Ophthalmology Integration The Next Frontier for KeepSight

There’s no doubt that since its introduction to the Australian health landscape by Diabetes Australia five years ago, KeepSight has had a significant impact.

Almost 1.9 million Australians have diabetes. This includes all types of diagnosed diabetes (almost 1.5 million known and registered on the National Diabetes Services Scheme) as well as silent, undiagnosed type 2 diabetes (up to 500,000 estimated).¹

It’s a problem that continues to grow. In the past year alone, almost 120,000 Australians have developed diabetes.¹

Diabetes is a complex, serious, and chronic condition. In the long term, diabetes can damage small and large blood vessels and nerves, which can cause damage to the heart, brain, kidneys, feet, and of course, the eyes. Diabetes is the leading cause of blindness in working age adults and approximately 7.7% of those with diabetes have vision loss attributable to the disease.²

THE ROLE FOR KEEPSIGHT

KeepSight is the national eye screening initiative for Australians with diabetes, introduced by Diabetes Australia in 2019, in partnership with the eye sector. KeepSight’s mission is to eliminate vision loss attributed to diabetes in Australia by increasing the number of people accessing routine diabetes eye care – connecting people with diabetes to the eye checks that they need.

Just over 450,000 Australians with diabetes have enrolled in KeepSight as a means of protecting their sight. This has created a new clinical pathway in optometry to better identify people with diabetes and improve their care experience.

KeepSight works by offering an awareness and alert/reminder system engaging people registered on the National Diabetes Services Scheme about the need for regular eye checks. This ongoing communication is complemented by periodic mass market advertising campaigns utilising conventional and digital media (Figure 1).

Figure 1.

The activation system is driving thousands of people with diabetes to have an eye check, referring them back to their last place of care in the first instance.

For those that don’t already see an eye health professional, KeepSight registrants are offered access to a database of optometry practices. This system has enabled eye health professionals to deliver thousands of extra comprehensive eye examinations.

A growing number of optometrists are now registering their patients for KeepSight reminders via an integrated registration process within the patient management systems of optometry practices. As well, people registered with the National Diabetes Services Scheme receive important eye health information and alerts encouraging them to have a diabetes eye check.

KEEPSIGHT INSIGHTS

Given the consistent growth of KeepSight over the past five years – there has been a 40% growth in the number of enrolments since July 2023 with over 700,000 reminders sent – key insights can be extrapolated from the program. For example, of the more than 450,000 people registered for reminders, 45% are considered high risk (defined as living with diabetes for over 10 years).

The program can generate a breakdown of key demographic insights by state, suburb, and public health area network. It is hoped that ultimately this information will guide targeted service provision in areas of need.

With the support of key sector stakeholders across government, optometry, and peak health bodies, KeepSight is improving eye health outcomes for Australians with diabetes.

But where can the program go from here? KeepSight is interested in understanding how to provide a continuation of support for people with diabetes once they are referred to an ophthalmologist.

UNDERSTANDING THE ROLE OF KEEPSIGHT IN OPHTHALMOLOGY

The management of diabetes related health issues and other co-morbidities can cause a prioritisation dilemma for people requiring multiple specialist consultations and invasive treatments.

An area of opportunity was identified by Diabetes Australia for KeepSight to delve further into the potential benefits of this program to assist people requiring ophthalmic management of their eye condition.

Funding was provided by Bayer to enable Diabetes Australia to understand ways in which ophthalmologists could engage with the KeepSight program.

While the program is primarily focussed on engaging people with diabetes in retinopathy screening, there is great interest in supporting people once they are referred to ophthalmologists for care.

To get perspectives on potential avenues for support, Diabetes Australia conducted research to understand the factors that influence adherence with care for diabetesrelated eye conditions.

It was found that barriers to adherence to care are well documented nationally and internationally.^3-7 Despite this large foundation of knowledge, comparatively little is known of methods to improve adherence.

Given the multifactorial nature of nonadherence, single strategy solutions are unlikely to be successful. Recurring specific features were found across papers that facilitated ongoing adherence to eye care such as high health literacy, government co-payment, small geographic distances to travel, and thorough referrals. Learnings can be taken from national key health programs with demonstrated success. The success of these programs is attributed to health information provided at the individual level, at a population level, targeted strategies for demographic specific needs, and demonstrated long-term economic benefit.^8-11

Several multi-pronged programs have shown promise. Examples include programs that combine patient education, support or coaching at home (or via tele-health initiatives), which show increases in patient compliance and persistence with treatment.8,12-13

Integration of support programs with electronic health records and management systems offer significant advantages.

GETTING LOST TO THE PROGRAM

Co-founder and Clinical Director of KeepSight, Professor Peter van Wijngaarden stressed the importance of engaging ophthalmologists in the program.

“At present KeepSight participants are lost to the program when they are referred to ophthalmologists for care. Bridging this gap will facilitate continuity of support for KeepSight registrants. Importantly, the evidence suggests that this will improve treatment adherence and save sight.”

Diabetes Australia’s Chief Strategy Officer Taryn Black said further collaboration with clinicians, patient support organisations, and government bodies was needed to optimise the program for ophthalmology.

“We’re keen to build on the success of the program within optometry but recognise that KeepSight is not a one size fits all solution for patient support.

“We know how valuable it is to partner with and learn from the sector to deliver fit-forpurpose support. We are keen to engage with ophthalmologists to understand how to best integrate KeepSight into ophthalmology patient management to ensure continuity of care for people living with later stage diabetes-related vision loss.”

Planning is underway to connect with the ophthalmology community and key support bodies to understand how KeepSight can best have an impact. Diabetes Australia welcomes expressions of interest and can be contacted via the National Program Manager of KeepSight, Jon Kidd: [email protected].

References

1. Australia, Diabetes. Diabetes in Australia (webpage) available at: diabetesaustralia.com.au/about-diabetes/ diabetes-in-australia/ [accessed May 2024].
2. Australian Institute of Health and Welfare. Indicators for the Australian National Diabetes Strategy 2016–2020: data update (webpage) available at: Iaihw.gov.au/reports/ diabetes/diabetes-indicators-strategy-2016-2020/contents/ goal-3-reduce-the-occurrence-of-diabetes-related-c/ indicator-3-6-prevalence-of-vision-loss-caused-by [accessed May 2024].
3. Rose, M.A., Vukicevic, M., Koklanis, K., Adherence of patients with diabetic macular oedema to intravitreal injections: A systematic review. Clin Exp Ophthalmol. 2020 Dec;48(9):1286–1298. DOI: 10.1111/ceo.13845.
4. Angermann, R., Rauchegger, T., Zehetner, C., et al., Treatment compliance and adherence among patients with diabetic retinopathy and age-related macular degeneration treated by anti-vascular endothelial growth factor under universal health coverage. Graefes Arch Clin Exp Ophthalmol. 2019 Oct;257(10):2119–2125. DOI: 10.1007/ s00417-019-04414-y.
5. Ford, B., Keay, L., White, A., et al., Quality and targeting of new referrals for ocular complications of diabetes from primary care to a public hospital ophthalmology service in Western Sydney, Australia. Aust J Prim Health. 2020 Aug;26(4):293–299. DOI: 10.1071/PY20084.
6. Ford, B.K., Angell, B., Keay, L., et al., Experiences of patients with diabetes attending a publicly funded eye care pathway in Western Sydney: A qualitative study. J Patient Exp. 2021 Oct 20;8:23743735211049652. DOI: 10.1177/23743735211049652.
7. Foreman, J., Keel, S., Dirani, M., et al Adherence to diabetic eye examination guidelines in Australia: The National Eye Health Survey. Med J Aust. 2017 May 15;206(9):402–406. DOI: 10.5694/mja16.00989.
8. Moinul, P., Barbosa, J., Chaudhary, V., et al., Does patient education improve compliance to routine diabetic retinopathy screening? Telemed Telecare. 2020 Apr;26(3):161–173. DOI: 10.1177/1357633X18804749.
9. Khair, Z., Rahman, M.M., Moriyama, M., et al., Health education improves referral compliance of persons with probable diabetic retinopathy: A randomized controlled trial. PLoS One. 2020 Nov 12;15(11):e0242047. DOI: 10.1371/journal.pone.0242047.
10. Public Health Association of Australia., Top 10 Public health successes over the last 20 years. PHAA Monograph Series No. 2, Canberra, Public Health Association of Australia, 2018.
11. Hollenhorst, C.N., Elliott, V., Newman-Casey, P.A., et al., Patient experience during the support, educate, empower glaucoma coaching program to improve medication adherence: A pilot study. Ophthalmol Glaucoma. 2020 Jul– Aug;3(4):238–252. DOI: 10.1016/j.ogla.2020.04.016.
12. Chang, A., Stokes, J., Said, P., et al., Impact of a patient support program on patient beliefs about neovascular age-related macular degeneration and persistence to anti-vascular endothelial growth factor therapy. Patient Prefer Adherence. 2021 Mar 3;15:511–521. DOI: 10.2147/ PPA.S293941.
13. Dahlan, K., Suman, P., Mian, U., et al., In a large healthcare system in the Bronx, teleretinal triaging was found to increase screening and healthcare access for an underserved population with a high incidence of T2DM and retinopathy. Int J Environ Res Public Health. 2023 Mar 31;20(7):5349. DOI: 10.3390/ijerph20075349.