title: Improving eye care follow-up adherence in diabetic patients with ocular abnormalities: the effectiveness of patient contracts in a free, pharmacy-based eye screening.
abstract: OBJECTIVE
  Patient contracts are increasingly utilized in medical practice and have the potential to improve health outcomes in high-risk populations. However, as a relatively new tool, there has been limited research regarding the efficacy of patient contracts. Diabetic retinopathy (DR) is one of the leading causes of vision impairment in adults in the US and only 50-60% of adults with diabetes adhere to annual dilated fundus exam recommendations. This study aimed to evaluate the impact of patient contracts on follow-up adherence in diabetic patients with ocular abnormalities after a free, pharmacy-based eye screening.
  
  
  METHODS
  This prospective study implemented a non-invasive, non-mydriatic fundus camera in an urban, community-based pharmacy setting to screen for ocular diseases in patients with diabetes. Patients were assigned to the contract or non-contract group. Patients who signed a contract agreed to: 1) review their results with their primary care doctor, 2) follow-up with an ophthalmologist if their results were abnormal, and 3) inform research staff if/when they completed an eye care appointment. All study participants and their primary care doctors were notified of their results via mail. Follow-up questionnaires were administered to all patients by telephone three months after the screening results.
  
  
  RESULTS
  500 patients were screened and 113 (22.6%) had abnormal results. Of the patients who had abnormal results, 83 (74.3%) were able to be contacted. Of the 83 patients who were able to be contacted, the majority of patients were African American (73.5%) and female (56.6%). The mean age was 54.7 years. Of those, 34 (41.0%) adhered to follow-up recommendations. There was no significant difference in follow-up adherence between the contract (38.1%) and non-contract group (43.9%) (P = 0.59). In addition, 70.4% of patients did not comply with at least one measure of the contract agreement.
  
  
  CONCLUSIONS
  Contracts did not increase follow-up adherence to eye appointments in diabetic patients with ocular abnormalities. The majority of patients did not comply with their contract and follow-up adherence was low in both groups. Most research has yielded mixed results regarding the efficacy of contracts in improving health outcomes. Therefore, different types of contracts or other patient-centered tools should be evaluated in order to increase follow-up adherence in patients at high risk for DR.
authors.affiliation: Wills Eye Hospital, Research, 840 Walnut Street, Suite 802, Philadelphia, PA 19107, USA. Electronic address: caleo@willseye.org.
authors.forename: C L
authors.initials: CL
authors.lastname: Aleo
authors.affiliation: Wills Eye Hospital, Emergency Department, 840 Walnut Street, Suite 802, Philadelphia, PA 19107, USA.
authors.forename: A P
authors.initials: AP
authors.lastname: Murchison
authors.affiliation: Wills Eye Hospital, Research, 840 Walnut Street, Suite 802, Philadelphia, PA 19107, USA.
authors.forename: Y
authors.initials: Y
authors.lastname: Dai
authors.affiliation: Research Department and Glaucoma, Research Center, Wills Eye Hospital, 840 Walnut Street, Suite 802, Philadelphia, PA 19107, USA.
authors.forename: L A
authors.initials: LA
authors.lastname: Hark
authors.affiliation: Wills Eye Hospital, Research, 840 Walnut Street, Suite 802, Philadelphia, PA 19107, USA.
authors.forename: E L
authors.initials: EL
authors.lastname: Mayro
authors.affiliation: Wills Eye Hospital, Research, 840 Walnut Street, Suite 802, Philadelphia, PA 19107, USA.
authors.forename: B
authors.initials: B
authors.lastname: Collymore
authors.affiliation: Wills Eye Hospital, 840 Walnut Street 1510, Philadelphia, PA 19107, USA.
authors.forename: J A
authors.initials: JA
authors.lastname: Haller
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D003157:Community Pharmacy Services; D003930:Diabetic Retinopathy / Q000175:diagnosis*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D013689:Telephone; D014505:Urban Population
keywords: Appointment adherence; Contract; Diabetic retinopathy; Screening