Optimizing Care in the Safety Net | DII
1 like97 views
The document discusses the implementation and evaluation of a teleretinal diabetic retinopathy screening program within the Los Angeles County Department of Health Services, aimed at addressing high prevalence rates of diabetic retinopathy among patients. The initiative successfully increased screening rates by 16.3% and significantly reduced wait times for treatment from 158 days to just 17 days post-implementation. Continued evaluation and analysis will focus on cost, time to treatment, and optimal screening intervals to further enhance patient care.
Optimizing Care in the Safety Net | DII
- 1. Lauren Patty Daskivich, MD, MSHS Director, Ophthalmology and Eye Health Programs LAC Department of Health Services Optimizing Care in the Safety Net: Implementation and Evaluation of a Large-Scale Teleretinal Diabetic Retinopathy Screening Program in the Los Angeles County Department of Health Services
- 2. Diabetic Retinopathy: a safety net epidemic Diabetic retinopathy (DR) is damage to blood vessels of the retina caused by diabetes Leading cause of blindness in working-age adults A large study of Latinos in Los Angeles showed a prevalence close to 50% Leading cause of blindness in LA County
- 3. But it’s treatable… Early Treatment Diabetic Retinopathy Study (ETDRS): effective treatment can reduce severe vision loss by up to 94% At least 40-45% of US diabetics who may benefit from earlier detection and treatment do not receive it US inner-city safety net clinic screening rates: < 25%
- 4. The problem…DHSFacilitiesand CommunityPartners Diabetic patient seen at primary care clinic LACountyDHSFacility Patient referred to county health facility for routine retinopathy screening >6-9monthsafterreferral Patient screened at county health facility, given follow-up as needed Historical process for DR screening in LAC DHS
- 5. Our Teleretinal Solution Digital nonmydriatic camera images are effective for DR screening High sensitivity and specificity Examples include VA, Joslin Vision Network, Indian Health Service, UK National Health Service No studies evaluating the effectiveness of teleretinal screening in a large, urban safety net health system
- 6. Diabetic patient identified at PCP visit Patient sent for teleretinal DR screening at end of PCP visit Photographer uploads image to software template and submits Images acquired Images transmitted to reading center Images reviewed, report generated back to PCP PCP clinic submits eConsult for eye care appointment based on diagnosis/triage recommendations Clinical Pathway for Teleretinal Imaging
- 7. Implementation: Building the LAC DHS Teleretinal Program With support of central/facility-based leadership: Obtained fundus cameras for 15 DHS primary care sites Identified and trained fundus photographers (LVN/Medical Assistant level) Selected and implemented the software platform for transmitting teleretinal images – EyePACS, LLC Certified DHS Optometrists as primary readers with QA oversight by Ophthalmology Established a protocol for standardized referral timelines by diagnosis Integrated referrals for abnormal results into eConsult, the new web-based LAC specialty referral system
- 8. Evaluation: Partnership with UCLA CTSI Research question: Are we truly meeting our goals of increasing the number of patients screened and triaging those in need of ophthalmology specialty care in a more timely manner? Are we screening more patients for DR? Are wait times shorter?
- 9. Specific Aims Aim 1: to assess the change in proportion of diabetics screened for diabetic retinopathy before and after implementation of primary care-based teleretinal screening Aim 2: to evaluate the change in wait time from referral to definitive treatment for diabetic retinopathy before and after implementation of teleretinal screening Aim 3: to compare wait times by diagnosis for severity of retinopathy to suggested time to treatment as defined by the American Academy of Ophthalmology (AAO) Preferred Practice Pattern
- 10. Methods Nonrandomized, quasi-experimental pretest- posttest design Exposure at clinic level Historical controls Powered to detect a 15% difference in screening rate/wait times (ICC = 0.02) between intervention and control populations 5 clinics with control and intervention groups 120 subjects per clinic
- 11. Outcomes: Aims 1-3 Control (120 patients) Intervention (120 patients) Teleretinal Screening 12 months 12 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
- 12. Results – Aim 1 Overall annual screening rates for DR increased 16.3% at all 15 targeted clinics (OR, 1.9; 95% CI, 1.3-2.9) 40.6% before implementation 56.9% after initiation of the program
- 13. Results – Aim 2 Median time to screening for DR decreased 89.2% 158 days (IQR, 68-324 days) before the intervention 17 days (IQR, 8-50 days) after initiation of the program
- 14. Results Eliminated the need for over 14,000 visits to eye clinic in the first 2 years of the program Daskivich LP, et al. JAMA Internal Med. Published online March 27, 2017.
- 15. LAC DHS Teleretinal DR Screening Program Sites Study Sites: Claude C. Hudson CHC El Monte CHC Long Beach CHC Hubert H. Humphrey CHC Harbor UCLA Family Medicine/Lomita Other Active Sites: MLK-OPC Olive View UCLA Clinic A Clinic M Harbor ULCA Adult Medicine Edward Roybal CHC Rancho Los Amigos LAC+USC Wilmington HC High Desert Health System Mid Valley CHC Bellflower HC
- 16. Current Program Statistics Total Encounters to Date – 40,799 No Referral Needed – 28,927 Referred for Diabetic Retinopathy – 7,449 Treatable DR – 3,083 Referred for Other Eye Conditions – 4,423 11% 71% 11% 7% Referable vs. Nonreferable Disease Referable DR Nonreferable Other Referable Condition Treatable DR 18% Referred for DR
- 17. Volume by Year 0 200 400 600 800 1000 1200 1400 1600 Jan-14 Jan-15 Jan-16 Jan-17 Yearly
- 18. Summary and Next Steps Example of successful implementation of Teleretinal DR Screening in a large urban safety net healthcare system Cameras placed CMA photographers trained, primary care workflows established 3% ungradable rate Reading center with QA and protocols created and standardized Triaging with use of eConsult, integrating into EHR Evaluation showed screening more people much faster than before Next steps: analysis of cost, time to treatment, and appropriate screening intervals Goal is to improve access to and quality of care, treating those that need it in a timely manner