Sustaining Gains in Diabetic Eye Screening: Outcomes from a Stakeholder-Based Implementation Program for Teleophthalmology in Primary Care

Yao Liu, Julia N Carlson, Alejandra Torres Diaz, Loren J Lock, Nicholas J Zupan, Todd D Molfenter, Jane E Mahoney, Mari Palta, Deanne Boss, Timothy D Bjelland, Maureen A Smith, Yao Liu, Julia N Carlson, Alejandra Torres Diaz, Loren J Lock, Nicholas J Zupan, Todd D Molfenter, Jane E Mahoney, Mari Palta, Deanne Boss, Timothy D Bjelland, Maureen A Smith

Abstract

Background: Teleophthalmology is a validated method for diabetic eye screening that is underutilized in U.S. primary care clinics. Even when made available to patients, its long-term effectiveness for increasing screening rates is often limited. Introduction: We hypothesized that a stakeholder-based implementation program could increase teleophthalmology use and sustain improvements in diabetic eye screening. Materials and Methods:We used the NIATx Model to test a stakeholder-based teleophthalmology implementation program, I-SITE at one primary care clinic (Main) and compared teleophthalmology use and diabetic eye screening rates with those of other primary care clinics (Outreach) within a U.S. multipayer health system where teleophthalmology was underutilized.Results:Teleophthalmology use increased post-I-SITE implementation (odds ratio [OR] = 5.73 [p < 0.001]), and was greater at the Main than at the Outreach clinics (OR = 10.0 vs. 1.69, p < 0.001). Overall diabetic eye screening rates maintained an increase from 47.4% at baseline to 60.2% and 64.1% at 1 and 2 years post-I-SITE implementation, respectively (p < 0.001). Patients who were younger (OR = 0.98 per year of age, p = 0.02) and men (OR = 1.98, p = 0.002) were more likely to use teleophthalmology than in-person dilated eye examinations for diabetic eye screening.Discussion: Our stakeholder-based implementation program achieved a significant increase in overall teleophthalmology use and maintained increased post-teleophthalmology diabetic eye screening rates. Conclusion: Stakeholder-based implementation may increase the long-term reach and effectiveness of teleophthalmology to reduce vision loss from diabetes. Our approach may improve integration of telehealth interventions into primary care.

Keywords: ophthalmology; technology; telehealth; telemedicine.

Conflict of interest statement

No competing financial interests exist.

Figures

Fig. 1.
Fig. 1.
Teleophthalmology use at Mile Bluff Main and Outreach clinics by quarter.
Fig. 2.
Fig. 2.
Diabetic eye screening rates at Mile Bluff overall, Main clinic, Outreach clinics, and national averages by year.

References

    1. Centers for Disease Control and Prevention. National diabetes statistics report: Estimates of diabetes and its burden in the United States, 2014. Available at (last accessed on May 26, 2020).
    1. American Diabetes Association. 11. Microvascular complications and foot care: Standards of medical care in diabetes-2020. Diabetes Care 2020;43:S135–S151.
    1. Lynch MG, Maa AY. Diagnostic time for teleophthalmic care. JAMA Ophthalmol 2019;137:808–809.
    1. National Committee for Quality Assurance. Comprehensive Diabetes Care (CDC). Available at (last accessed on April 2, 2020).
    1. Scanlon PH. The English national screening programme for sight-threatening diabetic retinopathy. J Med Screen 2008;15:1–4.
    1. Liew G, Michaelides M, Bunce C. A comparison of the causes of blindness certifications in England and Wales in working age adults (16–64 years), 1999–2000 with 2009–2010. BMJ Open 2014;4:6.
    1. Gibson DM. Estimates of the percentage of US adults with diabetes who could be screened for diabetic retinopathy in primary care settings. JAMA Ophthalmol 2019;137:440–444.
    1. Silva PS, Aiello LP. Telemedicine and eye examinations for diabetic retinopathy: A time to maximize real-world outcomes. JAMA Ophthalmol 2015;133:525–526.
    1. Zimmer-Galler IE, Kimura AE, Gupta S. Diabetic retinopathy screening and the use of telemedicine. Curr Opin Ophthalmol 2015;26:167–172.
    1. Centers for Medicare and Medicaid Services. List of telehealth services. Available at (last accessed on May 26, 2020).
    1. Mansberger SL, Sheppler C, Barker G, Gardiner SK, Demirel S, Wooten K, Becker TM. Long-term comparative effectiveness of telemedicine in providing diabetic retinopathy screening examinations a randomized clinical trial. JAMA Ophthalmol 2015;133:518–525.
    1. Modjtahedi BS, Theophanous C, Chiu S, Luong TQ, Nguyen N, Fong DS. Two-year incidence of retinal intervention in patients with minimal or no diabetic retinopathy on telemedicine screening. JAMA Ophthalmol 2019;137:445–448.
    1. Daskivich LP, Vasquez C, Martinez C, Jr.,Tseng CH, Mangione CM.. Implementation and evaluation of a large-scale teleretinal diabetic retinopathy screening program in the Los Angeles County Department of Health Services. JAMA Intern Med 2017;177:642–649.
    1. Jani PD, Forbes L, Choudhury A, Preisser JS, Viera AJ, Garg S. Evaluation of diabetic retinal screening and factors for ophthalmology referral in a telemedicine network. JAMA Ophthalmol 2017;135:706–714.
    1. Hussey P, Anderson GF. A comparison of single- and multi-payer health insurance systems and options for reform. Health Policy 2003;66:215–228.
    1. Liu Y, Zupan NJ, Swearingen R, Jacobson N, Carlson JN, Mahoney JE, Klein R, Bjelland TD, et al. . Identification of barriers, facilitators and system-based implementation strategies to increase teleophthalmology use for diabetic eye screening in a rural US primary care clinic: A qualitative study. BMJ Open 2019;9:e022594.
    1. Bouskill K, Smith-Morris C, Bresnick G, Cuadros J, Pedersen ER. Blind spots in telemedicine: A qualitative study of staff workarounds to resolve gaps in diabetes management. BMC Health Serv Res 2018;18:617.
    1. Centers for Healthcare Enhancement Systems Studies. What is NIATx? Available at (last accessed on June 30, 2020).
    1. County Health Ranking Roadmaps. Juneau County Demographics. Available at (last accessed on February 28, 2020).
    1. American Telemedicine Association. Telehealth practice recommendations for diabetic retinopathy, second edition. Telemed J E Health 2011;17:814–837.
    1. Perry CK, Damschroder LJ, Hemler JR, Woodson TT, Ono SS, Cohen DJ. Specifying and comparing implementation strategies across seven large implementation interventions: A practical application of theory. Implement Sci 2019;14:32.
    1. Holley CD, Lee PP. Primary care provider views of the current referral-to-eye-care process: Focus group results. Invest Ophthalmol Vis Sci 2010;51:1866–1872.
    1. Fowles JB, Rosheim K, Fowler EJ, Craft C, Arrichiello L. The validity of self-reported diabetes quality of care measures. Int J Qual Health Care 1999;11:407–412.
    1. Flaxel CJ, Bailey ST, Fawzi A, Lim JI, Adelman RA, Vemulakonda A, Ying G-S. Diabetic retinopathy Preferred Practice Pattern 2019. Available at (last accessed on April 2, 2020).
    1. National Committee for Quality Assurance. 2015. Diabetes Recognition Program (DRP) requirements. Available at (last accessed on May 26, 2020).
    1. Mamillapalli CK, Prentice JR, Garg AK, Hampsey SL, Bhandari R. Implementation and challenges unique to teleretinal diabetic retinal screening (TDRS) in a private practice setting in the United States. J Clin Transl Endocrinol 2020;19:100214.
    1. Ford I, Norrie J. Pragmatic trials. N Engl J Med 2016;375:454–463.
    1. Eppley SE, Mansberger SL, Ramanathan S, Lowry EA. Characteristics associated with adherence to annual dilated eye examinations among US patients with diagnosed diabetes. Ophthalmology 2019;126:1492–1499.
    1. Vision and Aging Resources. Available at (last accessed on March 9, 2020).
    1. Xu G, Liu B, Sun Y, Du Y, Snetselaar LG, Hu FB, Bao W. Prevalence of diagnosed type 1 and type 2 diabetes among US adults in 2016 and 2017: Population based study. BMJ 2018;362:k1497.
    1. National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control and Prevention, 2020.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere