5 MINUTES
The best weapon against diabetic retinopathy is early detection, but compliance with diabetic retinal exams is low – nationally, only 20-to-50 percent of patients comply.1 Yet, up to 95% of vision loss can be prevented if caught and treated early.2
Teleretinal imaging has been demonstrated to increase compliance rates for diabetic retinal exams with some clinics achieving compliance greater than 90%.3 However, few studies have examined the long-term outcomes of patients receiving a teleretinal diabetic retinal exam.
Summit Medical Group (SMG) is a large primary care organization in East Tennessee with more than 300 physicians located in 55 offices. SMG implemented the RetinaVue care delivery model in 2015 to provide diabetic retinal exams to their patients at their annual office visit. This study will analyze the compliance of patients who were referred for specialist care based on their results from the diabetic retinal exam:
The RetinaVue care delivery model helps primary healthcare providers detect diseases that manifest in the retina, including diabetic retinopathy. The handheld RetinaVue 100 Imager is used to acquire non-mydriatic fundus images in minutes. The clinician then transfers encrypted fundus images via secure HIPAA compliant RetinaVue Network software to a team of board certified ophthalmologists who provide a diagnostic report and referral/care plan generally the same day.
Most patients referred for diabetic retinopathy from the RetinaVue care delivery model in primary care receive appropriate follow-up care, including an examination by an eye specialist and treatment (as needed).
Since implementation of the RetinaVue care delivery model in 2015, SMG has offered diabetic retinal eye exams to all their diabetic patients. SMG’s clinicians acquire the retinal images on both the right and left eye using the RetinaVue 100 Imager during their routine office visit. The clinician then transfers the fundus images through the RetinaVue Network software to a team of board-certified ophthalmologists (RetinaVue, P.C.) who provide a diagnostic report and referral/care plan.
Patients that were identified with severe, non-proliferative diabetic retinopathy (NPDR) or worse were referred for follow up with an eye care specialist.
To determine how many of these patients complied with this recommendation, SMG searched their records through the RetinaVue Network database (June 2015 through September 2017). From those patients, an additional search was conducted in the electronic medical record (EMR) database to identify:
Based on the records from the EMR and the RetinaVue Network database, a total of 109 patients were identified with pathology for which referral was recommended. Of the 109 patients that SMG referred for follow-up care by ophthalmologists, 86 patients attended their appointment, a 79% compliance rate. Previous teleretinal imaging studies have recorded compliance rates ranging from 49% to 55%.4-8
Out of the 86 patients that were recommended to see an eye care specialist, 22 required immediate treatment for CSME or severe, active PDR. There was documented treatment for 18 of the 22 patients (82%) that were referred to treatment. There were 4 patients that did not have documented treatments results and it is unclear if these patients did not attend their treatment or were not documented.
This study demonstrated that primary care based teleretinal imaging may result in higher compliance rates along with accurate referrals for the eye care specialist.
Results show that 79% of SMG patients followed up with the recommended care plan - typically a referral to the eye specialist.Based on the results from the EMR, 92% of those patients were diagnosed with some type of eye disease by the eye care specialist.
Increasing access to the diabetic retinal exam in primary care settings effectively identifies previously undetected eye disease, ensuring timely treatment to help preserve vision. Over the 27-month study period, SMG identified 22 patients that required immediate medical invention by the eye specialist.
Of note, however, is an area for improvement in the U.S. healthcare system in general – the efficient sharing and documentation of patient data between disparate healthcare providers. While documentation of the diabetic eye exam in primary care settings is one of the benefits of teleretinal programs, primary care documentation of compliance with specialist referrals and treatments can still be a challenge. The primary care providers for the patients in this study contacted the specialist practices to obtain records missing from the primary care files. Better on-going communication and documentation between primary care providers and specialists will improve care planning and care delivery, since primary care providers are ideally positioned to encourage compliance with follow-up appointments and treatment.
References
1. Sloan FA, Brown DS, Carlisle ES, Picone GA, Lee PP. Monitoring visual status: Why patients do or do not comply with practice guidelines. Health Serv Res. 2004 Oct; 39(5):1429-48.
2. National Eye Institute, Facts about Diabetic Eye Disease. https://nei.nih.gov/health/diabetic/retinopathy
3. Mansberger SL, Gleitsmann K, Gardiner S, et al. Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: A randomized controlled trial. Telemed J E Health. 2013 Dec; 19(12):942-8.
4. Newman R, Cummings DM, Doherty L, Patel NR. Digital retinal imaging in a residency-based patient-centered medical home. Fam Med. 2012; 44(3): 159-63.
5. Jani PD, Forbes L, Choudhury A, Preisser JS, Viera AJ, Garg S. Evaluation of diabetic retinal screening and factors for ophthalmology referral in a telemedicine network. JAMA Ophthalmol. 2017 July;135(7):706-714.
6. Tsui I, Havunijan MA, Davis JA, Giaconi JA. Snapshot of teleretinal screening for diabetic retinopathy at the West Los Angeles Medical Center. Telemed J E Health. 2016 Oct; 22(10):843-846.
7. Keenum Z, McGwin G, Witherspoon CD, Haller JA, Clark ME, Owsley C. Patients’ adherence to recommended follow-up eye care after diabetic retinopathy screening in a publicly funded county clinic and factors associated with follow-up eye care use. JAMA Ophthalmol. 2016; 134(11): 1221-1228.
8. Chasan JE, Delaune B, Maa AY, Lynch MG. Effect of a teleretinal screening program on eye care use and resources. JAMA Ophthalmol. 2014; 132(9):1045-1051.
