Centralized Reading Center Improves Quality in a Real-World Setting

Teleophthalmology and retina: a review of current tools, pathways and services

Telemedicine, the use of telecommunication and information technology to deliver healthcare remotely, has evolved beyond recognition since its inception in the 1970s. Advances in telecommunication infrastructure, the advent of the Internet, exponential growth in computing power and associated computer-aided diagnosis, and medical imaging developments have created an environment where telemedicine is more accessible and capable than ever before, particularly in the field of ophthalmology. Ever-increasing global demand for ophthalmic services due to population growth and ageing together with insufficient supply of ophthalmologists requires new models of healthcare provision integrating telemedicine to meet present day challenges, with the recent COVID-19 pandemic providing the catalyst for the widespread adoption and acceptance of teleophthalmology. In this review we discuss the history, present and future application of telemedicine within the field of ophthalmology, and specifically retinal disease. We consider the strengths and limitations of teleophthalmology, its role in screening, community and hospital management of retinal disease, patient and clinician attitudes, and barriers to its adoption.

Severity of Diabetic Retinopathy and the Risk of Future Cerebrovascular Disease, Cardiovascular Disease, and All-Cause Mortality

PURPOSE

To determine the relationship between the severity of diabetic retinopathy and the future risk of cerebrovascular accident (CVA), myocardial infarction (MI), congestive heart failure (CHF), and all-cause mortality in patients with type 2 diabetes mellitus.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with type 2 diabetes who underwent diabetic retinopathy screening via fundus photography.

METHODS

The relationship between retinopathy status and the 5-year risk of first-time CVA, MI, CHF, and all-cause mortality was investigated using multivariate Cox proportional hazards regressions that controlled for age, gender, race or ethnicity, hemoglobin A1c, duration of diabetes, high-density lipoprotein level, low-density lipoprotein level, history of hypertension, systolic blood pressure, diastolic blood pressure, tobacco use, statin use, body mass index, urine microalbumin-to-creatinine ratio, and estimated glomerular filtration rate.

MAIN OUTCOME MEASURES

Five-year risk of first-time CVA, MI, CHF, and all-cause mortality.

RESULTS

Seventy-seven thousand three hundred seventy-six patients were included in this study. The average age was 59.8 years with 53.6% male, 31.2% non-Hispanic White, and 41.4% Hispanic patients. Diabetic retinopathy was significantly associated with all outcomes on multivariate analysis. Compared with patients with no retinopathy, those with minimal nonproliferative diabetic retinopathy (NPDR) had a higher risk of CVA (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.18-1.46), MI (HR, 1.30; 95% CI, 1.15-1.46), CHF (HR, 1.29; 95% CI, 1.19-1.40), and death (HR, 1.15; 95% CI, 1.05-1.25). Similarly, patients with moderate to severe NPDR had a higher risk of each outcome (CVA: HR, 1.56; 95% CI, 1.29-1.89; MI: HR, 1.92; 95% CI, 1.57-2.34; CHF: HR, 1.90; 95% CI, 1.66-2.18, and death: HR, 1.55; 95% CI, 1.32-1.82), as did patients with proliferative diabetic retinopathy (CVA: HR, 2.53; 95% CI, 1.84-3.48; MI: HR, 1.89; 95% CI, 1.26-2.83; CHF: HR, 1.96; 95% CI, 1.47-2.59; and death: HR, 1.87; 95% CI, 1.36-2.56).

CONCLUSIONS

Diabetic retinopathy is significantly associated with future risk of CVA, MI, CHF, and death, with higher degrees of retinopathy appearing to carry a heightened risk for each outcome. Retinal information may provide valuable insights into patients' risk of future vascular disease and death.

Two-Year Incidence of Retinal Intervention in Patients With Minimal or No Diabetic Retinopathy on Telemedicine Screening

Importance

Most patients with diabetes have little or no retinopathy on initial examination. Tracking the long-term outcomes of these patients may increase our understanding of how to best provide follow-up treatment.

Objective

To assess how many patients with minimal or no retinopathy require retinal intervention within 2 years of retinal evaluation.

Design, Setting, and Participants

This retrospective cohort study assessed patients who underwent screening for diabetic retinopathy within a telemedicine program at Kaiser Permanente Southern California and had minimal or no retinopathy on fundus photographs.

Exposure

Retinal interventions performed within 2 years of photographs.

Main Outcomes and Measures

Patients with minimal or no retinopathy on initial screening photographs taken in 2012 had their medical records searched for Current Procedural Terminology codes for intravitreal injections, retinal lasers, or pars plana vitrectomy. The medical records of patients identified as having received these interventions within 2 years of retinal evaluation were then manually reviewed for further characterization.

Results

Diabetic retinopathy screening photographs were taken for 116 134 patients (mean [SD] age, 58 [12.8] years; 54 582 [47.0%] female; 46 453 [40.0%] Latino). Of these patients, 79 445, including 69 634 patients without retinopathy and 9811 patients with minimal retinopathy, had 2 years of follow-up. Eleven patients without baseline retinopathy required treatment of diabetic retinopathy in the following 2 years (1 of 12 660 or 0.000079 patients per year), and 11 patients with minimal retinopathy required intervention during the same period (1 of 1784 or 0.000561 patients per year). In addition, retinal interventions were performed for conditions not directly related to diabetic eye disease in 44 patients without baseline retinopathy (1 of 3165 or 0.000316 patients per year) and 5 patients with minimal retinopathy at baseline (1 of 3924 or 0.000255 patients per year).

Conclusions and Relevance

These findings suggest that it is rare for patients with minimal or no baseline retinopathy to require retinal interventions in the 2 years after retinal evaluation. It appears that extending the recommended follow-up interval for low-risk patients may be reasonable as long as this does not lead to worse follow-up in later years, because most are unlikely to have vision-threatening disease that necessitates treatment.

Diabetic retinopathy screening using a virtual reading center

AIMS

To summarize the effects of centralization of diabetic fundus photograph interpretation into a virtual reading center.

METHODS

In 2016 Kaiser Permanente Northern California, a large, membership-based health plan with an ethnically and racially diverse population, centralized diabetic retinopathy screening into a virtual reading center. Retina screens were based on single field, 45-degree fundus photographs. We compared the accuracy of photography interpretation the year before centralization to the year after using masked reads performed by retina specialists of 1000 randomly selected screens from each time period.

RESULTS

In all, 1902 patient screens with adequate quality images were included in the primary analysis. Images from pre-centralization screens were largely read by ophthalmologists (76.2%), while screens post-centralization were mainly read by optometrists (84.6%). Despite being interpreted by readers with lower levels of professional training, the sensitivity of screening increased from 43.9% (95% CI 38.0-49.8%) to 66.0% (95% CI 60.5-71.4%).

CONCLUSION

A move to a centralized virtual reading center was associated with improved accuracy of diabetic retinopathy screening.

Clinical Components of Telemedicine Programs for Diabetic Retinopathy

Diabetic retinopathy is a leading cause of new-onset vision loss worldwide. Treatments supported by large clinical trials are effective in preserving vision, but many persons do not receive timely diagnosis and treatment of diabetic retinopathy, which is typically asymptomatic when most treatable. Telemedicine evaluation to identify diabetic retinopathy has the potential to improve access to care, but there are no universal standards regarding camera choice or protocol for ocular telemedicine. We review the literature regarding the impact of imaging device, number and size of retinal images, pupil dilation, type of image grader, and diagnostic accuracy on telemedicine assessment for diabetic retinopathy. Telemedicine assessment of diabetic retinopathy has the potential to preserve vision, but further development of telemedicine specific technology and standardization of operations are needed to better realize its potential.

Snapshot of Teleretinal Screening for Diabetic Retinopathy at the West Los Angeles Medical Center

INTRODUCTION

The West Los Angeles Veterans Affairs Medical Center is a large urban facility with a robust teleretinal screening program in primary care clinic, established in 2006. The purpose of this article is to provide a snapshot of teleretinal screening at this site.

METHODS

Diabetic patients from 2012 were analyzed with a prospective cohort study. Demographic information, results of teleretinal screening, referral to eye clinic, and loss to follow-up (defined as no eye care within 2 years) were collected.

RESULTS

Of 516 patients with diabetes screened with teleretinal imaging, 120 patient charts were reviewed for data analysis. Teleretinal imaging diagnosed 15% (18/120) of patients with varying stages of nonproliferative diabetic retinopathy (DR). Of patients screened, 55.8% (67/120) of the patients were referred to an eye clinic for further ophthalmic evaluation. Nondiabetic retinopathy reasons for eye clinic referral included glaucoma suspect (13.3%, 16/120) and age-related macular degeneration (10.0%, 12/120). Of all patients screened, 37.5% (45/120) of them were lost to follow-up, defined as no teleretinal screening or eye clinic appointment within 2 years. Patients who lived farther away from clinic had a higher risk of loss to follow-up (p = 0.04).

DISCUSSION

We found, although only 15% of patients were diagnosed with DR from teleretinal screening, more than 50% of patients were referred to eye clinic. In addition, of all screened patients, there was a high rate of not returning to the Veterans Affairs (VA) for eye care.

Methodologies for evaluating strategies to reduce diagnostic error: report from the research summit at the 7th International Diagnostic Error in Medicine Conference

In this article we review current evidence on strategies to evaluate diagnostic error solutions, discuss the methodological challenges that exist in investigating the value of these strategies in patient care, and provide recommendations for methods that can be applied in investigating potential solutions to diagnostic errors. These recommendations were developed iteratively by the authors based upon initial discussions held during the Research Summit of the 7th Annual Diagnostic Error in Medicine Conference in September 2014. The recommendations include the following elements for designing studies of diagnostic research solutions: (1) Select direct and indirect outcomes measures of importance to patients, while also practical for the particular solution; (2) Develop a clearly-stated logic model for the solution to be tested; (3) Use rapid, iterative prototyping in the early phases of solution testing; (4) Use cluster-randomized clinical trials where feasible; (5) Avoid simple pre-post designs, in favor of stepped wedge and interrupted time series; (6) Leverage best practices for patient safety research and engage experts from relevant domains; and (7) Consider sources of bias and design studies and their analyses to minimize selection and information bias and control for confounding. Areas of diagnostic error mitigation research identified for further attention include: role of competing diagnoses, understanding the impacts of organizational culture, timing of diagnosis, and sequencing of research studies. Future research will likely require novel clinical, health services, and qualitative research methods to address the age-old problem of arriving at an accurate diagnosis.