It is predicted that the number of individuals in the U.S. affected by diabetes will rise from approximately 28 million in 2007 to 60.7 million in 2030.1 With an increase in the prevalence of diabetes the need for routine examination for diabetic retinopathy (DR) in primary care settings can also be expected to increase. The use of telemedicine for DR screening has been well established.1–9
Telemedicine DR screening is becoming more widely implemented, but the previously reported rates of adherence to recommended ophthalmology follow-up for patients with retinal pathology after screening have been low.1–9 A recent study published in 2016 looked at rates of patient's adherence to recommendations on follow-up eye care after being diagnosed with DR at a publicly funded internal medicine clinic.10 The study reported that out of the 949 patients screened for DR, only 29.9% of patient adhered to follow-up as recommended.10
In rural and underserved regions where barriers to care exist, such as cost and accessibility, studies have shown that telemedicine screening for DR significantly increases the rate of evaluation of DR and referral visits. A study evaluating the effectiveness of telemedicine retinal screening for patients with type 1 or type 2 diabetes reported an increase in the mean rate of diagnosis of DR from 25.6% to 40.4% after implementation of the telemedicine retinal screening program in a rural and underserved region in North Carolina.11 In addition, of the patients referred by their primary care physician to undergo further evaluation by an ophthalmologist, 60% of those patients completed the referral visit.11
Public health intervention with telemedicine retinal imaging for DR is an important measure in preventing vision loss in patients with diabetes. A study in 2015 involving 1,894 patients reported that DR is found in approximately one in five individuals aged 18 years or older with diabetes type 1 or type 2 living in urban America.14 According to the study, screening programs across various urban populations report that 21.7% of individuals had at least one eye affected by DR, and 44.2% of individuals were found to have ocular disease other than DR detected by physicians evaluating retinal images at remote telemedicine reading centers.14
Early diagnosis and telemedicine screening for DR are important aspects in reducing the rates of ocular complications and improving patients' quality of life. This report reviews our 2-year experience using telemedicine to screen for DR in an urban, insured population.
Patients and Methods
We report our 2-year experience deploying telemedicine for DR screening with fundus cameras stationed in a primary care office setting from May of 2015 through April of 2017. A third-party company (Intelligent Retinal Imaging Systems [IRIS], Pensacola, FL) collaborated with a local retina reading center and primary care medical clinics to provide the cameras and infrastructure required for facilitating the acquisition and interpretation of fundus images. Three types of nonmydriatic fundus cameras used were to capture images of the posterior pole with a 45° field: the handheld Volk Pictor Plus camera (Volk Optical, Mentor, OH), the DRS by CenterVue (Padova, Italy), and the NW400 by Topon (Tokyo, Japan).
Both the local reading center and the primary care medical clinics were part of two independently operated health care facilities. Using primary care-based fundus cameras, images were captured and digitally uploaded to web-based software supplied by IRIS. These images were reviewed by a local retina reading center, Austin Retina Associates, which comprises eight retina specialists working at the retina specialty private practice whose staff coordinated follow-up examinations for patients with retinal pathology. The photo-acquiring primary care clinic paid the third-party company (IRIS) for photography and interpretation provided through the web-based platform and the local retina reading center was paid by the third party for each read.
Capture rates were defined as the number of patients evaluated by a retina specialist divided by the number of patients determined to need a retina exam based upon the screening fundus images (capture rate = number of patients examined/number of patients needing exam). Images were gathered initially using three cameras at three different urban locations. This was subsequently expanded to nine cameras in nine different locations at the request of the primary care clinics involved. The patients involved in this study were an urban, insured population, which included Medicare and commercial insurances.
Diabetic patients presenting to the primary care medical clinic who had no record of a fundus exam within the last year were screened using a fundus camera. Retina fundus images captured by nonmydriatic, table-top fundus cameras were electronically uploaded to a secure website and reviewed by a local retina reading center. Those patients determined to have sight-threatening retinal pathology were scheduled by the retina reading center administration to see a local retina specialist. Patient demographic data were retrievable using the third-party platform and in collaboration with the primary care regional medical clinics.
An algorithm was created to determine the patients' disposition based upon the type and degree of pathology detected by the retina reader. Patients noted to have ungradeable images or non-retinal, sight-threatening disease such as hazy media suggesting a cataract or increased cup-to-disc ratio were scheduled by the primary care regional medical clinic administration to see a local general ophthalmologist. Those images with no pathology or mild DR without macular edema were scheduled for a repeat image in 1 year. Those with moderate to severe background DR, macular edema, proliferative DR, or any other potential sight-threatening retinal problem were scheduled for a retinal exam by a retinal specialist within 1 month of screening. Patients complaining of any eye-related symptoms such as decreased vision, eye redness, or eye pain were referred to a general ophthalmology clinic for a comprehensive examination. The data obtained included number screened, number with retinal disease, number with DR, number needing retinal exam, and number seen by a retina specialist.
From May of 2015 through April of 2017, 5,764 patients were screened. Of the patients screened, 1,830 (31.7%) were noted to have retinal pathology. Twenty percent of patients (n = 1,152) were found to have any DR. Sight-threatening disease requiring a retinal exam was found in 668 (11.8%) patients, and 547 (9.7%) were evaluated by a retina specialist. The capture rate of those patients who actually were evaluated by a retina specialist divided by those who were recommended to see a retina specialist was 81.9% (547/668). Of all patients screened, 82 (1.42%) required retinal treatment in the form of anti-vascular endothelial growth factor (VEGF) injections, retina laser, and/or vitrectomy. Fifteen percent (82 of 547) of those patients who were examined by a retina specialist required treatment. The number of patients whose images were not gradable by the reading center was 132 (2.3%).
To our knowledge, this report is the first of its kind focused on telemedicine outcomes for DR screening in an urban, insured population. Our study of this population had a capture rate of 81.9%, which is much higher than previously reported at 29.9% in an urban, underserved population10 and 60% in a rural, underserved population.11
The higher capture rate in our study may be explained by the resources available to this insured patient population residing in an urban setting, where transportation needs are more easily accommodated. The prompt scheduling call from the reading center within 24 hours to those needing a retinal examination may have also increased adherence to recommended follow-up. The capture rate will become increasingly important to report in future studies since it confirms screening programs are accomplishing their ultimate goal of triaging at-risk patients to specialists without loss of patient follow-up.
The results of our study are similar to recent reports in that approximately 20% of diabetic patients screened were noted to have some form of DR.12–14
In our study, only 11.8% of patients screened required further evaluation by a retinal specialist, thus decreasing the number of eye care visits for 5,764 diabetic patients to 668 who actually required the services of a retinal specialist. Only 1.4% of those screened required retinal treatment in the form of anti-VEGF injections, laser therapy, and/or pars plana vitrectomy for sight-threatening disease. The telemedicine screening program considerably reduced the time and resources for both the patient and provider. One goal of screening programs is to identify those patients requiring more specialized care from those who do not. This may help reduce overall cost and allow specialists to use their time treating patients, not screening them. Future studies may further confirm the cost-effectiveness of these screening programs since they address the increasing burden of screening diabetic patients, which is predicted to overwhelm traditional avenues of delivering DR screening exams.
Modern health initiatives have the triple aim of improving individual patient outcomes, improving population health outcomes, and reducing cost. The deployment of telemedicine for DR screening using primary care-based fundus cameras may help accomplish this triple aim by improving individual patients' experience of care, improving population HEDIS scores, and reducing costs through early intervention. In conclusion, this report confirms the utility of telemedicine for diabetic retinopathy screening, particularly in an insured, urban population. It also documents a higher than previously reported capture rate (81.9%) of adherence to recommended follow-up for patients with sight-threatening retinal pathology.
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