Outreach screening to address demographic and economic barriers to diabetic retinopathy care in rural China

Importance Poor access to existing care for diabetic retinopathy (DR) limits effectiveness of proven treatments. 

Objectives We examined whether outreach screening in rural China improves equity of access. 

Design, setting and participants We compared prevalence of female sex, age > = 65 years, primary education or below, and requiring referral care for DR between three cohorts with diabetes examined for DR in neighboring areas of Guangdong, China: passive case detection at secondary-level hospitals (n = 193); persons screened during primary-level DR outreach (n = 182); and individuals with newly- or previously-diagnosed diabetes in a population survey (n = 579). The latter reflected the “ideal” reach of a screening program. 

Results Compared to the population cohort, passive case detection reached fewer women (50.8% vs. 62.3%, p = 0.006), older adults (37.8% vs. 51.3%, p < 0.001), and less-educated persons (39.9% vs. 89.6%, p < 0.001). Outreach screening, compared to passive case detection, improved representation of the elderly (49.5% vs. 37.8%, p = 0.03) and less-educated (70.3% vs. 39.9%, p<0.001). The proportion of women (59.8% vs 62.3%, P>0.300) and persons aged > = 65 years (49.5% vs 51.3%, p = 0.723) in the outreach screening and population cohorts did not differ significantly. Prevalence of requiring referral care for DR was significantly higher in the outreach screening cohort (28.0%) than the population (14.0%) and passive case detection cohorts (7.3%, p<0.001 for both). 

Conclusions and relevance Primary-level outreach screening improves access for the poorly-educated and elderly, and removes gender inequity in access to DR care in this setting, while also identifying more severely-affected patients than case finding in hospital.