Structured Counselling and Regular Telephonic Follow Up among Diabetic Retinopathy Patients to improve Timely Referral Flow and Compliance from peripheral eye care centre to tertiary centre in Nepal: A Randomised Controlled Trial (Preprint)

BACKGROUND Diabetic Retinopathy (DR) is an emerging public health issue. DR may lead to severe visual impairment or blindness. Referral communication and tracking system is helpful to monitor patients flow, timeliness and compliance; ensures a close relationship across health facilities and improves patient’s satisfaction. The aim of the study is to improve timely referral flow and compliance of patients diagnosed with DR. OBJECTIVE Primary objective: To assess the effect of intervention on timely referral compliance Secondary objectives: To assess the determinants and cost effectiveness of the intervention for timely referral compliance. METHODS This is an operational research study using cluster randomized controlled health facility-based trial. A situational analysis was conducted and problem tree was developed to identify different barriers to referral compliance (long waiting time, lack of knowledge about diabetic retinopathy, its impact on vision and different treatment options).Appropriate solutions were identified through comprehensive literature review and addressing individual barriers to improve poor referral and compliance of patients diagnosed with DR from peripheral centres (referring centre). These solutions were systemically arranged in the form of an intervention package, which will be tested using a cluster-based randomized controlled trial. Ten eligible peripheral hospitals out of 19will be randomly selected and allocated (lottery method); five each in intervention and control groups. Structured counselling and referral communication linkage will be implemented to the intervention group. Structured counselling, health educational material, and telephonic follow-up will be provided by a trained counsellor at the referring centre; patients will be told in detail about DR, its impact on eyes and vision, treatment options available and the treatment cost for different procedures. They will be explained process at LEIRC (referral centre) and a contact person shall facilitate their treatment at the referral centre. Patients in Control group will receive ongoing routine counselling and health education material. We collected data on referral and compliance, and their determinants using referral-and DR-registers, and structured questionnaires for 1.demographic and socioeconomic profile of patients, 2.telephonicfollow-up with noncompliant patients,3.Feedback of those referred, and 4.Performa for clinical information. Compliance is considered when the referred participant reports at referral centre within one month of counselling. Referral compliance between the two groups will be compared using appropriate statistical tests. Adjusted analysis will be conducted. RESULTS Due to COVID-19 pandemic the inflow of patients is reduced, thus the duration of the data collection will be increased. In the first 6 months of pilot data collection73 in intervention and 34 in control group were screened for referral; 12(21.82%) and 15(27,2%) already had severe NPDR or PDR at the time of screening. CONCLUSIONS Early stage of DR is asymptomatic and can go unnoticed until it affects vision leading to visual impairment and blindness. This study will assess the feasibility and effectiveness of a referral intervention package for improving early diagnosis and treatment with preservation of vision among DR patients. CLINICALTRIAL Clinicaltrials.gov NCT 04834648

Design and implementation of a standard care programme of therapeutic exercise and education for breast cancer survivors

Background Breast cancer survivors (BCS) face several symptoms and are at higher risk of weight gain following diagnosis. Current literature shows that both exercise and diet play a key role in recovery of BCS. However, there is a gap between current guidelines and the real-world context. The aim of this article is to describe the process behind a free, not-for-profit community-based therapeutic exercise and education programme (TEEP) for BCS in the clinical setting. Methods The “Onco-Health Club” (OHC) consists of therapeutic exercise (TE) intervention aimed at ameliorating cancer-related fatigue (CRF) and improving QoL and physical function. TE is supplemented with nutritional education, providing information about the Mediterranean diet. To this end, patients are recruited from an oncologist and are referred to a physiotherapist and a nutritionist for baseline assessment. TEEP consists of a 3-month intervention, delivered twice a week in a group format with 1 h of TE and 30 min of nutritional education. BCS then have a final assessment and are advised to continue with a healthy lifestyle. Data about referral, compliance and assessment were collected. Results From May 2017 to February of 2020, a total of 158 patients were recruited from 8 cohorts and 142 initially started the OHC. From 119 that joined the program, 96 patients were considered to have finished it with good adherence (assistance > 80%). BCS significantly improved their QoL, as well as upper and lower limb’s function, and increased their level of physical activity. CRF tended to decrease (p = 0.005). Conclusions This study obtained data on recruitment, compliance, and possible limitations of these kinds of programmes in a real-world context. Further research is needed in order to optimize patient engagement and compliance, as well as to determine the transferability of these programmes in the clinical setting. Trial registration NCT03879096, Registered 18th March 2019. Retrospectively registered.

Screening for Diabetes-Related Distress in an Outpatient Endocrine Clinic

Background: Identification and treatment of diabetes-related distress (DD) are essential for diabetes management, quality of life, and reducing health care costs for people with diabetes. There is no standardized workflow for DD screening in an outpatient endocrine clinic that manages approximately 2000 persons with diabetes. Aim: This quality improvement (QI) project aims to implement a DD screening and referral program in an outpatient endocrine clinic. Methods: The Mobilize, Assess, Plan, Implement, Track (MAP-IT) model was used to design the QI project. Patients without a diagnosis of diabetes, age less than 18 years, and pregnant women were excluded from the screening. DD was measured using the Problem Areas in Diabetes-5 (PAID-5) scale (0 - 20) points (1). An ambulatory systems analyst created a flowsheet in Epic for the PAID-5 questionnaire and routed the PAID-5 to MyChart. During the implementation phase, patients completed the PAID-5 on MyChart one week before their appointment or in-person during the encounter. Providers referred patients with a PAID-5 score ≥ 8 to a mental health provider (MHP). The primary outcomes were PAID-5 screening compliance and mental health referral compliance. Secondary outcomes include PAID-5 scores and hemoglobin A1C value percentage; changes in the PAID-5 scores and A1C values were compared pre- and post-intervention. Results: The project was implemented on August 31st, 2020. As of October 29th, 2020, the PAID-5 screening compliance was 66% (n = 385/585). The patient sample was 57% female and 43% male. It was identified that 113 (29%) patients had a PAID-5 score ≥ 8. Of these, only 33 (29%) patients received a referral to a MHP. Thirty-three patients (29%) refused a referral, and 5% were already seeing a MHP. Pre-intervention, the average PAID-5 score was 5, and the average baseline A1C value was 8% (< 5.7%). Conclusion: Based on the preliminary data, screening for DD in adults with diabetes utilizing the PAID-5 questionnaire is feasible and can facilitate the referral of distressed patients to mental health providers. Long-term implications for the practice change include a holistic and comprehensive approach to the management of diabetes and diabetes-related outcomes, including reduction of PAID-5 scores and A1C values in individuals referred to a MHP. References: (1) McGuire, B. E., Morrison, T. G., Hermanns, N., Skovlund, S., Eldrup, E., Gagliardino, J., Kokoszka, A., Mathews, D., Pibernik, M., Rodriguez, J., Wit, M., & Snoek, F. J. (2010). Short-form measures of diabetes-related emotional distress: The Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia, 53(1), 66–69. https://doi.org/10.1007/s00125-009-1559-5

Health education improves referral compliance of persons with probable Diabetic Retinopathy: A randomized controlled trial

Objective Lack of awareness about Diabetic Retinopathy (DR) is the most commonly cited reason why many persons with type 2 diabetes are non-compliant with referral instruction to undergo retinal screening. The purpose of this study was to evaluate the efficacy of a culturally, geographically and socially appropriate, locally adapted five-month-long health education on referral compliance of participants. Method A prospective randomized, open-label parallel group study was conducted on persons with type 2 diabetes who underwent basic eye screening at a diabetes hospital between September 2017 and August 2018. Participants who were noncompliant with referral instruction to visit a hospital for advanced DR management were randomly divided into health education intervention group (n = 143) and control group (n = 156). Both groups received information regarding DR and referral instruction at the diabetes hospital. The intervention group was provided personalized education followed by telephonic reminders. The primary endpoint was ‘increase in referral compliance’ and the secondary endpoint was ‘increase in knowledge of DR’. Multivariate logistic regression model was used to identify significant predictors of compliance to referral. Results A total of nine participants dropped and 290 completed the post intervention survey. The compliance rate in intervention group was found to be significantly higher than the control group (64.3% vs 28.2%; OR 4.73; 95% CI 2.87–7.79; p<0.001). Participants in the intervention group acquired better knowledge on DR (p<0.05). Apart from intervention, referral compliance rate was also found to be significantly associated with participants’ self-perception of vision problem (OR 2.02; 95% CI 1.02–4.01; p = 0.045) and participants’ income (OR 1.24; 95% CI 1.06–1.44; p = 0.008). Discussion Our results suggest that intensive health education on DR should be integrated with diabetes education as it may result in significantly improved referral compliance. Outcomes may be sustainable if interventions are institutionalized at referral point. Trial registration Clinical Trials.gov (Registration # NCT03658980); https://clinicaltrials.gov/ct2/show/NCT03658980.

Abstract TP380: Improving Outcomes for Stroke Patients at Risk for Cognitive and Mood Impairments

Background: Improved survival rates of stroke patients have resulted in a rise in disability within this population. Research demonstrates that stroke patients are at high risk for cognitive decline and depression. Neuropsychological intervention can improve outcomes for this population. At an academic medical center in the Midwest, the process in which stroke patients are screened for these impairments and subsequently referred to a neuropsychologist is ineffective. Purpose: The purpose of this quality improvement project was to critically appraise the process in which stroke patients are screened for cognitive decline and depression and to improve the process using a multi-disciplinary approach of nursing, medicine, rehabilitation and neuropsychology. Methods: A total of 231 patient charts were reviewed in this quality improvement project. The Plan-Do-Study-Act model was utilized. Process changes included: provider education on order placement of neuropsychology referrals, occupational therapist education on correct progress note use, and improvement of visibility of the stroke patient list to screening staff. Pre- and post-intervention data were examined to assess for changes in screening compliance and consultations. Results: Baseline data collected December 2016 showed 64% compliance with Montreal Cognitive Assessment (MoCA) screening, 50% compliance with Patient Health Questionnaire (PHQ-2) screening, and 50% compliance with neuropsychology referral. After new processes were implemented, April 2016 data showed 100% MoCA compliance, 95% PHQ-2 compliance, and 100% neuropsychology referral compliance. Although these numbers look promising, we will continue to gather and analyze data to ensure this positive compliance trend continues. Conclusion: Multidisciplinary education and increased visibility of stroke patients requiring a screening may increase compliance of cognitive decline and depression screening as well as subsequent referral to neuropsychology. The increase in screening compliance will ultimately lead to appropriate referrals and further resources for the stroke population.