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Cited by 59Retinal Diseases and TreatmentsRetinal Imaging and AnalysisDiabetes Management and Education

Adherence to ophthalmology referral, treatment and follow-up after diabetic retinopathy screening in the primary care setting

Open access
Bresnick, George, Cuadros, Jorge A, Khan, Mahbuba, Fleischmann, Sybille, Wolff, Gregory, Limon, Andrea, Chang, Jenny, Jiang, Luohua +2 more·2020·BMJ Open Diabetes Research & Care
DOI 10.1136/bmjdrc-2019-001154PMC PMC7312438
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Abstract

Introduction: Telemedicine-based diabetic retinopathy screening (DRS) in primary care settings has increased the screening rates of patients with diabetes. However, blindness from vision-threatening diabetic retinopathy (VTDR) is a persistent problem. This study examined the extent of patients’ adherence to postscreening recommendations. Research design/methods: A retrospective record review was conducted in primary care clinics of a large county hospital in the USA. All patients with diabetes detected with VTDR in two time periods, differing in record type used, were included in the study: 2012–2014, paper charts only; 2015–2017, combined paper charts/electronic medical records (EMRs), or EMRs only. Adherence rates for keeping initial ophthalmology appointments, starting recommended treatments, and keeping follow-up appointments were determined. Results: Adequate records were available for 6046 patients; 408 (7%) were detected with VTDR and recommended for referral to ophthalmology. Only 5% completed a first ophthalmology appointment within recommended referral interval, 15% within twice the recommended interval, and 51% within 1 year of DRS. Patients screened in 2015–2017 were more likely to complete a first ophthalmology appointment than those in 2012–2014. Ophthalmic treatment was recommended in half of the patients, of whom 94% initiated treatment. A smaller percentage (41%) adhered completely to post-treatment follow-up. Overall, 28% of referred patients: (1) kept a first ophthalmology appointment; (2) were recommended for treatment; and (3) initiated the treatment. Most patients failing to keep first ophthalmology appointments continued non-ophthalmic medical care at the institution. EMRs provided more complete information than paper charts. Conclusions: Reducing vision impairment from VTDR requires greater emphasis on timely adherence to ophthalmology referral and follow-up. Prevention of visual loss from VTDR starts with retinopathy screening, but must include patient engagement, adherence monitoring, and streamlining ophthalmic referral and management. Revision of these processes has already been implemented at the study site, incorporating lessons from this investigation.

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  • After AI interpretation, delayed result communication, unclear referral pathways, insufficient patient-facing communication, referral loss, or inadequate treatment capacity can prevent automated detection from becoming completed care.

    “After AI interpretation, delayed result communication, unclear referral pathways, insufficient patientfacing communication, referral loss, or inadequate treatment capacity can prevent automated detection from becoming completed care (17)(18)(19)(20)(21)(22)(23).”

    From From validation to public health impact: implementing equitable AI-enabled diabetic retinopathy screening (2026) · cites this paper as [19]

    The Discussion (page not supplied) documents referral loss: some patients who missed an ophthalmology appointment had no recorded formal referral, and the authors call for better referral tracking. The Introduction says patients need education about timely specialist care. But this study used human retinal graders, not AI, and the cited passages do not establish delayed result communication or inadequate treatment capacity as barriers. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Other US reports show 5-51% referral uptake within recommended timeframes.

    “These low baseline rates of referral uptake align with other US reports showing 5–51% referral uptake within recommended timeframes12, indicating substantial potential benefit in these settings.”

    From Referral uptake after diabetic retinopathy screening with artificial intelligence-assisted care pathways: a systematic review and meta-analysis (2026) · cites this paper as [12]

    The Results > Adherence rates section reports that 5% kept a first ophthalmology appointment within the recommended referral interval. It reports 48% and 56% within one year in two study periods, but one year was not the recommended interval for those patients. The cited paper therefore does not support describing the 51% figure as referral uptake within recommended timeframes. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • Even after primary care DR screening, adherence to ophthalmology referral, treatment, and follow-up can remain incomplete.

    “Bresnick and colleagues showed that even after primary care DR screening, adherence to ophthalmology referral, treatment, and follow-up can remain incomplete (19).”

    From From validation to public health impact: implementing equitable AI-enabled diabetic retinopathy screening (2026) · cites this paper as [19]

  • Referral uptake for those with referable diabetic retinopathy is sub-optimal.

    “Indeed, beyond challenges of access and attendance at routine DR screening, referral uptake for those with referable DR is sub-optimal11,12 resulting in unmanaged patients at risk of blindness.”

    From Referral uptake after diabetic retinopathy screening with artificial intelligence-assisted care pathways: a systematic review and meta-analysis (2026) · cites this paper as [12]

  • Sub-optimal referral uptake results in unmanaged patients at risk of blindness.

    “Indeed, beyond challenges of access and attendance at routine DR screening, referral uptake for those with referable DR is sub-optimal11,12 resulting in unmanaged patients at risk of blindness.”

    From Referral uptake after diabetic retinopathy screening with artificial intelligence-assisted care pathways: a systematic review and meta-analysis (2026) · cites this paper as [12]

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Cites

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Research works printed but not linked: 23

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Authors
Bresnick, G., Cuadros, J. A., Khan, M., Fleischmann, S., Wolff, G., Limon, A., Chang, J., Jiang, L., Cuadros, P., & Pedersen, E. R.
Affiliations
  • University of California, Berkeley (US)
  • Family Medicine, Riverside University Health System, Riverside, California, USA
  • Advanced Clinical, Chicago, Illinois, USA
  • EyePACS, Santa Cruz, California, USA
  • University of California, Irvine (US)
  • Google (United States) (US)
Corresponding author
Bresnick, George
ORCID
Venue
BMJ Open Diabetes Research & Care
Publisher
BMJ
Published
2020-06
Volume
8
Issue
1
Pages
e001154
ISSN
2052-4897 (ISSN-L)
DOI
10.1136/bmjdrc-2019-001154
PMC
PMC7312438
OpenAlex
W3036885589
Cited by
59
References
1
Citations by year
2026: 11 · 2025: 11 · 2024: 11 · 2023: 11 · 2022: 10 · 2021: 5
FWCI
5.15
Type
journal article
Language
en
Open access
Licence
Locations
  • BMJ Open Diabetes Research & Care (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • eScholarship (California Digital Library) (submittedVersion)
  • eScholarship (California Digital Library) (submittedVersion, cc-by-nc)
Funders
  • EyePACS LLC, Santa Cruz, CA (none)
  • Google LLC, Mountain View, CA (none)
Topics
  • Health Sciences › Medicine › Ophthalmology › Retinal Diseases and Treatments
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Retinal Imaging and Analysis
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Keywords
diabetic retinopathy, vision-threatening diabetic retinopathy, ophthalmology referral, medication adherence, follow-up visits, telemedicine screening, electronic health records, paper charts, primary care, diabetes mellitus, blindness prevention
MeSH terms
Diabetes Mellitus, Diabetic Retinopathy, Follow-Up Studies, Humans, Ophthalmology, Primary Health Care, Referral and Consultation, Retrospective Studies

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