Lauren Patty Daskivich, MD, MSHS
LAC DHS
Carol M. Mangione, MD, MSPH
UCLA
Implementation of a Primary Care-Based Teleretinal Screening Protocol for
the Los Angeles County Safety Net ___________________________
Diabetic Retinopathy Diabetic retinopathy (DR) is a leading cause of
blindness in working-age adults in the United States
Prevalence of diabetic retinopathy in a large study of Latinos in LA has been shown to be close to 50%
THE leading cause of blindness in Los Angeles County
Early Treatment Diabetic Retinopathy Study (ETDRS) showed that severe vision loss from diabetic retinopathy can be reduced by up to 94% by effective treatments.
At least 40-45% of diabetics who may benefit from earlier detection and treatment of retinopathy are not receiving it
Teleretinal Screening for Diabetic Retinopathy
High sensitivity and specificity when compared to gold standard (7 standard field fundus photographs and indirect ophthalmoscopy by an ophthalmic physician) Sensitivity: 71-82% Specificity: 92-96%
Recognized by the American Academy of Ophthalmology
No studies evaluating teleretinal screening in a safety net setting
Clinical Pathway for Teleretinal Imaging
Diabe&c pa&ent iden&fied at PCP visit
Pa&ent sent for telere&nal screening at end of PCP visit
Photographer uploads image to so:ware template and submits
Images acquired
Images transmi=ed to reading center
Images reviewed, report generated back to PCP
PCP clinic submits eConsult based on diagnosis/triage recommenda&ons
Research Question
Program evaluation:
Are we truly meeting our goals of increasing the number of patients screened and triaging those in need of care in a more timely manner?
Are we screening more patients for DR?
Are wait times shorter?
Does it cost less?
Methods
Nonrandomized, quasi-experimental pretest-posttest design
Exposure at clinic level
Historical controls
Powered to detect a 15% difference (with a 0.02 intra-clinic correlation) between intervention and control populations 5 clinics with control and intervention groups
120 subjects per clinic
Outcomes: Aims 1-3
Control (120 patients) Intervention (120 patients)
Teleretinal Screening
6 months 6 months
Pre-Post Analysis for Screening Rate for Diabetic Retinopathy: Screening rate at clinics post-TRS intervention – Screening rate at clinics pre-TRS intervention
Pre-Post Analysis for Patient Wait Time for Ophthalmology Appointment: Wait time for patients post-TRS intervention – Wait time for patients pre-TRS intervention
Pre-Post Analysis for Patient Wait Time for Definitive Ophthalmic Treatment for Moderate/Severe NPDR and PDR: Wait time for patients post-TRS intervention – Wait time for patients pre-TRS intervention
Primary Care Clinic
Outcomes: Aim 4
Complexity of societal vs. health systems perspective
What we can estimate Cost effectiveness of screening method – teleretinal
imaging vs. direct eye exam Number of cases of blindness prevented and
compare to national estimates of cost of blindness
Area for collaboration with health economist
CERP Aims Addressed
Aim 1 – Promote bidirectional knowledge exchange between community and academia.
Aim 2 – Build community and academic infrastructure for sustainable partnered research
Aim 4 – Build Health Services Research (HSR) methods into partnerships to accelerate design, production, and adoption of evidence-based interventions
Action Status Expected Completion Date
IRB approval from UCLA and LABioMed
Completed
IRB approval from USC Under Review January 2014
Pre-intervention data collection at 4 of 5 PC clinic sites
Completed
Pre-intervention data collection at remaining PC site and 3 Ophthalmology clinics
Underway January 2014
Implementation of DHS Teleretinal Screening Program
Underway January 2014 at study sites (June 2014 all sites)
Post-intervention Data Collection at 5 Clinic Sites
Pending February - March 2014
Data Analysis and Preparation of Extra-mural Grant Application
Pending April - June 2014
Timeline
Added Value from CTSI Funding
Access to Health Services Research and Biostatistical support available within the UCLA CTSI Availability of the biostatistics core and health
economist to assist with data analysis Consultation to ensure that our quality assurance
mechanisms are sufficient Advice on the design of a cost analysis of this
intervention Advice regarding additional pilot funding to assist
with dissemination if this project is found to be successful
Research Assistant support
Next Steps and Products IRB approval obtained from UCLA, LABioMed; USC under review
Major strides in implementation, including: Ensuring clinic access to fundus cameras for 13 DHS primary care sites
Identifying and training fundus photographers (LVN/Medical Assistant level)
Selecting and implementing the software platform for transmitting teleretinal images
Creating a quality assurance mechanism for image acquisition and evaluation
Establishing appropriate triage mechanisms for abnormal screening photographs integrated with eConsult, the new web-based LAC specialty referral system
Teleretinal Screening has begun at 2 sites and will rollout to 11 more over the next 6 months
Currently developing a protocol for standardized referral timelines across LA County that will further streamline patient care