Factors Associated with Ophthalmology Referral and Adherence in a Teleretinal Screening Program: Insights from a Federally Qualified Health Center

Abstract

Background: Early detection of ophthalmic conditions such as diabetic retinopathy (DR) and glaucoma is crucial to preventing vision loss. Previous studies have evaluated teleretinal screening programs for DR in well-insured populations. The purpose of this retrospective study was to evaluate a teleretinal screening program in a population of uninsured and underinsured patients seen in a Federally Qualified Health Center (FQHC). Methods: We conducted a retrospective chart review of patients (age ≥18) who underwent teleretinal imaging (TRI) at a FQHC between January 2015 and September 2019. TRI gradings and patient demographic and clinical information were abstracted. Factors associated with referral for a dilated eye exam by an ophthalmologist, adherence to recommended follow-up dilated eye exam, and ophthalmology visit attendance were examined. Results: 3130 TRIs were graded in 2216 eyes (1107 patients). 65.2% (N = 722) self-identified as Hispanic and 56.3% (N = 623) required interpreter services. Follow-up dilated fundus examination (DFE) was recommended for 388 TRIs, 49% (N = 190) of which were completed within 1 year. Adherence to the recommended ophthalmology exam was not associated with any baseline clinical or demographic characteristics (p > 0.05). Older age, male sex, hypertension, proteinuria, and higher A1c were significantly associated with greater odds of ophthalmology referral based on TRI (all p < 0.05), after adjusting for covariates. Less severe diabetic retinopathy, no insurance coverage, and Hispanic ethnicity were associated with lower odds of attending an ophthalmology visit, regardless of follow-up recommendations based on TRI (all p < 0.05). Conclusion:In an FQHC serving predominantly uninsured and underinsured patients, only 49% of recommended DFE were completed within one year. Less severe diabetic retinopathy, lack of insurance coverage, and Hispanic ethnicity were associated with a lower likelihood of having a DFE regardless of recommendation. These results suggest that greater system-level efforts are needed to increase adherence to follow-up eye exams after TRI to ensure sight-saving care for underserved populations.

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

“…10,12 Furthermore, compliance was shown to be more likely if a shorter follow-up time period was recommended, 11 the patient was prescribed eye drops, 13 or the patient received laser therapy. 10,13 Factors That Were Negatively Associated with Compliance Patient characteristics that were negatively associated with compliance included living alone, 16 smoking, 16 lacking a car, 16 Hispanic ethnicity, 23 or living farther from the hospital. 25…”

Advances in Teleophthalmology Screening for Diabetic Retinopathy

“…A drawback of teleophthalmology screening using the store-and-forward model is the delay in diagnosis, which necessitates after-visit care coordination, increasing the likelihood of loss to followup. 92 In contrast, AI-based screening programs had increased adherence to follow-up recommendations in high-and low-resource countries alike 20 Topcon NW400 mtmDR Sensitivity, 88%; specificity, 90% EyeArt V2.2.0 (Eyenuk Inc, Woodland Hills, CA) 21 Canon CR-2 AF, Canon CR-2 Plus AF, and Topcon NW400 mtmDR and vtDR* mtmDR: sensitivity, 94-96%; specificity, 87-91%. † vtDR: sensitivity: 97%; specificity: 92% AEYE-DS (AEYE Health Inc, New York, NY) 22 Topcon NW400 mtmDR Sensitivity: 93%; specificity: 91% *Including severe non-proliferative diabetic retinopathy, proliferative diabetic retinopathy, and diabetic macular edema.…”

“…An important benefit of some AI-based screening systems is immediate feedback. A drawback of teleophthalmology screening using the store-and-forward model is the delay in diagnosis, which necessitates after-visit care coordination, increasing the likelihood of loss to follow-up 92 . In contrast, AI-based screening programs had increased adherence to follow-up recommendations in high- and low-resource countries alike due to immediate feedback on referral status 93,94 .…”

Clinically significant macular edema in an underserved population: Association with demographic factors and hemoglobin A1c

“…In the underserved population sampled in this study, more than 60% of the 2050 diabetic patients reported that their last eye examination had been conducted more than 3 years previously 12 . This lack of adherence is significantly higher among underserved individuals with low-income levels and minority ethnic backgrounds, such as African Americans and non-Hispanic Caucasians 20–22 . Barriers preventing routine eye examinations present a major hurdle to the timely detection and treatment of diabetic retinopathy.…”

“…12 This lack of adherence is significantly higher among underserved individuals with lowincome levels and minority ethnic backgrounds, such as African Americans and non-Hispanic Caucasians. [20][21][22] Barriers preventing routine eye examinations present a major hurdle to the timely detection and treatment of diabetic retinopathy.…”