Implementation and evaluation of Exercise is Medicine in primary care clinics within a large academic health system.

OBJECTIVE: Exercise is Medicine (EIM) is a global initiative encouraging healthcare providers to routinely assess and promote physical activity (PA) among patients. The objective of this study was to evaluate the feasibility, adoption, implementation and effectiveness of EIM from patient, clinician and healthcare staff perspectives using a combination of electronic health record (EHR), survey and interview data. DESIGN: This study used a combination of the Practical Robust Implementation and Sustainability Model (PRISM) and the Learning Evaluation model to implement EIM. Data captured from the EHR, including Physical Activity Vital Sign (PAVS) scores, and data collected from qualitative surveys and interviews were used to evaluate the programme's Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM, which is embedded within PRISM) from provider, staff and patient perspectives. SETTING: Five primary care clinics within a large academic health system. PARTICIPANTS: A total of 24 443 patients from all participating clinics had at least one PAVS score during the study period. A total of 17 clinicians completed surveys, and 4 clinicians, 8 medical assistants and 9 patients completed interviews. RESULTS: Implementation fidelity metrics varied widely between components and across clinics but were generally consistent over time, indicating a high degree of programme maintenance. Fidelity was highest during the first 6 months of the COVID-19 pandemic when most visits were virtual. Mean PAVS scores increased from 57.7 (95% CI: 56 to 59.4) to 95.2 (95% CI: 91.6 to 98.8) min per week at 6 months for patients not meeting PA guidelines at baseline and decreased from 253.84 (95% CI: 252 to 255.7) to 208.3 (95% CI: 204.2 to 212.4) min per week at 6 months for patients meeting PA guidelines at baseline. After EIM implementation, clinician-estimated time spent discussing PA with patients increased for 35% of providers and stayed the same for 53%. CONCLUSION: Overall, this study established EIM's feasibility, adoption, implementation and maintenance in routine primary care practice within a large academic health system. From a population health perspective, EIM is a model to emulate to help primary care providers efficiently address healthy lifestyle behaviours in routine primary care visits.

Evaluation and Optimization of Diabetic Retinopathy Screenings for Uninsured Latinx Patients in a Resource-Limited Student-Run Free Clinic.

Background: Diabetic retinopathy (DR) is a sight-threatening condition that causes progressive retina damage. Student-run free clinics represent a valuable opportunity to provide DR screenings to high-risk populations. We characterized the patient population, evaluated the performance, and conducted a needs assessment of DR screenings at the University of California, San Diego Student-Run Ophthalmology Free Clinic, which provides care to predominantly uninsured, Latino patients. Methods: Retrospective chart review was conducted of all patients seen at the free clinic since 2019 with a diagnosis of type II diabetes. Date and outcome of all DR-related screenings or visits from 2015 onward, demographics information, and DR risk factors such as A1c and insulin dependence were recorded. Predictors of diabetic retinopathy and frequency of DR screenings for each patient were analyzed using multiple logistic regression, t-test for equality of means, and Pearson's correlation. Results: Of 179 uninsured diabetic patients receiving care at the free clinic, 71% were female and average age was 59. 83% had hypertension, 93% had hyperlipidemia, and 79% had metabolic syndrome. Prevalence of non-proliferative DR was 34% and that of proliferative DR was 15% in diabetic patients. The free clinic capacity in recent years plateaued at just under 50% of patients seen for DR screening or visit per year, though average wait time was over 2 years between visits. Patients with higher no-show rates had less frequent DR screenings. Chronic kidney disease and poor glycemic control were the strongest predictors of DR. Conclusion: The student-run free ophthalmology clinic has been effective in providing screening and follow-up care for DR patients. Creation of a protocol to identify which patients are at highest risk of DR and should be seen more urgently, addressing no-shows, and implementation of a tele-retina program are potential avenues for improving clinic efficiency in a resource-limited setting for vulnerable populations.

Impact of COVID-19 on the Delivery of Eye Care to Uninsured Diabetic Patients at a Student-Run Free Clinic: A Comprehensive Evaluation of Eye Clinic Performance.

Background: Diabetic retinopathy is the leading cause of blindness among working-age adults in the United States and requires timely screening and management. This study evaluates the impact of the coronavirus disease 2019 (COVID-19) pandemic on diabetic retinopathy screening (DRS) for uninsured, predominantly Latino patients at the University of California San Diego Student-Run Free Clinic Project (SRFCP). Methods: A retrospective chart review was conducted of all living diabetic patients at SRFCP who were seen in 2019 (n=196), 2020 (n=183), and 2021 (n=178). Ophthalmology clinic referrals, scheduled patient visits, and visit outcomes were analyzed longitudinally to determine the impact of the pandemic on screening patterns. Results: The study population was 92.1% Latino, 69.5% female, with a mean age of 58.7 years. The distribution of patients seen (p<0.001), referred (p=0.012), and scheduled (p<0.001) in 2020 and 2021 significantly differed from 2019. In 2019, 50.5% of 196 patients eligible for DRS were referred, 49.5% were scheduled, and 45.4% were seen. In 2020, 41.5% of 183 eligible patients were referred, but only 20.2% were scheduled and 11.4% were seen. In 2021, there was a rebound: 63.5% of 178 patients were referred, 56.2% scheduled and 46.1% seen. No shows and cancellations represented 12.4% and 6.2% of the 97 encounters scheduled in 2019, but were markedly higher (10.8% and 40.5% respectively) for the 37 encounters scheduled in 2020. Conclusions: The COVID-19 pandemic significantly impacted the delivery of eye care at SRFCP. The need for annual DRS exceeded the capacity of the ophthalmology clinic in all years studied, but the difference was especially pronounced with more stringent COVID-19 restrictions in 2020. SRFCP patients could benefit from telemedicine DRS programs to improve screening capacity.