Adherence to Ophthalmology Referral, Treatment and Follow-up after Diabetic Retinopathy Screening in the Primary Care Setting

Objective Telemedicine-based diabetic retinopathy screening (DRS) in the Primary Care setting has increased screening rates of patients with diabetes. However, blindness from vision threatening diabetic retinopathy (VTDR) is a persistent problem. This study examined the extent of patients’ adherence to post-screening recommendations. Research Design and Methods A retrospective record review was conducted in the primary care clinics of a large county hospital in the US. All diabetic patients detected with VTDR through telemedicine-based DRS over a 5-year period (2012-2017) were included in the study. Adherence rates for keeping initial ophthalmology appointments, starting recommended treatments, and keeping follow-up appointments were determined. Results
Adequate records were available for 6046 patients of whom 408 (7%) were detected with VTDR and recommended for referral to ophthalmology. Only 5% completed a first Ophthalmology appointment within the recommended referral interval; 15% within twice the recommended interval, and 51%% within one-year of DRS. Patients screened in 2015-2017 were somewhat more likely to complete a first Ophthalmology appointment than those in 2012-2014.  Ophthalmic treatment was recommended in half of the patients, of whom 94% initiated treatment. A smaller percentage (41%) adhered completely to post-treatment follow-up. Overall, 28% of referred patients: 1) kept a first Ophthalmology appointment; 2) were recommended for treatment; and, 3) initiated the treatment. Most patients failing to keep first Ophthalmology appointments continued medical care at the institution. EMRs provided more complete information than paper charts. Conclusions Reducing vision impairment from diabetic retinopathy will require a greater emphasis on promoting timely adherence to referral and follow up. Prevention of visual loss from VTDR starts with retinopathy screening, but must include patient engagement, adherence monitoring, and streamlining ophthalmic referral and management. Revision of these processes has already been implemented at the study site, incorporating lessons from this investigation.