Dataset Information

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

ABSTRACT:

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.

SUBMITTER: Ware SL

PROVIDER: S-EPMC9011929 | biostudies-literature | 2022 Apr

REPOSITORIES: biostudies-literature

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Publications

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

Ware S Lee SL Studts Christina R CR Lei Feitong F Bush Heather H Higgins Eric B EB Studts Jamie L JL Bastos de Carvalho Ana A

BMC health services research 20220414 1

<h4>Background</h4>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 barrier ...[more]

PMID: 35421978

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Project description:ContextDiabetic 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 methodsWith 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.ResultsOf 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 relevanceA 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.

Project description:BackgroundDiabetic retinopathy (DR) is a significant global public health and economic burden. DR accounts for approximately 15-17% of all cases of total blindness in the USA and Europe. Telemedicine is a new intervention for DR screening, however, there is not enough evidence to support its cost-effectiveness. The aim of this study is to review the most recent published literature on economic evaluations of telemedicine in DR screening and summarize the evidence on the cost-effectiveness of this technology.MethodsA systematic search of PubMed, Embase and Google Scholar for relevant articles published between January 2010 and January 2020. Studies were included if they met the following criteria: (1) recruited subjects with either type 1, type 2 diabetes (2) evaluated telemedicine technology (3) patients underwent primary screening for DR (4) compared a telemedicine-based intervention with standard care (5) performed an economic evaluation or provided sufficient data for evaluating the cost-effectiveness of the technology used.ResultsOf 2238 articles screened, seven studies were included. Four of the studies were conducted in developed countries: The United States, Singapore and two studies in Canada. Three studies were conducted in developing countries: India, Brazil and South Africa. The patient populations in all studies were diabetic patients over the age of 18, previously not screened for DR. All seven studies used a telemedicine program which included capturing a retinal image and subsequently transmitting it to an ocular imaging center to assess the severity of DR. All studies compared telemedicine to a standard screening method for DR, including the option of no screening as standard of care. Although telemedicine requires initial and maintenance costs, it has the potential to provide significant cost savings by increasing patients' working ability, increasing independent living ability, increasing quality of life and reducing travel costs.ConclusionsDiabetic retinopathy telemedicine technology has the potential to provide significant cost savings, especially in low-income populations and rural patients with high transportation costs.

Project description:PurposePrioritizing comparative effectiveness research may contribute to obtaining answers that clinicians perceive they need and may minimize research that could be considered wasteful. Our objective was to identify evidence gaps and set priorities for new systematic reviews and randomized controlled trials for managing diabetic retinopathy (DR), including diabetic macular edema (DME).DesignCross-sectional study.ParticipantsDiabetic Retinopathy Clinical Research Network (DRCR.net) investigators.MethodsWe provided recommendations from the American Academy of Ophthalmology's 2012 Preferred Practice Patterns for Diabetic Retinopathy as 91 answerable clinical research questions about intervention effectiveness to 410 DRCR.net investigators to rate each question's importance from 0 (not important) to 10 (very important) using a 2-round Delphi survey and to suggest additional questions. We considered questions as high priority if at least 75% of respondents to both rounds assigned an importance rating of 5 or more in round 2. We also extracted outcome measures relevant to DR and asked respondents to identify those that must be measured in all studies. We mapped Cochrane reviews published up to March 2016 to high-priority clinical research questions.Main outcome measureRanking of importance of each clinical question.ResultsThirty-two individuals completed rounds 1 and 2 and suggested 15 questions. Among the final list of 106 clinical research questions, 22 questions met our definition of high priority: 9 of 22 concerned the effectiveness of anti-VEGF therapy, and 13 of 22 focused on how often patients should be followed up (re-examination) and treatment effectiveness in patients with specific characteristics (e.g., DME). Outcomes that 75% or more of respondents marked as "must be measured in all studies" included visual acuity and visual loss, death of participants, and intraocular pressure. Only 1 prioritized question was associated with conclusive evidence from a Cochrane systematic review.ConclusionsA limited response rate among DRCR.net members identified 22 comparative effectiveness research questions as high priority for the management of DR, including DME, but few were associated with Cochrane reviews. These results support the need of systematic reviews and randomized controlled trials to address evidence gaps.

Project description:Diabetic Retinopathy stands as a leading cause of irreversible blindness, necessitating frequent examinations, especially in the early stages where effective treatments are available. However, current examination rates vary widely, ranging from 25-60%. This study scrutinizes the Point-of-Care Diabetic Retinopathy Examination Program at the University of Pittsburgh/UPMC, delving into its composition, evolution, challenges, solutions, and improvement opportunities. Employing a narrative approach, insights are gathered from key stakeholders, including ophthalmologists and staff from primary care clinics. A quantitative analysis from 2008 to 2020 provides a comprehensive overview of program outcomes, covering 94 primary care offices with 51 retinal cameras. Program components feature automated non-mydriatic 45° retinal cameras, a dedicated coordinator, rigorous training, and standardized workflows. Over this period, the program conducted 21,960 exams in 16,458 unique individuals, revealing a diverse population with an average age of 58.5 and a balanced gender distribution. Average body mass index (33.96±8.02 kg/m2) and hemoglobin A1c (7.58%±1.88%) surpassed normal ranges, indicating prevalent risk factors for diabetes-related complications. Notably, 24.2% of patients underwent more than one exam, emphasizing program engagement. Findings indicated that 86.3% of exams were gradable, with 59.0% within normal limits, 12.1% showing some evidence of diabetic retinopathy, and 6.4% exhibiting vision-threatening diabetic retinopathy. Follow-up appointments with ophthalmologists were recommended in 31.5% of exams due to indeterminate results, positive diabetic retinopathy (≥moderate or macular exudate), or other findings like age-related macular degeneration or suspected glaucoma. The program demonstrated high reproducibility across diverse healthcare settings, featuring a sustainable model with minimal camera downtime, standardized workflows, and financial support from grants, health systems, and clinical revenues. Despite COVID-19 pandemic challenges, this research emphasizes the program's reproducibility, user-friendly evolution, and promising outcomes. Beyond technical contributions, it highlights human factors influencing program success. Future research could explore adherence to follow-up ophthalmological recommendations and its associated factors.

Project description:IntroductionDiabetic retinopathy (DR) is the primary retinal vascular complication of diabetes mellitus and a leading cause of visual impairment and blindness. It affects the global diabetic population. In Ethiopia, about one-fifth of diabetic patients were affected by DR, but there were inconsistent finding across studies about the determinants factors of DR. Therefore, we aimed to identify the risk factors for DR among diabetic patients.MethodsWe have accessed previous studies through an electronic web-based search strategy using PubMed, Google (Scholar), the Web of Science, and the Cochrane Library with a combination of search terms. The quality of each included article was assessed using the Newcastle Ottawa Assessment Scale. All statistical analyses were carried out using Stata version 14 software. The odds ratios of risk factors were pooled using a fixed-effect meta-analysis model. Heterogeneity was assessed using the Cochrane Q statistics and I-Square (I2). Furthermore, publication bias was detected based on the graphic asymmetry test of the funnel plot and/or Egger's test (p< 0.05).ResultsThe search strategy retrieved 1285 articles. After the removal of duplicate articles, 249 articles remained. Following further screening, about 18 articles were assessed for eligibility, of which three articles were excluded because of reporting without the outcome of interest, poor quality, and not full text. Finally, fifteen studies were reviewed for the final analysis. Co-morbid hypertension (HTN) (AOR 2.04, 95%CI: 1.07, 3.89), poor glycemic control (AOR = 4.36, 95%CI: 1.47, 12.90), and duration of diabetes illness (AOR = 3.83, 95%CI: 1.17, 12.55) were found to be confirmed associated factors of diabetic retinopathy.ConclusionIn this study, co-morbid HTN, poor glycemic control, and longer duration of diabetes illness were found to be the determinant factors of DR. Aggressive treatment of co-morbid HTN and blood glucose, and regular eye screening should be implemented to reduce the occurrence of DR.Trial registrationThe review protocol was registered in the international prospective register of systematic reviews (PROSPERO) with registration number PROSPERO: CRD42023416724.

Dataset Information

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

Background

Methods

Results

Conclusions

Publications

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

Similar Datasets

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