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

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.

Effect of health system on the association of rurality and level of disadvantage with receipt of diabetic eye screening

“…In our prior work, we found that tailored implementation of telemedicinebased screening using health system-level interventions, such as primary care workflow changes and patient recall systems, led to significant and sustained increases in screening rates in a rural health system. 18 Targeted use of health system-level interventions in diabetes populations with lower screening rates, including rural and urban underserved populations, Black and Latinx communities, as well as younger populations, 8 10 33 could be highly effective in increasing screening rates.…”

“…A systematic review by Zhang et al 32 identified five randomized controlled trials in which health system-level interventions, including telemedicine, significantly increased diabetic retinopathy screening, with relative risks ranging from 1.12 (95% CI 1.03 to 1.22) to 5.56 (95% CI 2.19 to 14.10). In our prior work, we found that tailored implementation of telemedicine-based screening using health system-level interventions, such as primary care workflow changes and patient recall systems, led to significant and sustained increases in screening rates in a rural health system 18. Targeted use of health system-level interventions in diabetes populations with lower screening rates, including rural and urban underserved populations, Black and Latinx communities, as well as younger populations,8 10 33 could be highly effective in increasing screening rates.…”

“…A primary care provider’s recommendation is the strongest factor influencing a patient’s decision to obtain diabetic eye screening 16 17. Primary care provider behavior has been strongly linked to organizational goals, incentives, and infrastructure at the health system and clinic level 18–21. Previously, we observed that the median magnitude of the effect of health system on the odds of screening receipt was 1.24 (IQR, 1.11–1.48) using an all-payer, state-wide claims database that covers over 75% of Wisconsin residents (Wisconsin Health Information Organization (WHIO) All-Payer Claims Database) and including all health systems in the database 11.…”

“…Epidemiology/Health services research goals, incentives, and infrastructure at the health system and clinic level. [18][19][20][21] Previously, we observed that the median magnitude of the effect of health system on the odds of screening receipt was 1.24 (IQR, 1.11-1.48) using an all-payer, state-wide claims database that covers over 75% of Wisconsin residents (Wisconsin Health Information Organization (WHIO) All-Payer Claims Database) and including all health systems in the database. 11 Patients who obtained care from urban primary care clinics had a higher likelihood of screening receipt than those who obtained care from rural primary care clinics after adjusting for the effect of the health system, but those from urban clinics had a lower likelihood of screening receipt prior to adjusting for the effect of the health system.…”

Implementation of Teleophthalmology to Improve Diabetic Retinopathy Surveillance: Qualitative Interview Study of Clinical Staff Informed by Implementation Science Frameworks

“…Specific outcome measures have included changes in the number of patients screened, the number who followed up to eye care, demographics, modeled costs, and patient satisfaction [ 5 , 6 , 8 - 18 , 21 - 25 ]. A recent study focused on implementing teleophthalmology explored how rural primary clinics in Wisconsin viewed the implementation of teleophthalmology using qualitative analysis and an implementation science framework [ 26 ]. Another study focused on the implementation of teleophthalmology across federally qualified health centers in Kentucky using implementation science metrics [ 27 ].…”