy (OR=0.48, 95% CI=0.28, 0.82). Among those without self-reported diabetes, correlates of being unaware of diabetic retinopathy included older age (OR=1.02, 95% CI=1.01, 1.04), male sex (OR=1.83, 95% CI=1.31, 2.56), Black race (OR=1.81, 95% CI=1.12, 2.92), Hispanic race/ethnicity (OR=1.60, 95% CI=1.14, 2.25), elevated blood pressure (OR=1.54, 95% CI=1.23, 1.93), current smoking (OR=1.74, 95% CI=1.21, 2.51), and history of stroke (OR=2.20, 95% CI=1.06, 4.58).

CONCLUSIONS

A substantial proportion of individuals with diabetic retinopathy are unaware of the diagnosis. These data provide a path toward refining efforts to diagnose and treat diabetic retinopathy to decrease the burden of preventable blindness.

Barriers to Healthy Eating and Diabetes Diet Education: Divergent Perspectives of Patients and Their Providers

Patients report that adhering to diet is the most challenging aspect of diabetes management. Provision of diet education is often delegated to health care providers, despite a lack of nutrition education and training and limited awareness of environmental and cultural challenges faced by patients. Aim. We examined perceived barriers to diet self-management among low-income minority patients with type 2 diabetes and their health care providers within a single ecosystem, to test whether providers understood patient barriers. Method. We surveyed 149 members of a safety-net clinic (99 patients, 50 providers), using barriers derived from the literature. Binomial logistic regression was applied to investigate relationships between barriers and patients' sociodemographic variables and Pearson's χ² was used to compare differences in perceived barriers between patients and providers. Results. Providers expressed divergent perceptions of patients' barriers to healthy eating, including more total barriers and little agreement with patients on their relative importance. Largest differences in providers' perceptions of patient barriers included poor motivation, high use of fast food, inadequate family support, and lack of cooking skills-all suggesting patient inadequacy. In contrast, patients showed evidence of high motivation-in rate of blood glucose measurement and desire for diet education. Patients identified primary care providers as a main source of nutrition education, yet providers indicated lack of time for diet discussion and preferred other staff do the teaching. Conclusion. The findings from this study strongly suggest that health systems need to consider patient, provider, and system barriers when implementing nutrition education and management programs.

Impact of Intersecting Systems of Oppression on Diabetic Retinopathy Screening Among Those Who Identify as Women of Low Socioeconomic Status: Protocol for a Convergent Mixed Methods Study

Background

By 2025, 5 million Canadians will be diagnosed with diabetes, and women from lower socioeconomic groups will likely account for most new diagnoses. Diabetic retinopathy is a primary vision complication of diabetes and a leading cause of blindness among adults, with 26% prevalence among women. Tele-retina is a branch of telemedicine that delivers eye care remotely. Screening for diabetic retinopathy has great potential to reduce the incidence of blindness, yet there is an adverse association among screening, income, and gender.

Objective

We aim to explore gender disparity in the provision of tele-retina program services for diabetic retinopathy screening in a cohort of women of low socioeconomic status (SES) receiving services in South Riverdale Community Health Centre (SRCHC) between 2014 and 2019.

Methods

Using a convergent mixed methods design, we want to understand patients’, providers’, administrators’, and decision makers’ perceptions of the facilitators and barriers associated with the implementation and adoption of tele-retina. Multivariate logistic regression will be utilized to assess the association among client characteristics, referral source, and diabetic retinopathy screening. Guided by a grounded theory approach, systematic coding of data and thematic analysis will be utilized to identify key facilitators and barriers to the implementation and adoption of tele-retina.

Results

For the quantitative component, we anticipate a cohort of 2500 patients, and we expect to collect data on the overall patterns of tele-retina program use, including descriptions of program utilization rates (such as data on received and completed diabetic retinopathy screening referrals) along the landscape of patient populations receiving these services. For the qualitative component, we plan to interview up to 21 patients and 14 providers, administrators, and decision makers, and to conduct up to 14 hours of observations alongside review of relevant documents. The interview guide is being developed in collaboration with our patient partners. Through the use of mixed methods research, the inquiry will be approached from different perspectives. Mixed methods will guide us in combining the rich subjective insights on complex realities from qualitative inquiry with the standard generalizable data that will be generated through quantitative research. The study is under review by the University Health Network Research Ethics Board (19-5628). We expect to begin recruitment in winter 2021.

Conclusions

In Ontario, the screening rate for diabetic retinopathy among low income groups remains below 65%. Understanding the facilitators and barriers to diabetic retinopathy screening may be a prerequisite in the development of a successful screening program. This study is the first Ontario study to focus on diabetic retinopathy screening practices in women of low SES, with the aim to improve their health outcomes and revolutionize access to quality care.

International Registered Report Identifier (IRRID)

PRR1-10.2196/23492

Implementation and sustainment of a statewide telemedicine diabetic retinopathy screening network for federally designated safety-net clinics

CONTEXT

Diabetic retinopathy (DR) is the leading cause of incident blindness among working-age adults in the United States. Federally designated safety-net clinics (FDSC) often serve as point-of-contact for patients least likely to receive recommended DR screenings, creating opportunity for targeted interventions to increase screening access and compliance.

STUDY DESIGN AND METHODS

With such a goal, we implemented and assessed the longitudinal performance of an FDSC-based telemedicine DR screening (TDRS) network of 22 clinical sites providing nonmydriatic fundus photography with remote interpretation and reporting. Retrospective analysis of patient encounters between February 2014 and January 2019 was performed to assess rates of pathology and referral. A generalized estimating equation logistic regression model was used for subset analysis from audits of pre- and post-implementation screening rates. Finally, patient surveys were conducted and assessed as a measure of intervention acceptability.

RESULTS

Of the 13,923 individual telescreening encounters (4327 female, 4220 male, and 5376 unspecified; mean [SD] age, 54.9 [12.5] years) studied, 10,540 were of adequate quality to identify 3532 (33.5%) patients with ocular pathology: 2319 (22.0%) patients had some level of DR with 1604 (15.2%) requiring specialist referral, and 808 (7.7%) patients required referral for other ocular pathologies. The mean screening rate for audited clinics in the year prior to program implementation was 29.9% (641/2147), which increased to 47.7% (1012/2124) in the program's first year, doubling patients' odds of being screened (OR 2.2; 95% CI: 1.3-3.7; P = .003). These gains were sustained over four years following implementation (OR 1.9; 95% CI: 1.1-3.1; P = .018) despite varied clinic screening performance (4-year averaged range, 22.9-55.1%). Odds of early detection likewise doubled for patients with consecutive screenings (OR 2.2, 95% CI: 2.0-2.4; P < .001). Finally, surveyed patients preferred TDRS to specialist exams (82.5%; 776/941) and would recommend the service to friends (92.7%; 868/936).

CONCLUSION AND RELEVANCE

A statewide, FDSC-centered TDRS network was successfully established and sustained in a medically underserved region of the United States. Our results suggest that large TDRS networks in FDSCs can increase screening access and compliance for otherwise unscreened populations, but outcomes can vary greatly among clinics. Further work to optimize program implementation is needed to maximize this model's impact.

Identifying Barriers and Enablers to Attending Diabetic Retinopathy Screening in Immigrants to Canada From Ethnocultural Minority Groups: Protocol for a Qualitative Descriptive Study

Background

Immigrants to Canada belonging to ethnocultural minority groups are at increased risk of developing diabetes and complications, including diabetic retinopathy, and they are also less likely to be screened and treated. Improved attendance to retinopathy screening (eye tests) has the potential to reduce permanent complications, including blindness.

Objective

This study aims to identify the barriers and enablers of attending diabetic retinopathy screening among ethnocultural minority immigrants living with diabetes in Quebec and Ontario, Canada, to inform the development of a behavior change intervention to improve diabetic retinopathy screening attendance.

Methods

The research question draws on the needs of patients and clinicians. Using an integrated knowledge translation approach, the research team includes clinicians, researchers, and patient partners who will contribute throughout the study to developing and reviewing materials and procedures, helping to recruit participants, and disseminating findings. Using a convenience snowball strategy, we will recruit participants from three target groups: South Asian and Chinese people, and French-speaking people of African descent. To better facilitate reaching these groups and support participant recruitment, we will partner with community organizations and clinics serving our target populations in Ontario and Quebec. Data will be collected using semistructured interviews, using topic guides developed in English and translated into French, Mandarin, Hindi, and Urdu, and conducted in those languages. Data collection and analysis will be structured according to the Theoretical Domains Framework (TDF), which synthesizes predominant theories of behavior change into 14 domains covering key modifiable factors that may operate as barriers or enablers to attending eye screening. We will use directed content analysis to code barriers and enablers to TDF domains, then thematic analysis to define key themes within domains.

Results

This study was approved for funding in December 2017, and the research ethics board approved the conduct of the study as of January 13, 2018. Data collection then began in April 2018. As of August 28, 2018, we have recruited 22 participants, and analysis is ongoing, with results expected to be published in 2020.

Conclusions

Findings from this study will inform the codevelopment of theory-informed, culturally- and linguistically-tailored interventions to support patients in attending retinopathy screening.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15109

Barriers to and Facilitators of Diabetic Retinopathy Screening Utilization in a High-Risk Population

BACKGROUND

Diabetic retinopathy (DR) is among the leading causes of vision loss in the USA, yet an estimated 50% of patients with diabetes do not receive recommended annual screening eye exams. Patients with diabetes and low socioeconomic status or who are racial/ethnic minorities are at increased risk for vision loss.

METHODS

Qualitative interviews were conducted with 24 patients with diabetes at a federally qualified community health center in an urban area regarding factors influencing their use of screening. The interviews were recorded, transcribed, and analyzed line by line to identify themes. The themes were organized in a theoretical framework of factors influencing receipt of screening.

RESULTS

The median age of participants was 57.5 (range 44-73). Ten participants identified as female and 14 as male. Participants identified as Black (14), White (4), Hispanic (3), and other/no answer (3). Twenty-three had health insurance. Twenty-three had received an eye exam within in the past year, and 17 reported that they receive eye exams at least yearly. Four hundred fifteen comments were analyzed, and 22 concepts were identified under 7 broader themes and two overarching categories of individual and structural factors. Themes included vision status, competing concerns, emotional context, resource availability, in-clinic experience, cues to action, and knowledge about diabetes.

CONCLUSIONS

The factors that influence diabetic retinopathy screening utilization are complex. Visual symptoms and the need for glasses are important facilitators of screening. Many patients lack knowledge about diabetic retinopathy and the utility of preventative eye care. New strategies for engaging high-risk populations are necessary.

What works to increase attendance for diabetic retinopathy screening? An evidence synthesis and economic analysis

BACKGROUND

Diabetic retinopathy screening (DRS) is effective but uptake is suboptimal.

OBJECTIVES

To determine the effectiveness of quality improvement (QI) interventions for DRS attendance; describe the interventions in terms of QI components and behaviour change techniques (BCTs); identify theoretical determinants of attendance; investigate coherence between BCTs identified in interventions and determinants of attendance; and determine the cost-effectiveness of QI components and BCTs for improving DRS.

DATA SOURCES AND REVIEW METHODS

Phase 1 - systematic review of randomised controlled trials (RCTs) evaluating interventions to increase DRS attendance (The Cochrane Library, MEDLINE, EMBASE and trials registers to February 2017) and coding intervention content to classify QI components and BCTs. Phase 2 - review of studies reporting factors influencing attendance, coded to theoretical domains (MEDLINE, EMBASE, PsycINFO and sources of grey literature to March 2016). Phase 3 - mapping BCTs (phase 1) to theoretical domains (phase 2) and an economic evaluation to determine the cost-effectiveness of BCTs or QI components.

RESULTS

Phase 1 - 7277 studies were screened, of which 66 RCTs were included in the review. Interventions were multifaceted and targeted patients, health-care professionals (HCPs) or health-care systems. Overall, interventions increased DRS attendance by 12% [risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14] compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted and general QI interventions were effective, particularly when baseline attendance levels were low. All commonly used QI components and BCTs were associated with significant improvements, particularly in those with poor attendance. Higher effect estimates were observed in subgroup analyses for the BCTs of 'goal setting (outcome, i.e. consequences)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes (consequences) of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients and of '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 HCPs. Phase 2 - 3457 studies were screened, of which 65 non-randomised studies were included in the review. The following theoretical domains were likely to influence attendance: 'environmental context and resources', 'social influences', 'knowledge', 'memory, attention and decision processes', 'beliefs about consequences' and 'emotions'. Phase 3 - mapping identified that interventions included BCTs targeting important barriers to/enablers of DRS attendance. However, BCTs targeting emotional factors around DRS were under-represented. QI components were unlikely to be cost-effective whereas BCTs with a high probability (≥ 0.975) of being cost-effective at a societal willingness-to-pay threshold of £20,000 per QALY included 'goal-setting (outcome)', 'feedback on outcomes of behaviour', 'social support' and 'information about health consequences'. Cost-effectiveness increased when DRS attendance was lower and with longer screening intervals.

LIMITATIONS

Quality improvement/BCT coding was dependent on descriptions of intervention content in primary sources; methods for the identification of coherence of BCTs require improvement.

CONCLUSIONS

Randomised controlled trial evidence indicates that QI interventions incorporating specific BCT components are associated with meaningful improvements in DRS attendance compared with usual care. Interventions generally used appropriate BCTs that target important barriers to screening attendance, with a high probability of being cost-effective. Research is needed to optimise BCTs or BCT combinations that seek to improve DRS attendance at an acceptable cost. BCTs targeting emotional factors represent a missed opportunity to improve attendance and should be tested in future studies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016044157 and PROSPERO CRD42016032990.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Barriers to and enablers of diabetic retinopathy screening attendance: a systematic review of published and grey literature

AIMS

To identify and synthesize studies reporting modifiable barriers/enablers associated with retinopathy screening attendance in people with Type 1 or Type 2 diabetes, and to identify those most likely to influence attendance.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, Cochrane Library and the 'grey literature' for quantitative and qualitative studies to February 2017. Data (i.e. participant quotations, interpretive summaries, survey results) reporting barriers/enablers were extracted and deductively coded into domains from the Theoretical Domains Framework; with domains representing categories of theoretical barriers/enablers proposed to mediate behaviour change. Inductive thematic analysis was conducted within domains to describe the role each domain plays in facilitating or hindering screening attendance. Domains that were more frequently coded and for which more themes were generated were judged more likely to influence attendance.

RESULTS

Sixty-nine primary studies were included. We identified six theoretical domains ['environmental context and resources' (75% of included studies), 'social influences' (51%), 'knowledge' (51%), 'memory, attention, decision processes' (50%), 'beliefs about consequences' (38%) and 'emotions' (33%)] as the key mediators of diabetic retinopathy screening attendance. Examples of barriers populating these domains included inaccurate diabetic registers and confusion between routine eye care and retinopathy screening. Recommendations by healthcare professionals and community-level media coverage acted as enablers.

CONCLUSIONS

Across a variety of contexts, we found common barriers to and enablers of retinopathy screening that could be targeted in interventions aiming to increase screening attendance.

Divergent Perceptions of Barriers to Diabetic Retinopathy Screening Among Patients and Care Providers, Los Angeles, California, 2014-2015

Introduction

Despite availability of screening for diabetic retinopathy, testing is underused by many low-income and racial/ethnic minority patients with diabetes. We examined perceived barriers to diabetic retinopathy screening among low-income patients and their health care providers and provider staffers.

Methods

We collected survey data from 101 patients with diabetes and 44 providers and staffers at a safety-net clinic where annual diabetic retinopathy screening rates were low. Barriers specified in the survey were derived from the literature.

Results

Patients surveyed (mean [standard deviation] age, 54.0 [7.7] y; 41% were male) were primarily Hispanics (70%) and African Americans (27%) of low socioeconomic status. Overall, 55% of patients received diabetic retinopathy screening in the previous year. Patients who could not explain why this screening is needed reported more barriers than patients who could (2.5 vs 1.4 barriers, P = .02). Fewer patients reported that they experienced barriers such as transportation (15%), language issues (15%), cultural beliefs or myths (4%), denial (8%), and fear (5%), which providers and staffers considered very or extremely important (all P < .001). Financial burdens (26%) and depression (22%) were most commonly reported by patients as barriers, yet providers and staffers did not rate these barriers as important, P < .001.

Conclusion

Patients and health care providers had markedly divergent perceptions of barriers to diabetic retinopathy screening. Patients with poor understanding of the need for screening were more likely to report such barriers. These results suggest a need for active community engagement to find key elements for education programs and other interventions to increase rates of diabetic retinopathy screening, particularly among low-income, minority populations.