While a number of studies have shown that on average, only 60% of diabetic patients in the US receive timely eye examinations,22–26
some studies of the urban safety net setting have shown annual eye examination rates for inner-city diabetic patients to be lower than 25%.20, 27, 28
The challenges documented in our study may help to illuminate some of the reasons for the disparity in screening rates while the successes demonstrate the opportunities that teleretinal screening provides in spite of these challenges. Prior to the introduction of teleretinal screening, diabetic patients at the six safety net clinics had to be referred to Los Angeles County facilities for routine eye examinations. Patient wait times to receive appointments for routine eye screening at county facilities ranged from four to eight months, due to the high volume of uninsured and underinsured patients served by those facilities. Teleretinal screening thus presents a means of addressing the poor annual eye examination rates for inner-city safety net clinics and beginning to close the screening-rate gap. In the almost nine-month period between September 8, 2010 and June 6, 2011, our study has screened 1943 patients for diabetic retinopathy, which represents 20.6% of the diabetic patients seen at these clinics. We expect that by the 12-month mark, the annual screening rate achieved will exceed the national average for inner-city safety net clinics.
Our initial results show that the vast majority of diabetic patients screened for retinopathy did not have retinopathy and were not recommended for referral to specialty care. This suggests that teleretinal screening for diabetic retinopathy in the urban safety net setting can be an effective way of highlighting precisely those patients who need specialty care while simultaneously reducing the burden on county public health facilities with regards to access to specialists. The study also illustrates challenges in implementing teleretinal screening in the safety net setting, including the need for effective monitoring of image quality to ensure its suitability for diagnostic recommendations as well as camera repair and retraining of photographers when necessary. It is striking that of the subset of patients that had a current glycated hemoglobin (hemoglobin A1C) value available in their medical records, over 70% had levels above 7% (), an indication of less than satisfactory glycemic control. This has substantial implications for diabetic complications, including diabetic retinopathy.
Although the EyePACS protocol recommends screening of diabetic patients at the time of the visit with their primary care providers, (i.e., integrating diabetic retinopathy screening with the primary care visit), the six clinics involved in the study have different approaches to handling diabetic retinopathy screening based on their existing workflow, staffing levels and other resources. None of the clinics currently integrate retinopathy screening into the primary care visit. All the clinics in this study use medical assistants as photographers, in contrast to similar studies in developing countries in which primary care physicians themselves perform camera duties.16
Given the shortage of primary care physicians and nurses in safety net settings in California, the clinics’ decision to use trained medical assistants rather than physicians and nurses for photography is a necessary accommodation to circumstances.
Our study results show that image quality varied among the clinics; there were several factors that may have affected this outcome. These factors include: (a) the presence or absence of a dedicated diabetes program, (b) whether or not a clinic had staff allocated exclusively for teleretinal screening, (c) camera equipment problems, (d) the need for personnel to be retrained for teleretinal screening, and, (e) a clinic’s image-taking schedule for teleretinal screening (daily versus weekly). Only one clinic (Clinic E) has a dedicated diabetes management program staffed by two medical assistants who act as the photographers for diabetic retinopathy screening, in addition to their other duties for the program. Other clinics use between one and three medical assistants as photographers, however, these clinic staff are also involved in a variety of other programs (e.g., HIV prevention programs). Image upload rates and quality scores were also affected by camera equipment problems at two clinics and personnel retraining.
As of March 2011, the two clinics (D and E) that needed camera repairs had the highest percentages of images rated insufficient for any interpretation, at 18.6% and 18.8% respectively. Photographers at these two clinics were retrained in March 2011. Post-certification personnel retraining on camera use was needed at clinics for two reasons: (a) turnover of medical assistants at participating clinics, necessitating training for new medical assistants, and, (b) difficulty in consistently gaining expertise with camera use for medical assistants who take patient images just once or twice a week. Since all images rated as insufficient for full interpretation had to be retaken, in the long term, the clinics may weigh the associated costs of rescheduling patients for image-taking with the costs of retaining dedicated photographers for diabetic retinopathy screening. In addition to the retraining, as clinic E began to screen patients almost daily, the medical assistant responsible for photography improved tremendously in skill over medical assistants at other clinics that screen patients just once or twice a week.
To further address concerns about image quality, one of the ophthalmologists on the study (LP) met individually with photographers at different clinics to discuss image quality issues and to give them pointers for improving image quality. While Clinics D and E still have the highest percentage of images rated insufficient for any interpretation, by June 2011, those percentages had dropped to 12.2% and 10.2% respectively (). Interestingly, the two clinics (A and B) that had no prior experience with teleretinal screening had the highest percentages of images rated excellent. Clinic B, which had great difficulty in getting photographers certified in a timely manner and whose photographers required a large number of repeat trainings prior to eventual certification, ended up with the best image quality ratings across the six clinics by June 2011.
With regards to workflow, other researchers have observed that the introduction of telemedicine into a clinical setting alters existing work practices and power relationships.29
The ideal situation would be to integrate photography into the diabetic primary care visit. However, the clinics’ decision not to integrate teleretinal screening into the primary care visit is based primarily on financial considerations: none of the participating clinics can afford to have a medical assistant dedicated solely to photography at this time. In light of this, our study aims to implement teleretinal screening in a manner that the clinics can afford in terms of financial and personnel costs and that they will be able to continue at the end of the grant funding period. Since there is a relationship between the workflow at a clinic and ability to screen, image quality, image upload rates, etc., we will continue to monitor how different safety net clinics manage this with the limited resources that they have.
With regards to the assessment of images, although some international studies of teleretinal screening for diabetic retinopathy have found that non-ophthalmic physicians, with adequate training and ophthalmology oversight, may be able to provide effective review of teleretinal images,13, 30
to date, the use of non-eye care providers to screen for diabetic retinopathy is not considered standard of care within the United States. For this and other reasons (the time needed to train non-ophthalmologist image readers, the complicated specialty referral system currently in place in Los Angeles County, and the aforementioned shortage of family practice and primary care physicians), we decided to use board-certified ophthalmologists as readers for our study. In this study, the peer review process using ophthalmologists ensures a greater level of trust in the recommendations of image readers by the receiving ophthalmologists and removes the need for a repeat screening examination in patients that need to be scheduled for a treatment appointment directly.
As stated in the introduction, the potential benefits of a teleretinal screening program for the Los Angeles safety net system include reducing the screening burden on county facilities and providing timely treatment for diabetic patients identified as having retinopathy. At the present time, patients from the teleretinal screening program who need referral for specialty care are input into the county’s referral processing system (RPS) by each clinic’s referral specialists or photographers, based on varying personnel responsibilities at each clinic. This can result in patient wait times on the order of several months or greater, depending on the total number of patients referred from different clinics to that county facility. Currently, the county facility has one retinal specialist who can provide half a day a week of complicated laser treatment for 8 patients and a number of general ophthalmologists able to perform uncomplicated retinal laser therapy. The waiting list for the laser clinics includes patients from several South Los Angeles primary care clinics, and in the past has included referrals from another county facility while its laser was undergoing repair.
In order to flag patients requiring immediate attention, the CDU team has set up a stopgap system with the Chief Medical Officer (CMO) of the closest county facility for the duration of the project to identify patients with moderate or severe non-proliferative diabetic retinopathy, proliferative diabetic retinopathy, and clinically significant macular edema so that they can receive expedited treatment. The stopgap approach is intended to address the provision of timely treatment to patients in the short-term while the clinics and county facility devise a long-term solution. Working with other stakeholders, the director of the clinics’ collaborative has identified gaps in the system for triage and presented the county with a report identifying those gaps and potential solutions. The county intends to replace the existing referral system (RPS) with a new system that addresses these gaps and facilitates triage, which would allow for better integration of future referrals from teleretinal screening into the Los Angeles County eye care clinics. To improve the specialty care referral process, the participating safety net clinics have recently hired a patient navigator who sits in the county facility to which most of their patients are referred and guides the patients through the process for receiving specialty care.
In summary, our initial findings demonstrate both the feasibility and the challenges of utilizing teleretinal screening in the safety net setting as a means of identifying and increasing timely treatment for diabetic patients with retinopathy. Future work will include an analysis of the cost effectiveness of teleretinal screening and an assessment of the impact of different patient outreach methods on improving screening rates.