Telemedicine via PCPs Ups Diabetic Retinopathy Screenings

Marcia Frellick

March 10, 2015

Researchers have found long-term positive results when primary care physicians (PCPs) use telemedicine to screen for diabetic retinopathy.

Steven Mansberger, MD, MPH, from the Devers Eye Institute in Portland, Oregon, and colleagues found that telemedicine increased the percentage of diabetic retinopathy screening examinations. They also found that most participants did not require referral to an eye care professional after the screening and that diabetic retinopathy levels were relatively stable during the study period. Results were published online March 5 in JAMA Ophthalmology.

This finding suggests that PCPs can use telemedicine with nonmydriatic cameras to take retinal images without dilation, send images for remote evaluation, and watch for disease worsening over time.

This study builds on others that have shown you can improve the rate of diabetic eye exam with telemedicine, but this one adds long-term evaluation, Dr Mansberger told Medscape Medical News.

The results come in light of research that projects the percentage of US adults with diabetes will increase from 14% in 2010 to approximately 33% by 2050. Finding and treating diabetic retinopathy is key to avoiding vision loss. However, fewer than half of patients with diabetes get the annual screening.

Telemedicine increases the numbers by improving access in rural areas and providing convenience (15 minutes vs 2 hours) and lower cost than a full eye exam ($40 and no extra copay vs about $200) for patients in the primary care setting, according to the authors.

Testing patients in a primary care practice's office, however, has some hurdles, in that imaging is done in a separate room.

Physicians can look at feet, do a laboratory test, and get an electrocardiogram in the same room, but at this time, patients would then have to move to another room for the eye exam, Dr Mansberger said.

"In the future, we'll have devices that are much smaller and easier to use, and we can bring them right into the room," he said.

Comparing Telemedicine With Traditional Exam

Patients with diabetes were randomly assigned into two groups in a multicenter trial. Some received telemedicine in a primary care medical clinic (n = 296), and some received a traditional exam with an eye care professional (n = 271). Participants were followed for up to 5 years. Two years after enrollment, telemedicine was offered to all participants.

The results were as follows for the three major outcomes: With regard to likelihood of getting screening, the telemedicine group was more likely to receive the screening exams compared with the traditional group during the 6-month or less (94.6% [280/296] vs 43.9% [119/271]; 95% confidence interval [CI], 46.6% - 54.8%; P < .001) and greater than 6-month through 18-month (53.0% [157/296] vs 33.2% [90/271]; 95% CI,16.5% - 23.1%; P < .001) periods.

In addition, during the study, more than 90% (range, 90.4% - 94.1%) of eyes kept their diabetic retinopathy stage within ±1 of their baseline stage throughout the study. From 42 through 54 months, 35 (8.6%; 95% CI, 5.8% - 11.2%) of 409 participants had worsening by 2 stages or more, and 5 (1.2%; 95% CI, 0.1% - 2.3%) of 409 had an improvement by 2 stages or more.

Finally, when it comes to referral rate, referrals ranged from 19.2% (52/271) to 27.9% (58/208). Dr Mansberger said better imaging will eventually lower the referral numbers, adding to the cost-effectiveness. Poor imaging quality can come from small pupil size or ocular media abnormalities such as cataract.

In an invited commentary, Lloyd Paul Aiello, MD, PhD, and Paolo Silva, MD, from the Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, and the Department of Ophthalmology, Harvard Medical School in Boston, point to success using telemedicine in other countries, particularly in the United Kingdom. There, the UK National Health Service reports that for the first time in 50 years, diabetic retinopathy is no longer the leading cause of blindness in the working age population. A big part of that success, the authors say, appears to be the introduction of a telemedicine program.

Dr Silva told Medscape Medical News that universal healthcare in the United Kingdom means telemedicine faces different regulation there, but he sees much promise in the current article for applications in the United States.

One thing that was particularly striking, he said, was that when people could choose between telemedicine and a full eye exam, 30% chose only telemedicine. That means telemedicine has the ability to reach people who would not have otherwise gotten the exam, he said, which is key to reducing rates of blindness.

"Every patient not evaluated is a patient we've potentially lost to vision complications," he said.

Funding was received from the National Eye Institute, Centers for Disease Control and Prevention, and the Good Samaritan Foundation at Legacy Health. Dr Aiello reports having received travel reimbursement to meetings with Optos outside the submitted work. The other researchers and commentary authors have disclosed no relevant financial relationships.

JAMA Ophthalmol. Published online March 5, 2015. Article abstract, Commentary extract

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