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«Increasing Eye Care Screening & Referral for People with Diabetes via Telehealth Programs Charles R. Fox. O.D., Ph.D.1, Kim Kronenberg, M.P.H.2, Gary ...»

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Increasing Eye Care Screening & Referral for People with Diabetes

via Telehealth Programs

Charles R. Fox. O.D., Ph.D.1, Kim Kronenberg, M.P.H.2, Gary Chu, O.D., M.P.H. 3,

Belal Bakir, M.D.4,*Eric S. Weiskopf, M.Ed. 5, Pam Kovach, R.N. 6, and Kathy Berman,

M.P.H.7*

Professor & Dean, School of Arts and Sciences, Point Park University, Pittsburgh, PA.

Boston University School of Public Health, Massachusetts & Public Health Consultant, Boston, MA.

Associate Professor & Vice President for Community Collaborations, The New England College of Optometry/ / New England Eye Institute, Boston, MA.

Ophthalmology Resident, PGY2, University of Texas Medical Branch, Galveston, TX New York State Department of Health, Bureau of Community Chronic Disease Prevention, Diabetes Prevention and Control Program, Disability and Health Program, Albany, NY.

Nurse Consultant, New Mexico Department of Health, Diabetes Prevention and Control Program, Santa Fe, NM.

Manager, Dept. of Health & Human Services, Division of Public Health Services, New Hampshire Diabetes Education Program, Concord, NH.

* All authors are members of the National Association of Chronic Disease Directors, Vision & Eye Health Council, Primary Care Team; complete list of team members in appendix 1. The authors wish to thank Rebecca Hyder and members of the American Academy of Ophthalmology for careful review and commentary. We’d also like to acknowledge the contributions of Walter Young of the NACDD (National Association of Chronic Disease Directors.) Introduction Twenty-four million Americans are affected by the complications and premature morbidity and mortality rates associated with diabetes mellitus (DM)(Centers for Disease Control and Prevention, 2007). In this report, we focus on two of those complications, visual impairment and blindness. (We will use the term visual impairment to encompass both complications). This is important because many individuals with diabetes do not receive recommended vision care. In particular, we explore one strategy that can be used as a preliminary screen for diabetic retinal disease, the leading cause of blindness among working-aged adults(Centers for Disease Control and Prevention, 2009b). The strategy, known as digital teleretinal imaging, can reduce visual impairment by 1) increasing referrals for comprehensive eye exams, 2) improving patient awareness and compliance, and 3) facilitating timely treatment. We explore advantages and limitations of this strategy and discuss the role that state public health agencies can play in facilitating further research and implementation.

The Burden of Diabetic Eye Diseases Diabetes is the leading cause of blindness among adults aged 20-74 years(Centers for Disease Control and Prevention, 2007). In 2008, 3.6 million adults with diabetes (aged 18 years or older) reported visual impairment, defined as“difficulty seeing even with vision corrected by eyeglasses or contact lenses.”(Centers for Disease Control and Prevention, 2009a) In a recent prevalence report, 32.8% of people with diabetes (self-reported) had diabetic retinopathy and 5.2% had vision-threatening diabetic retinopathy (Xinzhi Zhang et al., 2010). People with diabetes are more likely to suffer from glaucoma (40% increase) and more likely to develop cataracts (60% increase) than those without diabetes(American Diabetes Association, 2010a). Cataracts in people with diabetes also occur at a younger age and progress more rapidly in people with diabetes (Prevention, 1991).

The number of individuals affected (diagnosed and undiagnosed) by diabetic eye diseases is rising(Saaddine et al., 2008). Between 2005 and 2050, the number of Americans 40 years or older with diabetic retinopathy is predicted to triple from 5.5 million to 16 million people and vision-threatening diabetic retinopathy will rise from 1.2 million in 2005 to 3.4 million in 2050 (Centers for Disease Control and Prevention, 2009; Saaddine et al., 2008).

Visual impairment imposes a significant burden on patients, providers, and the health care system. It can significantly interfere with a person’s ability to conduct such activities of daily living as reading or watching television, walking, driving, shopping and preparing meals. Visual impairment also limits an individual’s ability to attend to personal affairs and socialize(Crews, Jones, & Kim, 2006; Ellwein, Friedlin, McBean, & Lee, 1996). In older adults, vision impairment has been shown to be associated with a variety of co-morbidities such as depression, hearing loss, and stroke(Crews et al., 2006).

In 2005, the National Eye Institute (NEI) in collaboration with the Lions Club conducted a telephone survey of more than 3000 adults over the age of 18. When asked to rate a list of conditions on a scale of 1 to 10 according to their impact on daily living (with 1 connoting the lowest impact and 10 the highest), 71% of those surveyed gave eyesight a 10 (National Eye Institute, 2007a). In addition to its negative impact on quality of life, vision loss costs an estimated $51 billion each year in the U.S.(Prevention, 2009a) Diabetic retinopathy alone, independent of related impairments such as cataracts and glaucoma, costs the nation more than 1 billion annually in direct medical expenditures for people 40 years and older(Prevent Blindness America, 2007).

Prevention and Detection Although retinal disease is common in people with diabetes, many people with retinal disease do not seek eye care because diabetic retinopathy is often symptom free until vision is significantly compromised. At this late stage, visual impairment is more difficult and more expensive to manage and often the damage is irreversible. The most important approach to preventing sight-threatening diabetic retinopathy (DR) is early detection.





When pathology is identified early, control of hyperglycemia, lipid levels, and blood pressure can delay the progress of DR. In addition, success of treatment for DR with laser photocoagulation can be optimized when implemented early, before symptoms are manifest(Brechner et al., 1993; Porta & Bandello, 2002).

The benefits of early detection of diabetic retinopathy and other diabetic eye changes (including iris neovascularization, diabetic macular edema, cataract and glaucoma) provide strong incentives for professionals and public organizations to advocate for regular, comprehensive eye exams. A comprehensive exam is conducted by an eye care specialist (an ophthalmologist or optometrist) who assesses the entire health and function of the eye both before and after the pupil is dilated. Pupil dilation allows the provider enhanced viewing of the structures of the eye, and greatly increases detection and evaluation of diabetic retinopathy. (Pupil dilation is a component of a comprehensive eye exam, but is not a necessary procedure for a screening.) The American Diabetes Association (ADA) recommends that adults and children aged 10 years or older with type 1 diabetes have a comprehensive eye examination with dilation within 5 years after the onset of diabetes(American Diabetes Association, 2010b). For people with type 2 diabetes, the ADA recommends a dilated and comprehensive eye examination shortly after the diagnosis of diabetes, and annually thereafter. Finally, women with diabetes who are planning pregnancy or who have already become pregnant, should have a comprehensive eye examination, according to the ADA, and should be counseled on the risk of development and/or progression of diabetic retinopathy. The ADA recommends an eye examination in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum. Comprehensive eye exams for people with diabetes is also recommended by other professional organizations (i.e. American Academy of Family Physicians, American Academy of Ophthalmology, American Association of Clinical Endocrinologists, American College of Physicians, American Optometric Association, Centers for Disease Control and Prevention, the National Eye Institute, and others.) Barriers and Challenges Despite the availability of evidence-based prevention and treatment protocols for DR many adults with diabetes are not screened for the presence of diabetic retinopathy(Lee, Feldman, Ostermann, Brown, & Sloan, 2003; Prevention, 2009b). The National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS®1) of 2009, reported that for adults between the ages of 18 and 75 who were diagnosed with diabetes, only 56.5% of those covered by commercial health plans, 63.5% covered by Medicare, and 52.7% covered by Medicaid had a retinal exam in the prior year(National Center for Quality Assurance, 2009). Similarly, Healthy People 2010, set an objective of annual dilated eye exams for 75% of adults with diabetes; to date (2008) only 53% of people of this age group with diabetes (18) had actually received dilated eye exams(Prevention, 1991).

Confusion among definitions Screening as a means of detecting diabetic eye diseases early is well supported in the literature. However, the definition of the term “vision screening” is inconsistent thus confounding the implication of research results. Some researchers and authors use the term “vision screening” to refer to a medical procedure that identifies those at risk for eye HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

disease; some use the term to refer to a diagnostic procedure, and still others use the terms “vision screening” and “diagnosis” interchangeably. In this paper, we define “screening” to denote a preliminary assessment of risk. A vision screening, therefore, is like a mammography or colonoscopy in that it assesses an individual’s likelihood of having disease. While a mammography or colonoscopy may be followed by a biopsy to confirm a diagnosis, a vision screening is followed by a diagnostic procedure, the comprehensive, dilated eye exam.

Digital Teleretinal Imaging – Description In 2004, the American Telemedicine Association (ATA) published the “Telehealth Practice Recommendations for Diabetic Retinopathy,” representing a comprehensive review of existing evidence on ocular telehealth for diabetic retinopathy(American Telemedicine Association, 2004). It summarized clinical, ethical and technological recommendations for effective implementation of a teleretinal imaging program. Other research demonstrates the effectiveness of teleretinal imaging as an effective means to screen people with diabetes for diabetic retinopathy(Cavallerano & Conlin, 2008;

Gómez-Ulla et al., 2002) and as a means of improving adherence to screening guidelines and eye care(Fonda et al., 2007; Taylor et al., 2007).

With teleretinal imaging, technicians at primary care offices or other local or mobile imaging centers capture stereo images of the retina using a digital camera. The images can be electronically transmitted to and interpreted by trained interpreters, optometrists, or ophthalmologists, who may be offsite. The readers evaluate the image for evidence of diabetic retinopathy (or other pathology) and make a referral recommendation to the primary healthcare providers based on established protocol.

Teleretinal imaging can be performed with mydriatic or non-mydriatic cameras (those requiring pupil dilation versus those that don’t). In a 2001 randomized clinical trial, nonmydriatic cameras were shown to be comparable in their accuracy in detecting retinopathy to the established gold standard established in the Early Treatment Diabetic Retinopathy Study (ETDRS), which required pupillary dilation(Bursell et al., 2001).

Other studies have corroborated those results(Cavallerano & Conlin, 2008), with one study concluding that non-mydriatic digital imaging improves the rate of identification of diabetic retinopathy(Conlin et al., 2006). While researchers do not all agree on the greater efficacy of the non-mydriatic camera, the non-mydriatic camera has important advantages. Dilating the patients’ eye requires administration of controlled substance drops and thus requires a licensed provider. Dilation is disruptive to vision and visual function typically for many hours, and it is time consuming. These disadvantages increase barriers to screening and early detection.

A Potential Approach to Reduce Barriers to Screening and Early Detection The following are some of the attributes of the non-mydriatic teleretinal imaging technology.

Patient Awareness Lack of patient awareness of the importance of an eye care visit has been cited as an obstacle to eye health(Dervan, Lillis, Flynn, Staines, & O'Shea, 2008; National Eye Institute, 2005). Interventions to increase patient awareness alone have proven effective at increasing screening rates(Xuanping Zhang et al., 2007). This was demonstrated in two Veterans Affairs clinical studies utilizing the Joslin Vision Network Eye Health Care Model telemedicine program for diabetic retinopathy. In one project in Boston(Conlin et al., 2006), and another in Maine(Cavallerano et al., 2005), the digital image resulting from the process, using non-mydriatic technology, was found to increase the ability of the imaging specialist to educate the patient about the disease. The American Telemedicine Association recommends that provider-patient communication be a component of a telehealth program(American Telemedicine Association, 2004).

Primary Care Provider Knowledge Limited eye health knowledge by primary care doctors has also been raised as an impediment to adherence to eye care guidelines. In a national web-based study of primary care physicians conducted in 2007, only half of physicians believed they had adequate knowledge to advise their patients on vision health, and only 58% believed they could identify patients at higher risk for eye disease(National Eye Institute, 2007b). With an on-site teleretinal imaging system, identifying patients is done by the trained imager, the off-site reader, and the technology, thereby addressing this knowledge gap.



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