Patient and provider perspectives on barriers to screening for diabetic retinopathy: an exploratory study from southern India

Exploring patient and health care provider perspectives on barriers to diabetic retinopathy screening in public health facilities in North India

Diabetic retinopathy (DR), a prevalent microvascular complication of diabetes mellitus (DM), can be prevented with early detection and timely intervention. DR is asymptomatic in its early stages, highlighting the importance of screening for accurate referral and effective management. Multiple barriers impede access to diabetic retinopathy screening (DRS), creating significant public health challenges in regions with high DM prevalence. This study explores the perspectives of people with DM (PwDM) and healthcare providers (HCP) on these barriers. A qualitative study using in-depth interviews (IDI) was conducted between October 2022 and January 2023 in Punjab and Chandigarh. Through purposive sampling, IDIs were conducted with 7 PwDM and 19 HCPs, including retina specialists, ophthalmologists, optometrists, medical officers (MO), Community Health Officers (CHO), and ASHA workers from various public health facilities. A semi-structured topic guide facilitated the interviews, and thematic analysis was applied, utilizing the healthcare access barrier (HCAB) model as a framework. The study identified financial barriers due to insurance unawareness and employment constraints. Structural challenges included insufficient DRS infrastructure, untrained staff, the need for accompaniment, and limited access to screening sites. Limited awareness and misconceptions about DR characterized cognitive barriers, while psychological barriers involved mistrust of the health system, anxiety, and frustration from low vision. Addressing these issues is essential to improve DRS uptake and eye health outcomes. Managing diabetes and VTDR is challenging, highlighting the need for community-level DRS. Enhancing DR awareness and promoting public health insurance benefits are crucial for overcoming barriers and improving screening rates.

How to Improve Attendance for Diabetic Retinopathy Screening: Ideas and Perspectives From People With Type 2 Diabetes and Health-care Professionals

OBJECTIVES

Our aim in this study was to identify how to improve diabetic retinopathy screening from the perspectives of people with type 2 diabetes and health-care professionals and to elicit their thoughts on initiatives to increase attendance.

METHODS

A total of 38 semistructured interviews were conducted with people with type 2 diabetes (n=20), general practitioners (n=10), and ophthalmic staff (n=8). The interviews examined ideas for improving screening and elicited feedback on 3 initiatives: getting a fixed appointment; same-day screening; and outsourcing screening to general practice, including the use of artificial intelligence (AI). Data analysis was guided by content analysis approaches.

RESULTS

Ideas for improving screening were centred around reducing the inconvenience of attendance, making appointment scheduling easier, and improving health-care professionals' communication. Participants recognized the potential benefits of the initiatives but expressed important reservations to consider. Concerns included the following: that a fixed appointment would cause less active patient involvement and negatively affect attendance; that same-day screening may result in loss of patient-provider communication; that people with type 2 diabetes may be uneasy with having the screening performed outside the eye clinic; and that health-care professionals were concerned about the finances, validity, and examination quality associated with outsourcing screening and using AI.

CONCLUSIONS

Participants' thoughts on how to improve diabetic retinopathy screening should be seen as starting points for potential future interventions. Although outsourcing screening and the use of AI have gained traction, our study indicates that the target population has reservations that are important to consider in future development and implementation of such strategies.

A qualitative study to understand the barriers and enablers of access to diabetic screening services in Nigeria

Nigeria in working to redefine its health care system's approach to diabetic retinopathy (DR) screening services needs to reduce obstacles and highlight the enablers to services provision. Due to the increased prevalence of diabetes, this has become increasingly necessary. A qualitative study examining the perceptions, practices, and experiences of Nigerian DR healthcare practitioners (HCPs) in relation to the facilitators and barriers of access to DR screening services. Mode of participant recruitment was on-line through e-mails by using snowballing method. In-depth interviews were used to acquire information from 6 DR HCPs (all ophthalmologists) at three eye centers in the three geo-political areas of Nigeria and at international center for eye health (ICEH) in London via on-line Microsoft teams. Thematic analysis was used for data analysis and all the steps applied to the data analysis process. Non-systematic screening, poverty, poor transport systems, insecurity, and poor motivation are key barriers to DR screening access in Nigeria while enablers include government participation through subsidized costs and remuneration of workers. Screening in communities, and using low-cost techniques are key to enable access. Other enablers include collaboration and integration between endocrinology and ocular units in terms of referrals, information sharing, use of intermediary carers, technology, man-power and health resource provision including low- cost services. A dearth of personnel, screening technologies, and resources, have an impact on the effectiveness of the DR screening services in Nigeria as well as social and individual factors, such as the cost of the services and national insecurity.

Recommendations for initial diabetic retinopathy screening of diabetic patients using large language model-based artificial intelligence in real-life case scenarios

PURPOSE

To study the role of artificial intelligence (AI) to identify key risk factors for diabetic retinopathy (DR) screening and develop recommendations based on clinician and large language model (LLM) based AI platform opinions for newly detected diabetes mellitus (DM) cases.

METHODS

Five clinicians and three AI applications were given 20 AI-generated hypothetical case scenarios to assess DR screening timing. We calculated inter-rater agreements between clinicians, AI-platforms, and the "majority clinician response" (defined as the maximum number of identical responses provided by the clinicians) and "majority AI-platform" (defined as the maximum number of identical responses among the 3 distinct AI). Scoring was used to identify risk factors of different severity. Three, two, and one points were given to risk factors requiring screening immediately, within a year, and within five years, respectively. After calculating a cumulative screening score, categories were assigned.

RESULTS

Clinicians, AI platforms, and the "majority clinician response" and "majority AI response" had fair inter-rater reliability (k value: 0.21-0.40). Uncontrolled DM and systemic co-morbidities required immediate screening, while family history of DM and a co-existing pregnancy required screening within a year. The absence of these risk factors required screening within 5 years of DM diagnosis. Screening scores in this study were between 0 and 10. Cases with screening scores of 0-2 needed screening within 5 years, 3-5 within 1 year, and 6-12 immediately.

CONCLUSION

Based on the findings of this study, AI could play a critical role in DR screening of newly diagnosed DM patients by developing a novel DR screening score. Future studies would be required to validate the DR screening score before it could be used as a reference in real-life clinical situations.

CLINICAL TRIAL REGISTRATION

Not applicable.

Patient, family member, and health care provider perspective on barriers and facilitators to diabetic retinopathy screening in Thailand: A qualitative study

OBJECTIVES

Diabetic retinopathy (DR) can cause significant visual impairment which can be largely avoided by early detection through proper screening and treatment. People with DR face a number of challenges from early detection to treatment. The aim of this study was to investigate factors that influence DR screening in Thailand and to identify barriers to follow-up compliance from patient, family member, and health care provider (HCP) perspectives.

METHODS

A total of 15 focus group discussions (FGDs) were held, each with five to twelve participants. There were three distinct stakeholders: diabetic patients (n = 47) presenting to a diabetic retinopathy clinic in Thailand, their family members (n = 41), and health care providers (n = 34). All focus group conversations were transcribed verbatim. Thematic analysis was used to examine textual material.

RESULTS

Different themes emerged from the FGD on knowledge about diabetes, self-care behaviors of diabetes mellitus (DM), awareness about DR, barriers to DR screening, and the suggested solutions to address those barriers. Data showed lower knowledge and awareness about diabetes and DR in both patients and family members. Long waiting times, financial issues, and lack of a person to accompany appointments were identified as the major deterrents for attending DR screening. Family support for patients was found to vary widely, with some patients reporting to have received adequate support while others reported having received minimal support. Even though insurance covered the cost of attending diabetes/DR screening program, some patients did not show up for their appointments.

CONCLUSION

Patients need to be well-informed about the asymptomatic nature of diabetes and DR. Communication at the patient level and shared decision-making with HCPs are essential. Family members and non-physician clinicians (such as diabetes nurses, diabetes educators, physician assistants) who work in the field of diabetes play a vital role in encouraging patients to attend diabetes and DR follow-ups visits regularly.

'I don`t need an eye check-up'. A qualitative study using a behavioural model to understand treatment-seeking behaviour of patients with sight threatening diabetic retinopathy (STDR) in India

Diabetic Retinopathy (DR) affects about 27% of patients with diabetes globally. According to the World Health Organization (WHO), DR is responsible for37 million cases of blindness worldwide. The SMART India study (October 2020-August 2021) documented the prevalence of diabetes, and DR in people40 years and above across ten Indian states and one Union Territory by conducting community screening. About 90% of people with sight threatening diabetic retinopathy (STDR) were referred from this screening study to eye hospitals for management, but failed to attend. This qualitative study, a component of the SMART India study, explored perceptions of referred patients regarding their susceptibility to eye related problems in diabetes and the benefits/barriers to seeking care. Perceived barriers from the viewpoint of ophthalmologists were also explored. Guided by the Health Beliefs Model (HBM), 20 semi structured interviews were carried out with consenting patients diagnosed with STDR. They included nine patients who had sought care recruited from eight eye hospitals across different states in India and eleven patients who did not seek care. Eleven ophthalmologists also participated. Four themes of analysis based on the HBM were, understanding of DR and its treatment, perceptions about susceptibility and severity, perceived barriers, perceived benefits and cues to action. Findings revealed poor understanding of the effects of diabetes on the eye contributing to low risk perception. Prohibitive costs of treatment, difficulties in accessing care services and poor social support were major barriers to seeking care. Ophthalmologists acknowledged that the absence of symptoms and the slow progressive nature of the disease deluded patients into thinking that they were fine. The study attests to the need for greater health literacy around diabetes, DR and STDR; for making treatment more affordable and accessible and for the development of effective patient education and communication strategies towards increasing compliance.

Validation of diagnostic accuracy of retinal image grading by trained non-ophthalmologist grader for detecting diabetic retinopathy and diabetic macular edema

PURPOSE

To validate the fundus image grading results by a trained grader (Non-ophthalmologist) and an ophthalmologist grader for detecting diabetic retinopathy (DR) and diabetic macular oedema (DMO) against fundus examination by a retina specialist (gold standard).

METHODS

A prospective diagnostic accuracy study was conducted using 2002 non-mydriatic colour fundus images from 1001 patients aged ≥40 years. Using the Aravind Diabetic Retinopathy Evaluation Software (ADRES) images were graded by both a trained non-ophthalmologist grader (grader-1) and an ophthalmologist (grader-2). Sensitivity, specificity, positive predictive value and negative predictive value were calculated for grader-1 and grader-2 against the grading results by an independent retina specialist who performed dilated fundus examination for every study participant.

RESULTS

Out of 1001 patients included, 42% were women and the mean ± (SD) age was 55.8 (8.39) years. For moderate or worse DR, the sensitivity and specificity for grading by grader-1 with respect to the gold standard was 66.9% and 91.0% respectively and the same for the ophthalmologist was 83.6% and 80.3% respectively. For referable DMO, grader-1 and grader-2 had a sensitivity of 74.6% and 85.6% respectively and a specificity of 83.7% and 79.8% respectively.

CONCLUSIONS

Our results demonstrate good level of accuracy for the fundus image grading performed by a trained non-ophthalmologist which was comparable with the grading by an ophthalmologist. Engaging trained non-ophthalmologists potentially can enhance the efficiency of DR diagnosis using fundus images. Further study with multiple non-ophthalmologist graders is needed to verify the results and strategies to improve agreement for DMO diagnosis are needed.

Compliance with follow-up in patients with diabetic macular edema: Eye care center vs. diabetes care center

Purpose

The study was conducted to compare the compliance to intravitreal injection treatment and follow-up in patients with center-involving diabetic macular edema (CI-DME) and treatment outcomes between a tertiary eye care facility and a tertiary diabetes care center.

Methods

A retrospective review was conducted on treatment naïve DME patients who had received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections in 2019. Participants were people with type 2 diabetes who were under regular care at the eye care center or the diabetes care center in Chennai. The outcome measures were noted at months 1, 2, 3, 6, and 12.

Results

A review of 136 patients treated for CI-DME (72 from the eye care center and 64 from a diabetes care center) was carried out. The severity of diabetic retinopathy (DR) was similar in both centers. There was no statistically significant (P > 0.05) difference in the choice of initial intravitreal drug in the two centers. At 12-month follow-up, only 29.16% came for a follow-up in the eye center vs. 76.56% in a diabetes care center (P = 0.000). The multivariate logistic regression showed increasing age was associated with non-compliance in both the groups (eye care center: odds ratio [OR] 0.91; 95% confidence interval [CI] 0.82-1.21; P = 0.044) and diabetes care center (OR 1.15; 95% CI 1.02-1.29; P = 0.020).

Conclusion

The follow-up rate between eye care and diabetic care center with DME showed a significant disparity. By providing comprehensive diabetes care for all complications under one roof, compliance with follow-up can be improved in people with DME.

Barriers related to self-care management among people with diabetes mellitus- A narrative review

Diabetes is a challenging disease that is considered to be hard to live with as it encompasses a lot of restrictions, lifestyle and behavioural modifications. Self-care management behaviors are very much essential to control glycaemic values and future complications. Although an import aspect leading to positive health outcomes among diabetic patients, diabetes self-care management is usually is a complex process.  This narrative review summates barriers related to self-care management among people with diabetes. The literature was searched through databases like PubMed and google scholar with help of keywords and MeSH terminologies. Furthermore, selected articles reference list was also screened. It is concluded that self-care management in diabetes mellitus is often surrounded by many barriers. Deficiency of environmental resources and assisted strategies, poor awareness regarding self-care skills, lack of motivation and financial constraints are the major barriers faced by people with diabetes mellitus. Endeavour to withdraw barriers are prime in aiding people living with diabetes which will help to improve their quality of life and to attain positive results.

Improving equity, efficiency and adherence to referral in Pakistan's eye health programmes: Pre- and post-pandemic onset

Background

Over one billion people worldwide live with avoidable blindness or vision impairment. Eye Health Programmes tackle this by providing screening, primary eye care, refractive correction, and referral to hospital eye services. One point where patients can be lost in the treatment journey is adherence to hospital referral.

Context

Peek Vision's software solutions have been used in Pakistan with the goal of increasing eye health programme coverage and effectiveness. This involved collaboration between health system stakeholders, international partners, local community leaders, social organizers and “Lady Health Workers”.

Results

From the beginning of the programmes in November 2018, to the end of December 2021, 393,759 people have been screened, 26% of whom (n = 101,236) needed refractive services or secondary eye care, and so were referred onwards to the triage centers or hospital services. Except for a short period affected heavily by COVID-19 pandemic, the programmes reached an increasing number of people over time: screening coverage improved from 774 people per month to over 28,300 people per month. Gathering and discussing data regularly with stakeholders and implementers has enabled continuous improvement to service delivery. The quality of screening and adherence to hospital visits, gender balance differences and waiting time to hospital visits were also improved. Overall attendance to hospital appointments improved in 2020 compared to 2019 from 45% (95% CI: 42–48%) to 78% (95% CI: 76–80%) in women, and from 48% (95% CI: 45–52%) to 70% (95% CI: 68–73%) in men. These patients also accessed treatment more quickly: 30-day hospital referral adherence improved from 12% in 2019 to 66% in 2020. This approach helped to utilize refractive services more efficiently, reducing false positive referrals to triage from 10.6 to 5.9%. Hospital-based services were also utilized more efficiently, as primary eye care services and refractive services were mainly delivered at the primary healthcare level.

Discussion

Despite various challenges, we demonstrate how data-driven decisions can lead to health programme systems changes, including patient counseling and appointment reminders, which can effectively improve adherence to referral, allowing programmes to better meet their community's needs.

Non-mydriatic fundus photography as an alternative to indirect ophthalmoscopy for screening of diabetic retinopathy in community settings: a comparative pilot study in rural and tribal India

OBJECTIVES

The impending and increasing prevalence of diabetic retinopathy (DR) in India has necessitated a need for affordable and valid community outreach screening programme for DR, especially in rural and far to reach indigenous local communities. The present study is a pilot study aimed to compare non-mydriatic fundus photography with indirect ophthalmoscopy for its utilisation as a feasible and logistically convenient screening modality for DR in an older age, rural, tribal population in Western India.

DESIGN AND SETTING

This community-based, cross-sectional, prospective population study was a part of a module using Rapid Assessment of Avoidable Blindness and DR methodology in 8340 sampled participants with ≥50 years age. In this study, the diabetics identified were screened for DR using two methods: non-mydriatic fundus photography on the field by trained professionals, that were then graded by a retina specialist at the base hospital and indirect ophthalmoscopy by expert ophthalmologists in the field with masking of each other's findings for its utility and comparison.

RESULTS

The prevalence of DR, sight threatening DR and maculopathy using indirect ophthalmoscopy was found to be 12.1%, 2.1% and 6.6%, respectively. A fair agreement (κ=0.48 for DR and 0.59 for maculopathy) was observed between both the detection methods. The sensitivity and specificity of fundus photographic evaluation compared with indirect ophthalmoscopy were found to be 54.8% and 92.1% (for DR), 60.7% and 90.8% (for any DR) and 84.2% and 94.8% (for only maculopathy), respectively.

CONCLUSION

Non-mydriatic fundus photography has the potential to identify DR (any retinopathy or maculopathy) in community settings in Indian population. Its utility as an affordable and logistically convenient cum practical modality is demonstrable. The sensitivity of this screening modality can be further increased by investing in better resolution cameras, capturing quality images and training and validation of imagers.

TRIAL REGISTRATION NUMBER

CTRI/2020/01/023025; Clinical Trial Registry, India (CTRI).

Diabetic retinopathy service delivery and integration into the health system in Pakistan-Findings from a multicentre qualitative study

This paper is based on qualitative research carried out in a diabetic retinopathy (DR) programme in three districts of Pakistan. It analyses the organisation and delivery of DR services and the extent to which the interventions resulted in a fully functioning integrated approach to DR care and treatment. Between January and April 2019, we conducted 14 focus group discussions and 37 in-depth interviews with 144 purposively selected participants: patients, lady health workers (LHWs) and health professionals. Findings suggest that integration of services was helpful in the prevention and management of DR. Through the efforts of LHWs and general practitioners, diabetic patients in the community became aware of the eye health issues related to uncontrolled diabetes. However, a number of systemic pressure points in the continuum of care seem to have limited the impact of the integration. Some components of the intervention, such as a patient tracking system and reinforced interdepartmental links, show great promise and need to be sustained. The results of this study point to the need for action to ensure inclusion of DR on the list of local health departments’ priority conditions, greater provision of closer-to-community services, such as mobile clinics. Future interventions will need to consider the complexity of adding diabetic retinopathy to an already heavy workload for the LHWs.

Various models for diabetic retinopathy screening that can be applied to India

The increased burden of diabetes in India has resulted in an increase in the complications of diabetes including sight-threatening diabetic retinopathy (DR). Visual impairment and blindness due to DR can be prevented by early detection and management of sight-threatening DR. Life-long evaluation by repetitive retinal screening of people with diabetes is an essential strategy as DR has an asymptomatic presentation. Fundus examination by trained ophthalmologists and fundus photography are established modes of screening. Various modes of opportunistic screening have been followed in India. Hospital-based screening (diabetes care/eye care) and community-based screening are the common modes. Tele-ophthalmology programs based on retinal imaging, remote interpretation, and grading of DR by trained graders/ophthalmologists have facilitated greater coverage of DR screening and enabled timely referral of those with sight-threatening DR. DR screening programs use nonmydriatic or mydriatic fundus cameras for retinal photography. Hand-held/smartphone-based fundus cameras that are portable, less expensive, and easy to use in remote places are gaining popularity. Good retinal image quality and accurate diagnosis play an important role in reducing unnecessary referrals. Recent advances like nonmydriatic ultrawide field fundus photography can be used for DR screening, though likely to be more expensive. The advent of artificial intelligence and deep learning has raised the possibility of automated detection of DR. Efforts to increase the awareness regarding DR is essential to ensure compliance to regular follow-up. Cost-effective sustainable models will ensure systematic nation-wide DR screening in the country.