Target Product Profile for a Machine Learning-Automated Retinal Imaging Analysis Software for Use in English Diabetic Eye Screening: Protocol for a Mixed Methods Study

BACKGROUND

Diabetic eye screening (DES) represents a significant opportunity for the application of machine learning (ML) technologies, which may improve clinical and service outcomes. However, successful integration of ML into DES requires careful product development, evaluation, and implementation. Target product profiles (TPPs) summarize the requirements necessary for successful implementation so these can guide product development and evaluation.

OBJECTIVE

This study aims to produce a TPP for an ML-automated retinal imaging analysis software (ML-ARIAS) system for use in DES in England.

METHODS

This work will consist of 3 phases. Phase 1 will establish the characteristics to be addressed in the TPP. A list of candidate characteristics will be generated from the following sources: an overview of systematic reviews of diagnostic test TPPs; a systematic review of digital health TPPs; and the National Institute for Health and Care Excellence's Evidence Standards Framework for Digital Health Technologies. The list of characteristics will be refined and validated by a study advisory group (SAG) made up of representatives from key stakeholders in DES. This includes people with diabetes; health care professionals; health care managers and leaders; and regulators and policy makers. In phase 2, specifications for these characteristics will be drafted following a series of semistructured interviews with participants from these stakeholder groups. Data collected from these interviews will be analyzed using the shortlist of characteristics as a framework, after which specifications will be drafted to create a draft TPP. Following approval by the SAG, in phase 3, the draft will enter an internet-based Delphi consensus study with participants sought from the groups previously identified, as well as ML-ARIAS developers, to ensure feasibility. Participants will be invited to score characteristic and specification pairs on a scale from "definitely exclude" to "definitely include," and suggest edits. The document will be iterated between rounds based on participants' feedback. Feedback on the draft document will be sought from a group of ML-ARIAS developers before its final contents are agreed upon in an in-person consensus meeting. At this meeting, representatives from the stakeholder groups previously identified (minus ML-ARIAS developers, to avoid bias) will be presented with the Delphi results and feedback of the user group and asked to agree on the final contents by vote.

RESULTS

Phase 1 was completed in November 2023. Phase 2 is underway and expected to finish in March 2024. Phase 3 is expected to be complete in July 2024.

CONCLUSIONS

The multistakeholder development of a TPP for an ML-ARIAS for use in DES in England will help developers produce tools that serve the needs of patients, health care providers, and their staff. The TPP development process will also provide methods and a template to produce similar documents in other disease areas.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50568.

Factors Influencing Eye Screening Adherence Among Latinx Patients With Diabetes: A Qualitative Study

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.

Perspectives of Latinx Patients with Diabetes on Teleophthalmology, Artificial Intelligence-Based Image Interpretation, and Virtual Care: A Qualitative Study

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.

Barriers and enablers to diabetic eye screening attendance: An interview study with young adults with type 1 diabetes

AIM

The aim of this study was to identify barriers and enablers of diabetic eye screening (DES) attendance amongst young adults with diabetes living in the United Kingdom.

METHODS

Semistructured qualitative interviews with adults aged 18-34 years with diabetes. Participants were purposively sampled to aim for representation across gender, geographical locations, diabetes type, years since diabetes diagnosis and patterns of attendance (i.e. regular attenders, occasional non-attenders, regular non-attenders). Data were collected and analysed using the Theoretical Domains Framework (TDF) to explore potential individual, sociocultural and environmental influences on attendance. Data were analysed using a combined deductive and inductive thematic analysis approach. Barriers/enablers were mapped to behaviour change techniques (BCTs) to identify potential strategies to increase attendance.

RESULTS

Key barriers to attendance reported by the sample of 29 study participants with type 1 diabetes, fell within the TDF domains: [Knowledge] (e.g. not understanding reasons for attending DES or treatments available if diabetic retinopathy is detected), [Social Influences] (e.g. lack of support following DES results), [Social role and Identity] (e.g. not knowing other people their age with diabetes, feeling 'isolated' and being reluctant to disclose their diabetes) and [Environmental Context and Resources] (e.g. lack of appointment flexibility and options for rescheduling). Enablers included: [Social Influences] (e.g. support of family/diabetes team), [Goals] (e.g. DES regarded as 'high priority'). Many of the reported barriers/enablers were consistent across groups. Potential BCTs to support attendance include Instructions on how to perform the behaviour; Information about health consequences; Social support (practical) and Social comparison.

CONCLUSIONS

Attendance to diabetic eye screening in young adults is influenced by a complex set of interacting factors. Identification of potentially modifiable target behaviours provides a basis for designing more effective, tailored interventions to help young adults regularly attend eye screening and prevent avoidable vision loss.