Pharmacy Staff Opinions Regarding Diabetic Retinopathy Screenings in the Community Setting: Findings from a Brief Survey

Abstract

Background

Diabetic retinopathy is a retinal vascular disorder that affects more than 4.1 million people in the United States. New methods of detecting and ensuring adequate follow-up of this life-altering disease are vital to improving patient outcomes. Wills Eye Hospital and the Centers for Disease Control and Prevention are conducting a collaborative study to initiate a novel diabetic retinopathy screening in the community setting.

Objective

To evaluate the feasibility of a more widespread, large-scale implementation of this novel model of care for diabetic retinopathy screening in the community setting.

Methods

A simple, self-administered survey was distributed to pharmacists, pharmacy technicians, student pharmacists, and Wills Eye Hospital interns. The survey consisted of open-ended questions and responders were given 1 week to respond. A total of 22 surveys were distributed and 16 were completed. The responses were culled and analyzed to assess the feasibility of implementing this novel screening model in the pharmacy.

Results

The response rate to this pilot survey was 72%. The majority of the responding pharmacy staff members indicated that diabetic retinopathy screening in community pharmacies would greatly benefit patients and could improve patient care. However, they also noted barriers to implementing the screening, such as concerns about the cost of carrying out the screenings, the cost of the equipment needed to be purchased, and the lack of time and shortage of pharmacy staff.

Conclusion

The potential exists for pharmacists to positively influence diabetes care by implementing retinopathy care through the early detection of the disease and reinforcement of the need for follow-up; however, real-world barriers must be addressed before widespread adoption of such a novel model of care becomes feasible.

Diabetic retinopathy is a retinal vascular disorder that often presents asymptomatically in its early stages and can progress to include visual symptoms such as blurry vision, dark or floating spots, vision loss, and complete blindness in its later stages.1–3 Diabetic retinopathy affects more than 4.1 million people in the United States and can severely impact vision.2,4,5 The American Academy of Ophthalmology and the American Diabetes Association recommend that all patients affected by diabetes have fundus examinations at least annually.6,7 Dilated fundus examinations require dilating the pupils to better see into the periphery of the eye. However, lack of time, not understanding the importance of screening for diabetic retinopathy, and lack of access to screening have resulted in 35% to 79% of patients not adhering to current recommendations.7–10

A review of the literature for any type of community pharmacy–based patient intervention, performed in early January of 2013, revealed no published studies on the involvement of community pharmacists in diabetic retinopathy screenings. However, community pharmacy screenings that focused on other diseases have shown promising results for this type of intervention.11–17

The Table (page 550) summarizes the findings of these previously published pharmacist community screening programs for a variety of disease states, including osteoporosis, cardiovascular disease, peripheral arterial disease, and chlamydia.

Table.

Previously Published Studies Examining Community Pharmacy Screening Programs

Screening type/study (publication year)	Objective	Setting	Participants, type (N)	Results
Chlamydia screening study (2010)11	Qualitative analysis of pharmacists' views on chlamydia screening	Community pharmacy	Pharmacists (26)	Pharmacists appreciated the opportunity to expand their practice by providing chlamydia screenings, but were hesitant to provide screening to certain women (eg, married women or those in long-term relationships)
Study of diabetes and CV conditions (2006)12	To assess a new screening model for diabetes, hypertension, and dyslipidemia	Community pharmacy and non-healthcare settings	Patients: high-risk elderly (888)	Pharmacists were able to identify patients with elevated glucose, cholesterol, and blood pressure
Screening for PAD (2011)13	To evaluate the feasibility of a community pharmacy pharmacist-initiated PAD screening program	Community pharmacy	Patients (39)	The screening program was effective in increasing PAD recognition and demonstrated program feasibility
COPD screening study (2012)14	To assess the ability of pharmacists in community pharmacies to accurately conduct COPD screenings	Community pharmacy	Patients (185)	Pharmacists are able to effectively conduct COPD screenings and interpret results
Screening for CV risk (2010)15	To assess the ability of community pharmacists to conduct CV risk screenings	Community pharmacy	Patients (655)	The results show the ability of a CV screening program to improve diagnoses of high-risk individuals and to help contain the burden of CV disease
Osteoporosis screening (2010)16	To assess an osteoporosis screening and patient education program in community pharmacies	Community pharmacy	Patients (262)	The osteoporosis screening program doubled the number of patients who proceeded for further testing or treatment
Osteoporosis screening study (2008)17	To develop an effective community pharmacy screening program for the detection of osteoporosis in women	Community pharmacy	Patients: women (159)	With the benefit of an effective screening program, women who were screened revealed high proportions of lifestyle or medication modifications at 3- or 6-month follow-up

COPD indicates chronic obstructive pulmonary disease; CV, cardiovascular; PAD, peripheral arterial disease.

The successful outcomes of these studies provide insight into the feasibility of implementing diabetic retinopathy screenings in community pharmacies, showing that quick interventions, such as friendly reminders and on-the-spot counseling, are effective ways to motivate patients to improve their health.

Diabetic Retinopathy Community Pharmacy Study

The Wills Eye Institute Department of Research and the Centers for Disease Control and Prevention (CDC) are completing a collaborative study to test diabetic retinopathy screenings in a community pharmacy setting. The screening is performed using the Nidek fundus camera, which has a market price of $26,000 and can be completed in approximately 15 minutes. Patients do not require chemical dilation, and the process is painless.

Although the Nidek fundus camera is not the gold standard for screening for diabetic retinopathy, it is an emerging practice that shows promise in identifying eye abnormalities. Of the patients screened at Wills Eye Hospital, 10% showed signs of diabetic retinopathy and 49% showed signs of other eye abnormalities, such as cataracts and hypertensive changes.

Despite these promising findings, the technology can only be successfully integrated into pharmacy settings if staff members are trained and have the necessary time and tools to conduct the screenings. Pharmacies are often very busy, and additional staff may be required to operate the camera and spend time screening patients.

To explore these issues, we created and conducted a brief open-ended pharmacy staff survey assessing the potential benefits and barriers of such screening. This pilot survey was an unfunded research exercise conducted outside of the formal CDC parent project.

Methods

Surveys were self-administered on paper by 5 pharmacists, 3 pharmacy technicians, 3 pharmacy students, and 5 research interns who were working at or who were connected to the pharmacy that participated in the diabetic retinopathy screening study. Research interns were actively running the eye screenings, while the pharmacists and pharmacy technicians referred patients with diabetes to the beneficial free screening. Each respondent was given 1 week to answer the survey, and responses were collected in person at the end of the 1-week time frame.

The total study sample included 16 respondents (Figure 1, page 550) of a total of 22 surveys distributed, resulting in a 72% response rate.

Figure 1. Participants in the Pharmacy Staff Survey, by Type (N = 16).

The survey consisted of 7 open-ended questions regarding the benefits of the eye screening, possible barriers to widespread implementation (Figure 2, page 551), and personal opinions of the screening (see Appendix at www.ahdbonline.com). Because this was a pilot survey of attitudes and beliefs of the pharmacy staff, approval by an Institutional Review Board was not required.

Figure 2. Survey of Staff Opinions about Pharmacy Vision Screenings.

TJUH indicates Thomas Jefferson University Hospital.

KEY POINTS

• ▸Diabetic retinopathy, which can severely impair vision, affects more than 4.1 million patients in the United States.
• ▸Only approximately 50% to 60% of patients with diabetic retinopathy follow the recommendation for an annual fundus examination.
• ▸Community pharmacy screenings for other disease states show promise for the successful screening of patients with diabetic retinopathy as well.
• ▸This pilot survey is the first analysis regarding the potential role of community pharmacists in diabetic retinopathy screening.
• ▸For community pharmacies to successfully screen this patient population, staff members must be trained and have the necessary time and tools to conduct the screenings.
• ▸Barriers to the successful implementation of such screenings must be addressed and include lack of time, cost of the equipment needed, and a shortage of pharmacy staff.
• ▸Screenings can potentially reduce the burden of diabetic retinopathy through early detection and reinforcement of the need for follow-up.

Results

The responses to the survey by the pharmacy professionals revealed several potential benefits for the diabetic retinopathy screenings when done by pharmacists.

First, pharmacists are convenient and accessible healthcare providers who are trained to counsel patients to improve healthy behaviors.

Second, pharmacists can readily identify patients with diabetes for screening based on their medication histories.

Third, placing this technology at the hands of community pharmacists enables the detection not only of diabetic retinopathy but of other eye abnormalities that may remain otherwise undiagnosed. Furthermore, patients may feel comfortable approaching pharmacists, because doing so is free and does not require an appointment.

However, the survey findings also suggested a number of barriers to implementing diabetic retinopathy screening in community pharmacy settings. For example, in high-volume pharmacies, respondents indicated that there would not be enough time to run diabetic retinopathy screenings in addition to completing their daily responsibilities. To do so, they would need an additional staff dedicated to run the screenings to prevent the process from interfering with the daily workflow.

Another barrier relates to the cost of the Nidek fundus camera screening device. The expense associated with the purchase of this technology would only be justified if the volume of patients screened at each pharmacy resulted in reimbursements sufficient to recoup its cost. Currently, the diabetic nephropathy screening is being provided at no charge; however, the respondents noted that large-scale, sustainable implementation would require pharmacies to charge for this screening to make it financially feasible.

Conclusion

The responses to our pilot survey showed that diabetic retinopathy screenings by community pharmacies are beneficial to patients, although real-world implementation barriers exist. Pharmacists are in a unique position to identify diabetic retinopathy screening candidates based on their medication histories and can utilize the screenings as a vehicle for promoting patients to seek diabetic retinopathy care from their physicians. However, the time and resources required to implement the screenings must be addressed. If implemented, diabetic retinopathy community pharmacy screenings have the potential to reduce the burden of diabetic retinopathy at the population level and to also positively impact the care of individual patients through detection and reinforcement of the need for follow-up.