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Meta-Analysis
. 2018 Jan 15;1(1):CD012054.
doi: 10.1002/14651858.CD012054.pub2.

Interventions to increase attendance for diabetic retinopathy screening

John G Lawrenson  1 , Ella Graham-Rowe, Fabiana Lorencatto, Jennifer Burr, Catey Bunce, Jillian J Francis, Patricia Aluko, Stephen Rice, Luke Vale, Tunde Peto, Justin Presseau, Noah Ivers, Jeremy M Grimshaw
Affiliations
Meta-Analysis

Interventions to increase attendance for diabetic retinopathy screening

John G Lawrenson et al. Cochrane Database Syst Rev. .

Abstract

Background: Despite evidence supporting the effectiveness of diabetic retinopathy screening (DRS) in reducing the risk of sight loss, attendance for screening is consistently below recommended levels.

Objectives: The primary objective of the review was to assess the effectiveness of quality improvement (QI) interventions that seek to increase attendance for DRS in people with type 1 and type 2 diabetes.Secondary objectives were:To use validated taxonomies of QI intervention strategies and behaviour change techniques (BCTs) to code the description of interventions in the included studies and determine whether interventions that include particular QI strategies or component BCTs are more effective in increasing screening attendance;To explore heterogeneity in effect size within and between studies to identify potential explanatory factors for variability in effect size;To explore differential effects in subgroups to provide information on how equity of screening attendance could be improved;To critically appraise and summarise current evidence on the resource use, costs and cost effectiveness.

Search methods: We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, Web of Science, ProQuest Family Health, OpenGrey, the ISRCTN, ClinicalTrials.gov, and the WHO ICTRP to identify randomised controlled trials (RCTs) that were designed to improve attendance for DRS or were evaluating general quality improvement (QI) strategies for diabetes care and reported the effect of the intervention on DRS attendance. We searched the resources on 13 February 2017. We did not use any date or language restrictions in the searches.

Selection criteria: We included RCTs that compared any QI intervention to usual care or a more intensive (stepped) intervention versus a less intensive intervention.

Data collection and analysis: We coded the QI strategy using a modification of the taxonomy developed by Cochrane Effective Practice and Organisation of Care (EPOC) and BCTs using the BCT Taxonomy version 1 (BCTTv1). We used Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital (PROGRESS) elements to describe the characteristics of participants in the included studies that could have an impact on equity of access to health services.Two review authors independently extracted data. One review author entered the data into Review Manager 5 and a second review author checked them. Two review authors independently assessed risks of bias in the included studies and extracted data. We rated certainty of evidence using GRADE.

Main results: We included 66 RCTs conducted predominantly (62%) in the USA. Overall we judged the trials to be at low or unclear risk of bias. QI strategies were multifaceted and targeted patients, healthcare professionals or healthcare systems. Fifty-six studies (329,164 participants) compared intervention versus usual care (median duration of follow-up 12 months). Overall, DRS attendance increased by 12% (risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14; low-certainty evidence) compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted (RD 0.17, 95% CI 0.11 to 0.22) and general QI interventions (RD 0.12, 95% CI 0.09 to 0.15) were effective, particularly where baseline DRS attendance was low. All BCT combinations were associated with significant improvements, particularly in those with poor attendance. We found higher effect estimates in subgroup analyses for the BCTs 'goal setting (outcome)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients, and 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting healthcare professionals.Ten studies (23,715 participants) compared a more intensive (stepped) intervention versus a less intensive intervention. In these studies DRS attendance increased by 5% (RD 0.05, 95% CI 0.02 to 0.09; moderate-certainty evidence).Fourteen studies reporting any QI intervention compared to usual care included economic outcomes. However, only five of these were full economic evaluations. Overall, we found that there is insufficient evidence to draw robust conclusions about the relative cost effectiveness of the interventions compared to each other or against usual care.With the exception of gender and ethnicity, the characteristics of participants were poorly described in terms of PROGRESS elements. Seventeen studies (25.8%) were conducted in disadvantaged populations. No studies were carried out in low- or middle-income countries.

Authors' conclusions: The results of this review provide evidence that QI interventions targeting patients, healthcare professionals or the healthcare system are associated with meaningful improvements in DRS attendance compared to usual care. There was no statistically significant difference between interventions specifically aimed at DRS and those which were part of a general QI strategy for improving diabetes care. This is a significant finding, due to the additional benefits of general QI interventions in terms of improving glycaemic control, vascular risk management and screening for other microvascular complications. It is likely that further (but smaller) improvements in DRS attendance can also be achieved by increasing the intensity of a particular QI component or adding further components.

PubMed Disclaimer

Conflict of interest statement

JGL: None known EG‐R: None known FL: None known JP: None known JB: None known NI: None known PA: None known CB: None known JF: None known JG: None known TP: None known SR: None known LV: None known

Figures

1
1
Study flow diagram.
2
2
Quality improvement components used in intervention arm of included studies. (DRS=diabetic retinopathy screening, GQI=general quality improvement).
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Behaviour change techniques (BCTs) targeting patients used in intervention arm. of included studies (DRS=diabetic retinopathy screening, GQI=general quality improvement).
5
5
Behaviour change techniques (BCTs) targeting healthcare professionals used in intervention arm of included studies (DRS=diabetic retinopathy screening, GQI=general quality improvement).
6
6
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
7
7
Forest plot of comparison: 1 Any quality improvement intervention compared to usual care, outcome: 1.1 Proportion of participants attending screening.
8
8
Funnel plot of comparison: 1 Any quality improvement intervention compared to usual care, outcome: 1.1 Proportion of patients attending screening.
9
9
Forest plot of comparison: 2 Stepped quality improvement intervention compared to intervention alone (control), outcome: 2.1 Proportion of participants attending screening.
10
10
Bubble plot showing the relationship between the risk difference and baseline percentage screened
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD012054

References

References to studies included in this review

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McDermott 2001 {published data only}
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Meigs 2003 {published data only}
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References to studies excluded from this review

Abraira 2003 {published data only}
    1. Abraira C, Duckworth W, McCarren M, Emanuele N, Arca D, Reda D, et al. Design of the cooperative study on glycemic control and complications in diabetes mellitus type 2: Veterans Affairs Diabetes Trial. Journal of Diabetes and its Complications 2003;17(6):314‐22. - PubMed
Aleo 2015 {published data only}
    1. Aleo CL, Murchison AP, Dai Y, Hark LA, Mayro EL, Collymore B, et al. Improving eye care follow‐up adherence in diabetic patients with ocular abnormalities: the effectiveness of patient contracts in a free, pharmacy‐based eye screening. Public Health 2015;129(7):996‐9. - PubMed
Alfadda 2011 {published data only}
    1. Alfadda AA, Bin‐Abdulrahman KA, Saad HA, Mendoza CD, Angkaya‐Bagayawa FF, Yale JF. Effect of an intervention to improve the management of patients with diabetes in primary care practice. Saudi Medical Journal 2011;32(1):36‐40. - PubMed
Anderson 2003a {published data only}
    1. Anderson S, Broadbent DM, Swain JY, Vora JP, Harding SP. Ambulatory photographic screening for diabetic retinopathy in nursing homes. Eye 2003;17(6):711‐6. - PubMed
Anderson 2010 {published data only}
    1. Anderson DR, Christison‐Lagay J, Villagra V, Liu H, Dziura J. Managing the space between visits: a randomized trial of disease management for diabetes in a community health center. Journal of General Internal Medicine 2010;25(10):1116‐22. - PMC - PubMed
Arora 2014 {published data only}
    1. Arora S, Peters AL, Burner E, Lam CN, Menchine M. Trial to examine text message‐based mHealth in emergency department patients with diabetes (TExT‐MED): a randomized controlled trial. Annals of Emergency Medicine 2014;63(6):745‐54. - PubMed
Bellazzi 2004 {published data only}
    1. Bellazzi R, Arcelloni M, Ferrari P, Decata P, Hernando ME, Garcia A, et al. Management of patients with diabetes through information technology: tools for monitoring and control of the patients' metabolic behavior. Diabetes Technology and Therapeutics 2004;6(5):567‐78. - PubMed
Denig 2014 {published data only}
    1. Denig P, Schuling J, Haaijer‐Ruskamp F, Voorham J. Effects of a patient oriented decision aid for prioritising treatment goals in diabetes: pragmatic randomised controlled trial. BMJ 2014;349:g5651. - PubMed
Gangwar 2014 {published data only}
    1. Gangwar SS, Parimalakrishnan S, Monisha N, Singh SP. Impact of medication and psychological behavior assessment by community pharmacists in type 2 diabetes mellitus patients after hospital stay. International Research Journal of Pharmacy 2014;5:332‐9. - PMC - PubMed
Gary 2004 {published data only}
    1. Gary TL, Batts‐Turner M, Bone LR, Yeh HC, Wang NY, Hill‐Briggs F, et al. A randomized controlled trial of the effects of nurse case manager and community health worker team interventions in urban African‐Americans with type 2 diabetes. Controlled Clinical Trials 2004;25(1):53‐66. - PubMed
Harris 2013 {published data only}
    1. Harris S, Paquette‐Warren J, Roberts S, Fournie M, Thind A, Ryan BL, et al. Results of a mixed‐methods evaluation of partnerships for health: a quality improvement initiative for diabetes care. Journal of the American Board of Family Medicine 2013;26(6):711‐9. - PubMed
Hazavehei 2010 {published data only}
    1. Hazavehei SM, Khani Jeihooni A, Hasanzadeh A, Amini S. The effect of educational program based on BASNEF model for eye care in non‐insulin dependent diabetic patients. Journal of Research in Health Sciences 2010;10(2):81‐90. - PubMed
Hollander 2005 {published data only}
    1. Hollander P, Nicewander D, Couch C, Winter D, Herrin J, Haydar Z, et al. Quality of care of Medicare patients with diabetes in a metropolitan fee‐for‐service primary care integrated delivery system. American Journal of Medical Quality 2005;20(6):344‐52. - PubMed
Jones 2006 {published data only}
    1. Jones D, Curry W. Impact of a PDA‐based diabetes electronic management system in a primary care office. American Journal of Medical Quality 2006;21(6):401‐7. - PubMed
Kuvaja‐Kollner 2013 {published data only}
    1. Kuvaja‐Kollner V, Steffansson M, Kettunen A. Information and communications technology‐supported diabetes prevention and self‐care management: experiences from the EMOTIONAAL project in Finland. Journal of Diabetes Science and Technology 2013; Vol. 7, issue 1:287‐8. - PMC - PubMed
Lewis 2007 {published data only}
    1. Lewis K, Patel D, Yorston D, Charteris D. A qualitative study in the United Kingdom of factors influencing attendance by patients with diabetes at ophthalmic outpatient clinics. Ophthalmic Epidemiology 2007;14(6):375‐80. - PubMed
Maberley 2003 {published data only}
    1. Maberley D, Walker H, Koushik A, Cruess A. Screening for diabetic retinopathy in James Bay, Ontario: a cost‐effectiveness analysis. CMAJ 2003;168(2):160‐4. - PMC - PubMed
Mangione 2006 {published data only}
    1. Mangione CM, Gerzoff RB, Williamson DF, Steers WN, Kerr EA, Brown AF, et al. The association between quality of care and the intensity of diabetes disease management programs. Annals of Internal Medicine 2006;145(2):107‐16. - PubMed
Mazzuca 1988 {published data only}
    1. Mazzuca SA, Vinicor F, Cohen SJ, Norton JA, Fineberg NS, Fineberg SE, et al. The Diabetes Education Study: a controlled trial of the effects of intensive instruction of internal medicine residents on the management of diabetes mellitus. Journal of General Internal Medicine 1988;3(1):1‐8. - PubMed
McCulloch 1998 {published data only}
    1. McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. A population‐based approach to diabetes management in a primary care setting: early results and lessons learned. Effective Clinical Practice 1998;1(1):12‐22. - PubMed
Montori 2002 {published data only}
    1. Montori VM, Dinneen SF, Gorman CA, Zimmerman BR, Rizza RA, Bjornsen SS, et al. The impact of planned care and a diabetes electronic management system on community‐based diabetes care: the Mayo Health System Diabetes Translation Project. Diabetes Care 2002;25(11):1952‐7. - PubMed
Montori 2004 {published data only}
    1. Montori VM, Helgemoe PK, Guyatt GH, Dean DS, Leung TW, Smith SA, et al. Telecare for patients with type 1 diabetes and inadequate glycemic control: a randomized controlled trial and meta‐analysis. Diabetes Care 2004;27(5):1088‐94. - PubMed
Peters 1998 {published data only}
    1. Peters AL, Davidson MB. Application of a diabetes managed care program. The feasibility of using nurses and a computer system to provide effective care. Diabetes Care 1998;21(7):1037‐43. - PubMed
Polak 2003 {published data only}
    1. Polak BC, Crijns H, Casparie AF, Niessen LW. Cost‐effectiveness of glycemic control and ophthalmological care in diabetic retinopathy. Health Policy 2003;64(1):89‐97. - PubMed
Rees 2013 {published data only}
    1. Rees G, Lamoureux EL, Nicolaou TE, Hodgson LA, Weinman J, Speight J. Feedback of personal retinal images appears to have a motivational impact in people with non‐proliferative diabetic retinopathy and suboptimal HbA1c: findings of a pilot study. Diabetic Medicine 2013;30(9):1122‐5. - PubMed
Samoutis 2010 {published data only}
    1. Samoutis GA, Soteriades ES, Stoffers HE, Philalithis A, Delicha EM, Lionis C. A pilot quality improvement intervention in patients with diabetes and hypertension in primary care settings of Cyprus. Family Practice 2010;27(3):263‐70. - PubMed
Schectman 2004 {published data only}
    1. Schectman JM, Schorling JB, Nadkarni MM, Lyman JA, Siadaty MS, Voss JD. The effect of physician feedback and an action checklist on diabetes care measures. American Journal of Medical Quality 2004;19(5):207‐13. - PubMed
Shah 2014 {published data only}
    1. Shah BR, Bhattacharyya O, Yu CH, Mamdani MM, Parsons JA, Straus SE, et al. Effect of an educational toolkit on quality of care: a pragmatic cluster randomized trial. PLoS Medicine 2014;11(2):e1001588. - PMC - PubMed
Shea 2006 {published data only}
    1. Shea S, Weinstock RS, Starren J, Teresi J, Palmas W, Field L, et al. A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus. Journal of the American Medical Informatics Association 2006;13(1):40‐51. - PMC - PubMed
Solorio 2015 {published data only}
    1. Solorio R, Bansal A, Comstock B, Ulatowski K, Barker S. Impact of a chronic care coordinator intervention on diabetes quality of care in a community health center. Health Services Research 2015;50(3):730‐49. - PMC - PubMed
Thoolen 2008 {published data only}
    1. Thoolen B, Ridder D, Bensing J, Gorter K, Rutten G. Beyond Good Intentions: the development and evaluation of a proactive self‐management course for patients recently diagnosed with type 2 diabetes. Health Education Research 2008;23(1):53‐61. - PubMed
Wagner 2008 {published data only}
    1. Wagner H, Pizzimenti JJ, Daniel K, Pandya N, Hardigan PC. Eye on diabetes: a multidisciplinary patient education intervention. Diabetes Educator 2008;34(1):84‐9. - PubMed
Weston 2008 {published data only}
    1. Weston CM, Sciamanna CN, Nash DB. Evaluating online continuing medical education seminars: evidence for improving clinical practices. American Journal of Medical Quality 2008;23(6):475‐83. - PubMed
Young 2014 {published data only}
    1. Young H, Miyamoto S, Ward D, Dharmar M, Tang‐Feldman Y, Berglund L. Sustained effects of a nurse coaching intervention via telehealth to improve health behavior change in diabetes. Telemedicine Journal and E‐Health 2014;20(9):828‐34. - PMC - PubMed

References to ongoing studies

ACTRN12614001110673 {published data only}
    1. ACTRN12614001110673. The Diabetes and Eye Health project: increasing eye examinations for adults newly diagnosed with type 2 diabetes [Development and evaluation of a psycho‐educational leaflet to increase the rate of eye examinations for adults newly diagnosed with type 2 diabetes from the following two groups: 1. early onset type 2 diabetes (aged 18‐39 years), or 2. who live in rural and regional Victoria]. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367127 (registered 20 October 2014).
ISRCTN31439939 {published data only}
    1. ISRCTN31439939. The Kilimanjaro Diabetic Programme: the development of a sustainable regional eye health screening program to prevent blindness among diabetic patients due to diabetic retinopathy [A randomised controlled trial of screening strategies for diabetic retinopathy in Kilimanjaro region: a randomised controlled trial of the effect of a screening camera on uptake of screening for diabetic retinopathy (phase I) and a randomised controlled trial of the effect of mobile telephone text reminders of screening appointments on uptake of screening for diabetic retinopathy (phase II)]. www.isrctn.com/ISRCTN31439939 (assigned 2 June 2011).
ISRCTN87561257 {published data only}
    1. ISRCTN87561257. Individual risk‐based screening for diabetic retinopathy [Introducing personalised risk‐based intervals in screening for diabetic retinopathy: development, implementation and assessment of safety, cost‐effectiveness and patient experience]. www.isrctn.com/ISRCTN87561257 (assigned 8 May 2014).
NCT01212328 {published data only}
    1. NCT01212328. A multi‐site, individually randomized, controlled translation trial of integrated and comprehensive care strategies to reduce cardiovascular disease (CVD) risk among 1,120 type 2 diabetes mellitus(T2DM) patients in south Asia (CARRS) [Developing and testing integrated, multi‐factorial cardiovascular disease risk reduction strategies in south Asia (CARRS Translation Trial)]. clinicaltrials.gov/ct2/show/NCT01212328 (first received 6 September 2010).
NCT01351857 {published data only}
    1. NCT01351857. Diabetes care management compared to standard diabetes care in adolescents and young adults with type 1 diabetes (TransClin) [Multicentre randomized controlled trial of structured transition on diabetes care management compared to standard diabetes care in adolescents and young adults with type 1 diabetes]. clinicaltrials.gov/ct2/show/NCT01351857 (first submitted 10 May 2011). - PMC - PubMed
    1. Spaic T, Mahon J L, Hramiak I, Byers N, Evans K, Robinson T, et al. Multicentre randomized controlled trial of structured transition on diabetes care management compared to standard diabetes care in adolescents and young adults with type 1 diabetes (Transition Trial). BMC Pediatrics 2013;13:163. - PMC - PubMed
NCT01837121 {published data only}
    1. NCT01837121. A trial of using SMS reminder among diabetic retinopathy patients in rural China (SMS) [A randomized controlled trail to determine the impact of a SMS reminder among diabetic retinopathy patients in rural China]. clinicaltrials.gov/ct2/show/NCT01837121 (first submitted 14 April 2013).
NCT02339909 {published data only}
    1. NCT02339909. Incentives in Diabetic Eye Assessment by Screening (IDEAS). clinicaltrials.gov/ct2/show/NCT02339909 (first submitted 15 December 2014).
NCT02579837 {published data only}
    1. NCT02579837. CLEAR SIGHT: a trial of non‐mydriatic ultra‐widefield retinal imaging to screen for diabetic eye disease. clinicaltrials.gov/ct2/show/NCT02579837 (first submitted 16 October 2015).

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References to other published versions of this review

Lawrenson 2016
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