Barriers and facilitators to diabetic retinopathy screening within Australian primary care

Diabetic retinopathy (DR) is one of the earliest clinically observable complications of diabetes mellitus, and it is a major cause of vision impairment and blindness [1, 2]. According to Australia’s Eye Health Survey 2016, among adults 40 years of age and older, the sampling weight-adjusted prevalence of any DR and vision-threatening diabetic retinopathy (VTDR) was 39.4% (95% CI, 33.1–46.1) and 9.5% (95% CI, 6.8–13.1), respectively [3]. The Blue Mountains Eye Study reported that the 5-year DR cumulative-incidence and DR progression were 22.2 and 25.9% in Australia [4]. Among the global population, approximately 93 million people were affected by DR, 17 million were affected by proliferative DR, 21 million were affected by diabetic macular oedema, and 28 million had VTDR [5]. Vision loss affects the national economy by losing productivity and earning capacity [6]. With projected increases in people with diabetes, the economic burden of sight-threatening complications of diabetes will invariably increase [7, 8].

Approximately half of the people with proliferative DR who do not obtain prompt treatment will be blind in 5 years [9]. Critically, detecting DR at an early stage, followed by timely and adequate treatment, can prevent more than 90% of diabetes-related vision loss [10]. The early stages of DR are asymptomatic, and therefore, systematic retinal screening is essential. The Australian National Health and Medical Research Council (NHMRC) recommends biennial retinal screening for people with diabetes but no evidence of DR and annual retinal screening for Indigenous people with diabetes and those known to have DR [11].

Retinal photography has moved retinal examination away from the traditional method of using slit-lamp biomicroscopy or ophthalmoscope with mydriatics performed by optometrists or ophthalmologists [12]. Non-mydriatic retinal photography has become a more popular DR screening technique, with a sensitivity of at least 80% compared with a reference standard [13]. This technique is easy and safe and can be carried out by nurses or other trained personnel. Retinal photography also enables tele-retinal screening, referring to teleophthalmology whereby retinal images can be transferred online to offsite eye experts for further opinion [14]. This approach can enhance patients’ access to eye care, particularly for those in remote regions. Tele-retinal screening for DR has been successfully implemented in other health programs like the UK, USA, and Singapore [15‐18].

Medicare is Australia’s universal health insurance scheme equivalent to the UK National Health Service (NHS). In 2016, the Department of Health, Australia introduced two new Medicare Benefits Schedule items (MBS items 12,325 ‘for Aboriginal and Torres Strait Islander population’ and MBS items 12,326 ‘for general population’) to support retinal photography and image reporting by general practitioners (GPs) rather than ophthalmologists or optometrists [19]. Pre-introduction modelling suggested that over 400,000 patients with diabetes would be screened after introducing MBS items for retinal photography. However, data from the Department of Health show that these MBS items have been massively underused [19]. For instance, between July 2016 and July 2020, only 4256 Indigenous Australians and 3776 non-Indigenous Australians were screened by GPs with claims on the MBS [19].

Despite the appeal of retinal photography in facilitating retinal screening, including incentives through Medicare, comprehensive DR screening has not been achieved in Australia. Studies have shown that only 50–77% of non-Indigenous Australians and 20–44% of Indigenous Australians receive appropriate retinal screening [20‐23]. This gap between the recommended NHMRC retinal examination guidelines and actual DR screening rates relates to several factors, including patients’ knowledge of both the condition and the need for retinal screening, doctor-patient’s communications, travel, operating costs, infrastructure, and time constraints within general practice [24‐26].

There have been some qualitative analyses of the barriers to DR screening in the Australian general practice setting, but all were conducted before introducing MBS items for retinal photography in 2016 [27‐31]. The current study aimed to explore key factors affecting the provision of DR screening for patients with diabetes from GPs’ perspectives and determine effective strategies to enhance the successful integration of DR screening into practice workflow.

Qualitative research, utilising in-depth interviews with primary care providers in Australia, was conducted between November 2019 and March 2020. A descriptive qualitative content analysis approach, guided by the existing theoretical framework and naturalistic inquiry, was used to interpret meaning from data generated from the participants’ responses [32]. The current study was performed in accordance with the Standards for Reporting Qualitative Research [33] (supplementary file 1). The study was approved by the CSIRO Health and Medical Human Research Ethics Committee (Ref no: 2019_070_LR).

Thirteen male and two female GPs aged 54.7 ± 15.5 years completed phone interviews. All interviewees were based in WA or NSW, and 60% were practising in urban regions. Four GPs had attended medical schools overseas (namely, one in the UK, two in South Africa and one in India), while the remaining 11 GPs had attended Australian medical schools. A summary of participants’ characteristics is presented in Table 1.

None of the interviewees conducted DR screening in general practice. All interviewees had access to a direct ophthalmoscope, but none had retinal cameras or image analysis software in their general practices. Only three interviewees were aware that MBS items 12,325 and 12,326 allowed GPs to bill for retinal screening using a non-mydriatic retinal camera.

Seven themes were identified as related to potential facilitators and barriers to more widespread implementation of DR screening within Australian primary care (Table 2).

Although all vision loss due to DR is preventable with early detection and timely treatment, yet DR remains one of the common causes of vision impairment and blindness worldwide [1, 5]. The main findings of this study were that most interviewees were unaware of MBS items for retinal screening, did not carry out retinal screening in practice and felt that their primary role was to refer patients requiring DR screening to optometrists or ophthalmologists. These concerns were mainly attributed to the lack of skills to diagnose DR accurately, costs of retinal cameras, time constraints within the practice and the absence of dedicated staff to take the responsibility of retinal photography.

The number of times GPs screened for DR between 2016 and 2020 was far lower than they initially predicted [19]. Most interviewees were unaware of the MBS items for retinal photography and DR screening requirements in general practice. This is coupled with GPs lacking competence in interpreting retinal images and uncertainty about their role in this service. These system-level factors seem to underpin the underuse of MBS items for retinal screening and willingness to refer any patient requiring retinal examination to optometrists. If the intent of MBS items is to be successfully implemented, then there is a need to invest more in a nationwide awareness campaign amongst GPs to encourage the use of these items. Previous studies suggested increased opportunities for continuing professional development (CPD) as a viable solution for lacking skills and confidence to diagnose DR accurately [27, 29, 44]. For instance, the University of Melbourne launched an online Self-Directed Diabetic Retinopathy Grading Course in 2017 to train GPs in images’ interpretation and make appropriate referral timelines for DR [45].

Costs of the retinal cameras (around $30,000 AUD) and the current incentive structure through Medicare were perceived as DR screening barriers in general practice. Such system-level barriers have been observed in previous studies [27, 38]. Governmental assistance, particularly for small or rural general practices, could positively impact the uptake of MBS items and facilitate DR screening into practice workflow. Given that most interviewees reported that they are not competent in diagnosing DR from retinal images, some suggested uncoupling the need for GPs to undertake both retinal photography and image reporting. Letting GPs concentrate on capturing retinal images for forwarding to eye care experts to review. This was also considered by the Medicare Services Advisory Committee when approving these MBS items in 2014 [46].

The interviewees reported insufficient time to conduct retinal photography as a primary barrier to DR screening in general practice. This provider-level barrier was consistent with previous studies indicating GPs’ concerns about the time required for training and the time involved in taking and reading images [27, 44]. In the current study, interviewees recognised the need for a champion and took responsibility for DR screening to become part of an ongoing practice workflow. The need for dedicated staff within general practices has been observed previously [27]. Nurses could play a fundamental role in organising appointments and collecting retinal images from patients when attending regular check-ups. The availability of the MBS items for general practice DR screening and the MBS item number 10997 for chronic disease management by practice nurses would encourage GPs to support the delivery of DR screening.

The recent emergence of Artificial Intelligence (AI), particularly deep learning, provides an accurate, objective and timely automated reading for DR from retinal images [47‐49]. Interviewees’ attitudes to these technologies were overwhelmingly positive provided the sensitivity of the AI system is high enough, although some flagged there could be medico-legal issues concerning the responsibility for the results. The use of AI could help uncouple the two components of the MBS items for general practice DR screening. In addition, its use in clinical practice would significantly enhance the opportunity to increase DR screening rates and improve adherence to the NHMRC screening criteria.

GPs see patients with diabetes more than other health professionals and maintain good, long-standing relationships with many of their patients. Therefore, GPs are well-placed for conducting an opportunistic screening. Interviewees considered themselves gatekeepers of the healthcare system and were keen to play a more significant role in DR screening if their needs could be met. Therefore, it was reasonable to introduce the MBS items to encourage GPs for DR screening in general practice in targeting this important condition.

The present study fits in the international context as an existing theoretical framework [50, 51] was adopted to inform the interview topics guide and qualitative data analysis. Although findings from this study were specific to the Australian health system, several lessons can be drawn that can enrich the current literature. Our findings were consistent with the current literature [25, 26], which cited costs, infrastructure, and time constraints as main barriers to DR screening in primary care. The present study also identified other provider and system-level factors, including competency, training and reimbursements that may affect rolling out DR screening in primary care. Despite insurers’ support (e.g., incentives through Medicare) to implement a successful DR screening program within Australian primary care, this has been insufficient to increase the screening rates. The barriers within the same theme may interact with more than one of the healthcare system levels (i.e., system, provider and patient) [25]. For instance, unawareness of MBS items and lack of training were system-level barriers that caused health providers to underuse DR screening and uncertainty about their role in this service. Such shortcomings contributed to reduced uptake of DR screening and poor coordination and integration of retinal screening service, which require resolving the obstacles impacting all three levels, with the patient at the centre, to maximise DR screening rates and consequently reduce the risk of blindness from diabetes.

Against this background, there is a need to develop a better framework of crucial enablers that underpin the successful model of DR screening in general practice. Along with insurers’ support, the following enabling strategies can be adopted, which are consistent with other successful international DR screening models, the NHS retinal screening program [15]:

The purposive sampling methods used may restrict the variation of the participating sample. The majority of participants were male doctors, meaning that the views and experiences of female doctors in Australia were not well represented in our data. Thus, in-depth interviews with more GPs from both genders may have enabled more detailed reflections on barriers. Despite this, the study sample included GPs with varying experiences and ages from different practice settings and locations. The present study explored critical factors affecting the delivery of DR screening from GPs’ perspective; thus, further research is needed to identify other barriers in the healthcare system or from the patients’ perspectives. In addition, it would be worth investigating other common themes that have not been covered in the present study [25, 26], in particular, patients’ education, staff communications, infrastructure, coordination and integration of the service, quality assurance and the need for diabetes registry.

There has been an overestimation that introducing MBS items for retinal photography would offer adequate incentives for GPs to incorporate DR screening into practice workflow, yet significant barriers exist. The present study identified essential content themes at individual, provider and system levels that provide crucial and pragmatic additional insights into what needs to be addressed to promote widespread DR screening within primary care. Providing accessible one-stop comprehensive diabetes care service, reviewing the current incentive structures, subsidising the cost of retinal cameras, and improving GPs’ competency may all contribute to the success of DR screening in general practices and reduce preventable blindness.