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 . 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 . 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 .
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 . A well-implemented family doctor system has been positively related to better health outcomes and health care cost containment in practice . 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.