Implementing Diabetic Eye Care in Rural Primary Care Through Teleophthalmology and Pop-Up Clinics: Mixed Methods Study.

Background: Diabetic retinopathy is the leading cause of blindness in US adults. Fewer than half of patients with diabetes in rural areas complete the recommended screening that could prevent blindness. Store-and-forward teleophthalmology and mobile pop-up eye clinics have each been shown to improve screening access, but studies examining the implementation of both modalities within the same rural primary care system are lacking. Objective: This study aimed to identify multilevel facilitators and barriers to implementing teleophthalmology and pop-up eye clinics for diabetic eye care in 2 rural primary care clinics in upstate New York. Methods: We conducted a mixed methods implementation study with prospective semistructured interviews and retrospective, descriptive electronic health record data at 2 university-affiliated primary care clinics classified as "isolated rural," guided by the Consolidated Framework for Implementation Research (CFIR). Electronic health record data from 885 adults with diabetes were used to characterize patient demographics and eye care use. Patients were categorized into 3 groups: eye exam with an eye doctor (n=586), on-site primary care-based eye exam (n=91; teleophthalmology n=39 and pop-up clinic n=52), or no recent eye exam (n=208). Semistructured interviews were conducted with 20 patients (n=5 per subgroup) and 14 staff members (primary care clinicians, optometrists, and administrative personnel), purposively sampled to capture diverse perspectives across eye care pathways and roles. Interviews were coded using CFIR domains and analyzed thematically until no new themes emerged. Results: Patients in the on-site primary care eye exam group were the most socially disadvantaged, with the lowest proportions reporting no transportation needs (42/91, 46.2%), no housing instability (28/91, 30.8%), and no food insecurity (36/91, 39.6%). Over 18 months, 58.4% (52/89) of scheduled pop-up clinic appointments were completed, and 92.3% (36/39) of teleophthalmology images were gradable. Pop-up clinics detected higher rates of diabetic retinopathy (11/52, 21.2% vs 3/39, 7.7%), cataract (29/52, 55.8% vs 3/39, 7.7%), and reduced visual acuity (23/52, 44.2% vs 11/39, 28.2%) than teleophthalmology. Qualitative analysis revealed that patients viewed both modalities as a convenient "one-stop shop" and valued trust in primary care staff. Staff identified complementary barriers: training and workflow complexity for teleophthalmology, and underutilization and scheduling challenges for pop-up clinics. Implementation champions across roles proposed an integrated workflow in which same-day teleophthalmology becomes a default component of annual diabetes visits, with targeted referral to pop-up clinics for patients with abnormal findings. Conclusions: Primary care-based eye programs in rural settings preferentially reached socially vulnerable patients with diabetes and detected substantial unmet eye pathology. However, operating teleophthalmology and pop-up clinics as separate programs led to inefficiencies in both programs. A stakeholder-driven integrated model embedding teleophthalmology into routine diabetes care, with targeted pop-up clinic referrals, may improve the reach, efficiency, and sustainability of diabetic eye screening in rural populations.