The protocol of this study is registered as ''The Comparative Effectiveness of Telemedicine to Detect Diabetic Retinopathy'' with ClinicalTrials.gov having clinical trial registration number NCT01364129. The findings and conclusions in this article are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The sponsor or funding organization had no role in the design or conduct of this research. AbstractObjective: To determine the effectiveness of telemedicine for providing diabetic retinopathy screening examinations compared with the effectiveness of traditional surveillance in community health clinics with a high proportion of minorities, including American Indian/Alaska Natives. Subjects and Methods: We conducted a multicenter, randomized controlled trial and assigned diabetic participants to one of two groups: (1) telemedicine with a nonmydriatic camera or (2) traditional surveillance with an eye care provider. For those receiving telemedicine, the criteria for requiring follow-up with an eye care provider were (1) moderate nonproliferative diabetic retinopathy or higher, (2) presence of clinically significant macular edema, or (3) ''unable to grade'' result for diabetic retinopathy or macular edema. Results: The telemedicine group (n = 296) was more likely to receive a diabetic retinopathy screening examination within the first year of enrollment compared with the traditional surveillance group (n = 271) (94% versus 56%, p < 0.001). The overall prevalence of diabetic retinopathy at baseline was 21.4%, and macular edema was present in 1.4% of participants. In the telemedicine group, 20.5% would require further evaluation with an eye care provider, and 86% of these referrals were because of poorquality digital images. Conclusions: Telemedicine using nonmydriatic cameras increased the proportion of participants who obtained diabetic retinopathy screening examinations, and most did not require follow-up with an eye care provider. Telemedicine may be a more effective way to screen patients for diabetic retinopathy and to triage further evaluation with an eye care provider. Methods to decrease poor quality imaging would improve the effectiveness of telemedicine for diabetic retinopathy screening examinations.
Objective To identify variables that predict adherence with annual eye exams using the Compliance with Annual Diabetic Eye Exams Survey (CADEES), a new questionnaire designed to measure health beliefs related to diabetic retinopathy and annual eye exams. Design Questionnaire development. Participants Three hundred and sixteen adults with diabetes. Methods We developed the CADEES based on a review of the literature, the framework of the Health Belief Model, expert opinion, and pilot study data. To examine content validity, we analyzed participant responses to an open-ended question asking for reasons why people do not obtain annual eye exams; we then used these results to determine whether there were content areas missing from the survey. We evaluated construct validity with principal components analysis and examined internal consistency with Cronbach’s alpha. To assess predictive validity, we used multivariate logistic regression with self-reported adherence as the dependent variable. Main Outcome Measures Associations with self-reported adherence (defined as having a dilated eye exam in the past year). Results The content analysis showed that CADEES items covered 89% of the reasons given by participants for not obtaining an annual eye exam. The principal components analysis identified three informative components comprising 32% of the variance, and reliability analyses showed acceptable Cronbach’s alphas (>0.60) for all three components. Multivariate logistic regression modeling revealed several significant predictors of adherence, including beliefs concerning: whether insurance covered most of the eye exam cost (p<0.01), whether there were general barriers that make it difficult to get an eye exam (p<0.01), whether obtaining an eye exam was a top priority (p=0.02), and whether diabetic eye disease can be seen with an exam (p=0.05). Lower hemoglobin A1c levels (p<0.01), having insurance (p=0.01), and a longer duration of diabetes (p=0.02) were also associated with adherence. A multivariate model containing CADEES items and demographic variables classified cases with 72% accuracy and explained approximately 24% of the variance in adherence. Conclusions The CADEES showed good content and predictive validity. While future research is needed before finalizing a shorter version of the survey, researchers and clinicians may be able to improve adherence by (1) counseling newly diagnosed patients, as well as those with uncontrolled blood sugar control, on the importance of annual eye exams, and (2) discussing perceived barriers and misconceptions related to obtaining annual eye exams.
Objective Nonadherence reduces glaucoma treatment efficacy. Motivational interviewing (MI) is a well-studied adherence intervention, but has not been tested in glaucoma. Reminder interventions also may improve adherence. Design 201 patients with glaucoma or ocular hypertension were urn-randomized to receive MI delivered by an ophthalmic technician (OT), usual care, or a minimal behavioral intervention (reminder calls). Main Outcome Measures Outcomes included electronic monitoring with Medication Event Monitoring System (MEMS) bottles, two self-report adherence measures, patient satisfaction, and clinical outcomes. Multilevel modeling was used to test differences in MEMS results by group over time; ANCOVA was used to compare groups on other measures. Results Reminder calls increased adherence compared to usual care based on MEMS, p = .005, and self-report, p = .04. MI had a nonsignificant effect but produced higher satisfaction than reminder calls, p = .007. Treatment fidelity was high on most measures, with observable differences in behavior between groups. All groups had high baseline adherence that limited opportunities for change. Conclusion Reminder calls, but not MI, led to better adherence than usual care. Although a large literature supports MI, reminder calls might be a cost-effective intervention for patients with high baseline adherence. Replication is needed with less adherent participants.
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