Primary care-based, teleretinal-screening protocol (Los Angeles Safety Net)


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UCLA CTSI-Los Angeles County Department of Health Services (DHS) Projects

Principal Investigators: Lauren Daskivich (DHS), Carol Mangione (UCLA)

Diabetic retinopathy (DR) is the leading cause of blindness among working-age Americans, and among Los Angeles Latinos—the ethnic majority of patients in the Los Angeles County (LAC) safety net—the prevalence of DR is ~50%. Despite evidence that early detection and treatment can prevent blindness from DR, a significant number of persons with diabetes in our system fail to receive annual screening examinations and/or sight-saving treatments due to lack of access to specialty care. To date, the effect of a system level intervention on improving access to eye care and definitive treatment for diabetic retinopathy in an urban medically underserved, or safety net, population has not been evaluated. The objective of this project is to evaluate the impact of teleretinal screening on access to specialty ophthalmic care for diabetic patients in LAC who need monitoring or treatment for diabetic retinopathy. We propose a pre-post analysis of the LAC teleretinal screening implementation, and we aim to evaluate the number of patients screened for diabetic retinopathy, the number presenting for timely ophthalmic follow-up care and treatment, and the cost of the program.

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Primary care-based, teleretinal-screening protocol (Los Angeles Safety Net)

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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