Delayed follow-up in patients with diabetic retinopathy in South India: Social factors and impact on disease progression

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.

Insights into the systemic risk factors associated with diabetic retinopathy in the Indian population: A comprehensive systematic review and meta-analysis

Diabetic retinopathy (DR) is a predominant cause of vision impairment globally. Understanding risk factors is crucial for effective planning. The aim of this study is to comprehensively investigate the risk factors in the Indian population contributing to the increased incidence of DR, which is a potentially sight-threatening complication among diabetic individuals. A comprehensive literature search was done on PubMed, Embase, and Google Scholar databases for epidemiological studies reporting risk factors in the adult Indian population in the English language. Joanna Briggs Institute's (JBI) critical appraisal tools were used to assess the quality of the included studies. Analysis was performed using R studio. I2 statistic was used for the assessment of heterogeneity. Results are expressed as odds ratio (OR) and standardized mean difference (SMD) along with a 95% confidence interval (CI). Overall, 20 studies enrolling 4,12,421 patients with 1,04,104 DR-positive and 3,08,317 DR-negative adults were analyzed. Being male (OR: 1.38, 95% CI: 1.11-1.72), intake of insulin (OR: 2.05, 95% CI: 1.02-4.14), higher HbA1c levels (MD: 0.50, 95% CI: 0.06-0.94), higher random (MD: 0.32, 95% CI: 0.10-0.55), and fasting blood glucose levels (MD: 0.51, 95% CI: 0.10-0.93) were found to be significantly associated with increased risks of DR among diabetic patients, while age, body mass index, hypertension, lipid profile, and smoking status did not indicate any association with DR. Good glycemic control remains the most important modifiable risk factor to reduce the risk of progression of DR and vision loss.

Diabetic Retinopathy Screening at the Point of Care (DR SPOC): detecting undiagnosed and vision-threatening retinopathy by integrating portable technologies within existing services

INTRODUCTION

The aim of this study was to determine the prevalence of diabetic retinopathy (DR) in a low socioeconomic region of a high-income country, as well as determine the diagnostic utility of point-of-care screening for high-risk populations in tertiary care settings.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of patients with diabetes attending foot ulcer or integrated care diabetes clinics at two Western Sydney hospitals (n=273). DR was assessed using portable, two-field, non-mydriatic fundus photography and combined electroretinogram/ pupillometry (ERG). With mydriatic photographs used as the reference standard, sensitivity and specificity of the devices were determined. Prevalence of DR and vision-threatening diabetic retinopathy (VTDR) were reported, with multivariate logistic regression used to identify predictors of DR.

RESULTS

Among 273 patients, 39.6% had any DR, while 15.8% had VTDR, of whom 59.3% and 62.8% were previously undiagnosed, respectively. Non-mydriatic photography demonstrated 20.2% sensitivity and 99.5% specificity for any DR, with a 56.7% screening failure rate. Meanwhile, mydriatic photography produced high-quality images with a 7.6% failure rate. ERG demonstrated 72.5% sensitivity and 70.1% specificity, with a 15.0% failure rate. The RETeval ERG was noted to have an optimal DR cut-off score at 22. Multivariate logistic regression identified an eGFR of ≤29 mL/min/1.73 m2, HbA1c of ≥7.0%, pupil size of <4 mm diameter, diabetes duration of 5-24 years and RETeval score of ≥22 as strong predictors of DR.

CONCLUSION

There is a high prevalence of vision-threatening and undiagnosed DR among patients attending high-risk tertiary clinics in Western Sydney. Point-of-care DR screening using portable, mydriatic photography demonstrates potential as a model of care which is easily accessible, targeted for high-risk populations and substantially enhances DR detection.

Impact of Artificial Intelligence Assessment of Diabetic Retinopathy on Referral Service Uptake in a Low-Resource Setting: The RAIDERS Randomized Trial

PURPOSE

This trial was designed to determine if artificial intelligence (AI)-supported diabetic retinopathy (DR) screening improved referral uptake in Rwanda.

DESIGN

The Rwanda Artificial Intelligence for Diabetic Retinopathy Screening (RAIDERS) study was an investigator-masked, parallel-group randomized controlled trial.

PARTICIPANTS

Patients ≥ 18 years of age with known diabetes who required referral for DR based on AI interpretation.

METHODS

The RAIDERS study screened for DR using retinal imaging with AI interpretation implemented at 4 facilities from March 2021 through July 2021. Eligible participants were assigned randomly (1:1) to immediate feedback of AI grading (intervention) or communication of referral advice after human grading was completed 3 to 5 days after the initial screening (control).

MAIN OUTCOME MEASURES

Difference between study groups in the rate of presentation for referral services within 30 days of being informed of the need for a referral visit.

RESULTS

Of the 823 clinic patients who met inclusion criteria, 275 participants (33.4%) showed positive findings for referable DR based on AI screening and were randomized for inclusion in the trial. Study participants (mean age, 50.7 years; 58.2% women) were randomized to the intervention (n = 136 [49.5%]) or control (n = 139 [50.5%]) groups. No significant intergroup differences were found at baseline, and main outcome data were available for analyses for 100% of participants. Referral adherence was statistically significantly higher in the intervention group (70/136 [51.5%]) versus the control group (55/139 [39.6%]; P = 0.048), a 30.1% increase. Older age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.05; P < 0.0001), male sex (OR, 2.07; 95% CI, 1.22-3.51; P = 0.007), rural residence (OR, 1.79; 95% CI, 1.07-3.01; P = 0.027), and intervention group (OR, 1.74; 95% CI, 1.05-2.88; P = 0.031) were statistically significantly associated with acceptance of referral in multivariate analyses.

CONCLUSIONS

Immediate feedback on referral status based on AI-supported screening was associated with statistically significantly higher referral adherence compared with delayed communications of results from human graders. These results provide evidence for an important benefit of AI screening in promoting adherence to prescribed treatment for diabetic eye care in sub-Saharan Africa.

FOLLOW-UP ADHERENCE IN PATIENTS WITH NONPROLIFERATIVE DIABETIC RETINOPATHY PRESENTING TO AN OPHTHALMIC EMERGENCY DEPARTMENT

PURPOSE

To determine the rate of follow-up after emergent encounters for nonproliferative diabetic retinopathy and to identify patient or visit characteristics associated with follow-up adherence.

METHODS

A retrospective cohort study of patients presenting to an ophthalmic emergency department with nonproliferative diabetic retinopathy between May 2014 and December 2018 was conducted. Demographic and encounter data were gathered. Adherence to follow-up was defined as a completed encounter within 5 weeks of the recommended follow-up.

RESULTS

A total of 1,248 patients were included. The overall follow-up rate was 53%. Significantly decreased odds of follow-up adherence were associated with longer physician recommended follow-up intervals (odds ratio: 0.81, P < 0.001), longer interval to scheduled appointment (OR: 0.98, P < 0.001), commercial insurance (OR: 0.76, P = 0.01), and lack of any insurance (OR: 0.57, P < 0.01). Significantly increased odds were associated with a longer emergency department visit duration (OR: 1.002, P = 0.001), farther home distance (1.02, P < 0.01), increased likelihood of living in a higher income area (OR: 1.07, P = 0.04), greater NPDR severity (OR: 1.23, P < 0.01), Medicare (OR: 1.38, P = 0.04), presence of macular edema (OR: 1.66, P < 0.001), and worse vision (OR: 1.73, P < 0.001).

CONCLUSION

Patients presenting emergently with non-proliferative diabetic retinopathy are at high risk for follow-up nonadherence. Several patient and encounter characteristics were associated with follow-up adherence.

Profile of patients receiving intravitreal anti-vascular endothelial growth factor injections during COVID-19-related lockdown

Purpose:

The aim of this study was to analyze the impact on vision due to delay in presentation of patients requiring intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections, consequent to COVID-19-related travel restrictions.

Methods:

Data were collected retrospectively of patients who received anti-VEGF injections during four months of the COVID-19 pandemic. Visual acuities, indication for treatment were noted along with basic demographic characteristics.

Results:

Data were analyzed for 303 eyes of 263 patients. The indication for treatment was age-related macular degeneration (AMD) in 60 eyes (19.8%), while 162 eyes (53.5%) had Diabetic Macular Edema, 71 eyes (23.4%) had Retinal Vein Occlusion and 10 eyes (3.3%) had other diagnosis. The visual acuity in the treatment naïve eyes (Group A, n = 168) was significantly worse (P < 0.001) than those who presented for retreatment (Group B, n = 135). In Group B, there was a significant decline in vision for the entire cohort (P = 0.009) and those with AMD (P = 0.036). Those in Group B presented at a mean interval of 19.1 ± 10.6 (range, 4–64) weeks for retreatment.

Conclusion:

The COVID-19 pandemic has led to a delay in patients receiving anti-VEGF injections. The visual acuity is worse in both treatment naïve as well as those requiring retreatment. This could have long-term impact on vision of patients requiring this vision preserving treatment.

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

OBJECTIVE

Diabetic retinopathy is one of the leading causes of visual impairment after cataract and uncorrected refractive error. It has major public health implications globally, especially in countries such as India where the prevalence of diabetes is high. With timely screening and intervention, the disease progression to blindness can be prevented, but several barriers exist. As compliance to diabetic retinopathy screening in people with diabetes is very poor in India, this study was conducted to explore understanding of and barriers to diabetic retinopathy screening from the perspectives of patients and healthcare providers.

METHODS

Using qualitative methods, 15 consenting adult patients with diabetes were selected purposively from those attending a large tertiary care private eye hospital in southern India. Eight semistructured interviews were carried out with healthcare providers working in large private hospitals. All interviews were audiotaped, transcribed verbatim and analysed using the framework analytical approach.

RESULTS

Four themes that best explained the data were recognising and living with diabetes, care-seeking practices, awareness about diabetic retinopathy and barriers to diabetic retinopathy screening. Findings showed that patients were aware of diabetes but understanding of diabetic retinopathy and its complications was poor. Absence of symptoms, difficulties in doctor-patient interactions and tedious nature of follow-up care were some major deterrents to care seeking reported by patients. Difficulties in communicating information about diabetic retinopathy to less literate patients, heavy work pressure and silent progression of the disease were major barriers to patients coming for follow-up care as reported by healthcare providers.

CONCLUSIONS

Enhancing patient understanding through friendly doctor-patient interactions will promote trust in the doctor. The use of an integrated treatment approach including education by counsellors, setting up of patient support groups, telescreening approaches and use of conversation maps may prove more effective in the long run.

Impact of Socioeconomic Disadvantage and Diabetic Retinopathy Severity on Poor Ophthalmic Follow-Up in a Rural Vermont and New York Population

Objective

To investigate the impact of socioeconomic disadvantage and diabetic retinopathy severity on follow-up for vision care among people with diabetes mellitus (DM) residing in rural Vermont and northern New York State.

Methods

A retrospective chart review of people with DM who visited our academic eye clinic at least once between October 1, 2015, and March 31, 2016, was done. Of 1,466 unique patient visits, 500 were chosen for full chart review by simple random sampling. DM follow-up within 1 year was recommended for 331 adults. Data about prescribed and actual follow-up intervals were extracted. Regression models were used to identify factors associated with poor attendance at follow-up appointments.

Results

Sixty-eight [20.5%] patients had poor follow-up, defined as no ophthalmology visit within double the prescribed interval. Of these, 57 were not seen in follow-up by the end of study observation. Poor follow-up was greatest among socioeconomically disadvantaged patients, as defined by Medicaid enrollment (odds ratio [OR], 1.95; 95% CI, 1.07–3.56) in comparison to non-disadvantaged patients. Follow-up was better among those with moderate or worse diabetic retinopathy (OR, 0.38 95% CI, 0.20–0.70), and those with macular edema (OR, 0.19; 95% CI, 0.057–0.62).

Conclusion

Medicaid insurance and better diabetic retinopathy status were associated with worse follow-up among our predominantly rural population of patients. Patients who did not follow-up within double the recommended interval were unlikely to follow-up at all. Interventions are needed to target those at highest risk for poor follow-up.

Patients' perspectives on the barriers to referral after telescreening for diabetic retinopathy in communities

OBJECTIVE

To understand the referral completion and explore the associated barriers to the referral after telescreening for diabetic retinopathy (DR) among people with vision-threatening DR (VTDR).

RESEARCH DESIGN AND METHODS

All participants with VTDR after DR telescreening in the communities completed the self-reported questionnaires to assess referral completion and their perspectives on referral barriers. Sociodemographic characteristics and perceived barriers related to incomplete referrals were identified by conducting univariate analysis and multiple logistic regression model. The final model was then built to predict incomplete referral.

RESULTS

Of the 3362 participants, 46.1% had incomplete referral. Old age and lower education level showed significant association with incomplete referral. Almost all participants had at least one barrier during the referral process. Knowledge-related and attitude-related barriers, including 'Too old to want any more treatment', 'Difficulty in getting time to referral', 'No serious illness requiring treatment at present', 'My eyes are okay', 'Distrust the recommended hospital' and 'Have not been diagnosed or treated before', and logistics-related barrier 'Mobility or transportation difficulties' showed significant association with incomplete referral.

CONCLUSIONS

The issue of incomplete referral after DR telescreening is serious among individuals with VTDR, particularly in the elder and low education level population. The negativity of knowledge-related and attitude-related factors might be more prominent than logistic barriers in predicting incomplete referral. Therefore, new strategies to improve the compliance with referral assist in optimizing the referral accessibility, and the ongoing educational support to improve the awareness of disease and increase the effectiveness of physician-patient communication.

Diabetic patients in Saudi Arabia: The evaluation of glycemic control measures based on emergency department utilization and the percentages of adherence to the recommended follow-ups for microvascular complications

Objectives:

To determine the association between emergency department (ED) visits, glycemic control and the quality of preventive diabetes care among diabetic patients in a Saudi community.

Methods:

This study was an observational, cross-sectional study that collected data through interview-based surveys between February and April 2017. Data were collected from 530 diabetic patients in the diabetes clinics at King Saud Medical City, the tertiary center of Riyadh, Kingdom of Saudi Arabia.

Results:

This study found statistically significant relationships (p<0.05) between ED visits and patient age, the glycated hemoglobin (HbA1c) and education level. Emergency department visits increased by 43% for each unit of increase in HbA1c (odds ratio [OR]=1.43, 95% confidence interval (CI)=1.26-1.62). Graduating from high school decreased the odds of visiting the ED by 43% (OR=0.57, 95% CI=0.34-0.94). Most of the participants were not followed for possible microvascular complications; the majority did not visit nephrology (96.2%), ophthalmology (78.3%) and neurology (97.9%) clinics within the 12 months prior to the interviews.

Conclusion:

Emergency department visits can indicate poor glycemic control in diabetic patients. Additionally, the current practices of preventive diabetes care in Saudi Arabia are not sufficient, according to the diabetic standards of care recommended by the American Diabetes Association.

Sensitivity and Specificity of Smartphone-Based Retinal Imaging for Diabetic Retinopathy: A Comparative Study

PURPOSE

To determine the sensitivity and specificity of a smartphone-based fundus camera, the Remidio Fundus on Phone (FOP; Remidio Innovative Solutions Pvt. Ltd., Bengaluru, India) in detecting diabetic retinopathy (DR) compared with a conventional tabletop fundus camera and clinical examination.

DESIGN

Cross-sectional, single-site, instrument validation study.

PARTICIPANTS

Consecutive patients with diabetes who had no DR (n = 55 eyes), mild to moderate nonproliferative diabetic retinopathy (NPDR; n = 70 eyes), severe NPDR (n = 46 eyes), proliferative diabetic retinopathy (PDR; n = 62 eyes), and diabetic macular edema (DME; n = 44 eyes).

METHODS

All participants underwent a dilated examination to determine the grade of DR. Then all participants had mydriatic 45° fundus photographs obtained from three fields of view with the Remidio FOP and a Topcon tabletop fundus camera (Topcon Medical Systems, Inc., Oakland, NJ). Two masked retina specialists graded images for DR and DME, using National Health Service guidelines as well as for image quality using predefined criteria.

MAIN OUTCOME MEASURE

Sensitivity and specificity of the Remidio FOP for the detection of any DR compared to clinical examination.

RESULTS

One hundred thirty-five subjects (233 eyes) were recruited for the study. Compared with the reference clinical examination, using images from the Remidio FOP, graders 1 and 2 reported a sensitivity of 93.1% (95% confidence interval [CI] = 88.3-96.4) and 94.3% (95% CI = 89.7-97.2) and a specificity of 89.1% (95% CI = 68.2-92.2) and 94.5% (95% CI = 84.9-98.9), respectively, in identifying any DR (κ = 0.55; 95% CI = 0.50-0.57). With images from the Topcon camera, graders reported similar sensitivities and specificities with marginally better agreement (κ = 0.68; 95% CI = 0.67-0.73). The sensitivity of detecting DR gradually increased from R1 to R3 disease using both cameras. Both graders classified significantly fewer images as "ungradable" (2.6%-4.3% for Topcon vs. 1.7%-2.1% for Remidio FOP) and more images as excellent from the Remidio FOP (59%-74%) than the Topcon device (52%-61%).

CONCLUSIONS

The Remidio FOP device was found to have high sensitivity and specificity for the detection of any grade of DR with good agreement between graders. The rate of ungradable images was acceptably low and image quality was marginally better with the Remidio FOP.

Factors Associated with Non-compliance for Diabetic Retinopathy Follow-up in an Urban Safety-Net Hospital

PURPOSE

Diabetic retinopathy (DR) is the leading cause of preventable blindness in working-aged adults, and compliance in ophthalmic follow-up appointments is critical to prevent vision loss. However, barriers to follow-up care have not been well studied, especially in socio-economically disadvantaged groups. We investigated the risk factors for non-compliance to DR follow-up appointments in a safety-net county hospital.

METHODS

Two hundred and nine patients who were treated for DR at the Zuckerberg San Francisco General Hospital retina clinic between 1 July 2015 and 30 January 2016 were enrolled in the study. Multivariate logistic regression analysis of demographic and medical information was used to determine independent risk factors for non-compliance to DR follow-up appointments.

RESULTS

The mean patient age was 58 years. Sixty-three percent (132/209) of patients were male; the mean haemoglobin A1c level was 8.5 (SD 0.14). Forty-six percent (97/209) of patients attended <80% of their DR follow-up appoinments. Independent risk factors for non-compliance after multivariate logistic regression analysis were diabetic foot involvement [OR: 2.40, 95% CI: (1.04-5.55)] and foot/kidney involvement [OR: 3.79 (1.35-10.5)], history of major depressive disorder (MDD) [OR: 2.11 (1.05-4.26), and having Medi-Cal [OR: 5.01 (2.00-12.5)] or SF Health insurance [OR: 6.79 (2.14-21.5)].

CONCLUSIONS AND RELEVANCE

In conclusion, this is the first study to identify diabetic end organ damage and MDD as independent risk factors for non-compliance in DR follow-up appointments. It is important that health care providers identify these patient subsets and increase efforts to more deliberately encourage follow-up in these high-risk patient groups for DR.

Diabetic Retinopathy in the Asia-Pacific

Diabetic retinopathy (DR), the most common complication of diabetes mellitus, is the leading cause of new cases of blindness in middle-aged and elderly in the Asia-Pacific. It has been estimated that 51% of all those with blindness due to DR globally (n = 424,400) and 56% of those with visual impairment due to DR (2.1 million) come from the Asia-Pacific. Prevalence of DR among those with diabetes ranged from 10% in India to 43% in Indonesia within the Asia-Pacific. Awareness of DR among persons with diabetes ranged from 28% to 84%. Most common modifiable risk factors for DR in the Asia-Pacific were hyperglycemia, blood pressure, dyslipidemia, and obesity. Implementation of systematic screening programs for DR and advancement in telemedicine screening methods have increased patient coverage and cost-effectiveness, though there are still numerous factors impeding screening uptake in the low-middle income regions of the Asia-Pacific. Management and treatment of DR in the Asia-Pacific is mainly limited to traditional laser retinopexy, but it is suboptimal despite new clinical approaches such as use of intravitreal anti.vascular endothelial growth factor and steroids due to limited resources. Further research and data are required to structure a more cost-effective public healthcare program and more awareness-building initiatives to increase the effectiveness of DR screening programs.