Feasibility of a multifaceted implementation intervention to improve attendance at diabetic retinopathy screening in primary care in Ireland: a cluster randomised pilot trial

Abstract

Objectives: Diabetic retinopathy screening (DRS) uptake is suboptimal in many countries with limited evidence available on interventions to enhance DRS uptake in primary care. We investigated the feasibility and preliminary effects of an intervention to improve uptake of Ireland's national DRS programme, Diabetic RetinaScreen, among patients with type 1 or type 2 diabetes.

Design/setting: We conducted a cluster randomised pilot trial, embedded process evaluation and cost analysis in general practice, July 2019 to January 2020.

Participants: Eight practices participated in the trial. For the process evaluation, surveys were conducted with 25 staff at intervention practices. Interviews were conducted with nine staff at intervention practices, and 10 patients who received the intervention.

Interventions: The intervention comprised practice reimbursement, an audit of attendance, electronic prompts targeting professionals, General Practice-endorsed patient reminders and a patient information leaflet. Practices were randomly allocated to intervention (n=4) or wait-list control (n=4) (usual care).

Outcomes: Staff and patient interviews explored their perspectives on the intervention. Patient registration and attendance, including intention to attend, were measured at baseline and 6 months. Microcosting was used to estimate intervention delivery cost.

Results: The process evaluation identified that enablers of feasibility included practice culture and capacity to protect time, systems to organise care, and staff skills, and workarounds to improve intervention 'fit'. At 6 months, 22/71 (31%) of baseline non-attenders in intervention practices subsequently attended screening compared with 15/87 (17%) in control practices. The total delivery cost across intervention practices (patients=363) was €2509, averaging €627 per practice and €6.91 per audited patient. Continuation criteria supported proceeding to a definitive trial.

Conclusions: The Improving Diabetes Eye screening Attendance intervention is feasible in primary care; however, consideration should be given to how best to facilitate local tailoring. A definitive trial of clinical and cost-effectiveness is required with preliminary results suggesting a positive effect on uptake.

Trial registration number: NCT03901898.

Keywords: diabetes & endocrinology; diabetic retinopathy; primary care.

Figure 1

Improving Diabetes Eye screening Attendance (IDEAs) intervention overview; implementation strategies in italics. *Delivered by FR. HCP, Health Care Professional.

Figure 2

Consolidated Standards of Reporting Trials (CONSORT) flow diagram of practices and patients through the study, and timing of data collection (audit, research processes, questionnaires and interviews). *Practices were selected from 39 who expressed an interest during the recruitment period (1 month). They represented a mix of practices and we were able to sample for different practice characteristics (deprivation, size) at this point. In total, 60 practices expressed an interest in the 2-month period after the study was first advertised. βDropout: on initiating the audit the practice found it would require significantly more time than they could allocate to it, partly as many patient records had relevant data in older handwritten charts. ¶12/83 non-attenders were not deemed suitable for follow-up reminders by intervention practices.

Figure 3

Thematic map representing the inter-relationship between implementation outcomes. S denotes where staff-level data contributed to the theme; P denotes where patient-level data contributed. Gradients demonstrate whether themes relate to specific or multiple outcomes. Arrows indicate the directionality of influence (eg, both appropriateness and practicability influenced perceptions of acceptability). DRS, diabetic retinopathy screening.