The largest publicly operated county safety net public health system in the United States recently reported in JAMA Internal Medicine a reduction in median wait time to screening for diabetic retinopathy (DR) from 158 days to 17 days (an 89% reduction in wait time), and an increase in the rate of screening for patients diagnosed with diabetes from 57% to 69% (a 16.3% increase in screening rate). How was this accomplished? Through teleretinal diabetic retinopathy screening (TDRS) in 15 primary care clinics using the EyePACS system. By moving the DR screening into the primary care setting, more than 14,000 visits to specialty eye care practitioners were eliminated, an important feature in a health care system with limited specialty care resources.
The study, conducted by the Los Angeles County Department of Health Services (LAC DHS) from September 1, 2013, to December 31, 2015, was reported by Dr. Lauren P. Daskivich and her associates at the LA County Health Department, UCLA, and Charles Drew University. The Los Angeles County safety net serves more than 800,000 patients annually (64,000+ with diabetes), most of whom are underinsured or uninsured. Noting that only 60% of patients with diabetes in the US receive recommended annual eye examinations – that rate dropping to less than 25% in the safety net – the authors conclude that, “Teleretinal DR screening is well suited to solve the problems of the safety net because it increases access by screening through primary care rather than specialty care, improves efficiency by moving patients with normal retinal photographs out of the queue for appointments with specialty care professionals, and reduces wait times for those with treatable disease.”
“We implemented a TDRS program throughout 15 of the largest LAC DHS–operated primary care clinics. Our first clinic began screening in September 2013, followed by rolling expansion to all LAC DHS comprehensive health center primary care clinics, medical center primary care clinics, and multispecialty ambulatory care center primary care clinics by March 2015.” Fifty-eight existing certified medical assistants and licensed vocational nurses were trained and certified as fundus photographers; they uploaded patient images to the EyePACS system. DHS created a retinal photography clinic for which patients were scheduled in advance by their primary care professional or a care manager. “This method best uses the photographers’ time because they often perform other services,” the authors explain. Protocol also allowed for walk-in, same-day screenings.
“We mandate that photographers upload a minimum number of cases monthly to maintain certification, thereby maximizing the quality of the images. Image quality is also graded by our readers, and photographers who do not meet adequacy requirements in any three-month period undergo retraining.” Ten primary certified image readers, optometrists employed by the LAC DHS, read the screening photographs. Referrals for abnormal results were submitted via eConsult, a web-based referral system for specialty care, allowing for submission of screening results and scheduling of follow-up as needed. Based on screening results, patients were triaged into optometry or ophthalmology clinics.
“A key to the sustainability of our program is the integration of DR screening into primary care practices, treating it as a diagnostic test to establish a need for referral to specialty eye care. By eliminating the need for a separate visit to a specialist, we are able to increase the number of patients screened for DR without increasing demand on specialty care, which is critical in a system in which more than 3000 people are currently waiting for eye care appointments.” The report notes that this system also allows for better use of patients’ limited resources such as transportation and time off work.
The authors point out that the “education of all critical stakeholders and support of hospital, clinic, and health system leadership are essential… Eye care professionals fear that TDRS programs will decrease referrals for in-clinic visits. However, eye care professionals need to understand that improved rates of screening for DR and triage actually result in increased detection of patients with significant disease and therefore increased referrals of patients needing higher-level care.”
The conclusion? “With standardization and oversight, primary care–based teleretinal DR screening programs have the potential to maximize access and efficiency in the safety net, where the need for such programs is most critical. Our paradigm for implementation is a model for other urban safety net populations where the need for such programs is arguably the greatest.” The authors note, however, that, “although our TDRS program substantially reduced wait times to screening and improved rates of screening, more information is needed to demonstrate that patients who need treatment are actually receiving this care in an expedited fashion.”
