Skip to main content
Download PDF

Telescreening satisfaction: disparities between individuals with diabetic retinopathy and community health center staff

BMC Health Services Research volume 22, Article number: 160 (2022) Cite this article

Abstract

Background

The success of telescreening and the management of diabetic retinopathy (DR) in communities depends on stakeholder satisfaction, including both individuals with diabetes and community health center (CHC) staff. In this study, we investigated the satisfaction of both individuals with vision-threatening DR (VTDR) and CHC staff within the Shanghai Eye Disease Study (SEDS) comprehensive system for managing diabetic eye diseases at the primary care level.

Methods

The cross-sectional survey of patients receiving the service included 3,817 respondents with VTDR and focused on their satisfaction with the SEDS system, including the telescreening process, speed of feedback, interpretation of results, increased awareness of related diseases, and eye care services. The survey of the providers included 234 CHC staff respondents and focused on their satisfaction and the main barriers encountered during the implementation of the system. Sociodemographic characteristics and perceived barriers related to satisfaction were identified by conducting univariate and multivariate logistic regression analyses.

Results

The overall satisfaction of service recipients was 96.0%, and 75.8% of them were willing to undergo future telescreening for DR. The convenience of telescreening, organization of telescreening, and improvement in related disease awareness significantly correlated with satisfaction. Only 48.3% of the providers were satisfied with the SEDS system. The most frequently mentioned barriers to the development of the system were the inadequate levels of staffing (particularly technical staff), insufficient funding, and incomplete information transmission systems.

Conclusions

Disparities between high patient satisfaction and low provider satisfaction with the SEDS system were mainly related to the current weak level of ophthalmic expertise in the CHCs and the low awareness of screening for diabetic eye diseases among both patients and providers.

Peer Review reports

Background

The prevalence of chronic diseases, such as diabetes and hypertension, continues to rise along with increasing population longevity and lifestyle transformation [1, 2]. Individuals with chronic diseases require high-quality, accessible health care with disease management that is comprehensive, continuous, and personalized [3]. Although community-based primary care health services have existed in the People’s Republic of China (China) for more than 10 years, they have not achieved development goals and exhibit significant regional disparity [4, 5]. Moreover, the level of health care in community health centers (CHCs) is generally low owing to inadequate levels of staffing, low professional quality, and a shortage of medical resources [6, 7].

Against the background of its Healthy China strategy, the Chinese government has initiated reforms to its three-tier hierarchical medical system, which includes primary (community), general (secondary), and specialized (tertiary) hospitals. CHCs—a critical component of the primary health care system—are responsible for disease prevention and control, improvement of the general quality of life among the Chinese population, and promotion of health equality [8]. As such, CHCs undertake tasks such as the screening and diagnosis of diseases, referrals to hospitals, and the implementation of optimal strategies for the management of diseases based on intervention classification and outcomes. For example, community screening for individuals with diabetes can prevent visual impairment and blindness caused by diabetic retinopathy (DR) [9, 10]. However, although regular community DR screening is common in wealthy nations in Europe and the United States [11, 12], implementation is challenging in low- and middle-income countries owing to the increasing prevalence of diabetes, lack of eye care resources, and limited access to quality, affordable eye care [10, 13, 14]. Furthermore, most of the community management guidelines for DR are for higher-income countries with higher available resources, but no standardized guidelines exist in most developing countries with limited resources, such as China [15, 16].

In 2015, the Shanghai Diabetic Eye Study (SDES) initiated the development of a comprehensive management system for diabetic eye diseases that focuses on telescreening, referrals, and eye health management [17, 18]. It meets the eye care needs of individuals with diabetes at the community level, including the early screening, diagnosis, and intervention of DR. The success of the system depends on the satisfaction of patients receiving the services. However, the satisfaction of CHC staff—who are responsible for DR telescreening, intervention classification, and disease management—with the system is also an important factor in judging whether China’s health care system reform efforts are successful [19]. Service providers (CHC staff) and service recipients (patients) were regularly surveyed during the SDES project and seldom shared the same perspective regarding satisfaction.

In this study, we investigated the satisfaction of both service providers and recipients with the SEDS management system to understand the needs of patients with DR and clarify the difficulties faced by CHC staff. Our study has implications for scholars, public health policymakers, and stakeholders for the development of policies to promote a comprehensive management system of diabetic eye diseases at the primary care level and improve the usage of community eye care services among the targeted population.

Methods

Shanghai Diabetic Eye Study

The SDES was conducted from 2015 to 2017. A total of 211,469 patients with diabetes, aged 35 years and above, in 240 CHCs were enrolled in the study. All participants were telescreened for diabetic eye diseases by qualified optometrists and general practitioners in the CHCs, who had completed training in the SEDS comprehensive management system for diabetic eye diseases, including visual acuity assessment, autorefraction, and non-mydriatic fundus photography. A desktop digital 45° to 55° non-mydriatic retinal camera was used to obtain color retinal photographs of the early treatment DR study standard field 1 (centered on the optic disc) and field 2 (centered on the macula) for each eye [20]. Ophthalmologists in hospitals set up a remote retinal reading group and were responsible for the DR grading. Participants diagnosed with vision-threatening diabetic retinopathy (VTDR) were referred to general (secondary) and specialized (tertiary) hospitals for further diagnosis and treatment. Patients with diabetes were classified as “management” in the CHCs, based on patient diagnosis after telescreening and referrals [17, 18].

Study subjects

Recipients (individuals with DR)

Among the participants, all patients were from the SDES project. The inclusion criteria were as follows for individuals with diabetes: (1) completed DR telescreening; (2) assessed with VTDR by remote retinal image reading; (3) received classification management of diabetic eye diseases; and (4) independently completed our study’s self-report questionnaire. The eligible participants were informed about the investigation time and place, and a door-to-door survey was conducted for participants with limited physical mobility.

Providers (CHC staff)

All 240 CHC staff were involved in establishing and implementing the SEDS comprehensive management system. They were responsible for telescreening and the classification of interventions that the CHCs, general (secondary), and specialized (tertiary) hospitals perform for diabetic eye diseases. The leader of the SDES project developed the satisfaction self-report questionnaire based on staff feedback.

This study was approved by the institutional review board of Shanghai General Hospital and adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all the participants and from a legal guardian or next of kin in case of illiterate participants prior to enrollment.

Satisfaction self-report questionnaire development

Key informant interviews were conducted with both patients with DR (service recipients) and CHC staff (service providers) to assess their views and satisfaction regarding all aspects of the SEDS comprehensive management system prior to questionnaire development. The survey for individuals with DR focused on sociodemographic characteristics and perceived satisfaction with the system, including the following: the convenience of telescreening; organization of the community telescreening process; speed of feedback; interpretation of telescreening results; improvement in awareness of related diseases; eye care services in the communities. The survey of CHC staff focused on the current status of prevention and treatment of diabetic eye diseases in the communities, the main barriers currently encountered in the SEDS system, and challenges to address in the long-term development of the system. The satisfaction questionnaire includes a 5-point Likert scale ranging from 1 (very unsatisfied) to 5 (very satisfied) and multiple-choice questions.

Data analysis

From January 1 to March 31, 2018, 3,817 patients (3817/4140, 92.2% completion rate) and 234 CHCs (234/240, 97.5% completion rate) completed a self-report questionnaire of satisfaction with the SEDS comprehensive management system. The data were analyzed using IBM® SPSS® Statistics 22, and a p value < 0.05 was considered statistically significant. The responses dichotomized between “satisfied” or “very satisfied” were considered an indication of satisfaction with the system, while others were considered an indication of dissatisfaction with the system.

First, descriptive statistical analysis was applied to analyze the following: the general condition of individuals with DR; the current situation of prevention and treatment of diabetic eye diseases in the CHCs; the overall satisfaction of both service recipients and providers with the SEDS comprehensive management system; their opinions and suggestions. Second, univariate associations with variables of the overall satisfaction of the system were tested using the chi-squared test or independent-samples t-test. Furthermore, the variables with significant univariate associations were included in a multivariate logistic regression model to calculate the odds ratios and 95% confidence intervals of the variables related to the overall satisfaction with the comprehensive management system.

Results

Satisfaction of service recipients

Sample characteristics

The patients’ ages ranged from 35 to 93 years, with an average age of 66.8 years (standard deviation: 8.2); 82.7% were older than 60 years. More than 40% of the participants had only a primary school education or were illiterate. The sociodemographic data of the patients are presented in Table 1.

Table 1 Descriptives and satisfaction of the people with diabetic retinopathy with the System
Full size table

Satisfaction analysis

The overall satisfaction with the SEDS system reported by patients receiving the service (recipients) was 96.0% (3665/3817); 75.8% (2892/3817) of them were willing to continue telescreening for diabetic eye diseases in the communities the following year. No significant difference was observed in the overall satisfaction with the system among individuals with DR living in different areas or with different age, sex, marital status, and educational levels (Table 1).

According to the satisfaction survey regarding all aspects of the SEDS system (Table 2), the following were significantly associated with overall satisfaction (p < 0.05): the convenience of community telescreening (95.8%); organized process of telescreening (92.0%); environment (94.2%); staff (95.6%); feedback speed (89.1%) and interpretation (92.0%) of telescreening results; improvement in the awareness of the related diseases (96.0%); satisfaction with eye care services provided by the CHCs (96.1%). In the multivariate logistic regression model, the convenience of community telescreening, organization of telescreening processes, and improvement in the related disease awareness significantly correlated with overall satisfaction (Table 2).

Table 2 Description of satisfaction with various phases of the telescreening in people with diabetic retinopathy
Full size table

Satisfaction of providers

Sample characteristics

Among the 234 CHCs, only 49 (20.9%) had independent ophthalmic clinics; 78 (33.3%) had ophthalmic and otolaryngologic comprehensive clinics. Further, 47 (20.1%) had ophthalmologists from hospitals regularly providing eye care services, and 89 (38.0%) had no eye care service.

The number of CHCs without eye care services in the suburban area was much higher than that in the urban and semi-urban areas (Supplemental Table 1). The prevention and treatment of diabetic eye diseases were integrated into the medical services of the family doctor teams in the 66 CHCs (28.2%) and general practice services in 80 CHCs (34.2%). Moreover, 160 CHCs (68.4%) signed bilateral cooperation agreements with general (secondary) and specialized (tertiary) hospitals (Supplemental Table 2).

Satisfaction analysis

Among the CHCs, 113 (48.3%) were satisfied with the SEDS comprehensive management system (Table 3). Significant differences were found in satisfaction among the CHCs in different areas (χ2 = 45.0, P < 0.001); the satisfaction in the semi-urban areas was the highest (78.4%), and that in the suburban areas was the lowest (25.6%). Only 99 CHCs (42.3%) considered that it was necessary to conduct diabetic eye disease telescreening at the community level for individuals with diabetes, which significantly correlated with overall satisfaction with the system (P < 0.001). Furthermore, telescreening and management of diabetic eye diseases in the community were considered to incorporate routine work in 119 CHCs (51.3%) and add to the performance review of 128 CHCs (54.7%) (Table 4).

Table 3 Description of satisfaction with the System among the community health service centers’ staff
Full size table
Table 4 Necessity of screening for diabetic eye diseases in the communities and correlation with the satisfaction
Full size table

CHC recommendations

A total of 161 CHCs (68.5%) suggested that diabetic eye disease telescreening and management could be merged with other community health work. Among these, 79 (49.1%) believed that it could be merged with the ongoing management of patients with diabetes. Further, 52 (32.3%) thought that it could be merged with physical examinations for older adults, and the remaining 30 (18.6%) presumed that it could help in telescreening for diabetic eye diseases in the outpatient clinic on weekdays (Supplemental Fig. 1).

Fig. 1
figure 1

Potential difficulties in the long-term development of telescreening for diabetic eye disease (N = 234)

Full size image

Regarding the difficulties in the long-term development of the SDES comprehensive management system (Fig. 1), the most frequently mentioned barriers were the following: inadequate number of staff (particularly, technical staff) for telescreening in the communities; insufficient funding; an incomplete information transmission system for telescreening. Inadequate telescreening equipment, insufficient staff training, and fees for eye health care were also frequently mentioned barriers. Other barriers included the following: the lack of publicity and promotion of telescreening for diabetic eye diseases in the communities; the low compliance of eye health screening among individuals with diabetes; the slow feedback of remote reading; the lack of a dedicated green channel for referral patients to reduce time and costs and facilitate the use of the referral system.

Discussion

As telescreening for DR has matured, CHCs have become more capable of providing screening, diagnosis, intervention classification, management, and follow-up for diabetic eye diseases. This has significantly improved the coverage rate of individuals with diabetes and the accessibility of eye care services [21]. Although telescreening for DR in communities has achieved significant advantages owing to the comprehensive management system in Shanghai, many challenges still exist.

The first challenge is to determine whether stakeholders—specifically, individuals with diabetes and CHC staff—were satisfied with the comprehensive management system. A satisfaction survey is a quantitative tool for obtaining information directly from service recipients and providers [19]. Higher recipient satisfaction can improve their willingness to participate in future telescreening for diabetic eye diseases while increasing the popularity of the system. Higher provider satisfaction is closely related to implementation efficiency and the long-term development of a comprehensive management system [22].

In this study, we investigated the satisfaction of both service recipients and providers participating in the SEDS comprehensive management system of diabetic eye diseases in Shanghai. The findings are as follows.

First, most individuals with DR were satisfied with telescreening for diabetic eye diseases in their community. Additionally, they were willing to participate in the telescreening the following year, which was consistent with other studies that reported higher satisfaction in individuals with diabetes for DR telescreening [19, 23]. Overall satisfaction was significantly related to the actual experience of individuals with DR during the telescreening process. The convenience of telescreening, the organization of the telescreening process, and the improvement in awareness of related diseases were significantly associated with the overall satisfaction with the SEDS comprehensive management system among individuals with DR. The fact that telescreening for DR was free also contributed to the high satisfaction of service recipients. Similar to findings in other countries, this study’s results demonstrated that individuals with diabetes believed that DR telescreening, compared with the traditional fundus examination, was more convenient and faster. It reduced the time and cost of visiting doctors and increased their understanding of their disease. Further, it provided support for further clinical diagnosis and treatment [23,24,25]. Additionally, the common reasons for dissatisfaction in all developing countries are inconvenient communication facilities and interrupted network support. The transfer of information in real time is often impossible. Telescreening data are stored and transferred at a convenient time to hospitals for diagnosis; hence, the patients are not promptly informed of their examination results and interventions. Therefore, the following are crucial to improve patients’ satisfaction with the SEDS system: further optimization of the DR telescreening process; a comfortable telescreening environment; timely feedback of telescreening results and referral recommendations; strengthening the training of community staff and education about related diseases for individuals with DR.

Second, the overall satisfaction of the CHCs with the comprehensive management system was not ideal. Less than half of the CHCs were satisfied with the system, and satisfaction of the suburban CHCs was relatively low. According to our study, nearly two-fifths of the CHCs did not provide eye care services, and this situation was especially prevalent in the suburban CHCs. Thus, weaker ophthalmic clinical competence in the suburban CHCs caused a heavier telescreening workload, resulting in lower satisfaction with the system. Through the establishment of the SEDS comprehensive management system, one-third of the CHCs included the prevention and treatment of diabetic eye diseases as part of the services of general practitioners or family doctors teams, among which the CHCs in urban areas had the highest proportion. In China, family doctors are mainly registered general practitioners, and some qualified village doctors are also considered family doctors. Family doctor teams—including family doctors, community nurses, public health physicians, and village doctors—provided health management services to community residents [26]. A well-implemented family doctor system has been positively related to better health outcomes and health care cost containment in practice [27]. Therefore, including telescreening for DR into the routine work of family doctors teams should significantly help promote the system and improve the prevention and treatment effect. Nearly 70% of CHCs signed cooperation agreements with general (secondary) and specialized (tertiary) hospitals, with the highest proportion in urban areas. However, nearly half of the CHCs complained that telescreening for diabetic eye diseases at the community level was not necessary at present, considering the inadequate number of technical staff, inadequate funding, and the lack of awareness of the DR disease. Consequently, staff enthusiasm for their work was negatively affected, and this was significantly associated with overall satisfaction with the system. Meanwhile, many of the CHCs suggested merging diabetic eye disease telescreening with the disease management of individuals with diabetes, physical examinations for older adults, or routine outpatient clinics on weekdays.

Furthermore, several problems must be solved for the long-term successful development of the SEDS comprehensive management system. First, the inadequate number of CHC staff—especially those who can operate the telescreening equipment, particularly non-mydriatic fundus photography—must be addressed. Hence, training for CHC staff should be increased. Second, insufficient funding affects project implementation and staff motivation. Third, inadequate telescreening equipment affects screening efficiency; the improvement of the information management system of telescreening, increased publicity and promotion of the system, and improvement of disease awareness of community residents must be addressed. Hospitals should improve the speed of remote reading feedback and set up a referral clinic for patients requiring further diagnosis and treatment for DR to improve compliance and satisfaction with referrals. Furthermore, personalized risk-based screening schedules should be examined to optimize workload and time in telescreening programs for diabetic eye diseases [28, 29].

This study is the first to investigate the satisfaction of service recipients and providers with telescreening for DR at the primary (community) care level. The participants, including patients with VTDR and CHC staff, were recruited from all the communities in Shanghai, and this reflects the diversity of the study participants.

Nevertheless, this study has several limitations. All participants who received the service were diagnosed with VTDR. Thus, the study lacked a control group (with mild DR or no apparent retinopathy), which may limit the applicability of the findings. Moreover, satisfaction with the system is based on participants’ recollections, but it could lead to inaccurate results owing to imperfect memory.

Conclusions

This study found disparities between the high satisfaction of service recipients and the low satisfaction of providers with the comprehensive management system. This was mainly related to the current weak ophthalmic diagnosis and treatment level in the CHCs and the low awareness of screening for diabetic eye diseases among individuals with diabetes and the CHC staff. Therefore, it is important to improve the satisfaction of CHC staff with the system. For example, measures should be taken to establish a new performance evaluation system, strengthen staff training, improve the allocation of community ophthalmic equipment, and increase publicity, education, and financial support. The satisfaction of the SEDS comprehensive management system stakeholders—specifically, individuals with DR (recipients) and CHC staff (providers)— should be considered the critical assessment criteria to measure the effectiveness of public health projects. The purpose is to effectively improve the satisfaction of stakeholders in the reform of the community medical and health care system in China.

Availability of data and materials

The datasets used and analyzed during this study are available from the corresponding author upon reasonable request.

Abbreviations

CHC:

Community health center

DR:

Diabetic retinopathy

The system:

A comprehensive management system for diabetic eye diseases

SDES:

Shanghai Diabetic Eye Study

VTDR:

Vision-threatening diabetic retinopathy

References

  1. Tham TY, Tran TL, Prueksaritanond S, Isidro JS, Setia S, Welluppillai V. Integrated health care systems in Asia: an urgent necessity. Clin Interv Aging. 2018;13:2527–38.

    Article  Google Scholar 

  2. Skýbová D, Šlachtová H, Tomášková H, Dalecká A, Maďar R. Risk of chronic diseases limiting longevity and healthy aging by lifestyle and socioeconomic factors during the life-course - a narrative review. Med Pr. 2021;72(5):141909.

    Article  Google Scholar 

  3. Flor LS, Wilson S, Bhatt P, Bryant M, Burnett A, Camarda JN, et al. Community-based interventions for detection and management of diabetes and hypertension in underserved communities: a mixed-methods evaluation in Brazil, India, South Africa and the USA. BMJ Glob Health. 2020;5:e001959.

    Article  Google Scholar 

  4. Song H, Feng D, Wang R, Tang S, Ghose B, Li G, et al. Urban-rural disparity in the utilization of national community-based hypertension monitoring service-results from the China Health and Retirement Longitudinal Study 2015. PeerJ. 2019;7:e7842.

    Article  Google Scholar 

  5. Gu T, Yuan J, Li L, Shao Q, Zheng C. Demand for community-based care services and its influencing factors among the elderly in affordable housing communities: a case study in Nanjing City. BMC Health Serv Res. 2020;20:241.

    Article  Google Scholar 

  6. Liu M, Zhang Q, Lu M, Kwon CS, Quan H. Rural and urban disparity in health services utilization in China. Med Care. 2007;45:767–74.

    Article  Google Scholar 

  7. Fang H, Eggleston K, Hanson K, Wu M. Enhancing financial protection under China’s social health insurance to achieve universal health coverage. BMJ. 2019;365:12378.

    Google Scholar 

  8. Zhou Z, Zhao Y, Shen C, Lai S, Nawaz R, Gao J. Evaluating the effect of hierarchical medical system on health seeking behavior: A difference-in-differences analysis in China. Soc Sci Med. 2020;268:113372.

    Article  Google Scholar 

  9. Wong TY, Sun J, Kawasaki R, Ruamviboonsuk P, Gupta N, Lansingh VC, et al. Guidelines on Diabetic Eye Care: The International Council of Ophthalmology Recommendations for Screening, Follow-up, Referral, and Treatment Based on Resource Settings. Ophthalmology. 2018;125:1608–22.

    Article  Google Scholar 

  10. Ting DS, Cheung GC, Wong TY. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review. Clin Exp Ophthalmol. 2016;44:260–77.

    Article  Google Scholar 

  11. Liu Y, Torres Diaz A, Benkert R. Scaling Up Teleophthalmology for Diabetic Eye Screening: Opportunities for Widespread Implementation in the USA. Curr Diab Rep. 2019;19:74.

    Article  CAS  Google Scholar 

  12. Labiris G, Panagiotopoulou EK, Kozobolis VP. A systematicreview of teleophthalmological studies in Europe. Int J Ophthalmol. 2018;11:314–25.

    PubMed  PubMed Central  Google Scholar 

  13. He J, Zou H, Zhu J, He X, Lu L. Investigation and strategy research of eye disease prevention resources in community health service centers in Shanghai. Zhonghua Yan Ke Za Zhi. 2015;51:493–8.

    PubMed  Google Scholar 

  14. Resnikoff S, Felch W, Gauthier TM, Spivey B. The number of ophthalmologists in practice and training worldwide: a growing gap despite more than 200,000 practitioners. Br J Ophthalmol. 2012;96:783–7.

    Article  Google Scholar 

  15. Rajavi Z, Safi S, Javadi MA, Azarmina M, Moradian S, Entezari M, et al. Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population. J Ophthalmic Vis Res. 2016;11:394–414.

    Article  Google Scholar 

  16. Ziemssen F, Lemmen K, Bertram B, Hammes HP, Agostini H. National guidelines for treatment of diabetic retinopathy. Second edition of the national guidelines for treatment of diabetic retinopathy. Ophthalmologe. 2016;113:623–38.

    Article  CAS  Google Scholar 

  17. Zhu X, Xu Y, Lu L, Zou H. Patients’ perspectives on the barriers to referral after telescreening for diabetic retinopathy in communities. BMJ Open Diabetes Res Care. 2020;8:e000970.

    Article  Google Scholar 

  18. Zhu X, Xu Y, Xu X, Zhu J, He X, Lu L, et al. Psychometric assessment and application of the Chinese version of the Compliance with Annual Diabetic Eye Exams Survey in people with diabetic retinopathy. Diabet Med. 2020;37:84–94.

    Article  CAS  Google Scholar 

  19. Valpuesta Martin Y, Pacheco Callirgos GE, Maroto Martín TM, PirizVeloso M, Hernández Santamaría S, LópezGálvez MI. Satisfaction of patients and primary care professionals with a teleophthalmology-based screening programme for diabetic retinopathy in a rural area in Castilla y León. Spain Rural Remote Health. 2020;20:5180.

    PubMed  Google Scholar 

  20. Moss SE, Meuer SM, Klein R, Hubbard LD, Brothers RJ, Klein BE. Are seven standard photographic fields necessary for classification of diabetic retinopathy? Invest Ophthalmol Vis Sci. 1989;30(5):823–8.

    PubMed  CAS  Google Scholar 

  21. Kumari Rani P, Raman R, Manikandan M, Mahajan S, Paul PG, Sharma T. Patient satisfaction with tele-ophthalmology versus ophthalmologist-based screening in diabetic retinopathy. J Telemed Telecare. 2006;12:159–60.

    Article  Google Scholar 

  22. González García F, SarriugarteIrigoien G, CerdáMota T. Studies and opinion surveys of users. Implementation and evaluation of population-based screening programmes. 3rd monographic volume of the Spanish Epidemiology Society. 2006.

    Google Scholar 

  23. Boucher MC, Nguyen QT, Angioi K. Mass community screening for diabetic retinopathy using a nonmydriatic camera with telemedicine. Can J Ophthalmol. 2005;40:734–42.

    Article  Google Scholar 

  24. Luzio S, Hatcher S, Zahlmann G, Mazik L, Morgan M, Liesenfeld B, et al. Feasibility of using the TOSCA telescreening procedures for diabetic retinopathy. Diabet Med. 2004;21:1121–8.

    Article  CAS  Google Scholar 

  25. Tuulonen A, Ohinmaa T, Alanko HI, Hyytinen P, Juutinen A, Toppinen E. The application of teleophthalmology in examining patients with glaucoma: a pilot study. J Glaucoma. 1999;8:367–73.

    Article  CAS  Google Scholar 

  26. Liu S, Liu Y, Zhang T, Wang L, Huang J, Liang H, et al. The developing family doctor system: evidence from the progress of the family doctor signing service from a longitudinal survey (2013–2016) in Pudong New Area, Shanghai. BMC Fam Pract. 2021;22(1):11.

    Article  CAS  Google Scholar 

  27. Startfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502.

    Article  Google Scholar 

  28. Ochs A, McGurnaghan S, Black MW, Leese GP, Philip S, Sattar N, et al. Use of personalised risk-based screening schedules to optimise workload and sojourn time in screening programmes for diabetic retinopathy. A retrospective cohort study PLoS Med. 2019;16:e1002945.

    PubMed  Google Scholar 

  29. Lund SH, Aspelund T, Kirby P, Russell G, Einarsson S, Palsson O, et al. Individualised risk assessment for diabetic retinopathy and optimisation of screening intervals: a scientific approach to reducing healthcare costs. Br J Ophthalmol. 2016;100:683–7.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The SDES Research Group gratefully acknowledges the commitment and dedication of SDES participants.

Funding

This research was supported by National Natural Science Foundation of China (grant number: 81700844, 82071012), Shanghai engineering research center of precise diagnosis and treatment of eye diseases, Shanghai, China (Project No. 19DZ2250100), The Project of Shanghai Shen Kang Hospital Development Centre (Grant No. SHDC2018110, SHDC2020CR30538), The Science and Technology Commission of Shanghai Municipality (Project No. 20DZ1100200), Shanghai General Hospital, Clinical Research (Project No.CTCCR-2018Z01), and Basic research and cultivation project of Shanghai Eye Disease Prevention and Control Center (Project No.20JC01001).

Author information

Author notes

  1. Xiaofeng Zhu and Yi Xu contributed equally to this work.

Authors and Affiliations

  1. Department of Preventative Ophthalmology, Shanghai Eye Disease Prevention and Treatment Center/Shanghai Eye Hospital, Shanghai, China

    Xiaofeng Zhu, Yi Xu, Lina Lu & Haidong Zou

  2. Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Xiaofeng Zhu, Yi Xu, Lina Lu & Haidong Zou

  3. Shanghai Engineering Research Center of Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China

    Xiaofeng Zhu & Haidong Zou

  4. National Clinical Research Center for Eye Diseases, Shanghai, China

    Xiaofeng Zhu & Haidong Zou

  5. Shanghai Key Laboratory of Fundus Diseases, Shanghai, China

    Xiaofeng Zhu & Haidong Zou

Authors
  1. Xiaofeng Zhu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yi Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lina Lu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Haidong Zou
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

XZ and YX analyzed and interpreted the patient data. XZ was a major contributor to the clinical trial. HZ and LL contributed to the study design and interpretation. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Lina Lu or Haidong Zou.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the institutional review board of Shanghai General Hospital and adhered to the tenets of the Declaration of Helsinki (2013KY023). Written informed consent was obtained from all the participants prior to enrollment.

Consent for publication

Written informed consent was obtained from all participants before enrollment.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhu, X., Xu, Y., Lu, L. et al. Telescreening satisfaction: disparities between individuals with diabetic retinopathy and community health center staff. BMC Health Serv Res 22, 160 (2022). https://doi.org/10.1186/s12913-022-07500-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12913-022-07500-w

Keywords

BMC Health Services Research

ISSN: 1472-6963

Contact us