Article

Teleretinal Imaging for Diabetic Patients

Collaboration between primary care and retina specialists will be critical.

By SEEMA GARG, MD, PHD

Related

Several national organizations, including the American Diabetes Association (ADA), the American Academy of Ophthalmology (AAO), and the American Association of Clinical Endocrinologists (AACE), recommend annual comprehensive eye exams for all patients with diabetes, beginning 5 years after diagnosis for Type 1 patients and at the time of diagnosis for Type 2 patients.1-3 Unfortunately, diabetic retinal exam (DRE) compliance rates in the United States remain less than 60%4 and diabetic retinopathy (DR) remains the leading cause of blindness of working-age adults.5

New modalities, like teleretinal imaging, have been developed to provide initial retinal assessment and subsequent referral in the primary care setting for patients who have diabetes. Although teleretinal imaging programs have produced excellent results in other countries, such as the United Kingdom,6 their deployment in the United States has been limited. One reason may be the lack of a standardized process to track referred patients and ensure they are receiving the recommended follow-up care in the office of the eye-care provider, either the general ophthalmologist or the retinal specialist. Without ensuring access to follow-up care, an increase in DRE rates does not necessarily result in a reduction of blindness due to diabetes. If specialty care services, such as retinal imaging, are to be provided in the primary care setting, it is vitally important that primary care providers (PCPs) and eye care specialists communicate and collaborate.

Seema Garg, MD, PhD, is a retina specialist and associate professor at The University of North Carolina Department of Ophthalmology. Dr. Garg reports membership on the vision care advisory board of Welch Allyn. Reach Dr. Garg at seema_garg@med.unc.edu.

TELERETINAL IMAGING

Teleretinal imaging can help increase patient compliance with the DRE by identifying patients with diabetes within the primary care setting and providing retinal imaging on site as part of the routine diabetic appointment. Retinal images can be obtained by trained medical assistants or clinic staff using nonmydriatic digital retinal cameras, which have recently become more advanced and require only basic training to operate. Typically, the images are remotely read by eye care specialists trained in retinal image interpretation. Within 24 hours to 48 hours, the reader returns a report to the PCP. The report consists of a preliminary diagnosis of stage of retinopathy and a recommendation for follow-up care. Patients who have no retinopathy can be re-imaged in 1 year. Only patients receiving referrals are scheduled for follow-up with an eye-care specialist for additional evaluation and care. Patients with mild or moderate levels of DR are referred to an ophthalmologist for frequent monitoring, while patients with proliferative DR or diabetic macular edema are often directly referred to a retina specialist for further assessment and treatment.

There are several comprehensive programs available that are suitable for teleretinal imaging for DR, including RetinaVue (Welch Allyn) and the Eye Picture Archive Communication System (EyePACS; Google Research, Inc.). RetinaVue includes affordable, hand-held nonmydriatic cameras, software to transfer and store images and diagnostic reports, and RetinaVue, PC, a group of board-certified, state-licensed ophthalmologists who perform remote image interpretation. Solutions such as these allow the PCP to provide retinal imaging in the primary care setting for their patients who have diabetes. Additionally, most programs using teleretinal imaging for DR are reimbursed by several major commercial payers and can help primary care practices meet quality metrics, like the Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Advantage Stars.

Patients who have diabetes attend at least 1 appointment with their PCP each year, which makes this an ideal setting to perform teleretinal imaging. Several studies have investigated compliance with the DRE, showing improved DRE rates to around 90% within the first year of the introduction of teleretinal imaging programs.7,8 Even clinics with initial compliance rates as low as 32% can increase compliance to more than 70% within 1 year.9

TELERETINAL IMAGING AND ARTIFICIAL INTELLIGENCE

With the prevalence of diabetes on the rise in the United States, the number of patients with diabetes requiring a routine retinal exam may far exceed the capacity of existing eye care providers. Thus, the advent of automated diagnostic systems may increase value and efficiency to existing teleretinal imaging programs. In April 2018, the Food and Drug Administration approved the first automated diagnostic system for DR, known as IDx-DR.10 According to the automated algorithm, if a patient has no DR or mild DR, the system provides a recommendation to “rescreen in 12 months” and a recommendation to “refer to an eye-care professional” for patients with severity more than mild DR, clinically-significant macular edema, or ungradable images.10

However, the future use of automated diagnostic systems may allow PCPs to immediately refer patients at risk for vision-threatening eye disease. Patients may be more likely to comply with the follow-up appointment with the ophthalmologist or retina specialist if the patients discuss their condition with their PCP and have the referral appointment scheduled while they are still in the PCP’s office.

Not surprisingly, there are also limitations to automated diagnostic systems. For example, human image readers may identify diseases other than DR when reviewing retinal images, like choroidal lesions, age-related macular degeneration, and glaucoma, which may be missed by automated algorithms. Additionally, the “refer” result is provided to patients ranging from moderate DR to severe proliferative DR, without indication of the urgency with which the patient needs to be seen by an eye care specialist.10 This may result in prioritization of patients with milder levels of disease and a delay in care for patients who need immediate treatment. Furthermore, at this time, there is no allowable reimbursement for systems that use automated diagnosis and artificial intelligence, and it does not meet the criteria to fulfill quality metrics.

IMPACT OF TELERETINAL IMAGING ON OPHTHALMOLOGISTS

Ophthalmologists working in networks where PCPs adopt teleretinal imaging may find an increase in patient volume and procedures. When teleretinal imaging is effective, a large proportion of previously unexamined patients who have diabetes may be identified to require eye care. Prior studies have shown that between 24% and 38% of previously noncompliant patients examined via teleretinal imaging will be referred for additional ophthalmologic care, such as retinal photocoagulation.11-13 While most patients are referred for further management of DR, one study found that more than 50% of the patients without DR had nondiabetic ocular findings that also required a follow-up appointment.11

Many patients referred from diabetic teleretinal imaging programs will likely require repeat appointments and ongoing treatments. A retrospective study performed at the Veterans Affairs (VA) Administration found that 42% of referred patients required 1 clinic visit, 22% required 2 visits, and 36% needed 3 or more visits.11 Using additional data from the study, a practice that provides teleretinal imaging to 5,000 patients would result in 1,200 eye examinations, 544 visual fields tests, 510 optical coherence tomography image encounters, and 143 cataract surgeries.11 Patients diagnosed with diabetic macular edema required the most ophthalmologic care with an average of 5 clinic visits, 6 diagnostic procedures, and 2 surgical procedures during a 2-year period.11

Ophthalmology and retina clinics may need to develop a strategy to handle increased patient volume when teleretinal imaging is implemented in the community, possibly including changes to patient scheduling and workflow or hiring additional support staff. Above all, facilitating communication between the eye-care specialist office and the PCP will help eye-care specialists handle the increased patient volume while continuing to provide high-quality care for patients. For example, eye specialists may work with PCPs to encourage patients who have milder forms of DR to be referred to a general ophthalmologist for close monitoring, while patients who have vision-threatening DR are referred directly to retina specialists for potential treatment. This system of appropriate referrals helps to improve healthcare delivery and enhance the efficiency of both the general ophthalmologist clinic and the retina specialist practice.

COMMUNICATION BETWEEN PCPS AND OPHTHALMOLOGISTS

Teleretinal imaging increases compliance to the DRE,14 which can result in a decrease of diabetes-related blindness. To achieve this outcome, it is critical that diabetic patients, PCPs, and eye specialists work closely together to ensure patients attend follow-up appointments and receive treatment when needed. Some US-based studies demonstrated only a moderate level of patient compliance with follow-up and treatment,11,15-18 but more recent studies have demonstrated follow-up compliance rates of more than 80%.19 Communication between the PCP and the specialist is the key to achieving these improved patient outcomes.

As noted earlier, PCPs need to be guided to make efficient referrals to the appropriate specialists. Patients who have mild and moderate DR will require close monitoring, potentially for years, before their disease progresses to the stage that treatment is required. These patients are most effectively referred to general ophthalmologists for close monitoring. Patients who have more advanced levels of DR, particularly proliferative DR and macular edema, should be directly referred to retina specialists for laser treatments or anti-VEGF injections. Once patients have been referred for further care, they should not return to the teleretinal imaging DRE program in the primary care setting, but should continue to follow up directly with the appropriate specialist.

Good lines of communication additionally provide an avenue whereby both the eye-care provider and PCP collaborate in the optimal care of the patient who has diabetic retinopathy. Both the eye-care provider and the PCP can educate the patient about the importance of diabetes care, including appropriate glycemic, blood pressure, and cholesterol control, exercise, and good nutrition. PCPs can help reinforce the importance of the ophthalmologist follow-up visit with the patient, even scheduling the follow-up appointment for them if necessary. Following all DR-related eye care appointments, the eye care provider should send a visit report to the PCP. This allows the PCP to track the patient’s progress with treatment and encourage attendance when appointments are missed. Because the PCP is likely to see the patient more often and on a regularly recurring basis, the PCP is a key resource to help ascertain the barriers to follow-up attendance and determine how these can be overcome. Collaboration between the eye-care provider and the PCP is critical to tracking patients through the health care system and ultimately reducing rates of blindness due to diabetes in the United States. RP

REFERENCES

  1. American Diabetes Association. Diabetic retinopathy. Diabetes Care. 2002;25(suppl 1):s90-s93.
  2. American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2016. Available at www.aao.org/ppp
  3. Handelsman Y, Grunberger G, Zimmerman RS, et al. American Association of Clinical Endocrinologists and American College of Endocrinology- clinical practice guidelines for developing a diabetes mellitus comprehensive care plan – 2015. Endocr Pract. 2015;21(suppl 1):1-87.
  4. Centers for Disease Control and Prevention. Diabetes Report Card 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2018.
  5. National Eye Institute. Facts about diabetic eye disease. Available at: https://nei.nih.gov/health/diabetic/retinopathy .
  6. Liew G, Michaelides M, Bunce C. A comparison of the causes of blindness certifications in England and Wales in working age adults (16-64 years), 1999-2000 with 2009-2010. BMJ Open. 2014;4(4):1.
  7. Tsan GL, Hoban KL, Jun W, Riedel KJ, Pedersen AL, Hayes J. Assessment of diabetic teleretinal imaging program at the Portland Department of Veterans Affairs Medical Center. J Rehabil R D. 2015;52(2):193-200.
  8. Conlin PR, Fisch BM, Cavallerano AA, Cavallerano JD, Bursell SE, Aiello LM. Nonmydriatic teleretinal imaging improves adherence to annual eye examinations in patients with diabetes. J Rehabil R D. 2006;43(6):733-740.
  9. Garg S, Jani PD, Kshirsagar AV, King B, Chaum E. Telemedicine and retinal imaging for improving diabetic retinopathy evaluation. Arch Intern Med. 2012;172(21):1677-1678.
  10. US Food and Drug Administration. FDA permits marketing of artificial intelligence-based device to detect certain diabetes-related eye problems. Available at: https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm604357.htm .
  11. Chasan JE, Delaune B, Maa AY, Lynch MG. Effect of a teleretinal screening program on eye care use and resources. JAMA Ophthalmol. 2014;132(9):1045-1051.
  12. Cavallerano AA, Cavallerano JD, Katalinic P, et al. A telemedicine program for diabetic retinopathy in a Veterans Affairs Medical Center- the Joslin Vision Network Eye Health Care Model. Am J Ophthalmol. 2005 Apr;139(4):597-604.
  13. Ogunyemi O, George S, Patty L, Teklehaimanot S, Baker R.Teleretinal screening for diabetic retinopathy in six Los Angeles urban safety-net clinics: Final study results. AMIA Annu Symp Proc. 2013;2013:1082-1088.
  14. Scanlon PH. The English National Screening Programme for diabetic retinopathy 2003-2016. Acta Diabetol. 2017; 54(6): 515-525.
  15. Newman R, Cummings DM, Doherty L, Patel NR. Digital retinal imaging in a residency-based patient-centered medical home. Fam Med. 2012;44(3):159-163.
  16. Jani PD, Forbes L, Choudhury A, Preisser JS, Viera AJ, Garg S. Evaluation of diabetic retinal screening and factors for ophthalmology referral in a telemedicine network. JAMA Ophthalmol. 2017;135(7):706-714.
  17. Tsui I, Havunijan MA, Davis JA, Giaconi JA. Snapshot of teleretinal screening for diabetic retinopathy at the West Los Angeles Medical Center. Telemed J E Health. 2016;22(10):843-846.
  18. Keenum Z, McGwin G, Witherspoon CD, Haller JA, Clark ME, Owsley C. Patients’ adherence to recommended follow-up eye care after diabetic retinopathy screening in a publicly funded county clinic and factors associated with follow-up eye care use. JAMA Ophthalmol. 2016;134(11):1221-1228.
  19. Martinez JA, et al. Telemedicine for diabetic retinopathy screening in an urban, insured population using fundus cameras in a primary care office setting. Poster presented at: American Society of Retina Specialists Annual Meeting; July 22, 2018; Vancouver, BC, Canada.