PDF icon Download (851.42 KB)


Diabetic retinopathy (DR) is the leading cause of blindness in working age Canadians. Despite all eye care resources, including tele-ophthalmology, DR screening rates remain low; 35% of individuals with diabetes are unscreened for DR. New strategies are required to identify, engage and provide ongoing monitoring to those requiring DR screening.


Using administrative health data, we developed a population-based approach to DR screening at community health centres (CHCs).Patients with diabetes who have not had DR screening in 425 days have been identified using linked provincial and community-based datasets. Through a cohort disclosure process, a patient’s DR screening status is forwarded to each CHC and patients are directly contacted and invited for screening and ongoing monitoring.


We identified areas with lowest DR screening rates, and engaged culturally diverse 3 CHCs in Toronto. Through their electronic medical record, close to 2,100 unscreened patients have been identified, and contacted at the CHCs. After obtaining consent, available in 13 different languages, these patients are invited to attend DR screening using existing Tele-Retina services at the CHCs, with referral to an ophthalmologist as clinically required.


Our trial leverages existing digital data and utilizes a population-based approach to DR screening in Ontario. This community-based approach could improve health outcomes by increasing awareness and DR screening accessibility, especially for vulnerable populations. If successful, this strategy could be expanded nationally, and provide an innovative approach to the management of other diabetes complications and chronic disease.