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Implementation daskivich
Implementation daskivich
Implementation daskivich
Implementation daskivich
Implementation daskivich
Implementation daskivich
Implementation daskivich
Implementation daskivich
Implementation daskivich
Implementation daskivich
Implementation daskivich
Implementation daskivich
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Implementation daskivich

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  • 1. 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 ___________________________
  • 2. 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
  • 3. 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
  • 4. 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 
  • 5. 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?
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. 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

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