Implementation daskivich

Lauren Patty Daskivich, MD, MSHS

LAC DHS

Carol M. Mangione, MD, MSPH

UCLA

Implementation of a Primary Care-Based Teleretinal Screening Protocol for

the Los Angeles County Safety Net ___________________________

Diabetic Retinopathy   Diabetic retinopathy (DR) is a leading cause of

blindness in working-age adults in the United States

  Prevalence of diabetic retinopathy in a large study of Latinos in LA has been shown to be close to 50%

  THE leading cause of blindness in Los Angeles County

  Early Treatment Diabetic Retinopathy Study (ETDRS) showed that severe vision loss from diabetic retinopathy can be reduced by up to 94% by effective treatments.

  At least 40-45% of diabetics who may benefit from earlier detection and treatment of retinopathy are not receiving it

Teleretinal Screening for Diabetic Retinopathy

  High sensitivity and specificity when compared to gold standard (7 standard field fundus photographs and indirect ophthalmoscopy by an ophthalmic physician)   Sensitivity: 71-82%   Specificity: 92-96%

  Recognized by the American Academy of Ophthalmology

  No studies evaluating teleretinal screening in a safety net setting

Clinical Pathway for Teleretinal Imaging

Diabe&c pa&ent iden&fied at PCP visit 

Pa&ent sent for telere&nal screening at end of PCP visit 

Photographer uploads image to so:ware template and submits 

Images acquired

Images transmi=ed to reading center 

Images reviewed, report generated back to PCP 

PCP clinic submits eConsult based on diagnosis/triage recommenda&ons 

Research Question

Program evaluation:

Are we truly meeting our goals of increasing the number of patients screened and triaging those in need of care in a more timely manner?

  Are we screening more patients for DR?

  Are wait times shorter?

  Does it cost less?

Methods

 Nonrandomized, quasi-experimental pretest-posttest design

  Exposure at clinic level

 Historical controls

  Powered to detect a 15% difference (with a 0.02 intra-clinic correlation) between intervention and control populations   5 clinics with control and intervention groups

  120 subjects per clinic

Outcomes: Aims 1-3

Control (120 patients) Intervention (120 patients)

Teleretinal Screening

6 months 6 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

Outcomes: Aim 4

  Complexity of societal vs. health systems perspective

  What we can estimate   Cost effectiveness of screening method – teleretinal

imaging vs. direct eye exam   Number of cases of blindness prevented and

compare to national estimates of cost of blindness

  Area for collaboration with health economist

CERP Aims Addressed

  Aim 1 – Promote bidirectional knowledge exchange between community and academia.

  Aim 2 – Build community and academic infrastructure for sustainable partnered research

  Aim 4 – Build Health Services Research (HSR) methods into partnerships to accelerate design, production, and adoption of evidence-based interventions

Action Status Expected Completion Date

IRB approval from UCLA and LABioMed

Completed

IRB approval from USC Under Review January 2014

Pre-intervention data collection at 4 of 5 PC clinic sites

Completed

Pre-intervention data collection at remaining PC site and 3 Ophthalmology clinics

Underway January 2014

Implementation of DHS Teleretinal Screening Program

Underway January 2014 at study sites (June 2014 all sites)

Post-intervention Data Collection at 5 Clinic Sites

Pending February - March 2014

Data Analysis and Preparation of Extra-mural Grant Application

Pending April - June 2014

Timeline

Added Value from CTSI Funding

  Access to Health Services Research and Biostatistical support available within the UCLA CTSI   Availability of the biostatistics core and health

economist to assist with data analysis   Consultation to ensure that our quality assurance

mechanisms are sufficient   Advice on the design of a cost analysis of this

intervention   Advice regarding additional pilot funding to assist

with dissemination if this project is found to be successful

  Research Assistant support

Next Steps and Products   IRB approval obtained from UCLA, LABioMed; USC under review

  Major strides in implementation, including:   Ensuring clinic access to fundus cameras for 13 DHS primary care sites

  Identifying and training fundus photographers (LVN/Medical Assistant level)

  Selecting and implementing the software platform for transmitting teleretinal images

  Creating a quality assurance mechanism for image acquisition and evaluation

  Establishing appropriate triage mechanisms for abnormal screening photographs integrated with eConsult, the new web-based LAC specialty referral system

  Teleretinal Screening has begun at 2 sites and will rollout to 11 more over the next 6 months

  Currently developing a protocol for standardized referral timelines across LA County that will further streamline patient care