Diabetic Eye Screening: Knowledge and Perspectives from Providers and Patients

Perceptions of a Teleophthalmology Screening Program for Diabetic Retinopathy in Adults With Type 1 and Type 2 Diabetes in Urban Primary Care Settings

OBJECTIVES

Teleophthalmology has improved diabetic retinopathy screening, and should be expanded in urban areas, where most unscreened individuals reside. In this study we explored facilitators and barriers of teleophthalmology in primary care settings in Toronto, Canada.

METHODS

Semistructured interviews were conducted with 7 health-care providers and 7 individuals with diabetes to explore their perspectives of teleophthalmology in urban primary care settings. Interview data were analyzed using interpretive thematic analysis to generate themes.

RESULTS

Six themes were identified. Facilitators included patient-centred implementation, access to teleophthalmology at primary care sites and patients' trust in their providers' recommendations. Barriers included patients' lack of understanding of diabetic retinopathy and the health-care system, providers' lack of interest and the need to streamline administrative processes.

CONCLUSIONS

Although teleophthalmology was well-received by patients, there was limited interest from primary care providers. Strategies for increasing uptake include increasing primary care providers' awareness of teleophthalmology's value in urban centres, improving administrative processes and centralizing patient recruitment.

A review on albumin as a biomaterial for ocular drug delivery

Development of ocular drug delivery system is one of the most technically challenging tasks, when compared with other routes of drug delivery. Eye (an intricate organ) is highly sophisticated and sensitive organ due to presence of various structurally differed anatomical layers, which many times limits the drug delivery approaches. Despite several limitations, many advancements have been made as evidence from various recent studies involving improvement of both residence time and permeation of the drug at the ocular region. In the last few decades, albumin(s) based ophthalmic products have been gained most attention to solve the major challenges associated with conventional ocular drug delivery systems. Interestingly, an albumin-based micro, nano, conjugates, and genetically fused target specific to ligand(s) formulation being exploited through many studies for successful ocular delivery of bioactives (mostly repurposed drugs). Past and current studies suggested that albumin(s) based ocular drug delivery system is multifunctional in nature and capable of extending both drug residence time and sustaining the release of drugs to deliver desired pharmacological outcomes. Despite wide applications, still complete progress made in albumin based ocular drug delivery is limited in literature and missing in market. So, herein we presented an overview to explore the key concepts of albumin-based nanocarrier(s) including strategies involved in the treatment of ocular disease, that have yet to be explored.

Preferred practice pattern of physicians regarding diabetic retinopathy in diabetes mellitus patients

Purpose:

To assess the perceptions of physicians about diabetic retinopathy (DR) screening, barriers to DR screening, and change in management protocol of Diabetes Mellitus (DM) patients with DR.

Methods:

A cross-sectional descriptive study was conducted using a standard predesigned and pretested structured questionnaire through online mode in the month of April 2021 to assess the criteria used for referral of diabetic patients for DR screening, barriers to DR screening, and the management plan among physicians after the patient has been diagnosed with DR.

Results:

In total, 100 physicians participated in the study. Physicians responded that criteria used for referral for DR screening according to duration was <5 years (n = 0), 5–10 years (n = 60), >10 years (n = 10), and irrespective of the duration (n = 30). According to severity, well-controlled DM without (n = 30) and with other system involvement (n = 50) and uncontrolled DM without (20) and with other system involvement (n = 50) and irrespective of the severity of disease (n = 30) was reported. Physicians (n = 40) responded that patients who were diagnosed with DR belonged to the Type 1 DM category rather than Type 2 DM (P < 0.05). With regard to the barriers and challenges faced in ensuring DR screening, the following themes emerged: no ocular symptoms, lack of compliance, time constraint for the patient, and lack of motivation.

Conclusion:

We found that the preferred practice pattern of physicians regarding referral for DR screening was dependent on the duration of the disease (mostly 5–10 years of the disease) and severity (when other systems were involved). Noncompliance with advice was the major barrier to DR screening.

Encouraging the scale-up of proven interventions: Infrastructure development for the "Evidence-to-Implementation" award

Background/Objective

Although most research universities offer investigators help in obtaining patents for inventions, investigators generally have few resources for scaling up non-patentable innovations, such as health behavior change interventions. In 2017, the dissemination and implementation (D & I) team at the University of Wisconsin's Clinical and Translational Science Award (CTSA) created the Evidence-to-Implementation (E2I) award to encourage the scale-up of proven, non-patentable health interventions. The award was intended to give investigators financial support and business expertise to prepare evidence-based interventions for scale-up.

Methods

The D & I team adapted a set of criteria named Critical Factors Assessment, which has proven effective in predicting the success of entrepreneurial ventures outside the health care environment, to use as review criteria for the program. In March 2018 and February 2020, multidisciplinary panels assessed proposals using a review process loosely based on the one used by the NIH for grant proposals, replacing the traditional NIH scoring criteria with the eight predictive factors included in Critical Factors Assessment.

Results

two applications in 2018 and three applications in 2020 earned awards. Funding has ended for the first two awardees, and both innovations have advanced successfully.

Conclusion

Late-stage translation, though often overlooked by the academic community, is essential to maximizing the overall impact of the science generated by CTSAs. The Evidence-to-implementation award provides a working model for supporting late-stage translation within a CTSA environment.

Integrating SWATH-MS proteomics and transcriptome analysis to preliminarily identify three DEGs as biomarkers for proliferative diabetic retinopathy

PURPOSE

We intended to preliminarily find differentially expressed proteins that play crucial roles in proliferative diabetic retinopathy (PDR), and lay the foundation for subsequent further research on the mechanism.

EXPERIMENTAL DESIGN

Here, we developed a new strategy integrated the sequential windowed acquisition of all theoretical fragment ion (SWATH) mass spectra (MS) with multi-dataset joint analysis to screen for the PDR plasma biomarker. The annotation of the given gene list was performed with ClueGO function analysis. Additionally, the protein-protein interaction relationship was also revealed by the STRING database.

RESULTS

In SWATH-MS assays, we identified 23 upregulated and 13 downregulated proteins in PDR plasma. In the mRNA database analysis, 375 genes were identified as differentially expressed genes in GSE102485. Only three genes (FCGR3A, DPEP2, and ADGRF5) were characterized as upregulated in both the dataset and the SWATH-MS list. The area under the ROC curve (AUC) of FCGR3A, DPEP2, and ADGRF5 in distinguishing PDR from others was 0.739, 0.770, and 0.739.

CONCLUSIONS AND CLINICAL RELEVANCE

We provide a novel strategy for biomarker screening and identified plasma FCGR3A, DPEP2, and ADGRF5 as potential biomarkers for patients with PDR. Identifying the key molecules of the disease is essential for the development of new therapeutic molecules and new uses of existing drugs.

Clinical staff impressions on implementation of a teleophthalmology program to improve diabetic retinopathy surveillance informed by implementation science frameworks (Preprint)

Background

The store-and-forward camera-based evaluation of the eye, or teleophthalmology, is an effective way to identify diabetic retinopathy, the leading cause of blindness in the United States, but uptake has been slow. Understanding the barriers to and facilitators of implementing teleophthalmology programs from those actively adopting, running, and sustaining such programs is important for widespread adoption.

Objective

This study aims to understand the factors that are important in introducing teleophthalmology to improve access to diagnostic eye care for patients with diabetes in primary care clinics by using implementation science.

Methods

This qualitative study in 3 urban, low-income, largely racial and ethnic minority–serving safety-net primary care clinics in Rochester, New York, interviewed nurses and physicians on implementing a teleophthalmology program by using questions informed by the Practical, Robust Implementation and Sustainability Model and the Consolidated Framework for Implementation Research.

Results

Primary care nurses operationalizing the program in their clinics saw increased work burden and a lack of self-efficacy as barriers. Continuous training on the teleophthalmology process for nurses, physicians, and administrative staff through in-service and peer training by champions and superusers were identified by interviewees as needs. Facilitators included the perceived convenience for the patient and a perceived educational advantage to the program, as it gave an opportunity for providers to discuss the importance of eye care with patients. Concerns in making and tracking referrals to ophthalmology because of challenges related to care coordination were highlighted. The financial aspects of the program (eg, patient coverage and care provider reimbursement) were unclear to many staff members, influencing adoption and sustainability.

Conclusions

Streamlining processes and workflows, training and assigning adequate staff, effectively coordinating care between primary care and eye care to improve follow-ups, and ensuring financial viability can all help streamline the adoption of teleophthalmology.

Feasibility Study of a Multimodal, Cloud-Based, Diabetic Retinal Screening Program in a Workplace Environment

Purpose

To evaluate the feasibility of capturing and interpreting retinal images in a workplace environment using a multimodal, cloud-based, diabetic retinal screening program combined with electronic self-reported questionnaires. The burden of diabetic retinopathy (DR) and other retinal conditions, healthcare utilization, and visual function were also assessed.

Methods

A cross-sectional feasibility study was conducted at the Genentech, Inc., Campus Health Center. Eyes of participants were imaged using ultra-widefield (UWF) color fundus photography (CFP) and spectral-domain optical coherence tomography (SD-OCT). A cloud-based platform was used for the automated, seamless transfer of images to a remote reading center for evaluation for DR and other retinal pathologies. Electronic surveys collected participants’ self-reported medical histories, healthcare utilization, and visual function data.

Results

Among 100 participants (mean age, 43.9 years; 44% male), 33% of them self-reported diabetes. Eye examinations within the past 12 months were reported by 71% of all participants (n = 71/100) and by 85% (n = 28/33) of those with self-reported diabetes. Among participants with complete screening images from both UWF-CFP and SD-OCT, 20% (n = 6/30) of those with self-reported diabetes and 8.5% (n = 5/59) of participants with no history of diabetes were unaware they had mild/moderate nonproliferative DR. Among all participants, 20% (20/100) had a retinal finding, on either UWF-CFP or SD-OCT, or both, which prompted a referral for further evaluation.

Conclusions

A retinal screening program deployed via a secure, scalable, and interoperable cloud-based platform was feasible and conveniently integrated into the workplace.

Translational Relevance

Cloud-based platforms could be used to promote a secure, scalable, and interoperable system for retinal screening in nontraditional environments.

The role of health beliefs in affecting patients' chronic diabetic complication screening: a path analysis based on the health belief model

AIMS AND OBJECTIVES

To explore the role of health beliefs in affecting patients' chronic diabetic complication (CDC) screening.

BACKGROUND

Patients' adherence to the guideline-recommended CDC screening was far from optimal. While many demographic and clinical characteristics were documented to influence patients' adherence, psychological profiles, such as health beliefs, were not well studied before. It is crucial to understand how health beliefs affect patients' CDC screening behaviour and thus to provide implications for future intervention programmes.

DESIGN

A cross-sectional study was conducted.

METHODS

785 type 2 diabetes were enrolled from the community health centre in Wuhou District, Chengdu, China. Structured questionnaires were used to collect data regarding the demographic and clinical information, knowledge about CDC, health belief model constructs and CDC screening behaviour. Mediation analysis was performed to explore the mechanisms of health belief model constructs on CDC screening behaviour. The study methods were compliant with the STROBE checklist.

RESULTS

Knowledge had a significant indirect effect on CDC screening behaviour through perceived susceptibility, perceived benefits, perceived barriers and self-efficiency. Cues to action exerted both significant direct and indirect effects on CDC screening behaviour. The indirect effects of cues to action were exerted through perceived susceptibility, perceived barriers and self-efficiency.

CONCLUSION

Health beliefs played vital roles in mediating the effects of knowledge and cues to action on patients' CDC screening behaviour. Health beliefs should be assessed and modified through creative educational methods. Strategies aimed at increasing cues to action are also expected to facilitate patients' CDC screening behaviour.

RELEVANCE TO CLINICAL PRACTICES

The study contributes to the exploration of how health beliefs affect patients' CDC screening behaviour. The results could be used to inspire future community-based intervention programmes.

The effect of educational program based on theory of planned behavior on promoting retinopathy preventive behaviors in patients with type 2 diabetes: RCT

BACKGROUND

Diabetic retinopathy is the most common microvascular complication of diabetes and it is a leading cause of visual impairment and blindness among patients with diabetes. This study aimed to investigate the effect of educational program based on Theory of Planned Behavior (TPB) on promoting retinopathy preventive behaviors in patients with type 2 diabetes.

METHODS

The present study is an educational randomized controlled trial research that was conducted on 94 patients with type 2 diabetes who had gone to diabetes clinic. The samples were randomly assigned to the intervention (N = 47) and control groups (N = 47). Data collection instrument was a researcher-made questionnaire based on TPB and FBS and HbA1C tests. Then, educational program was performed for the intervention group through four educational sessions. After 3 months, data collection was repeated for the two groups and FBS, HbA1C testes were done again and data were analyzed.

RESULTS

The performance of the intervention group on preventive behaviors of retinopathy increased from 2.48 ± 1.42 to 4.48 45 1.45 after the education (p < 0.001). The mean of FBS and HbA1c in the intervention group also decreased after the intervention (P < 0.05).

CONCLUSION

Applying the TPB model proved is very effective in developing an educational program for patients with diabetes, to control their blood sugar and enhance preventive behaviors of retinopathy. Besides such programs, follow-up education for controlling and monitoring are highly recommended. This theory serves as a helpful theoretical framework for health-related behaviors and can be an appropriate pattern to plan for educational interventions.

TRIAL REGISTRATION

This trial has been registered at Iranian Registry of Clinical Trials, IRCT20180819040834N1 . Prospectively registered 8 Apr 2019, https://en.irct.ir/trial/38401.

The role of tele-ophthalmology in diabetic retinopathy screening

Diabetic retinopathy (DR) is the leading cause of legal blindness in the United States. Considering the increasing incidence of DR, it is extremely important to detect the most cost-effective tools for DR screening, so as to manage this surge in demand and the socioeconomic burden it places on the health care system. Despite the advances in retinal imaging, analysis techniques are still superseded by expert ophthalmologist interpretation. Teleophthalmology presents an immense opportunity, with high rates of sensitivity and specificity, to manage the steadily increasing demand for eye care of patients with diabetes, but challenges remain in the delivery of practical, viable, and clinically proven solutions.

Factors affecting the likelihood of a hospitalization following a diabetes-related emergency department visit: A regional and urban-rural analysis

BACKGROUND

The objective of this study is to examine place-based and individual-level predictors of diabetes-related hospitalizations that stem from emergency department (ED) visits.

METHODS

We conducted a pooled cross-sectional analysis of the National Inpatient Sample (NIS) for 2009 to 2014 to identify ED-initiated hospitalizations that were driven by the need for diabetes care. The odds of an ED-initiated diabetes-related hospitalization were assessed for the United States as a whole and separately for each census region.

RESULTS

Nationally, residents of noncore areas (odds ratio [OR] 1.10; CI 1.08, 1.12), the South (OR 8.03; CI 6.84, 9.42), Blacks (OR 2.49; CI 2.47, 2.52), Hispanics (OR 2.32; CI 2.29, 2.35), Asians or Pacific Islanders (OR 1.20; CI 1.16, 1.23), Native Americans (OR 2.18; CI 2.10, 2.27), and the uninsured (OR 2.14; CI 2.11, 2.27) were significantly more likely to experience an ED-initiated hospitalization for diabetes care. Census region-stratified models showed that noncore residents of the South (OR 1.17; CI 1.14, 1.20) and Midwest (OR 1.06; CI 1.02, 1.11) had higher odds of a diabetes-related ED-initiated hospitalization.

CONCLUSIONS

As continued efforts are made to reduce place-based disparities in diabetes care and management, targeted focus should be placed on residents of noncore areas in the South and Midwest, racial and ethnic minorities, as well as the uninsured population.

Patient perceived value of teleophthalmology in an urban, low income US population with diabetes

Dilated eye exams are the standard of care to detect advancing, vision threatening, but often asymptomatic retinopathy in a timely fashion, allowing for vision preserving treatments. Annual exam rates are suboptimal, especially in underserved populations. Although teleophthalmology programs tremendously improve annual exam rates in low income/under resourced settings, widespread adoption is limited. Using a mixed methods approach, three focus groups and individual interviews were conducted for patients with type 2 diabetes (N = 23) who had a teleophthalmology exam or a dilated eye exam. A survey and discussion assessed patients’ perspectives and value of teleophthalmology, including willingness to pay (WTP). Financial, transportation, and motivational barriers to obtaining an annual dilated eye exam were identified. Patients greatly valued having primary care (PC) based teleophthalmology for its convenience and ability to detect disease to allow for timely treatment and would recommend such a service. Although their WTP was at least the amount of their usual copay, cost was universally cited as a concern. Having a conveniently offered PC based teleophthalmology exam was valued. Educating patients on the value and costs of having such exams may be helpful to encourage informed discussions on eye care, especially in low income, underserved populations. Our study is among the few to provide insight on the value and perceptions of teleophthalmology in US low income, urban minority populations needed to help increase uptake of this innovation. Using surveys followed by facilitated discussion allowed for richer and more varied responses.

Scaling Up Teleophthalmology for Diabetic Eye Screening: Opportunities for Widespread Implementation in the USA

PURPOSE OF REVIEW

We discuss opportunities to address key barriers to widespread implementation of teleophthalmology programs for diabetic eye screening in the United States (U.S.).

RECENT FINDINGS

Teleophthalmology is an evidence-based form of diabetic eye screening. This technology has been proven to substantially increase diabetic eye screening rates and decrease blindness. However, teleophthalmology implementation remains limited among U.S. health systems. Major barriers include financial concerns as well as limited utilization by providers, clinical staff, and patients. Possible interventions include increasingly affordable camera technology, demonstration of financially sustainable billing models, and engaging key stakeholders. Significant opportunities exist to overcome barriers to scale up and promote widespread implementation of teleophthalmology in the USA. Further development of methods to sustain effective increases in diabetic eye screening rates using this technology is needed. In addition, the demonstration of cost-effectiveness in a variety of billing models should be investigated to facilitate widespread implementation of teleophthalmology in U.S. health systems.

Modeling a Telemedicine Screening Program for Diabetic Retinopathy in Iran and Implementing a Pilot Project in Tehran Suburb

PURPOSE

To model a community-based telescreening program for diabetic retinopathy (DR) in Iran and to implement a pilot project at the Iranian Diabetes Society (IDS) branch in a Tehran suburb.

METHODS

In this mixed model study, a web application called the "Iranian Retinopathy Teleophthalmology Screening (IRTOS)" was launched. The educational course for DR screening was established for general practitioners (GPs). Registered patients in IDS branch were recalled for fundus photography; images were transferred to the reading center via IRTOS to be graded by GPs, and patients were informed about the results via mobile messaging. All images were independently reviewed by a retina specialist as the gold standard. Patients who required further assessment were referred to an eye hospital.

RESULTS

Overall, 604 subjects with diabetes were screened; of these, 50% required referral. The sensitivity and specificity for diagnosis of any stage of DR by trained GPs were 82.8% and 86.2%, respectively, in comparison to the gold standard. The corresponding values for detecting any stage of diabetic macular edema (DME) were 63.5% and 96.6%, respectively.

CONCLUSIONS

Telescreening was an effective method for detecting DR in a Tehran suburb. This screening model demonstrated its capacity for promoting diabetic eye care services at the national level. However, the sensitivity for detecting DME needs to be improved by modifying the referral pathway and promoting the skill of GPs.

Factors influencing patient adherence with diabetic eye screening in rural communities: A qualitative study

Objective

Diabetic retinopathy remains the leading cause of blindness among working-age U.S. adults largely due to low screening rates. Rural populations face particularly greater challenges to screening because they are older, poorer, less insured, and less likely to receive guideline-concordant care than those in urban areas. Current patient education efforts may not fully address multiple barriers to screening faced by rural patients. We sought to characterize contextual factors affecting rural patient adherence with diabetic eye screening guidelines.

Research design and methods

We conducted semi-structured interviews with 29 participants (20 adult patients with type 2 diabetes and 9 primary care providers) in a rural, multi-payer health system. Both inductive and directed content analysis were performed.

Results

Factors influencing rural patient adherence with diabetic eye screening were categorized as environmental, social, and individual using the Ecological Model of Health. Major themes included limited access to and infrequent use of healthcare, long travel distances to obtain care, poverty and financial tradeoffs, trusting relationships with healthcare providers, family members’ struggles with diabetes, anxiety about diabetes complications, and the burden of diabetes management.

Conclusions

Significant barriers exist for rural patients that affect their ability to adhere with yearly diabetic eye screening. Many studies emphasize patient education to increase adherence, but current patient education strategies fail to address major environmental, social, and individual barriers. Addressing these factors, leveraging patient trust in their healthcare providers, and strategies targeted specifically to environmental barriers such as long travel distances (e.g. teleophthalmology) may fill crucial gaps in diabetic eye screening in rural communities.

Quantitative proteomics analysis of vitreous body from type 2 diabetic patients with proliferative diabetic retinopathy

Background

To compare the abundance of vitreous proteins between the patients with proliferative diabetic retinopathy (PDR) and idiopathic macular hole (IMH).

Methods

In this study, we performed mass spectrometry-based label-free quantitative proteomics analysis of vitreous samples from type 2 diabetic patients with PDR (n = 9) and IMH subjects (n = 9) and identified the abundance of 610 proteins.

Results

Out of 610 proteins, 64 proteins (Group A) were unique to PDR patients, while 212 proteins (Group B) could be identified in IMH vitreous only. Among the other 334 proteins that could be detected in both PDR and IMH eyes, 62 proteins differed significantly (p < 0.05, fold change > 2), which included 52 proteins (Group C) and 10 proteins (Group D) over- and under-expressed in PDR vitreous compared with the control. All proteins in these four groups were counted as significant proteins in our study.

Conclusions

We identified and quantified 610 proteins in total, which included 338 significant proteins in our study. Protein distribution analysis demonstrated a clear separation of protein expression in PDR and IMH. The protein function analysis illustrated that immunity and transport related proteins might be associated with PDR.

Clinical and Psychosocial Factors Influencing Retinal Screening Uptake Among Young Adults with Type 2 Diabetes

PURPOSE OF REVIEW

Young adults with type 2 diabetes (T2D, 18-39 years) experience early-onset and rapid progression of diabetic retinopathy (DR), the leading cause of vision loss for working age adults. Despite this, uptake of retinal screening, the crucial first step in preventing vision loss from DR, is low. The aim of this review is to summarize the clinical and psychosocial factors affecting uptake of retinal screening.

RECENT FINDINGS

Barriers include lack of diabetes-related symptoms, low personal DR risk perception, high rates of depression and diabetes-related distress, fatalism about inevitability of complications, time and financial constraints, disengagement with existing diabetes self-management services, and perceived stigma due to having a condition associated with older adults. Young adults with T2D are an under-researched population who face an accumulation of barriers to retinal screening. Tailored interventions that address the needs, characteristics, and priorities of young adults with T2D are warranted.

The Role of Teleophthalmology in the Management of Diabetic Retinopathy

The emergence of diabetes as a global epidemic is accompanied by the rise in diabetes‑related retinal complications. Diabetic retinopathy, if left undetected and untreated, can lead to severe visual impairment and affect an individual's productivity and quality of life. Globally, diabetic retinopathy remains one of the leading causes of visual loss in the working‑age population. Teleophthalmology for diabetic retinopathy is an innovative means of retinal evaluation that allows identification of eyes at risk for visual loss, thereby preserving vision and decreasing the overall burden to the health care system. Numerous studies worldwide have found teleophthalmology to be a reliable and cost‑efficient alternative to traditional clinical examinations. It has reduced barriers to access to specialized eye care in both rural and urban communities. In teleophthalmology applications for diabetic retinopathy, it is critical that standardized protocols in image acquisition and evaluation are used to ensure low image ungradable rates and maintain the quality of images taken. Innovative imaging technology such as ultrawide field imaging has the potential to provide significant benefit with integration into teleophthalmology programs. Teleophthalmology programs for diabetic retinopathy rely on a comprehensive and multidisciplinary approach with partnerships across specialties and health care professionals to attain wider acceptability and allow evidence‑based eye care to reach a much broader population.