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Telemedicine Can Expand Screening for Retinopathy

Screening for diabetic retinopathy may be feasible in a primary care setting using telemedicine, researchers found.

Implementation of a telemedicine network in a single primary care clinic improved the percentage of patients who were screened for the condition from 32% to 71% within 1 year, according to Seema Garg, MD, PhD, of the University of North Carolina at Chapel Hill, and colleagues.

Most of the patients (86.7%) did not have retinopathy, the researchers reported online in a research letter in Archives of Internal Medicine.

"Primary care physicians are at the front line of this epidemic and already play a critical role in primary prevention of retinopathy with the management of serum glucose and lipid levels and blood pressure," Garg and colleagues wrote. "Telemedicine potentially allows primary care physicians to manage the screening and monitoring of this potentially blinding disease."

Although early detection and treatment of diabetic retinopathy is recognized as important in preventing blindness, fewer than half of patients with diabetes undergo screening in the U.S. That problem is expected to be exacerbated in the coming decades, as the number of Americans with diabetes is projected to increase from 25 million to 125 million by 2050.

To evaluate the feasibility of easing the burden on ophthalmologists by shifting screening to the primary care setting, the researchers looked at screening rates before and 1 year after the TRIAD ocular telemedicine network was introduced into a UNC primary care clinic.

The system involved a staff member in the clinic taking retinal photographs of both eyes using a nonmydriatic fundus camera. The images were then sent over a secure, web-based network to a single retina specialist, who sent her report back to the primary care physician within 48 hours. Based on the findings, the patient was either scheduled for more photographs in the clinic or referred to an ophthalmologist for management.

The current analysis included 1,002 patients with type 1 or type 2 diabetes who were evaluated with the telemedicine network in 1 year. The mean age was 57, the mean hemoglobin A1c was 7.6%, and the mean duration of diabetes was 9 years.

Most of the patients did not have diabetic retinopathy, but the prevalence was significantly higher among black patients compared with white patients (71% versus 27%). Nonwhite patients were more than twice as likely to have retinopathy (OR 2.2, 95% CI 1.2 to 4.1).

Compared with white patients, black patients had more severe retinopathy, with higher rates of both mild nonproliferative disease (11.5% versus 3.6%) and moderate disease (4.3% versus 1.8%).

In an accompanying editorial, Lauren Patty Daskivich, MD, MSHS, of the Los Angeles County Department of Health Services, and Carol Mangione, MD, MSPH, of the University of California Los Angeles, noted that other studies have shown similar results to the current analysis, indicating that fundus photography in the primary care setting can be used to effectively screen for diabetic retinopathy.

They said, however, that several issues need to be resolved before moving forward with the strategy.

"Most importantly, we must avoid creating an unregulated cottage industry," they wrote.

"Instead," they continued, "we should strive for national standardization in the protocol and work flow processes from the outset, including use of a validated grading scale, furnishing reading centers with certified readers and ophthalmic oversight, and enabling seamless bidirectional communication between primary care and specialist providers through the use of electronic health records (EHRs)."

In addition, uniform reporting of results and linkage of data to a shared EHR or diabetic registry is important, they said, in order to help target populations that would derive the most benefit from screening in the primary care setting, such as individuals in the healthcare safety net.

"Using teleretinal imaging to move screening for diabetic retinopathy into the primary care arena has the potential to substantially reduce blindness among some of the most vulnerable persons in the U.S. population," Daskivich and Mangione wrote.

The study received funding from the NIH, Prevent Blindness North Carolina, Research to Prevent Blindness, and the Plough Foundation.

Garg reported having no conflicts of interest. One of her co-authors, Edward Chaum, MD, PhD, of the University of Tennessee's Hamilton Eye Institute in Memphis, is the principal investigator of an NIH grant under which some of the technology used in the TRIAD telemedical network described in this research letter has been developed. Chaum is also an author on a patent application describing technology that is, in part, being developed and implemented in the TRIAD network, and is a co-founder and equity holder of Hubble Telemedical, a start-up company that has licensed the technology developed under the aforementioned grant for commercial use.

Daskivich and Mangione are supported in part by the UCLA Robert Wood Johnson Clinical Scholars Program and the U.S. Department of Veterans Affairs. Mangione received support from the Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly under an NIH/National Institute on Aging grant, and from an NIH/National Center on Advancing Translational Sciences UCLA Clinical and Translational Science Institute grant.

Daskivich and Mangione reported that they had no conflicts of interest.

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Todd Neale

Senior Staff Writer

Todd Neale, MedPage Today Staff Writer, got his start in journalism at Audubon Magazine and made a stop in directory publishing before landing at MedPage Today. He received a B.S. in biology from the University of Massachusetts Amherst and an M.A. in journalism from the Science, Health, and Environmental Reporting program at New York University.