Medical Research: What are the main findings of the study?
- Since 2006, the VA has been systematically using teleretinal screening of patients with diabetes to screen for retinopathy in the Primary Care Clinics. Under this program, 90% of veterans with diabetes are evaluated on a regular basis. A number of patients who are screened have findings that warrant a face-to-face ophthalmic exam. No information exists on the effect of such a program on medical center resources.
- 1,935 patients underwent teleretinal screening through the Atlanta VA over a 6 month period. We reviewed the charts of the 465 (24%) of the patients who were referred for a face to face exam in the Eye Clinic.
- Data was collected for these patients to determine the reasons for referral, the accuracy of the teleretinal interpretation, the resources needed in the Eye Clinic of the Medical Center to evaluate and care for the referred patients over a two year period and possible barriers to patient care.
- Of the 465 patients referred for an exam, 260 (55.9%) actually came in for an exam. Community notes were available for an additional 66 patients. Information was available for 326 (70.1%) of the referred patients.
- The most common referring diagnoses were nonmacular diabetic retinopathy (43.2% of referrals), nerve related issues (30.8%), lens or media opacity (19.1%), age-related macular degeneration (12.9%) and diabetic macular edema (5.6%).
- 16.9% of the referred patients had 2 or more concurrent problems that put them at high risk for visual loss.
- The percentage agreement between teleretinal screening and the ophthalmic exam was high: 90.4%. Overall sensitivity was 73.6%. The detection of diabetic macular edema had the lowest sensitivity.
- A visually significant condition was detected for the first time through teleretinal screening for 142 of the patients examined (43.6%).
- The resource burden to care for referred patients was substantial.
- 36% of patients required 3 or more visits over the ensuing 2 year period.
- The treatment of diabetic macular edema had the highest resource use involving on average 5 clinic visits, 6 diagnostic procedures and 2 surgical procedures
- The most common non-refractive diagnostic procedures were visual fields and optical coherence tomography.
- The average cost to care for the referred patients (in Medicare dollars) in work RVUs alone was approximately $1,000 per patient. The cost to care for a patient with diabetic macular edema was $2673.36.
Medical Research: Were any of the findings unexpected?
Dr. Lynch: Yes. 21% of patients failed to show for their scheduled eye clinic appointment. Age and travel distance did not contribute to the no show rate. The patient’s historical no show rate was actually the best predictor; a patient with a historical no show rate of 26% had a 58% chance of failing to show for the Eye appointment. Predicting and managing no shows is a critical factor in any large healthcare system.
Medical Research: What should clinicians and patients take away from your report?
Dr. Lynch: Teleretinal imaging in the primary care setting is a highly effective tool to screen patients for eye disease. The VA and other healthcare systems are going to have to look at innovative ways of bringing basic eye care services to the community in a cost effective way. Telemedicine is going to be one of those methods and eventually it will be expanded beyond screening for diabetes.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Lynch: The study generated ratios that could be used to predict the number of appointment slots, diagnostic tests and surgical procedures that would be needed to care for patients who are referred from a teleretinal screening program. For example, placing a camera in a primary care clinic that includes 5,000 patients with diabetes may generate approximately 1,200 referrals to an eye clinic. Assuming that all patients are evaluated with an ophthalmic exam, these referrals might require 544 visual fields, 516 OCTs and 143 cataract extractions over the next 2 years. This is important information for clinic managers to have as they adjust personnel, equipment and space in anticipation of a telemedicine expansion.
Effect of a Teleretinal Screening Program on Eye Care Use and Resources
Joel E. Chasan, MD; Bill Delaune, PhD; April Y. Maa, MD; Mary G. Lynch, MD
JAMA Ophthalmol. 2014; 132(9):1045-1051. doi: 10.1001/jamaophthalmol.2014.1051