Tele-ophthalmology and conventional ophthalmology using a mobile medical unit in remote Greece

Primary Health Center: Can it be made mobile for efficient healthcare services for hard to reach population? A state-of-the-art review

Indian healthcare system is in immediate need of a new healthcare delivery model to increase healthcare accessibility and improve the health outcomes of the marginalized. Inaccessibility and underutilization of Primary Health Centers (PHCs) disproportionately affect people living in remote areas. It is thus imperative for the designers, engineers, health professionals, and policymakers to come together with a collaborative mindset to develop innovative interventions that sustainably manage the accessibility of PHCs at large, promote preventive health, and thus improve the health outcomes of hard-to-reach communities. This article examines the available literature on barriers to primary healthcare in Indian context, the reason of failure of PHCs and the way forward. The article further analysis literature on existing Mobile Medical Units (MMUs) as an alternate solution to conventional PHCs and attempt to extract the major lessons to propose a mobile Primary Health Center (mPHC) in contrast to the existing conventional static PHCs. The intention is to find out the research gaps in the existing literature and try to address the same for future researchers, designers, engineers, health professionals and policy makers to think forward to make this idea of a mobile Primary Health Center (mPHC), as the main delivery model to cater basic healthcare services to the underserved communities.

Making primary healthcare delivery robust for low resource settings: Learning from Mohalla Clinics

The present healthcare scenario is still in its compromised state, whether it is the lack of infrastructure, medicines and human resources, especially in rural India. Moreover, the condition worsens in rural areas due to several reasons like lack of awareness, proper roads to access, and lack of proper delivery of healthcare model. The state government of Delhi, India, set up the "Mohalla" Clinics to provide essential healthcare to residents of Delhi and the surrounding areas, focusing on the urban poor. Essential health services, such as vaccinations, family planning, and counselling, are available at the Mohalla Clinics, where a doctor, a nurse, a pharmacist, and a lab technician are staffed. Despite a strong start and low operating costs, the Mohalla Clinic initiative still struggles to cover all Delhi state as envisioned. This study analyses the operational challenges of Delhi's "Mohalla" Clinics and proposes lessons to be implemented for other primary healthcare infrastructure services for remote areas. The analysis is based on the systems (infrastructure, facilities, and services) strengths and limitations from a literature review and qualitative interview conducted among 55 respondents, including doctors, nurses, and patients among 11 Mohalla Clinics using the SUTD-MIT (Singapore University of Technology and Design-Massachusetts Institute of Technology Industrial Design Centre) interview template for Product Service System (PSS). The results show that there are lessons to learn from the model of Delhi Mohalla Clinics for other states to implement in their primary healthcare sectors. To achieve Universal Health Coverage (UHC), the Delhi Mohalla Clinic falls short due to several limitations. Thus, to achieve UHC, the Indian healthcare system needs a new healthcare delivery model. Hence, we ought to propose a new healthcare delivery model based on the gained insights from the study. One such delivery model proposed is a mobile Primary Health Center (mPHC). This collapsible system can be taken to far-flung regions, deployed for some hours, run the Out-Patient Department (OPD), collapsed, and returned to base.

Effective Low-Cost Ophthalmological Screening With a Novel iPhone Fundus Camera at Community Centers

Ophthalmologic care is inaccessible to many people due to a variety of factors, including the availability of providers, cost of equipment for ophthalmologic care, and transportation to clinics and appointments. Because many causes of blindness are both highly prevalent and preventable once identified, it is essential to address gaps in care for underserved populations. We developed a novel 3D-printed mobile retinal camera. In this study, we organized recurring student-run screening events around New York City that took place in community centers and churches, at which we utilized our device to take retinal images. Our screening events reached a diverse population of New Yorkers, disproportionately those with lower household income, many of whom had not had recent eye exams. To validate the device for use in telehealth ophthalmologic visits, we transmitted the images to a remote ophthalmologist for evaluation and compared the result with an on-site attending physician’s dilated eye exam. The subjective assessment indicated that 97% of images captured with the mobile retinal camera were acceptable for telehealth analysis. Remote image assessment by achieved 92% sensitivity and 83% specificity in detecting optic disc cupping, compared to the gold-standard on-site dilated eye exam. In addition, the device was portable, affordable, and able to be used by those with relatively little ophthalmologic training. We have demonstrated the utility of this affordable mobile retinal camera for telehealth ophthalmologic evaluation during community screening events that reached an underserved population to detect disease and connect with long-term care.

Designing Mobile Epidemic Prevention Medical Stations for the COVID-19 Pandemic and International Medical Aid

The demand for mobile epidemic prevention medical stations originated from the rapid spread of the COVID-19 pandemic. In order to reduce the infection risk of medical practitioners and provide flexible medical facilities in response to the variable needs of the pandemic, this research aimed to design mobile medical stations for COVID-19 epidemic prevention, the emergence of which began in February 2020. The mobile medical stations include a negative pressure isolation ward, a positive pressure swabbing station, a fever clinic and a laboratory. In Taiwan, many medical institutions used the mobile swabbing station design of this study to practice COVID-19 screening pre-tests. Internationally, this study assisted Palau in setting up medical stations to provide anti-epidemic goods and materials. The design of this study not only provides a highly flexible and safe medical environment but the benefits of screening can also be used as resources for medical research, forming an economic circulation for operation sustainability. In addition, the design of this study can also be used during the non-epidemic period as a healthcare station for rural areas or as a long-term community medical station.

Quality-adjusted life years in macular oedema due to age-related macular degeneration, diabetes and central retinal vein occlusion: the impact of anti-VEGF agents in a tertiary centre in Greece

INTRODUCTION

Neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME), and macular oedema due to central retinal vein occlusion (CRVO) are leading causes of vision loss, currently managed with anti-vascular endothelial growth factor injections (anti-VEGF). The aim of this study was to calculate QALYs in patients with nAMD, DME, and CRVO treated with anti-VEGF agents (QALYs⁺) in a Greek tertiary hospital setting and compare them to theoretical QALYs that the patients would have without treatment (QALYs^-).

MATERIAL AND METHODS

The study included 143 treatment-naive patients with macular oedema due to nAMD (n = 79), DME (n = 57), and CRVO (n = 7), who received anti-VEGF injections as monotherapy according to the Treat-and-Extend (T&E) protocol. The anti-VEGF agents were ranibizumab and aflibercept in equivalent fractions. QALYs where calculated by the formula QALY = Utility Value × Time, where "Time" refers to the follow-up period of the study. For QALYs^-, we assumed that visual acuity remained unchanged during this period.

RESULTS

Mean follow-up time was 1.3 ± 1.2 years in the nAMD group, 1 ± 1.3 years in the DME group, and 0.5 ± 1 years in the CRVO group. There was no statistically significant difference between QALYs^- and QALYs⁺ in all three ocular pathologies for the study period (p > 0.05 for each of the three statistical tests performed).

DISCUSSION/CONCLUSION

Possible explanations for the lack of significant difference between QALYs - and QALYs + in nAMD, DME, and CRVO groups, may be the short time horizon used in this analysis, the inclusion of data from the better-seeing eye (BSE) and the specific socio-economic, geographical and health care characteristics of this rural Greek area.

5G Use in Healthcare: The Future is Present

Background:

Most healthcare providers are unaware of the extraordinary opportunities for implementation in healthcare which can be enabled by 5G wireless networks. 5G created enormous opportunities for a myriad of new technologies, resulting in an integrated through 5G ‘ecosystem’. Although the new opportunities in healthcare are immense, medicine is slow to change, as manifest by the paucity of new, innovative applications based upon this ecosystem. Thus, emerges the need to “avoid technology surprise” - both laparoscopic and robotic assisted minimally invasive surgery were delayed for years because the surgical community was either unaware or unaccepting of a new technology.

Database:

PubMed (Medline) and Scopus (Elsevier) databases were searched and all published studies regarding clinical applications of 5G were retrieved. From a total of 40 articles, 13 were finally included in our review.

Discussion:

The important transformational properties of 5G communications and other innovative technologies are described and compared to healthcare needs, looking for opportunities, limitations, and challenges to implementation of 5G and the ecosystem it has spawned. Furthermore, the needs in the clinical applications, education and research in medicine and surgery, in addition to the administrative infrastructure are addressed. Additionally, we explore the nontechnical challenges, that either support or oppose this new healthcare renovation. Based upon proven advantages of these innovative technologies, current scientific evidence is analyzed for future trends for the transformation of healthcare. By providing awareness of these opportunities and their advantages for patients, it will be possible to decrease the prolonged timeframe for acceptance and implementation for patients.

Anterior Segment and Others in Teleophthalmology: Past, Present, and Future

ABSTRACT

Teleophthalmology, a subfield of telemedicine, has recently been widely applied in ophthalmic disease management, accelerated by ubiquitous connectivity via mobile computing and communication applications. Teleophthalmology has strengths in overcoming geographic barriers and broadening access to medical resources, as a supplement to face-to-face clinical settings. Eyes, especially the anterior segment, are one of the most researched superficial parts of the human body. Therefore, ophthalmic images, easily captured by portable devices, have been widely applied in teleophthalmology, boosted by advancements in software and hardware in recent years. This review aims to revise current teleophthalmology applications in the anterior segment and other diseases from a temporal and spatial perspective, and summarize common scenarios in teleophthalmology, including screening, diagnosis, treatment, monitoring, postoperative follow-up, and tele-education of patients and clinical practitioners. Further, challenges in the current application of teleophthalmology and the future development of teleophthalmology are discussed.

Digital technology, tele-medicine and artificial intelligence in ophthalmology: A global perspective

The simultaneous maturation of multiple digital and telecommunications technologies in 2020 has created an unprecedented opportunity for ophthalmology to adapt to new models of care using tele-health supported by digital innovations. These digital innovations include artificial intelligence (AI), 5th generation (5G) telecommunication networks and the Internet of Things (IoT), creating an inter-dependent ecosystem offering opportunities to develop new models of eye care addressing the challenges of COVID-19 and beyond. Ophthalmology has thrived in some of these areas partly due to its many image-based investigations. Tele-health and AI provide synchronous solutions to challenges facing ophthalmologists and healthcare providers worldwide. This article reviews how countries across the world have utilised these digital innovations to tackle diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration, glaucoma, refractive error correction, cataract and other anterior segment disorders. The review summarises the digital strategies that countries are developing and discusses technologies that may increasingly enter the clinical workflow and processes of ophthalmologists. Furthermore as countries around the world have initiated a series of escalating containment and mitigation measures during the COVID-19 pandemic, the delivery of eye care services globally has been significantly impacted. As ophthalmic services adapt and form a "new normal", the rapid adoption of some of telehealth and digital innovation during the pandemic is also discussed. Finally, challenges for validation and clinical implementation are considered, as well as recommendations on future directions.

Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic

BACKGROUND

We introduced a video consultation (VC) during the coronavirus (COVID-19) pandemic in an ophthalmology practice with eight doctors to ensure continuous ophthalmological care, infection prophylaxis and to compensate a decreased number of patient presentations.

OBJECTIVE

Evaluation of the most common reasons for patient presentations in the VC, the proportion of re-presentations in the practice despite VC, practical challenges associated with the introduction of VC and patient satisfaction.

MATERIAL AND METHODS

Patients with a recent acute visual deterioration and severe eye pain were excluded from the VC. The VC were carried out by a trained specialist in ophthalmology. A questionnaire with eight questions was completed after the VC appointment in order to evaluate the proportion of completed VC and patient satisfaction.

RESULTS

We included 29 (13 male, Ø 52.6 years, 16 female, Ø 64.7 years) patients in this analysis. The VC could be performed with 68.97% of the participants who rated their overall experience with an average grade of 1.6 (1 very good to 6 insufficient) and all of them indicated that they would recommend the VC. Of presentations in VC 70% were related to the symptoms of the anterior eye segment. In 70% of the cases no re-presentations took place in the unit.

CONCLUSION

Our study represents a significant practical application of VC for the management of non-urgent ocular conditions with maximum infection prophylaxis. The introduction of VC was severely limited by technological or user-related issues by the establishment of video connections. Patient satisfaction with VC was high to very high.

[Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic]

BACKGROUND

We introduced a video consultation (VC) during the coronavirus (COVID-19) pandemic in an ophthalmology practice with eight doctors to ensure continuous ophthalmological care, infection prophylaxis and to compensate a decreased number of patient presentations.

OBJECTIVE

Evaluation of the most common reasons for patient presentations in the VC, the proportion of re-presentations in the practice despite VC, practical challenges associated with the introduction of VC and patient satisfaction.

MATERIAL AND METHODS

Patients with a recent acute visual deterioration and severe eye pain were excluded from the VC. The VC were carried out by a trained specialist in ophthalmology. A questionnaire with eight questions was completed after the VC appointment in order to evaluate the proportion of completed VC and patient satisfaction.

RESULTS

We included 29 (13 male, Ø 52.6 years, 16 female, Ø 64.7 years) patients in this analysis. The VC could be performed with 68.97% of the participants who rated their overall experience with an average grade of 1.6 (1 very good to 6 insufficient) and all of them indicated that they would recommend the VC. Of presentations in VC 70% were related to the symptoms of the anterior eye segment. In 70% of the cases no re-presentations took place in the unit.

CONCLUSION

Our study represents a significant practical application of VC for the management of non-urgent ocular conditions with maximum infection prophylaxis. The introduction of VC was severely limited by technological or user-related issues by the establishment of video connections. Patient satisfaction with VC was high to very high.

Incorporating Video Visits into Ophthalmology Practice: A Retrospective Analysis and Patient Survey to Assess Initial Experiences and Patient Acceptability at an Academic Eye Center

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has led to rapid adoption of teleophthalmology to deliver eyecare remotely. The purpose of our study was to assess the implementation and patient acceptability of video consultation for outpatient ophthalmic care at our institution.

METHODS

We conducted a retrospective, cross-sectional analysis and patient survey of adult patients who completed a virtual video visit at our institution from 18 March 18 through to 27 April 2020. All video visit encounters were assessed for patient characteristics, diagnoses, management, and follow-up outcomes. Patients were surveyed for their feedback on acceptability and utility of their virtual video consultation.

RESULTS

A total of 219 patients (mean age 55 years; range 21-89 years) completed 231 video visit encounters at our department over a 6-week period, of whom 118 were women (54%). About half of these encounters were acute visits (102 visits, 47%). The most common diagnosis of these visits was postoperative state (20 visits, 9% of the total), followed by conjunctivitis (16 visits, 7%), and keratitis (14 visits, 6%). The most common management decisions were medication prescription (102 visits, 46%) or reassurance (86 visits, 39%), while 17 video visit patients (8%) were escalated to an urgent, in-person evaluation. Ninety-two patients completed a follow-up survey (42% response rate), of whom 45 (49%) indicated that they might have delayed seeking care during this pandemic in the absence of a virtual video option. Seventy-two (78%) reported that they would consider participating in a video visit as an alternative to an office-based encounter in the future, and the overall video visit experience was rated highly, with a weighted mean Likert scale rating of 4.3 out of 5 (Cronbach's α = 0.88).

CONCLUSION

Virtual video visits may be used to manage a range of ophthalmic complaints. Patients participating in this survey found such video visits acceptable and timesaving, and the majority would consider using video consultations for future eyecare encounters.

Glaucoma Patient Knowledge, Perceptions, and Predispositions for Telemedicine

PURPOSE

The purpose was to identify factors associated with older glaucoma patients' knowledge of, perceptions of, and predispositions for telemedicine use.

MATERIALS AND METHODS

Established patients age 60 years and above with a diagnosis of primary open-angle glaucoma, glaucoma suspect, or ocular hypertension followed by a glaucoma fellowship-trained ophthalmologist were enrolled in the study at an academic, urban, tertiary referral eye clinic. Enrolled patients were administered a Life Space Questionnaire (LSQ), scored 0 to 9, and Preferences for Telemedicine Questionnaire (PTQ), a Likert scale validated tool. χ testing analyzed PTQ responses by age, race, education, employment status, LSQ score, and distance traveled from home address to clinic. A Mann-Whitney U test was used to compare PTQ responses by visual field index and visual acuity for the better and worse eye.

RESULTS

Of 110 patients enrolled, 71% of patients agreed or were neutral to receiving telediagnosis and 74% of patients agreed or were neutral to receiving teleintervention. Patients aged 60 to 69 years compared with those 70 and above had significantly greater knowledge about types of telemedicine: telediagnosis (53% vs. 31%, P=0.02), teleintervention (49% vs. 24%, P=0.006), teletriage (80% vs. 47%, P=0.0004), and telemonitoring (55% vs. 27%, P=0.003). Patients of European descent had significantly more knowledge about teletriage compared with those of non-European descent (72% vs. 53%, P=0.04). Patients with more education (>high school) compared with those with less education (≤high school) had more knowledge about telemedicine (39% vs. 16%, P=0.007) and all the uses of it: telediagnosis (61% vs. 45%, P<0.001), teleintervention (54% vs. 14%, P<0.001), teletriage (86% vs. 35%, P<0.001), and telemonitoring (59% vs. 18%, P=0.001). Patients with a LSQ score ≥6, meaning they traveled a greater distance from home in the previous 3 days, displayed significantly more knowledge about telediagnosis (49% vs. 25%, P=0.02), teleintervention (43% vs. 19%, P=0.01), and telemonitoring (47% vs. 25%, P=0.03) than those with an LSQ<6. Responses to the PTQ were not significantly different by distance traveled.

CONCLUSIONS

Knowledge of telemedicine was variable but between one third and one half of patients had favorable attitudes toward using telemedicine for glaucoma care.

Teleophthalmology through handheld mobile devices: a pilot study in rural Nepal

Background

To compare screening referral recommendations made by remotely located ophthalmic technicians with those of an ophthalmologist examining digital photos obtained by a portable ophthalmic camera system powered by an iOS handheld mobile device (iPod Touch).

Methods

Dilated screening eye exams were performed by ophthalmic technicians in four remote districts of Nepal. Anterior and posterior segment photographs captured with a Paxos Scope ophthalmic camera system attached to an iPod Touch 6^th generation device were uploaded to a secure cloud database for review by an ophthalmologist in Kathmandu. The ophthalmic technicians' referral decisions based on slit-lamp exam were compared to the ophthalmologist's recommendation based on the transmitted images.

Results

Using the transmitted images, the ophthalmologist recommended referral for an additional 20% of the 346 total subjects screened who would not have been referred by the ophthalmic technician. Of those subjects, 34% were referred to the retina clinic. Conversely, among the 101 patients referred by the technician, the ophthalmologist concurred with the appropriateness of referral in more than 97% of cases but thought eight (2.8%) of those patients had variants of normal eye pathology.

Conclusion

An ophthalmologist who reviewed data and photos gathered with the mobile device teleophthalmology system identified a significant number of patients whose need for referral was not identified by the screening technician. Posterior segment pathology was most frequently found by the remote reader and not by the technician performing dilated slit lamp examinations. These results are promising for further clinical implementation of handheld mobile devices as tools for teleophthalmic screening in resource-limited settings.

A systematic review of teleophthalmological studies in Europe

A systematic review of the recent literature regarding a series of ocular diseases involved in European telemedicine projects was performed based on the PubMed, Google Scholar and Springer databases in June 2017. Literature review returned 44 eligible studies; among them, emergency ophthalmology, diabetic retinopathy, glaucoma, age-related macular disease, cataract and retinopathy of prematurity. The majority of studies indicate teleophthalmology as a valid, reliable and cost-efficient method for care-provision in ophthalmology patients which delivers comparable outcomes to the traditional examination methods.

Teleophthalmic Approach for Detection of Corneal Diseases: Accuracy and Reliability

PURPOSE

Corneal and anterior segment diseases cause most of the urgent visits to eye care professionals. We evaluated the diagnostic accuracy of detecting corneal diseases using external photographs from 2 portable cameras for telemedicine purposes.

METHODS

This is a prospective study of adults with a clinical diagnosis of corneal pathology including corneal abrasions, ulcers, scars, and pterygia. A cornea specialist provided the gold standard diagnosis by slit-lamp examination. Images of both eyes were obtained using iTouch 5S and Nidek VersaCam cameras in multiple gazes and interpreted by 3 cornea specialists for the presence of pathology. Accuracy to detect disease was compared with gold standard diagnosis, stratified by the camera and grader. Reliability was evaluated with weighted kappa statistics. Graders assessed image quality on a Likert scale from 1 (poor) to 9 (optimal).

RESULTS

A total of 198 eyes (110 subjects) were photographed. By gold standard diagnosis, 59 eyes (30%) had corneal scars, 34 (17%) had ulcers, 13 (7%) had abrasions, 10 (5%) had pterygia, and 82 (41%) were normal. Sensitivity to detect AS pathology ranged from 54% to 71% for the iTouch and 66% to 75% for the Nidek, across graders; specificity ranged from 82% to 96% for the iTouch and 91% to 98% for the Nidek. The intergrader reliability was moderate to strong (kappa ranges: 0.54-0.71 for the iTouch; 0.75-0.76 for the Nidek). Quality ratings were variable between graders.

CONCLUSIONS

External photographs taken by standard, nonenhanced portable cameras and interpreted remotely by ophthalmologist graders yielded sensitivity values that are not yet suitable for telemedicine applications. Additional work is needed to improve the ability to detect AS pathology remotely.

A Remote Operating Slit Lamp Microscope System

Objectives: To develop a remote-operating slit lamp microscope system (the remote slit lamp) as the core for highly specialized ophthalmology diagnoses, and to compare the utility of this system with the conventional slit lamp microscope system (the conventional slit lamp) in making a diagnosis.

Methods: The remote slit lamp system was developed. Three factors were evaluated in comparison to the conventional slit lamp. The ability to acquire skills was investigated using a task loading system among specialists and residents in ophthalmology. Participants repeated a task up to ten times and the time required for each task was analyzed. The consistency of the two systems in making a diagnosis was investigated using eyes of patients with ocular diseases as well as healthy volunteers.

Results: The remote slit lamp is composed of a patient’s unit and ophthalmologist’s unit connected by high-speed internet. The two units share images acquired by the slit lamp in addition to the images and voices of patients and ophthalmologists. Both ophthalmology specialists and residents could minimize the completion times after several trials. The remote slit lamp took more time than the conventional slit lamp. Both systems showed a high consistency in evaluations among eyes with healthy eyes or those with ocular diseases.

Conclusions: The remote slit lamp has a similar diagnostic ability, but required more examination time in comparison to the conventional slit lamp. The currently developed remote slit lamp has the potential to be employed for telemedicine purposes in the field of ophthalmology.

Eye Care Quality and Accessibility Improvement in the Community (EQUALITY): impact of an eye health education program on patient knowledge about glaucoma and attitudes about eye care

Purpose

To assess the impact of the education program of the Eye Care Quality and Accessibility Improvement in the Community (EQUALITY) telemedicine program on at-risk patients’ knowledge about glaucoma and attitudes about eye care as well as to assess patient satisfaction with EQUALITY.

Patients and methods

New or existing patients presenting for a comprehensive eye exam (CEE) at one of two retail-based primary eye clinics were enrolled based on ≥1 of the following at-risk criteria for glaucoma: African Americans ≥40 years of age, Whites ≥50 years of age, diabetes, family history of glaucoma, and/or preexisting diagnosis of glaucoma. A total of 651 patients were enrolled. A questionnaire was administered prior to the patients’ CEE and prior to the patients receiving any of the evidence-based eye health education program; a follow-up questionnaire was administered 2–4 weeks later by phone. Baseline and follow-up patient responses regarding knowledge about glaucoma and attitudes about eye care were compared using McNemar’s test. Logistic regression models were used to assess the association of patient-level characteristics with improvement in knowledge and attitudes. Overall patient satisfaction was summarized.

Results

At follow-up, all patient responses in the knowledge and attitude domains significantly improved from baseline (P≤0.01 for all questions). Those who were unemployed (odds ratio =0.63, 95% confidence interval =0.42–0.95, P=0.026) or had lower education (odds ratio =0.55, 95% confidence interval =0.29–1.02, P=0.058) were less likely to improve their knowledge after adjusting for age, sex, race, and prior glaucoma diagnosis. This association was attenuated after further adjustment for other patient-level characteristics. Ninety-eight percent (n=501) of patients reported being likely to have a CEE within the next 2 years, whereas 63% (n=326) had a CEE in the previous 2 years. Patient satisfaction with EQUALITY was high (99%).

Conclusion

Improved knowledge about glaucoma and a high intent to pursue eye care may lead to improved detection of early disease, thus lowering the risk of blindness.

Eye Care Quality and Accessibility Improvement in the Community (EQUALITY) for adults at risk for glaucoma: study rationale and design

Background

Primary open angle glaucoma is a chronic, progressive eye disease that is the leading cause of blindness among African Americans. Glaucoma progresses more rapidly and appears about 10 years earlier in African Americans as compared to whites. African Americans are also less likely to receive comprehensive eye care when glaucoma could be detected before irreversible blindness. Screening and follow-up protocols for managing glaucoma recommended by eye-care professional organizations are often not followed by primary eye-care providers, both ophthalmologists and optometrists. There is a pressing need to improve both the accessibility and quality of glaucoma care for African Americans. Telemedicine may be an effective solution for improving management and diagnosis of glaucoma because it depends on ocular imaging and tests that can be electronically transmitted to remote reading centers where tertiary care specialists can examine the results. We describe the Eye Care Quality and Accessibility Improvement in the Community project (EQUALITY), set to evaluate a teleglaucoma program deployed in retail-based primary eye care practices serving communities with a large percentage of African Americans.

Methods/Design

We conducted an observational, 1-year prospective study based in two Walmart Vision Centers in Alabama staffed by primary care optometrists. EQUALITY focuses on new or existing adult patients who are at-risk for glaucoma or already diagnosed with glaucoma. Patients receive dilated comprehensive examinations and diagnostic testing for glaucoma, followed by the optometrist’s diagnosis and a preliminary management plan. Results are transmitted to a glaucoma reading center where ophthalmologists who completed fellowship training in glaucoma review results and provide feedback to the optometrist, who manages the care of the patient. Patients also receive eye health education about glaucoma and comprehensive eye care. Research questions include diagnostic and management agreement between providers, the impact of eye health education on patients’ knowledge and adherence to follow-up and medication, patient satisfaction, program cost-effectiveness, and EQUALITY’s impact on Walmart pharmacy prescription rates.

Discussion

As eye-care delivery systems in the US strive to improve quality while reducing costs, telemedicine programs including teleglaucoma initiatives such as EQUALITY could contribute toward reaching this goal, particularly among underserved populations at-risk for chronic blinding diseases.

The effectiveness of teleglaucoma versus in-patient examination for glaucoma screening: a systematic review and meta-analysis

Background

Glaucoma is the leading cause of irreversible visual impairment in the world affecting 60.5 million people worldwide in 2010, which is expected to increase to approximately 79.6 million by 2020. Therefore, glaucoma screening is important to detect, diagnose, and treat patients at the earlier stages to prevent disease progression and vision loss. Teleglaucoma uses stereoscopic digital imaging to take ocular images, which are transmitted electronically to an ocular specialist. The purpose is to synthesize literature to evaluate teleglaucoma, its diagnostic accuracy, healthcare system benefits, and cost-effectiveness.

Methods

A systematic search was conducted to help locate published and unpublished studies. Studies which evaluate teleglaucoma as a screening device for glaucoma were included. A meta-analysis was conducted to provide estimates of diagnostic accuracy, diagnostic odds ratio, and the relative percentage of glaucoma cases detected. The improvements to healthcare service quality and cost data were assessed.

Results

Of 11237 studies reviewed, 45 were included. Our results indicated that, teleglaucoma is more specific and less sensitive than in-person examination. The pooled estimates of sensitivity was 0.832 [95% CI 0.770, 0.881] and specificity was 0.790 [95% CI 0.668, 0.876]. The relative odds of a positive screen test in glaucoma cases are 18.7 times more likely than a negative screen test in a non-glaucoma cases. Additionally, the mean cost for every case of glaucoma detected was $1098.67 US and of teleglaucoma per patient screened was $922.77 US.

Conclusion

Teleglaucoma can accurately discriminate between screen test results with greater odds for positive cases. It detects more cases of glaucoma than in-person examination. Both patients and the healthcare systems benefit from early detection, reduction in wait and travel times, increased specialist referral rates, and cost savings. Teleglaucoma is an effective screening tool for glaucoma specifically for remote and under-services communities.

Teleglaucoma: improving access and efficiency for glaucoma care

Teleglaucoma is the application of telemedicine for glaucoma. We review and present the current literature on teleglaucoma; present our experience with teleglaucoma programs in Alberta, Canada and Western Australia; and discuss the challenges and opportunities in this emerging field. Teleglaucoma is a novel area that was first explored a little over a decade ago and early studies highlighted the technical challenges of delivering glaucoma care remotely. Advanced technologies have since emerged that show great promise in providing access to underserviced populations. Additionally, these technologies can improve the efficiency of healthcare systems burdened with an increasing number of patients with glaucoma, and a limited supply of ophthalmologists. Additional benefits of teleglaucoma systems include e-learning and e-research. Further work is needed to fully validate and study the cost and comparative effectiveness of this approach relative to traditional models of healthcare.

Strategic Procedures and Revisions for implementing Telemedicine and Telecare in Greece

The development of telemedicine and telecare has been changed all over the world the recent decades as practitioners and health care managers reached better understanding of the use of information and communication technologies to offer urgent and qualified medical services at a distance. Governments and health care providers have shown a large initial interest in the benefits of telemedicine services to reduce costs mostly for patient's transfer to tertiary hospitals or for educational purposes but have been slow to provide strategic plans and procedures in order to proceed the projects into practice. The paper identifies the involvement of governments, healthcare management, healthcare professionals and IT suppliers in telemedicine policy development and reviews the experience of Greece in the specific field which seems that despite the enormous scientific interest for both medicine and health informatics, the practice until now has not gained the expected results. Furthermore, the analysis concerns the critical success factors that have to be revised simultaneously with the main managerial principles for the design and implementation of quality telemedicine and telecare services.

A proposed methodology for the assessment of glaucoma awareness in Greece: introduction of the EIT-8G scale

PURPOSE

To develop a reliable and practical questionnaire for glaucoma awareness and evaluate the impact of potential determinants.

METHODS

Patients with primary open-angle, pigmentary, and exfoliation glaucoma, as well as healthy controls, were recruited. The instrument included questions about demographic characteristics, as well as 8 questions assessing the participant's familiarity with glaucoma. Rasch analysis was used for the validation of the questionnaire. The effect of demographics as potential determinants of awareness was examined with a multivariate logistic regression analysis. Bonferroni-corrected statistical significance was tested with the Mann-Whitney U test or one-way analysis of variance. Association between demographics and questionnaire scores was examined with Spearman correlation.

RESULTS

As indicated by power analysis, responses from 175 patients (mean age 65.5 years) and 314 controls (mean age 43.3 years) were analyzed. Rasch analysis indicated no multidimensionality and good item-person targeting. Mean ± SD awareness scores for the glaucoma and control groups were 4.43 ± 2.10 and 4.20 ± 2.11, respectively (p=0.207). Sex and residence were not predictors of disease awareness, whereas educational level was only a determinant in the control group (p<0.001). Income was a predictor only for patients (r=0.357, p<0.001), whereas family history was predictive for both groups (p<0.001). Logistic regression analysis revealed that only family history was associated with increased awareness (Chi(2)=4.61, p=0.03, odds ratio 1.98).

CONCLUSIONS

This study introduces a practical and valid instrument for the assessment of glaucoma awareness.