Setting and Meeting Goals for Retinopathy Detection

Most clinics have a compliance benchmark or standard in mind when they launch their EyePACS DR screening program, but experience has taught us that setting meaningful goals and understanding how well your clinic is meeting them are challenging undertakings. Several years ago we sampled key personnel from quite a few of our partner clinic programs, and their guesstimates as to their compliance rates were wildly overconfident. The individuals believed they were probably screening 50-74% of their diabetic patients, but they had no data to support that guess, and our data suggested the average rate was actually much lower.

So how do you go about setting realistic goals for diabetic retinopathy exams? Every clinic faces this step as they launch their EyePACS program. We always ask them: How many diabetic patients do you have? How many are you screening now? How many do you hope to screen?  It’s not easy to get even that information. So the first goal is specific, measurable numbers.

Just about everyone has heard of S.M.A.R.T. goals. (You can learn about them from Wikipedia.) Let’s talk about how to apply SMART goals to diabetic retinopathy detection and prevention.

First, your clinic needs to be specific about goals, and that means answering those first three key questions: Size of diabetic patient population; percentage now undergoing annual exams; percentage we can reasonably hope to screen over the next one year, three years, five years. And be very specific too about why you hope to raise that percentage. Is it about HEDIS points, reimbursement, clinical quality data, a healthier population? Identify exactly who must be involved, and ensure they are all part of the goal-setting process. Together determine the space and time that must be allocated to improve your DR compliance rate, and be brutally honest about the constraints you will face. That is the “S” – specific.

Now, how will you measure progress? An EyePACS encounter is one completed exam you can count. But you must also count the patients who have live retinal exams from a doctor (as evidenced in the patient’s record). Who will measure your results, using what sources, and how will results be reported? Do you have the systems in place to gather and report on this data? How will you know when you have accomplished your goal? Now you have the “M” – measurable.

And, as our evidence cited above reflects, the “A” (attainable) should be your reality check. First you must know what percentage of diabetic patients you are currently screening annually, and then you must set an attainable goal that you can actually accomplish. It might be that, in your first year, your goal is to establish that baseline data. Or, if you have a low compliance rate now, set a modest goal for your first year or two: 10%, 15%, 20% - whatever you can attain, given the constraints reality imposes. A challenge is important, but better to achieve a small goal than to perpetually pursue a dream. And now you have accomplished “S.M.A.”

Relevancy is the fourth touchstone. Will this make a difference in mission accomplishment? Are we including the right staff, and have we chosen the right leadership for this program? Is our DR screening program, as we envision it, actually going to save sight? Does our screening program goal complement our diabetes education program and other current efforts? How does this goal fit with our broader strategic goals? And that is “R” – relevant.

Finally, is your goal timely? Can you actually do this within the timeframe you’ve established? Have you set the right time parameters for incremental improvement? Do you need to adjust? Now, you should have a goal that is specific, measurable, attainable, relevant and timely, and it should be based on actual numbers of actual diabetic patients.

Obviously, a goal of 100% compliance is unrealistic – and it’s also unnecessary. If you have mutually agreed on a challenging goal that will meaningfully save vision for your diabetic patients, then start there. Feel free to re-evaluate and adjust your strategic vision as necessary. And keep the whole process positive. Sometimes goals are made to be more important than they ought to be. Keep in mind that you are dealing with the main cause of blindness among working age adults. Even with advances in detection and treatment of retinopathy and glycemic control medications, the incidence of diabetes continues to rise, and so will your challenge.

As you set your SMART goals, keep in mind the reality of the landscape. EyePACS data coincides with other published retinopathy detection studies: 40% of all diabetic patients are likely to have some retinopathy; 8-10% will have sight-threatening retinopathy; and 7-8% will likely develop other conditions requiring referral, such as glaucoma or cataracts. Most clinics that begin an EyePACS screening program are starting with annual exam rates under 60%; the average is 15%.

Just start from where you are, move forward steadily, and keep us apprised of your progress. Understand that you are taking on a behemoth. As far back as 1989, under the aegis of the World Health Organization, European countries joined together in St. Vincent, Italy, to proclaim that new blindness from diabetes around the world would be reduced by one third. (This is known as the St. Vincent Declaration.) For Great Britain that would mean saving the sight of 491 additional diabetic patients each year. And so health ministers in the UK invited 2.5 million people to have their retinas examined annually. They managed to screen 80% of those invited, but the cost for one year was $3.4 million.

Our own Department of Veterans Affairs, with 800,000 diabetic veterans, set a goal to provide teleretinal imaging to 20% of its patients with diabetes. It was a modest, manageable goal, and the VHA also included plans to incorporate patient education with each encounter and also to integrate this new program with its system-wide electronic health record. For that organization, those were S.M.A.R.T. goals.

EyePACS clinics vary dramatically in the goals they set and the time it takes to achieve them. One superbly performing clinic sought to screen 23% of its diabetes patients in less than five years; they fell slightly short but, using one screening site for 1600 patients, they made measurable improvements. Another clinic set a goal of 100% compliance and had reached 56% compliance within three years. A third clinic also set the 100% goal, and within six months had reached the halfway mark. Each clinic must set goals that are SMART for that clinic.

Finally, you will want to correctly calculate the screening rate of your retinopathy detection intervention. This is how to do it. First, accurately count your total number of diabetic patients. Then count your total number of EyePACS encounters, but also count the number of unique patient retinal exams outside of EyePACS, such as from a doctor, as verified in the patient’s record. Add those two together, and divide the sum by the total number of diabetic patients. Now you know what percentage of your diabetic patients you have actually screened for DR – your compliance rate for the year. (As you go, you may use your EyePACS monthly report to estimate how close you are coming to your goal. Feel free to request help from the EyePACS staff to set realistic goals and measure progress.)

And always keep in mind these four important considerations, which make the entire effort meaningful:

·      Make sure the intervention you have designed is actually preventing blindness. Is it accessible to those who are at greatest risk for blindness? Are they taking advantage of the program?

·      A high number of retinal photographs are of little use if the image quality doesn’t allow for accurate image grading. Consider setting and measuring a goal for image quality for each photographer.

·      Are you closing the loop? That is, what percentage of patients with sight-threatening retinopathy, once identified, are actually making it to specialty care and following up with the recommended treatment?

·      Think about how you can incorporate patient education into the process and reduce complications by encouraging better control of blood sugar and hypertension.