Population-Level Teleretinal Screening Bulk Orders to Improve Diabetic Retinopathy Screening Rates: A Randomized Quality Improvement Trial

Background: Diabetic retinopathy (DR) is a leading cause of blindness; however, many patients with type 2 diabetes (T2DM) are not up to date with screening guidelines. This study explored the impact of teleretinal screening bulk orders on the DR screening completion rate. Methods: In this randomized controlled trial, eligible patients with T2DM due for DR screening were randomly assigned to receive a teleretinal screening bulk order at one of four monthly time points, following a stepped-wedge design. Teleretinal screening bulk orders are placed by a centralized provider for a defined patient cohort. They include a retinal fundus photo order and an associated electronic patient education message. Logistic regression at the patient-month level, with errors clustered at the patient level, was used to evaluate the effect of bulk orders on DR screening completion rate. Two-stage least squares was used to evaluate the effects of opening the message, using random assignment as an instrument. Results: A total of 5,665 eligible patients were identified for this study. At six months from the first bulk order, the overall DR screening completion rate was 17.5% ( n = 994). Receiving a bulk order increased odds of completing screening (odds ratio [OR]: 1.78; confidence interval [CI] 95%: 1.49, 2.14; p < 0.001). 2,763 patients (48.7%) opened the electronic patient message. Opening the message increased completion rates by 8.5% (95% CI; 6.0%, 11.1%; p < 0.001) and retinal fundus photo appointments scheduled by 19.1% (95% CI; 16.8%, 21.3%; p < 0.001). Conclusion: Teleretinal screening bulk orders were associated with a significant increase in DR screening. Population-level interventions should be implemented to improve diabetes preventative care.