Barriers and facilitators to diabetic retinopathy screening within Australian primary care

BMC Family Practice - Tập 22 Số 1 - 2021
Matthew J. Watson1, Peter McCluskey2, John Grigg2, Yogesan Kanagasingam3, Judith Daire4, Mohamed Estai5
1The Australian e-Health Research Centre, CSIRO, 147 Underwood Avenue, Floreat, WA, 6014, Australia
2Save Sight Institute, The Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
3School of Medicine, University of Notre Dame Australia, Fremantle, Australia
4School of Population Health, The Faculty of Health Sciences, Curtin University, Bentley, Australia
5School of Human Sciences, The University of Western Australia, Perth, Australia

Tóm tắt

Abstract Background Despite recent incentives through Medicare (Australia’s universal health insurance scheme) to increase retinal screening rates in primary care, comprehensive diabetic retinopathy (DR) screening has not been reached in Australia. The current study aimed to identify key factors affecting the delivery of diabetic retinopathy (DR) screening in Australian general practices. Methods A descriptive qualitative study involving in-depth interviews was carried out from November 2019 to March 2020. Using purposive snowballing sampling, 15 general practitioners (GPs) were recruited from urban and rural general practices in New South Wales and Western Australia. A semi-structured interview guide was used to collect data from participants. All interviews were conducted over the phone by one facilitator, and each interview lasted up to 45 min. The Socio-Ecological Model was used to inform the content of the interview topic guides and subsequent data analysis. Recorded data were transcribed verbatim, and thematic analysis was conducted to identify and classify recurrent themes. Results Of 15 GPs interviewed, 13 were male doctors, and the mean age was 54.7 ± 15.5 years. Seven participants were practising in urban areas, while eight were practising in regional or remote areas. All participants had access to a direct ophthalmoscope, but none owned retinal cameras. None of the participants reported performing DR screening. Only three participants were aware of the Medicare Benefits Schedule (MBS) items 12,325 and 12,326 that allow GPs to bill for retinal screening. Seven themes, a combination of facilitators and barriers, emerged from interviews with the GPs. Despite the strong belief in their role in managing chronic diseases, barriers such as costs of retinal cameras, time constraints, lack of skills to make DR diagnosis, and unawareness of Medicare incentives for non-mydriatic retinal photography made it difficult to conduct DR screening in general practice. However, several enabling strategies to deliver DR screening within primary care include increasing GPs’ access to continuing professional development, subsidising the cost of retinal cameras, and the need for a champion ace to take the responsibility of retinal photography. Conclusion This study identified essential areas at the system level that require addressing to promote the broader implementation of DR screening, in particular, a nationwide awareness campaign to maximise the use of MBS items, improve GPs’ competency, and subsidise costs of the retinal cameras for small and rural general practices.

Từ khóa


Tài liệu tham khảo

GBD 2019 Blindness and Vision Impairment Collaborators, Vision Loss Expert Group of the Global Burden of Disease Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the right to sight: an analysis for the global burden of disease study. Lancet Glob Health. 2021;9(2):e144–e60.

Group UKPDS. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837–53.

Keel S, Xie J, Foreman J, van Wijngaarden P, Taylor HR, Dirani M. The prevalence of diabetic retinopathy in Australian adults with self-reported diabetes: the National Eye Health Survey. Ophthalmology. 2017;124(7):977–84.

Cikamatana L, Mitchell P, Rochtchina E, Foran S, Wang J. Five-year incidence and progression of diabetic retinopathy in a defined older population: the Blue Mountains Eye Study. Eye (Lond). 2007;21(4):465–71.

Yau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012;35(3):556–64.

Taylor HR, Pezzullo ML, Keeffe JE. The economic impact and cost of visual impairment in Australia. Br J Ophthalmol. 2006;90(3):272–5.

Magliano DJ, Peeters A, Vos T, Sicree R, Shaw J, Sindall C, et al. Projecting the burden of diabetes in Australia–what is the size of the matter? Aust N Z J Public Health. 2009;33(6):540–3.

Hammes H-P, Feng Y, Pfister F, Brownlee M. Diabetic retinopathy: targeting vasoregression. Diabetes. 2011;60(1):9–16.

Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4–14.

Cheung N, Mitchell P, Wong TY. Diabetic retinopathy. Lancet. 2010;376(9735):124–36.

National Health and Medical Research Council. Guidelines for the management of diabetic retinopathy. Australia: NHMRC; 2008.

Hutchinson A, McIntosh A, Peters J, O’keeffe C, Khunti K, Baker R, et al. Effectiveness of screening and monitoring tests for diabetic retinopathy–a systematic review. Diabet Med. 2000;17(7):495–506.

Ting DSW, Cheung GCM, Wong TY. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review. Clin Exp Ophthalmol. 2016;44(4):260–77.

Rubino A, Rousculp MD, Davis K, Wang J, Girach A. Diagnosed diabetic retinopathy in France, Italy, Spain, and the United Kingdom. Prim Care Diabetes. 2007;1(2):75–80.

Scanlon PH. The English national screening programme for diabetic retinopathy 2003–2016. Acta Diabetol. 2017;54(6):515–25.

Nguyen HV, Tan GSW, Tapp RJ, Mital S, Ting DSW, Wong HT, et al. Cost-effectiveness of a national telemedicine diabetic retinopathy screening program in Singapore. Ophthalmology. 2016;123(12):2571–80.

Misra A, Bachmann M, Greenwood R, Jenkins C, Shaw A, Barakat O, et al. Trends in yield and effects of screening intervals during 17 years of a large UK community-based diabetic retinopathy screening programme. Diabet Med. 2009;26(10):1040–7.

Conlin PR, Fisch BM, Orcutt JC, Hetrick BJ, Darkins AW. Framework for a national teleretinal imaging program to screen for diabetic retinopathy in Veterans Health Administration patients. J Rehabil Res Dev. 2006;43(6):741–8.

Australian Government Department of Human Services. Medicare item reports. Canberra: Australian Government; 2021. Available from: http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml

Foreman J, Keel S, Xie J, Van Wijngaarden P, Taylor HR, Dirani M. Adherence to diabetic eye examination guidelines in Australia: the National Eye Health Survey. Med J Aust. 2017;206(9):402–6.

Xie J, Arnold AL, Keeffe J, Goujon N, Dunn RA, Fox S, et al. Prevalence of self-reported diabetes and diabetic retinopathy in indigenous Australians: the National Indigenous Eye Health Survey. Clin Exp Ophthalmol. 2011;39(6):487–93.

McCarty DJ, Fu CL, Harper CA, Taylor HR, McCarty CA. Five-year incidence of diabetic retinopathy in the Melbourne Visual Impairment Project. Clin Exp Ophthalmol. 2003;31(5):397–402.

Tapp RJ, Zimmet PZ, Harper CA, De Courten MP, Balkau B, McCarty DJ, et al. Diabetes care in an Australian population: frequency of screening examinations for eye and foot complications of diabetes. Diabetes Care. 2004;27(3):688–93.

Piyasena MMPN, Murthy GVS, Yip JL, Gilbert C, Zuurmond M, Peto T, et al. Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings. PLoS One. 2019;14(4):e0198979.

Egunsola O, Dowsett LE, Diaz R, Brent M, Rac V, Clement FM. Diabetic retinopathy screening: a systematic review of qualitative literature. Can J Diabetes. 2021. https://doi.org/10.1016/j.jcjd.2021.01.014.

Graham-Rowe E, Lorencatto F, Lawrenson J, Burr J, Grimshaw J, Ivers N, et al. Barriers to and enablers of diabetic retinopathy screening attendance: a systematic review of published and grey literature. Diabet Med. 2018;35(10):1308–19.

Crossland L, Jackson C. Successfully implementing a diabetic retinopathy screening service in general practice: what does the evidence tell us? Aust Fam Physician. 2017;46(7):529.

Lake AJ, Browne JL, Rees G, Speight J. What factors influence uptake of retinal screening among young adults with type 2 diabetes? A qualitative study informed by the theoretical domains framework. J Diabetes Complicat. 2017;31(6):997–1006.

Glasson NM, Larkins SL, Crossland LJ. What do patients with diabetes and providers think of an innovative Australian model of remote diabetic retinopathy screening? A qualitative study. BMC Health Serv Res. 2017;17(1):1–16.

Spurling GK, Askew DA, Hayman NE, Hansar N, Cooney AM, Jackson CL. Retinal photography for diabetic retinopathy screening in indigenous primary health care: the Inala experience. Aust N Z J Public Health. 2010;34:S30–S3.

Livingston P, McCarty C, Wood C, Harper A, Keeff J, Taylor H. Use of focus groups to identify health promotion strategies for the early detection of diabetic retinopathy. Aust N Z J Public Health. 1998;22(2):220–2.

Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–15.

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51.

Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):1–17.

Richard L, Gauvin L, Raine K. Ecological models revisited: their uses and evolution in health promotion over two decades. Annu Rev Public Health. 2011;32:307–26.

Villalba C, Askew D, Jaiprakash A, Donovan J, Roberts J, Russell A, et al. A mixed-methods retrospective study: 10 years of diabetic retinopathy screening in urban Aboriginal and Torres Strait Islander primary care. Aust J Prim Health. 2019;25(1):24–30.

Lindenmeyer A, Sturt JA, Hipwell A, Stratton IM, Al-Athamneh N, Gadsby R, et al. Influence of primary care practices on patients’ uptake of diabetic retinopathy screening: a qualitative case study. Br J Gen Pract. 2014;64(625):e484–e92.

Cavan D, Makaroff L, da Rocha FJ, Sylvanowicz M, Ackland P, Conlon J, et al. The diabetic retinopathy barometer study: global perspectives on access to and experiences of diabetic retinopathy screening and treatment. Diabetes Res Clin Pract. 2017;129:16–24.

Hipwell AE, Sturt J, Lindenmeyer A, Stratton I, Gadsby R, O'Hare P, et al. Attitudes, access and anguish: a qualitative interview study of staff and patients’ experiences of diabetic retinopathy screening. BMJ Open. 2014;4(12):e005498.

Ghaljaie F, Naderifar M, Goli H. Snowball sampling: a purposeful method of sampling in qualitative research. Strides Dev Med Educ. 2017;14(3)1–6. https://doi.org/10.5812/SDME.67670.

Morse JM. The significance of saturation. Thousand Oaks: Sage publications Sage CA; 1995.

Guest G, Bunce A, Johnson L. How many interviews are enough?: an experiment with data saturation and variability. Field Methods. 2006;18(1):59–82.

Clarke V, Braun V. Teaching thematic analysis: overcoming challenges and developing strategies for effective learning. Psychologist. 2013;26(2):120–3.

Askew D, Schluter PJ, Spurling G, Maher CM, Cranstoun P, Kennedy C, et al. Diabetic retinopathy screening in general practice: a pilot study. Aust Fam Physician. 2009;38(8):650.

University of Melbourne. Online self-directed diabetic retinopathy grading course. 2017. https://drgrading.iehu.unimelb.edu.au/cera/index.asp. Accessed 27 Oct 2020.

Ellery B, Milverton J, Newton S, Morona J, Gum D, Parsons J, et al. Retinal photography with a non-mydriatic retinal camera in people with diabetes. MSAC application no. 1181, Assessment Report. Canberra: Commonwealth of Australia; 2014.

Nielsen KB, Lautrup ML, Andersen JKH, Savarimuthu TR, Grauslund J. Deep learning–based algorithms in screening of diabetic retinopathy: a systematic review of diagnostic performance. Ophthalmol Retina. 2019;3(4):294–304.

Xiao D, Bhuiyan A, Frost S, Vignarajan J, Tay-Kearney M-L, Kanagasingam Y. Major automatic diabetic retinopathy screening systems and related core algorithms: a review. Mach Vis Appl. 2019;30(3):423–46.

Li Z, Keel S, Liu C, He M. Can artificial intelligence make screening faster, more accurate, and more accessible? Asia Pac J Ophthalmol (Phila). 2018;7(6):436–41.

Piyasena MMPN, Murthy GVS, Yip JL, Gilbert C, Peto T, Premarathna M, et al. A qualitative study on barriers and enablers to uptake of diabetic retinopathy screening by people with diabetes in the Western province of Sri Lanka. Trop Med Health. 2019;47(1):1–10.

Fairless EA. Factors influencing the receipt of diabetic retinopathy screening in a high-risk population; 2020.

Thông tin
Thông tin xuất bản

BMC Family Practice

Tập 22 Số 1

Thông tin tác giả