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Pdfs/​NEI ​Factsheet ​July ​ 3 2015 ​V2.​Pdf Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-022594 on 18 February 2019. Downloaded from Identification of barriers, facilitators and system-based implementation strategies to increase teleophthalmology use for diabetic eye screening in a rural US primary care clinic: a qualitative study Yao Liu, 1,2 Nicholas J Zupan,1 Rebecca Swearingen,1,2 Nora Jacobson,3 Julia N Carlson,1 Jane E Mahoney,4 Ronald Klein,1 Timothy D Bjelland,5 Maureen A Smith2,6 To cite: Liu Y, Zupan NJ, ABSTRACT Strengths and limitations of this study Swearingen R, et al. Objective Teleophthalmology for diabetic eye screening is Identification of barriers, an evidence-based intervention substantially underused in facilitators and system-based ► We used qualitative methods to capture the re- US multipayer primary care clinics, even when equipment implementation strategies to al-world perspectives of patients and providers increase teleophthalmology use and trained personnel are readily available. We sought regarding barriers and facilitators to teleophthalmol- for diabetic eye screening in to identify patient and primary care provider (PCP) ogy use in a rural US multipayer primary care clinic a rural US primary care clinic: barriers, facilitators, as well as strategies to increase with an active teleophthalmology programme. a qualitative study. teleophthalmology use. BMJ Open ► We identified and categorised implementation strat- 2019;9:e022594. doi:10.1136/ Design We conducted standardised open-ended, egies directly suggested by patients and providers bmjopen-2018-022594 individual interviews and analysed the transcripts using using the Chronic Care Model. ► Prepublication history and both inductive and directed content analysis to identify ► All patients were Caucasian and native English additional material for this barriers and facilitators to teleophthalmology use. The speakers. paper are available online. To Chronic Care Model was used as a framework for the ► Most patients in this study self-reported high levels view these files, please visit development of the interview guide and for categorising of general health literacy (85%), which was greater the journal online (http:// dx. doi. implementation strategies to increase teleophthalmology than that reported by rural adults from a similar pop- org/ 10. 1136/ bmjopen- 2018- use. ulation (70.9%). http://bmjopen.bmj.com/ 022594). Setting A rural, US multipayer primary care clinic with an ► We did not systematically assess patient knowledge Received 3 March 2018 established teleophthalmology programme for diabetic eye of diabetic eye screening. Revised 9 October 2018 screening. Accepted 18 December 2018 Participants We conducted interviews with 29 participants (20 patients with diabetes and 9 PCPs). based implementation strategies primarily targeting PCP Results Major patient barriers to teleophthalmology barriers in conjunction with improved patient and provider use included being unfamiliar with teleophthalmology, education may increase teleophthalmology use in rural, US misconceptions about diabetic eye screening and multipayer primary care clinics. logistical challenges. Major patient facilitators included on October 1, 2021 by guest. Protected copyright. a recommendation from the patient’s PCP and factors related to convenience. Major PCP barriers to referring INTRODUCTIOn patients for teleophthalmology included difficulty There are an estimated 4.2 million Amer- identifying when patients are due for diabetic eye icans with diabetic retinopathy, which is screening and being unfamiliar with teleophthalmology. the most common cause of blindness in Major PCP facilitators included the ease of the referral working-age US adults.1 2 The risk of severe process and the communication of screening results. vision loss decreases by 90% with early diag- Based on our results, we developed a model that maps nosis and treatment, but fewer than half of © Author(s) (or their where these key patient and PCP barriers occur in the the 29.1 million Americans with diabetes employer(s)) 2019. Re-use teleophthalmology referral process. Patients and PCPs also permitted under CC BY. identified implementation strategies to directly address receive yearly recommended diabetic reti- Published by BMJ. 3–5 barriers and facilitators to teleophthalmology use. nopathy screening. Teleophthalmology For numbered affiliations see Conclusions Patients and PCPs have limited familiarity is an evidence-based intervention proven to end of article. with teleophthalmology for diabetic eye screening. PCPs substantially improve diabetic eye screening 6 Correspondence to were expected to initiate teleophthalmology referrals, rates and reduce blindness from diabetes. Dr Yao Liu; liu463@ wisc. edu, but reported significant difficulty identifying when A retinal camera is used to image patients’ yaoliumd@ gmail. com patients are due for diabetic eye screening. System- eyes in a convenient location, such as a Liu Y, et al. BMJ Open 2019;9:e022594. doi:10.1136/bmjopen-2018-022594 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-022594 on 18 February 2019. Downloaded from primary care clinic (where more than 90% of patients complex phenomena needing further explanatory anal- with diabetes obtain their care).7 These images are then ysis, such as real-world patient and provider barriers to electronically transmitted to and evaluated by specialists teleophthalmology use, through a rich description of at a distant site, typically within a time frame of the same key perspectives.22 We conducted individual interviews day to 1 week. Patients needing additional eye care are to understand what prevents or motivates patients and then identified for expedited treatment. The prevalence primary care providers (PCPs) to use teleophthalmology, of diabetes and the demand for eye screening is projected as well as strategies to increase teleophthalmology use, in to double by 2050 without a concurrent increase in the a rural multipayer health system with an active teleoph- supply of eye care providers.8 Thus, there is an urgent thalmology programme. need to expand teleophthalmology use to improve screening rates and respond to growing demand. In England, the National Health Service achieves RESEARCH DESIGN AND METHODS screening rates of over 80% using teleophthalmology and Research setting subsequently, diabetic retinopathy is no longer the leading We conducted standardised open-ended, individual inter- 6 9 cause of blindness in working-age English adults. Pres- views with patients with diabetes and PCPs at Mile Bluff ently, successful implementation of teleophthalmology in Medical Center. Mile Bluff is a rural, multipayer health the USA is largely limited to single-payer or highly special- system in Mauston, Wisconsin, USA. A teleophthalmology 10 11 ised health systems. Teleophthalmology programmes programme was established in 2015 (1 year prior to the in these settings have achieved sustained screening rates start of our study) in partnership with the University of as high as 80% or more. Success in multipayer settings Wisconsin (UW)-Madison. This programme allows PCPs has been much more limited. A multipayer health system to refer patients for teleophthalmology with walk-in is one in which individuals (or their employers) pay for scheduling. Referrals are completed by PCPs in the Mile healthcare services through a variety of private or public Bluff electronic health record (EHR). Retinal images are health insurance sources, in contrast to a single-payer electronically transmitted to and evaluated by university health system in which healthcare is paid for by a single eye specialists. Imaging reports are then sent back to the payer (eg, government-financed healthcare supported by PCP and patient within 1 week, which is consistent with 12 taxes). A recent 5-year randomised controlled trial in the usual time frame for receiving results of other clinical a multipayer health system compared teleophthalmology studies (eg, laboratory tests and X-rays) provided by this to traditional screening methods (ie, in-person dilated rural health system and was considered acceptable to all eye examinations) and found initial improvement in patients and PCPs in our study. Patients are referred to screening rates with teleophthalmology, but screening local eye doctors for further care if found to have visu- rates declined within 18 months and did not exceed 55% ally significant eye disease. even when teleophthalmology became available to both This teleophthalmology programme was established 13 http://bmjopen.bmj.com/ groups. However, this study did not use a systematic prior to our study based on the 2011 American Telemed- implementation approach designed to sustain the inte- icine Association Telehealth Practice Recommendations gration of this technology into the primary care workflow. for Diabetic Retinopathy.23 The Topcon NW400 camera Teleophthalmology is particularly well suited to rural (Topcon Medical Systems, Oakland, New Jersey, USA) was populations, which have less access and greater travel used to obtain a single 45° image of the disc and macula 14–18 distances to obtain eye care. Rural communities are in each eye, along with an anterior segment photograph. largely served by multipayer health systems, which are If a fundus image was considered to be poor quality by the less likely to encourage preventive services because of imager, then the camera’s ‘small pupil’ mode was used to poor reimbursement for such services due to insurers’
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