Grading of DR by first-line caregivers needs improvement

Most optometrists perform a dilated fundus exam to screen for diabetic retinopathy, but there is disparity between their assessment and DR classification.

The majority of optometrists perform a dilated fundus examination to screen for diabetic retinopathy, but the concordance between the examination and grading for diabetic retinopathy needs improvement, according to a retrospective chart review.

“The screening of most diabetic patients is done by first-line caregivers, such as general optometrists or general ophthalmologists, and what we wanted to do was look at our optometry colleagues who evaluate these patients and determine if they’re meeting the criteria of screening these diabetic patients and properly assessing their level of diabetic retinopathy,” Healio/OSN Board Member and study co-author Rishi P. Singh, MD, said.

Singh and colleagues retrospectively reviewed 1,300 patient records from 26 optometrists for documentation of dilated fundus examination, imaging, follow-up appointments and referrals. The concordance between clinical exams and coding was also evaluated as a surrogate for their ability to assess stage of diabetic retinopathy.

Rishi P. Singh, MD
Rishi P. Singh

In 97.8% of patient encounters, dilated fundus examination was performed, the patient was referred for dilated fundus examination, or dilated fundus examination was scheduled for follow-up. However, imaging tests were not routinely performed; only 2.6% of patients received a fundus photograph while 14.5% underwent OCT examination, Singh said.

“Multiple studies have found imaging, along with an examination, can improve the overall detection of retinopathy in patients. That is something we can certainly do better,” he said.

Additionally, the overall concordance between the optometrist’s assessment and plan, ICD codes and dilated fundus examination findings was 78.8%.

“What this tells us is that the level of DR was not always following the dilated eye assessment, and in an era of DR treatment, it is important to identify and refer these patients for possible treatment,” Singh said.

In a follow-up study that has been submitted for publication, Singh and colleagues invited optometrists to targeted interventions to receive further education on retinopathy scales, better imaging practices and new clinical strategies to identify retinopathy and retinopathy severity.

Evaluation cards were distributed at the conclusion of the symposia, informing each optometrist on their diabetic population by giving them specifics such as the average HgbA1c value for their patients, and assessing their individual ability to evaluate diabetic retinopathy.

After 1 year, the optometrists who participated in the symposia were reevaluated by chart review. Singh and colleagues noted a drastic improvement in the level of concordance between diabetic retinopathy seen in an examination and what was actually coded by the optometrists. The concordance increased from 78.8% in the recently published study to nearly 90% in the follow-up evaluation.

This is an important development, according to Singh, in that the treatment paradigm for diabetic retinopathy has changed. Both optometrists and ophthalmologists now should be informed about how retina specialists are addressing diabetic retinopathy before it develops into a proliferative state.

“Now we know patients can be treated earlier and prevented from developing complications over time,” Singh said. – by Robert Linnehan

Disclosure: Singh reports he received grants and personal fees from Genentech during the conduct of the study and grants and personal fees from Regeneron and Novartis/Alcon and personal fees from Optos, Bausch + Lomb and Zeiss outside the submitted work.

The majority of optometrists perform a dilated fundus examination to screen for diabetic retinopathy, but the concordance between the examination and grading for diabetic retinopathy needs improvement, according to a retrospective chart review.

“The screening of most diabetic patients is done by first-line caregivers, such as general optometrists or general ophthalmologists, and what we wanted to do was look at our optometry colleagues who evaluate these patients and determine if they’re meeting the criteria of screening these diabetic patients and properly assessing their level of diabetic retinopathy,” Healio/OSN Board Member and study co-author Rishi P. Singh, MD, said.

Singh and colleagues retrospectively reviewed 1,300 patient records from 26 optometrists for documentation of dilated fundus examination, imaging, follow-up appointments and referrals. The concordance between clinical exams and coding was also evaluated as a surrogate for their ability to assess stage of diabetic retinopathy.

Rishi P. Singh, MD
Rishi P. Singh

In 97.8% of patient encounters, dilated fundus examination was performed, the patient was referred for dilated fundus examination, or dilated fundus examination was scheduled for follow-up. However, imaging tests were not routinely performed; only 2.6% of patients received a fundus photograph while 14.5% underwent OCT examination, Singh said.

“Multiple studies have found imaging, along with an examination, can improve the overall detection of retinopathy in patients. That is something we can certainly do better,” he said.

Additionally, the overall concordance between the optometrist’s assessment and plan, ICD codes and dilated fundus examination findings was 78.8%.

“What this tells us is that the level of DR was not always following the dilated eye assessment, and in an era of DR treatment, it is important to identify and refer these patients for possible treatment,” Singh said.

In a follow-up study that has been submitted for publication, Singh and colleagues invited optometrists to targeted interventions to receive further education on retinopathy scales, better imaging practices and new clinical strategies to identify retinopathy and retinopathy severity.

Evaluation cards were distributed at the conclusion of the symposia, informing each optometrist on their diabetic population by giving them specifics such as the average HgbA1c value for their patients, and assessing their individual ability to evaluate diabetic retinopathy.

After 1 year, the optometrists who participated in the symposia were reevaluated by chart review. Singh and colleagues noted a drastic improvement in the level of concordance between diabetic retinopathy seen in an examination and what was actually coded by the optometrists. The concordance increased from 78.8% in the recently published study to nearly 90% in the follow-up evaluation.

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This is an important development, according to Singh, in that the treatment paradigm for diabetic retinopathy has changed. Both optometrists and ophthalmologists now should be informed about how retina specialists are addressing diabetic retinopathy before it develops into a proliferative state.

“Now we know patients can be treated earlier and prevented from developing complications over time,” Singh said. – by Robert Linnehan

Disclosure: Singh reports he received grants and personal fees from Genentech during the conduct of the study and grants and personal fees from Regeneron and Novartis/Alcon and personal fees from Optos, Bausch + Lomb and Zeiss outside the submitted work.