Telemedicine Cuts Wait Time for Diabetic Retinopathy Screening

Veronica Hackethal, MD

March 28, 2017

Telemedicine based in a primary-care doctor's office can reduce waiting time and improve screening rates for diabetic retinopathy in a large public-safety-net health system, according to the results of a new study, published online in JAMA Internal Medicine.

The project took place in the Los Angeles County Department of Health Services, the largest publicly operated county safety-net healthcare system in the United States.  

Other health systems, like the Indian Health Service and the Veterans Health Administration, have shown advantages to using telemedicine screening for diabetic retinopathy. However, the LA County project is the first to implement primary-care–based telemedicine screening for diabetic retinopathy on such a large scale.

"I was very happy to find that a program like this could work in the safety-net setting, [which has] many different levels of insurance coverage, insurance plans, and really varied geographic range, from urban to rural," says first author Lauren Daskivich, MD, MSHS, of the Department of Health Services, Los Angeles County, California, in an audio interview with JAMA on its website.

"[It] gave me hope that this project could spread to other resource-limited settings, where the need for services like this is really critical," she added.

Wait Times for Screening Fell by Almost 90%

Diabetic retinopathy is a leading cause of blindness in working-age adults in the United States. The prevalence of diabetic retinopathy is about 50% among Latinos in Los Angeles, who represent the largest ethnic majority in the LA County safety-net system.

Vision loss can be prevented with early screening and treatment. But demand often exceeds supply in the LA County Department of Health Services — this public safety net cares for over 800,000 underinsured and uninsured patients each year and has limited specialty-care resources. Over 200 primary-care clinics refer patients to just six optometry and four ophthalmology clinics, producing waiting times of 8 months or longer — too long for a condition like diabetic retinopathy.

Dr Daskivich's countywide project took place between September 2013 and December 2015. It placed screening cameras in 15 primary-care clinics, so that patients could be screened on the same day as their primary-care checkup. Medical assistants and licensed vocational nurses trained in fundus photography took the photos, then uploaded the images to web-based screening software.

Using a standardized, validated protocol, staff optometrists read the images, graded them, and provided their results with recommended times for follow-up. They also gave feedback on image quality.

Researchers also analyzed the project in a subset of five clinics. They took a random sample of 120 patients from each of these clinics (600 patients total) and compared annual screening rates before and after implementation of the project.

Among 21,222 patients who underwent screening in all 15 clinics, waiting times for screening decreased by 89.2% — from 158 days before the intervention to 17 days after it (P < .001). Almost 70% of patients had normal results and did not require a specialty referral, decreasing the need for over 14,000 visits to eyecare clinics.

And in the subset of five clinics, annual diabetic retinopathy screening rates increased by 16%, from 40.6 % before the intervention to 56.9% after it (odds ratio, 1.9; P = .002).

Improvement in Care Without Large Increases in Cost

"I think everyone involved should really be commended for making this [project] happen. What really made this program work is not one single intervention but the combination of several clearly evidence-based approaches," commented Urmimala Sarkar, MD, MPH, University of California, San Francisco, in the audio interview.

Dr Sarkar, along with Courtney Lyles, PhD, also of the University of California, San Francisco, coauthored a commentary accompanying Dr Daskivich's paper.

First, the project standardized work flow so that clinic staff used the same process for each person who needed diabetic retinopathy screening. Second, nonphysician team members did the standard work, which has been shown to improve delivery of recommended care. Third, the project used an existing electronic referral platform to facilitate communication between the eye clinic and primary-care clinics.

"Combining several evidence-based strategies for health-system innovations has produced improved provision of care without large increases in cost," note Drs Sarkar and Lyles in their commentary.

Whether this project can translate to other healthcare systems will depend on culture change among not only the staff in primary-care practices but also eye-clinic professionals, they add.

"Whoever wants to implement this intervention…in other places, which I think is very encouraging and very worthy, will need to do a lot of work to understand the local culture," she said.

"They will need to understand promoters and barriers to changing responsibilities for medical assistants, changing the type of referrals that go to the eye clinic, and changing the conditions for each patient with diabetes."

And letting patients know that they are still receiving vision screening even without referral to an eye clinic will be important, she explained.

"This project is an example of safety-net systems really leading the way. I think private and other types of healthcare systems can learn a lot from how this project was implemented and from the results, which are becoming increasingly relevant across different types of healthcare systems," Dr Sarkar concluded.

The project continues to run in the LA County Department of Health Services and has added three more clinics. It plans to continually update and integrate new technological advances to smooth clinic work flow.

The study was supported by the Robert Woods Johnson Foundation Clinical Scholars Program and the National Institutes of Health. The authors and editorialists report no relevant financial relationships.

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JAMA Intern Med. Published online March 27, 2017. Article, Editorial



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