Telehealth program reduced unneeded diabetic retinopathy referrals

The Los Angeles County Department of Health Services safety net clinics successfully implemented a primary care-based teleretinal diabetes retinopathy screening (TDRS) program, eliminating the need for more than 14,000 visits to specialty care professionals, according to the results of a study published recently in JAMAInternal Medicine.

“We see an immense amount of preventable blindness from diabetic retinopathy in our Los Angeles County population and, as in most U.S. safety net populations, our screening rates for this disease were low,” Lauren P. Daskivich, MD, MSHS, of the department’s Ophthalmology and Eye Health Programs told Medical Economics. “While our goal was to implement an intervention to help address this, we also wanted to study what we implemented to ensure that it was truly meeting the needs of our patients and our healthcare system.”

Daskivich and colleagues tested a primary care-based TDRS program in five of 15 Los Angeles County Department of Health Services safety net clinics between September 2013 and December 2015. The safety net program is a “nonvertically integrated system” that serves underinsured and uninsured patients.

The TDRS program was designed to move patients with normal retinal photographs out of line to be seen by specialty care professionals, reducing wait times for patients who do require treatment. In the program, 58 certified medical assistants and licensed vocational nurses were trained and certified as fundus photographers and existing medical assistants were trained to use the cameras in primary care settings and to upload these digital images to a web-based screening software.

Next: Study details

The study evaluated the annual rates of screening for diabetes retinopathy (DR) before and after implementation of the program and time to screening for DR in a random sample of 600 patients.

In all, 21,222 patients underwent screening through the program and the median time to screening for DR significantly decreased (P<.001).

“We increased our screening rate for diabetic retinopathy by 16.3% in the study clinics and the median time to DR screening decreased significantly from 158 days before the intervention to 17 days after implementation of the program (89.2%), while at the same time eliminating the need for over 14,000 specialty eye care visits overall,” Daskivich said.

Annual screening rates increased significantly from 40.6% (5,942 of 14,633 patients) to more than one-half (56.9%; 7,470 of 13,122 patients; OR=1.9; 95% CI, 1.3-2.9; P=.002).

According to Daskivich, “these are visits that are then available for patients waiting to see eye care providers for other sight-threatening conditions.”

Of screened patients, 19.6% were referred for treatment or monitoring of DR, 68.8% did not require referral for eye care, and 11.6% were referred for other eye conditions.

Daskivich said that an important aspect of this program is its integration into the primary care clinics, allowing for patients to be screened within their primary care medical homes, even at their initial point of contact with the healthcare system.

“This requires collaboration with our primary care and specialty care colleagues, an interaction integral to the overall care of persons with diabetes,” she said. “Earlier screening for diabetic retinopathy in U.S. safety net populations, leading to earlier detection and treatment, could lead to a significant cost-savings to society in terms of blindness prevention. Integration of the diabetic retinopathy screening process into primary care clinics using certified medical assistant photographers could also provide a less costly option than performing these screenings in specialty care clinics by eye care providers.”