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Pelayo C, Mora Pinzón M, Lock LJ, Fowlkes C, Stevens CL, Hoang J, Garcia JL, Jacobson NA, Channa R, Liu Y. Factors Influencing Eye Screening Adherence Among Latinx Patients With Diabetes: A Qualitative Study. Transl Vis Sci Technol 2023; 12:8. [PMID: 38060234 PMCID: PMC10709803 DOI: 10.1167/tvst.12.12.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023] Open
Abstract
Purpose Latinx populations have the highest rates of visual impairment and blindness of any ethnic group in the United States, with most cases of diabetic retinopathy remaining undiagnosed. We aimed to identify factors influencing adherence with diabetic eye screening in Latinx communities. Methods We conducted semistructured individual interviews with adult Latinx patients in Dane County, WI. Interviews were transcribed verbatim, translated from Spanish to English, and analyzed using QSR NVivo software. We performed both inductive open coding and deductive coding using the National Institute on Minority Health and Health Disparities Research Framework, as well as the Campbell and Egede Model. Results All participants (n = 20) self-identified as Latinx and were diagnosed with type 2 diabetes. The mean age was 61.5 years (range 33-79 years). Most participants were uninsured (60%), self-reported low or moderate health literacy (60%), and preferred to speak Spanish during their clinic appointments (75%). Individual-level barriers to diabetic eye screening included limited eye health literacy, lack of insurance coverage, and low self-efficacy with diabetes management. Health system-level facilitators included a recommendation to obtain eye screening from a primary care provider and the use of nonwritten forms of patient education. Community-level barriers included social isolation, concerns about inconveniencing others, machismo, and immigration status. Conclusions We identified several health system- and community-level factors, in addition to individual-level factors, influencing adherence with diabetic eye screening in Latinx communities. Translational Relevance Strategies addressing these factors may enhance the effectiveness of interventions to prevent blindness from diabetes and contribute to advancing health equity in Latinx communities.
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Affiliation(s)
- Christian Pelayo
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Maria Mora Pinzón
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Loren J. Lock
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christiana Fowlkes
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Chloe L. Stevens
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Johnson Hoang
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Juan L. Garcia
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nora A. Jacobson
- Institute for Clinical and Translational Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Pelayo C, Hoang J, Mora Pinzón M, Lock LJ, Fowlkes C, Stevens CL, Jacobson NA, Channa R, Liu Y. Perspectives of Latinx Patients with Diabetes on Teleophthalmology, Artificial Intelligence-Based Image Interpretation, and Virtual Care: A Qualitative Study. Telemed Rep 2023; 4:317-326. [PMID: 37908628 PMCID: PMC10615055 DOI: 10.1089/tmr.2023.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/02/2023]
Abstract
Background Latinx populations in the United States bear a disproportionate burden of diabetic eye disease. Teleophthalmology with and without artificial intelligence (AI)-based image interpretation are validated methods for diabetic eye screening, but limited literature exists on patient perspectives. This study aimed at understanding the perspectives of Latinx patients with diabetes on teleophthalmology, AI-based image interpretation, and general virtual care to prevent avoidable blindness in this population. Methods We conducted semi-structured, individual interviews with 20 Latinx patients with diabetes at an urban, federally qualified health center in Madison, WI. Interviews were transcribed verbatim, professionally translated from Spanish to English, and analyzed using both inductive open coding and deductive coding. Results Most participants had no prior experience with teleophthalmology but did have experience with virtual care. Participants expressed a preference for teleophthalmology compared with traditional in-person dilated eye exams but were willing to obtain whichever method of screening was recommended by their primary care clinician. They also strongly preferred having human physician oversight in image review compared with having images interpreted solely using AI. Many participants preferred in-person clinic visits to virtual health care due to the ability to have a more thorough physical exam, as well as for improved non-verbal communication with their clinician. Discussion Leveraging primary care providers' recommendations, human oversight of AI-based image interpretation, and improving communication may enhance acceptance and utilization of teleophthalmology, AI, and virtual care by Latinx patients. Conclusions Understanding Latinx patient perspectives may contribute toward the development of more effective telemedicine interventions to enhance health equity in Latinx communities.
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Affiliation(s)
- Christian Pelayo
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Johnson Hoang
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Maria Mora Pinzón
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Loren J. Lock
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Christiana Fowlkes
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Chloe L. Stevens
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nora A. Jacobson
- Institute for Clinical and Translational Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- School of Nursing, Madison, Wisconsin, USA
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Luo S, Lock LJ, Xing B, Wingelaar M, Channa R, Liu Y. Factors Associated with Follow-Up Adherence After Teleophthalmology for Diabetic Eye Screening Before and During the COVID-19 Pandemic. Telemed J E Health 2023; 29:1171-1178. [PMID: 36576981 PMCID: PMC10440654 DOI: 10.1089/tmj.2022.0391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/16/2022] [Indexed: 12/29/2022] Open
Abstract
Abstract Background: Follow-up adherence with in-person care is critical for achieving improved clinical outcomes in telemedicine screening programs. We sought to quantify the impact of the COVID-19 pandemic upon follow-up adherence and factors associated with follow-up adherence after teleophthalmology for diabetic eye screening. Methods: We retrospectively reviewed medical records of adults screened in a clinical teleophthalmology program at urban and rural primary care clinics between May 2015 and December 2020. We defined follow-up adherence as medical record documentation of an in-person eye exam within 1 year among patients referred for further care. Regression models were used to identify factors associated with follow-up adherence. Results: Among 948 patients, 925 (97.6%) had health insurance and 170 (17.9%) were referred for follow-up. Follow-up adherence declined from 62.7% (n = 52) prepandemic to 46.0% (n = 40) during the pandemic (p = 0.04). There was a significant decline in follow-up adherence among patients from rural (p < 0.001), but not urban (p = 0.72) primary care clinics. Higher median household income (odds ratio [OR] 1.68, 95% confidence interval [CI]: 1.19-2.36) and obtaining care from an urban clinic (OR 5.29, 95% CI: 2.09-13.43) were associated with greater likelihood of follow-up during the pandemic. Discussion: Follow-up adherence remains limited after teleophthalmology screening even in a highly insured patient population, with a further decline observed during the COVID-19 pandemic. Our results suggest that rural patients and those with lower socioeconomic status experienced greater barriers to follow-up eye care during the COVID-19 pandemic. Conclusions: Addressing barriers to in-person follow-up care is needed to effectively improve clinical outcomes after teleophthalmology screening.
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Affiliation(s)
- Susan Luo
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Loren J. Lock
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Bohan Xing
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Maxwell Wingelaar
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Lock LJ, Channa R, Brennan MB, Cao Y, Liu Y. Effect of health system on the association of rurality and level of disadvantage with receipt of diabetic eye screening. BMJ Open Diabetes Res Care 2022; 10:10/6/e003174. [PMID: 36517109 PMCID: PMC9756146 DOI: 10.1136/bmjdrc-2022-003174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/04/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Rural versus urban disparities have been observed in diabetic eye screening, but whether the level of disadvantage in rural versus urban areas is related to these disparities is unclear. Our goal was to determine the role of level of disadvantage in explaining the effect of health systems on rural and urban disparities in diabetic eye screening. RESEARCH DESIGN AND METHODS This is a retrospective cohort study using an all-payer, state-wide claims database covering over 75% of Wisconsin residents. We included adults with diabetes (18-75 years old) who had claims billed throughout the baseline (2012-2013) and measurement (2013-2014) years. We performed multivariable regressions to assess factors associated with receipt of diabetic eye screening. The primary exposure was the primary care clinic's combined level of rurality and disadvantage. We adjusted for the health system as well as patient-level variables related to demographics and comorbidities. Health system was defined as an associated group of physicians and/or clinics. RESULTS A total of 118 707 adults with diabetes from 698 primary care clinics in 143 health systems met the inclusion criteria. Patients from urban underserved clinics were less likely to receive screening than those from rural underserved clinics before adjusting for health system in the model. After adjusting for health system fixed effects, however, the directionality of the relationship between clinic rurality and screening reversed: patients from urban underserved clinics were more likely to receive screening than those from rural underserved clinics. Similar findings were observed for both Medicare and non-Medicare subgroups. CONCLUSIONS The effect of health system on receipt of diabetic eye screening in rural versus urban areas is most pronounced in underserved areas. Health systems, particularly those providing care to urban underserved populations, have an opportunity to increase screening rates by leveraging health system-level interventions to support patients in overcoming barriers from social determinants of health.
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Affiliation(s)
- Loren J Lock
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Meghan B Brennan
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ying Cao
- Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Lock LJ, Banghart M, Channa R, Smith MA, Brennan MB, Torres Diaz A, Liu Y. Analysis of Health System Size and Variability in Diabetic Eye Disease Screening in Wisconsin. JAMA Netw Open 2022; 5:e2143937. [PMID: 35040971 PMCID: PMC8767430 DOI: 10.1001/jamanetworkopen.2021.43937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cohort study uses statewide claims data to assess variability in diabetic eye disease screening across Wisconsin health systems and to examine the association between patient health system and screening receipt.
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Affiliation(s)
- Loren J. Lock
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Mark Banghart
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Maureen A. Smith
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Meghan B. Brennan
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Alejandra Torres Diaz
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Yao Liu
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison
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Liu Y, Carlson JN, Torres Diaz A, Lock LJ, Zupan NJ, Molfenter TD, Mahoney JE, Palta M, Boss D, Bjelland TD, Smith MA. Sustaining Gains in Diabetic Eye Screening: Outcomes from a Stakeholder-Based Implementation Program for Teleophthalmology in Primary Care. Telemed J E Health 2021; 27:1021-1028. [PMID: 33216697 PMCID: PMC8558054 DOI: 10.1089/tmj.2020.0270] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 11/13/2022] Open
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.
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Affiliation(s)
- Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Julia N. Carlson
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Alejandra Torres Diaz
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Loren J. Lock
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nicholas J. Zupan
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Todd D. Molfenter
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jane E. Mahoney
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Mari Palta
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Biostatistics and Medical Informatics, and University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Deanne Boss
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Maureen A. Smith
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Torres Diaz A, Lock LJ, Molfenter TD, Mahoney JE, Boss D, Bjelland TD, Liu Y. Implementation for Sustained Impact in Teleophthalmology (I-SITE): applying the NIATx Model for tailored implementation of diabetic retinopathy screening in primary care. Implement Sci Commun 2021; 2:74. [PMID: 34229748 PMCID: PMC8258481 DOI: 10.1186/s43058-021-00175-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/16/2021] [Indexed: 11/27/2022] Open
Abstract
Background Teleophthalmology provides evidence-based, telehealth diabetic retinopathy screening that is underused even when readily available in primary care clinics. There is an urgent need to increase teleophthalmology use in the US primary care clinics. In this study, we describe the development of a tailored teleophthalmology implementation program and report outcomes related to primary care provider (PCP) adoption. Methods We applied the 5 principles and 10 steps of the NIATx healthcare process improvement model to develop and test I-SITE (Implementation for Sustained Impact in Teleophthalmology) in a rural, the US multi-payer health system. This implementation program allows patients and clinical stakeholders to systematically tailor teleophthalmology implementation to their local context. We aligned I-SITE components and implementation strategies to an updated ERIC (Expert Recommendations for Implementing Change) framework. We compared teleophthalmology adoption between PCPs who did or did not participate in various components of I-SITE. We surveyed PCPs and clinical staff to identify the strategies they believed to have the highest impact on teleophthalmology use. Results To test I-SITE, we initiated a year-long series of 14 meetings with clinical stakeholders (n=22) and met quarterly with patient stakeholders (n=9) in 2017. Clinical and patient stakeholder groups had 90.9% and 88.9% participant retention at 1 year, respectively. The increase in teleophthalmology use was greater among PCPs participating in the I-SITE implementation team than among other PCPs (p < 0.006). The proportion of all PCPs who used the implementation strategy of electing diabetic eye screening for their annual performance-based financial incentive increased from 0% (n=0) at baseline to 56% (n=14) following I-SITE implementation (p = 0.004). PCPs and clinical staff reported the following implementation strategies as having the highest impact on teleophthalmology use: reminders to ask patients about diabetic eye screening during clinic visits, improving electronic health record (EHR) documentation, and patient outreach. Conclusions We applied the NIATx Model to develop and test a teleophthalmology implementation program for tailored integration into primary care clinics. The NIATx Model provides a systematic approach to engaging key stakeholders for tailoring implementation of evidence-based telehealth interventions into their local context.
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Affiliation(s)
- Alejandra Torres Diaz
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, 2870 University Ave., Ste. 206, Madison, WI, 53705, USA
| | - Loren J Lock
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, 2870 University Ave., Ste. 206, Madison, WI, 53705, USA
| | - Todd D Molfenter
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Jane E Mahoney
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Deanne Boss
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, 2870 University Ave., Ste. 206, Madison, WI, 53705, USA.
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