April Y. Maa

Effect of a Teleretinal Screening Program on Eye Care Use and Resources

IMPORTANCE Telemedicine is a useful clinical method to extend health care to patients with limited access. Minimal information exists on the subsequent effect of telemedicine activities on eye care resources. OBJECTIVE To evaluate the effect of a community-based diabetic teleretinal screening program on eye care use and resources. DESIGN, SETTING, AND PARTICIPANTS The current study was a retrospective medical record review of patients who underwent diabetic teleretinal screening in the community-based clinics of the Atlanta Veterans Affairs Medical Center from October 1, 2008, through March 31, 2009, and who were referred for an ophthalmic examination in the eye clinic. EXPOSURES Clinical medical records were reviewed for a 2-year period after patients were referred from teleretinal screening. The following information was collected for analysis: patient demographics, referral and confirmatory diagnoses, ophthalmology clinic visits, diagnostic procedures, surgical procedures, medications, and spectacle prescriptions. MAIN OUTCOMES AND MEASURES The accuracy between referring and final diagnoses and the eye care resources that were used in the care of referred patients. RESULTS The most common referral diagnoses were nonmacular diabetic retinopathy (43.2%), nerve-related disease (30.8%), lens or media opacity (19.1%), age-related macular degeneration (12.9%), and diabetic macular edema (5.6%). The percentage of agreement among these 5 visually significant diagnoses was 90.4%, with a total sensitivity of 73.6%. Diabetic macular edema required the greatest number of ophthalmology clinic visits, diagnostic tests, and surgical procedures. Using Medicare cost data estimates, the mean cost incurred during a 2-year period per patient seen in the eye clinic was approximately

A novel device for accurate and efficient testing for vision-threatening diabetic retinopathy

1000. CONCLUSIONS AND RELEVANCE Although a teleretinal screening program can be accurate and sensitive for multiple visually significant diagnoses, measurable resource burdens should be anticipated to adequately prepare for the associated increase in clinical care.

Early Experience with Technology-Based Eye Care Services (TECS): A Novel Ophthalmologic Telemedicine Initiative

AIMS To evaluate the performance of the RETeval device, a handheld instrument using flicker electroretinography (ERG) and pupillography on undilated subjects with diabetes, to detect vision-threatening diabetic retinopathy (VTDR). METHODS Performance was measured using a cross-sectional, single armed, non-interventional, multi-site study with Early Treatment Diabetic Retinopathy Study 7-standard field, stereo, color fundus photography as the gold standard. The 468 subjects were randomized to a calibration phase (80%), whose ERG and pupillary waveforms were used to formulate an equation correlating with the presence of VTDR, and a validation phase (20%), used to independently validate that equation. The primary outcome was the prevalence-corrected area under the receiver operating characteristic (ROC) curve for the detection of VTDR. RESULTS The area under the ROC curve was 0.86 for VTDR. With a sensitivity of 83%, the specificity was 78% and the negative predictive value was 99%. The average testing time was 2.3 min. CONCLUSIONS With a VTDR prevalence similar to that in the U.S., the RETeval device will identify about 75% of the population as not having VTDR with 99% accuracy. The device is simple to use, does not require pupil dilation, and has a short testing time.

Retrospective Evaluation of a Teleretinal Screening Program in Detecting Multiple Nondiabetic Eye Diseases

PURPOSE The aging population is at risk of common eye diseases, and routine eye examinations are recommended to prevent visual impairment. Unfortunately, patients are less likely to seek care as they age, which may be the result of significant travel and time burdens associated with going to an eye clinic in person. A new method of eye-care delivery that mitigates distance barriers and improves access was developed to improve screening for potentially blinding conditions. We present the quality data from the early experience (first 13 months) of Technology-Based Eye Care Services (TECS), a novel ophthalmologic telemedicine program. DESIGN With TECS, a trained ophthalmology technician is stationed in a primary care clinic away from the main hospital. The ophthalmology technician follows a detailed protocol that collects information about the patients eyes. The information then is interpreted remotely. Patients with possible abnormal findings are scheduled for a face-to-face examination in the eye clinic. PARTICIPANTS Any patient with no known ocular disease who desires a routine eye screening examination is eligible. METHODS Technology-Based Eye Care Services was established in 5 primary care clinics in Georgia surrounding the Atlanta Veterans Affairs hospital. MAIN OUTCOME MEASURES Four program operation metrics (patient satisfaction, eyeglass remakes, disease detection, and visit length) and 2 access-to-care metrics (appointment wait time and no-show rate) were tracked. RESULTS Care was rendered to 2690 patients over the first 13 months of TECS. The program has been met with high patient satisfaction (4.95 of 5). Eyeglass remake rate was 0.59%. Abnormal findings were noted in 36.8% of patients and there was >90% agreement between the TECS reading and the face-to-face findings of the physician. TECS saved both patient (25% less) and physician time (50% less), and access to care substantially improved with 99% of patients seen within 14 days of contacting the eye clinic, with a TECS no-show rate of 5.2%. CONCLUSIONS The early experience with TECS has been promising. Tele-ophthalmology has the potential to improve operational efficiency, reduce cost, and significantly improve access to care. Although further study is necessary, TECS shows potential to help prevent avoidable vision loss.

Original articleEarly Experience with Technology-Based Eye Care Services (TECS): A Novel Ophthalmologic Telemedicine Initiative

BACKGROUND Diabetic teleretinal screening programs have been utilized successfully across the world to detect diabetic retinopathy (DR) and are well validated. Less information, however, exists on the ability of teleretinal imaging to detect nondiabetic ocular pathology. INTRODUCTION This study performed a retrospective evaluation to assess the ability of a community-based diabetic teleretinal screening program to detect common ocular disease other than DR. MATERIALS AND METHODS A retrospective chart review of 1,774 patients who underwent diabetic teleretinal screening was performed. Eye clinic notes from the Veterans Health Administrations electronic medical record, Computerized Patient Record System, were searched for each of the patients screened through teleretinal imaging. When a face-to-face examination note was present, the physical findings were compared to those obtained through teleretinal imaging. Sensitivity, specificity, and positive and negative predictive values were calculated for suspicious nerve, cataract, and age-related macular degeneration. RESULTS A total of 903 patients underwent a clinical examination. The positive predictive value was highest for cataract (100%), suspicious nerve (93%), and macular degeneration (90%). The negative predictive value and the percent agreement between teleretinal imaging and a clinical examination were over 90% for each disease category. DISCUSSION A teleretinal imaging protocol may be used to screen for other common ocular diseases. CONCLUSION It may be feasible to use diabetic teleretinal photographs to screen patients for other potential eye diseases. Additional elements of the eye workup may be added to enhance accuracy of disease detection. Further study is necessary to confirm this initial retrospective review.

Differences in Tertiary Glaucoma Care in the Veterans Affairs Health Care System

PURPOSE The aging population is at risk of common eye diseases, and routine eye examinations are recommended to prevent visual impairment. Unfortunately, patients are less likely to seek care as they age, which may be the result of significant travel and time burdens associated with going to an eye clinic in person. A new method of eye-care delivery that mitigates distance barriers and improves access was developed to improve screening for potentially blinding conditions. We present the quality data from the early experience (first 13 months) of Technology-Based Eye Care Services (TECS), a novel ophthalmologic telemedicine program. DESIGN With TECS, a trained ophthalmology technician is stationed in a primary care clinic away from the main hospital. The ophthalmology technician follows a detailed protocol that collects information about the patients eyes. The information then is interpreted remotely. Patients with possible abnormal findings are scheduled for a face-to-face examination in the eye clinic. PARTICIPANTS Any patient with no known ocular disease who desires a routine eye screening examination is eligible. METHODS Technology-Based Eye Care Services was established in 5 primary care clinics in Georgia surrounding the Atlanta Veterans Affairs hospital. MAIN OUTCOME MEASURES Four program operation metrics (patient satisfaction, eyeglass remakes, disease detection, and visit length) and 2 access-to-care metrics (appointment wait time and no-show rate) were tracked. RESULTS Care was rendered to 2690 patients over the first 13 months of TECS. The program has been met with high patient satisfaction (4.95 of 5). Eyeglass remake rate was 0.59%. Abnormal findings were noted in 36.8% of patients and there was >90% agreement between the TECS reading and the face-to-face findings of the physician. TECS saved both patient (25% less) and physician time (50% less), and access to care substantially improved with 99% of patients seen within 14 days of contacting the eye clinic, with a TECS no-show rate of 5.2%. CONCLUSIONS The early experience with TECS has been promising. Tele-ophthalmology has the potential to improve operational efficiency, reduce cost, and significantly improve access to care. Although further study is necessary, TECS shows potential to help prevent avoidable vision loss.

Remote eye care screening for rural veterans with Technology-based Eye Care Services: a quality improvement project

Importance Glaucoma is a common cause of visual impairment in the Veterans Affairs (VA) health care system, but to our knowledge, no data exist concerning tertiary glaucoma care (ie, laser and filtering surgery). Objective To determine whether the rate of tertiary glaucoma care differs among veterans cared for through the 4 different eye care delivery models that are present in the VA: optometry-only clinics, ophthalmology-only clinics, clinics with optometry and ophthalmology functioning as a single integrated clinic with ophthalmology as the lead, and clinics with optometry and ophthalmology functioning as separate clinics. Design, Setting, and Participants In this retrospective review of the Veterans Health Administration Support Service Center database, 490 926 veterans with a glaucoma-related diagnosis received care from 136 VA medical centers during fiscal year 2016. Demographic and baseline clinical factors, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, and Current Procedural Terminology codes, and the rates of glaucoma surgery procedures were extracted from the database. The organizational structure of each VA eye clinic was obtained. Univariate and multivariate regression analyses were performed for log percent for laser peripheral iridotomy (LPI), laser trabeculoplasty (LTP), and filtering surgery. Main Outcomes and Measures Rates of LPI, LTP, and filtering surgery. Results Of the 490 926 veterans with a glaucoma-related diagnosis, 465 842 (94.9%) were male, 309 677 (63.1%) were white, and 203 243 (41.4%) were aged 65 to 74 years. The rate of LPI was 0.30%, 0.28%, 0.67%, and 0.69% in optometry-only clinics, ophthalmology-only clinics, integrated clinics, and separated clinics, respectively (P < .001). The rate of LTP was 0.31%, 1.06%, 0.93%, and 0.92% in care delivery models that included optometry-only clinics, ophthalmology-only clinics, integrated clinics, and separated clinics, respectively (P < .001). The rate of filtering surgery was 0.32%, 0.51%, 0.69%, and 0.60% in optometry-only clinics, ophthalmology-only clinics, integrated clinics, and separated clinics, respectively (P < .001). Multivariate regression analyses showed that these differences remained significantly different even after adjusting for potential confounders. Conclusions and Relevance Disparities exist in the use of tertiary glaucoma services within the VA, and different care delivery models may play a role. Outcomes of glaucoma care for the different models of eye care delivery were not analyzed in this study.

The Use of Telemedicine to Extend Ophthalmology Care

CONTEXT Veterans are at high risk for eye disease because of age and comorbid conditions. Access to eye care is challenging within the entire Veterans Hospital Administrations network of hospitals and clinics in the USA because it is the third busiest outpatient clinical service and growing at a rate of 9% per year. ISSUE Rural and highly rural veterans face many more barriers to accessing eye care because of distance, cost to travel, and difficulty finding care in the community as many live in medically underserved areas. Also, rural veterans may be diagnosed in later stages of eye disease than their non-rural counterparts due to lack of access to specialty care. In March 2015, Technology-based Eye Care Services (TECS) was launched from the Atlanta Veterans Affairs (VA) as a quality improvement project to provide eye screening services for rural veterans. LESSONS LEARNED By tracking multiple measures including demographic and access to care metrics, data shows that TECS significantly improved access to care, with 33% of veterans receiving same-day access and >98% of veterans receiving an appointment within 30 days of request. TECS also provided care to a significant percentage of homeless veterans, 10.6% of the patients screened. Finally, TECS reduced healthcare costs, saving the VA up to US

Veteran Eye Disease After Eligibility Reform: Prevalence and Characteristics

148 per visit and approximately US

Variant prostate carcinoma and elevated serum CA-125.

52 per patient in round trip travel reimbursements when compared to completing a face-to-face exam at the medical center. Overall savings to the VA system in this early phase of TECS totaled US