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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
  1. Yao Liu1,2,
  2. Nicholas J Zupan1,
  3. Rebecca Swearingen1,2,
  4. Nora Jacobson3,
  5. Julia N Carlson1,
  6. Jane E Mahoney4,
  7. Ronald Klein1,
  8. Timothy D Bjelland5,
  9. Maureen A Smith2,6
  1. 1 Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
  2. 2 Health Innovation Program, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
  3. 3 Institute for Clinical and Translational Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
  4. 4 Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
  5. 5 Mile Bluff Medical Center, Mauston, Wisconsin, USA
  6. 6 Departments of Population Health Sciences, Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
  1. Correspondence to Dr Yao Liu; liu463{at}wisc.edu, yaoliumd{at}gmail.com

Abstract

Objective Teleophthalmology for diabetic eye screening is an evidence-based intervention substantially underused in US multipayer primary care clinics, even when equipment and trained personnel are readily available. We sought to identify patient and primary care provider (PCP) barriers, facilitators, as well as strategies to increase teleophthalmology use.

Design We conducted standardised open-ended, individual interviews and analysed the transcripts using both inductive and directed content analysis to identify barriers and facilitators to teleophthalmology use. The Chronic Care Model was used as a framework for the development of the interview guide and for categorising implementation strategies to increase teleophthalmology use.

Setting A rural, US multipayer primary care clinic with an established teleophthalmology programme for diabetic eye screening.

Participants We conducted interviews with 29 participants (20 patients with diabetes and 9 PCPs).

Results Major patient barriers to teleophthalmology use included being unfamiliar with teleophthalmology, misconceptions about diabetic eye screening and logistical challenges. Major patient facilitators included a recommendation from the patient’s PCP and factors related to convenience. Major PCP barriers to referring patients for teleophthalmology included difficulty identifying when patients are due for diabetic eye screening and being unfamiliar with teleophthalmology. Major PCP facilitators included the ease of the referral process and the communication of screening results. Based on our results, we developed a model that maps where these key patient and PCP barriers occur in the teleophthalmology referral process. Patients and PCPs also identified implementation strategies to directly address barriers and facilitators to teleophthalmology use.

Conclusions Patients and PCPs have limited familiarity with teleophthalmology for diabetic eye screening. PCPs were expected to initiate teleophthalmology referrals, but reported significant difficulty identifying when patients are due for diabetic eye screening. System-based implementation strategies primarily targeting PCP barriers in conjunction with improved patient and provider education may increase teleophthalmology use in rural, US multipayer primary care clinics.

  • diabetic retinopathy
  • organisation of health services
  • public health
  • telemedicine
  • qualitative research

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

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Footnotes

  • Patient consent for publication Not required.

  • Contributors YL, RS and NJ developed the interview guides. RS conducted the interviews. YL, NJZ, JNC and NJ analysed the data. JEM, RK, TDB and MAS contributed to the discussion and reviewed/edited the manuscript. YL and NJZ wrote the manuscript.

  • Funding This work was supported by NIH/NEI K23 EY026518-02 and a Wisconsin Partnership Program New Investigator Award. It was also supported, in part, by an institutional grant from Research to Prevent Blindness, New York City, New York, USA to the University of Wisconsin School of Medicine and Public Health, Department of Ophthalmology and Visual Sciences. Additional support came from the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. Further support was received from the University of Wisconsin (UW) School of Medicine and Public Health Innovation Program, the Wisconsin Partnership Program and the UW Institute for Clinical and Translational Research-Community Academic Partnerships (ICTR-CAP) core.

  • Disclaimer The study sponsors had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and the decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

  • Competing interests None declared.

  • Ethics approval The University of Wisconsin School of Medicine and Public Health Human Subjects Institutional Review Board (IRB) staff reviewed all study activities in detail and determined that this research met criteria for exemption from full IRB review based on US federal Common Rule (45 CFR 46.101(b)), which provides exemptions for interview research protocols with minimal risk to participants.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data from this study are available on request from the corresponding author to those who fulfill requirements set by the University of Wisconsin Institutional Review Board.

  • Author note YL accepts full responsibility for this work as a whole, including the study design, access to the data and the decision to submit and publish the manuscript.

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