Danish teleophthalmology platform reduces optometry referrals into the national eye care system

Implementing teleophthalmology services to improve cost-effectiveness of the national eye care system

BACKGROUND AND PURPOSE

Optometrist-assisted and teleophthalmology-enabled referral pathway (OTRP) for community optometry referrals has the potential to improve the capacity and efficiency of eye care delivery systems through risk stratification and limiting the number of improved referrals. This study investigates the expected future costs and benefits of implementing OTRP under various possible organizational set-ups relevant to a Danish context.

METHODS

A decision-analytic model (decision tree) with a one-year time horizon was constructed to portray alternative future patient referral pathways for people examined in optometry stores for suspected ocular posterior segment eye disease. The main outcomes were total healthcare costs per patient, average waiting time from eye examination in store until the start of treatment or end of referral pathway, and quality-adjusted life-years (QALY) gained. The economic evaluation compares the general ophthalmologist referral pathway (GO-RP) with a potential reimbursement model for the optometrist-assisted teleophthalmology referral pathways (R-OTRP) and a procurement model for the optometrist-assisted teleophthalmology referral pathways (P-OTRP).

RESULTS

The cost per individual with suspected ocular posterior segment eye disease was estimated to be £116 for GO-RP and £75 and £94 for P-OTRP and R-OTRP respectively. The average waiting time for diagnosis or end of referral pathway was 25 weeks for GO-RP and 5.8 and 5.7 for P-OTPR and R-OTPR respectively. QALY gain was 0.15 for P-OTRP/R-OTRP compared to 0.06 for GO-RP.

CONCLUSION

OTRP is effective in reducing unnecessary referrals and waiting times, increasing patients' HRQoL, and decreasing the costs of diagnosing individuals with suspected ocular posterior segment eye disease.

Analysis of patient referrals from primary care to ophthalmology. The role of the optometrist

PURPOSE

The aim of this study was to characterize the quality of primary care referrals of patients to ophthalmology at the Virgen Macarena Hospital in Seville. This will enable us to optimize ophthalmologic resources and to evaluate the role of the optometrist in improving referrals.

METHODS

We performed a retrospective cross-sectional review of 220 ophthalmology consultations referred from primary care to the hospital from March to May 2022. The following data were extracted: age, sex, reason for consultation, diagnosis, priority level, whether it was an initial consultation or a follow-up visit, whether there was a secondary referral and whether the referral was appropriate. Excel (version 2312) was used for the data analysis.

RESULTS

The age range of the patients was from 3 years to 91 years. The patients were 41.8 % male and 58.2 % female. The conditions found were grouped as follows: cataracts (27.27 %), refractive errors (20.9 %), anterior segment disease (18.8 %), posterior segment disease (14.07 %), normal examination (18.63 %) and others (0.9 %). The most common reason for consultation was blurred vision or loss of vision (43.63 %). In total, 41.36 % of the consultations were considered inappropriate. The age group requiring the highest number of consultations was over 65 years (38.64 %).

CONCLUSIONS

With 41.36 percent of referrals deemed unnecessary, it is clear that referrals can be improved. This would reduce strain on the ophthalmology service and improve patient care. The importance of the optometrist in primary care is demonstrated by the fact that 20.9 % of the diagnoses were refractive errors.

The Impact of the COVID-19 Pandemic on Tele-ophthalmology-Based Retinal Screening

INTRODUCTION

This study reports our experiences with systematic retinal screening in Denmark through optometrists with access to tele-ophthalmological services before, during, and after the COVID-19 pandemic.

METHODS

We evaluated an optometrist-based retinal screening system with a referral option for tele-ophthalmological service by a consultant ophthalmologist within the time period of August 1, 2018 to September 30, 2023. The optometrist collected patient history, refraction, best-corrected visual acuity, intraocular pressure, basic slit-lamp examination, 4-in-1 visual field report, and retinal imaging using color fundus 45° photography. Tele-ophthalmological services were provided by consultant ophthalmologists. Within pre-defined periods of pre-COVID-19, COVID-19, and post-COVID-19, we evaluated the rate of referrals to the tele-ophthalmological service, diagnoses made, and referrals to the public healthcare system.

RESULTS

A total of 1,142,028 unique individuals, which corresponded to 19.1% of the entire population of Denmark, underwent screening by the optometrists; 50,612 (4.4%) of these individuals were referred to the tele-ophthalmological examination by consultant ophthalmologists. A referral for further ophthalmic examination, either at hospital or at an ophthalmic practice, was made for 10,300 individuals (20.4% of those referred for tele-ophthalmology, corresponding to 0.9% of the population screened). The referral rate from the screening to the tele-ophthalmological service increased from before COVID-19 (3.4%) to during COVID-19 (4.3%) and further after COVID-19 (6.4%). This increase coincided with an increasing prevalence of conditions seen in the tele-ophthalmological service.

CONCLUSION

During a period of 5 years, 19.1% of the entire population of Denmark underwent retinal screening. This provided an adjunctive health service during a period of severe strain on the public healthcare system, while limiting the number of excessive referrals to the public healthcare system. Temporal trends illustrated an increased pattern of use of a large-scale tele-ophthalmological system.

What are the experiences of teleophthalmology in optometric referral pathways? A qualitative interview study with patients and clinicians

OBJECTIVE

Implementing teleophthalmology into the optometric referral pathway may ease the current pressures on hospital eye services caused by over-referrals from some optometrists. This study aimed to understand the practical implications of implementing teleophthalmology by analysing lived experiences and perceptions of teleophthalmology in the optometric referral pathway for suspected retinal conditions.

DESIGN

Qualitative in-depth interview study SETTING: Fourteen primary care optometry practices and four secondary care hospital eye services from four NHS Foundation Trusts across the UK.

PARTICIPANTS

We interviewed 41 participants: patients (17), optometrists (18), and ophthalmologists (6) who were involved in the HERMES study. Through thematic analysis, we collated and present their experiences of implementing teleophthalmology.

RESULTS

All participants interviewed were positive towards teleophthalmology as it could enable efficiencies in the referral pathway and improve feedback and communication between patients and healthcare professionals. Concerns included setup costs for optometrists and anxieties from patients about not seeing an ophthalmologist face to face. However, reducing unnecessary visits and increasing the availability of resources and capacity were seen as significant benefits.

CONCLUSIONS

Overall, we report positive experiences of implementing teleophthalmology into the optometric referral pathway for suspected retinal conditions. Successful implementation will require appropriate investment to set up and integrate new technology and remunerate services, and continued evaluation to ensure timely feedback to patients and between healthcare professionals is received.

TRIAL REGISTRATION NUMBER

ISRCTN18106677.

Teleophthalmology and retina: a review of current tools, pathways and services

Telemedicine, the use of telecommunication and information technology to deliver healthcare remotely, has evolved beyond recognition since its inception in the 1970s. Advances in telecommunication infrastructure, the advent of the Internet, exponential growth in computing power and associated computer-aided diagnosis, and medical imaging developments have created an environment where telemedicine is more accessible and capable than ever before, particularly in the field of ophthalmology. Ever-increasing global demand for ophthalmic services due to population growth and ageing together with insufficient supply of ophthalmologists requires new models of healthcare provision integrating telemedicine to meet present day challenges, with the recent COVID-19 pandemic providing the catalyst for the widespread adoption and acceptance of teleophthalmology. In this review we discuss the history, present and future application of telemedicine within the field of ophthalmology, and specifically retinal disease. We consider the strengths and limitations of teleophthalmology, its role in screening, community and hospital management of retinal disease, patient and clinician attitudes, and barriers to its adoption.

Feasibility Analysis of Teleophthalmology Diagnosis and Referral in Remote Areas of Taiwan

Background: Remote areas of Taiwan lack routine and specialized ophthalmology services. This study aimed to analyze feasibility of teleophthalmology service for diseases diagnosis and referral in remote areas of Taiwan. Methods: A retrospective study of medical records from 11 remote teleophthalmology clinics in the Taitung area of Taiwan was conducted from May 2020 to December 2021. Vision and intraocular pressure were checked. Ophthalmic imaging was performed by local trained nurses using a hand-held ophthalmoscope and slit lamp biomicroscope. The images were transmitted by telemedicine system to a medical center. Consultation was conducted via face-to-face real-time video calls. Ophthalmologists in the medical center provided diagnosis and treatment advice based on the real-time images and interactive history taking via the telemedicine system. All the images and data were collected and well-reviewed by ophthalmologists in the medical center, and disease prevalence and referral were analyzed for the program. A small-scale satisfaction questionnaire survey was conducted for efficacy evaluation of the program. Results: A total of 1,401 medical records from 1,094 patients were collected and screened. Patients' ages ranged from 9 months to 94 years, with a mean age of 57.27 (standard deviation ±20.47) years. The most frequent ophthalmologic diagnosis was dry eye disease (20.2%), followed by conjunctivitis (12.4%). Among 322 patients with underlying diseases of diabetes mellitus, 59 patients (18.3%) were diagnosed with diabetic retinopathy. Major diagnosis was made in 102 patients (7.3%) and referral to hospital for further management was suggested. This program had high overall satisfaction score of 89% (mean 4.43 ± 0.52 points) in satisfaction questionnaire survey. Conclusion: Teleophthalmology provides an alternative tool for ocular disease diagnosis and screening for patients in remote areas, especially during the COVID-19 pandemic. This service helps to detect major but undiagnosed diseases and promotes health care accessibility and availability in remote areas that lack specialists.

Diagnostic Accuracy of the Amsler Grid Test for Detecting Neovascular Age-Related Macular Degeneration: A Systematic Review and Meta-analysis

Importance

Patients with nonneovascular age-related macular degeneration (AMD) are encouraged to use the Amsler grid test for self-assessment to facilitate early diagnosis. The test is widely recommended, suggesting a belief that it signals worsening AMD, warranting its use in home monitoring.

Objective

To systematically review studies of the diagnostic test accuracy of the Amsler grid in the diagnosis of neovascular AMD and to perform diagnostic test accuracy meta-analyses.

Data Sources

A systematic literature search was conducted in 12 databases for relevant titles from database inception until May 7, 2022.

Study Selection

Studies included those with groups defined as having (1) neovascular AMD and (2) either healthy eyes or eyes with nonneovascular AMD. The index test was the Amsler grid. The reference standard was ophthalmic examination. After removal of obviously irrelevant reports, 2 authors (J.B. and M.S.) independently screened the remaining references in full text for potential eligibility. Disagreements were resolved by a third author (Y.S.).

Data Extraction and Synthesis

Two authors (J.B. and I.P.) independently extracted all data and evaluated quality and applicability of eligible studies using the Quality Assessment of Diagnostic Accuracy Studies 2. Disagreements were resolved by a third author (Y.S.).

Main Outcomes and Measures

Sensitivity and specificity of the Amsler grid for detecting neovascular AMD with comparators being either healthy control participants or patients with nonneovascular AMD.

Results

Of 523 records screened, 10 studies were included with a total of 1890 eyes (mean participant age ranging from 62 to 83 years). Sensitivity and specificity to diagnose neovascular AMD were 67% (95% CI, 51%-79%) and 99% (95% CI, 85%-100%), respectively, when comparators were healthy control participants and 71% (95% CI, 60%-80%) and 63% (95% CI, 49%-51%), respectively, when control participants were patients with nonneovascular AMD. Overall, potential sources of bias were low across studies.

Conclusions and Relevance

Although the Amsler grid is easy and inexpensive to use for detection of metamorphopsia, its sensitivity may be at levels typically not recommended for monitoring. Coupling this lower sensitivity with only moderate specificity to identify neovascular AMD in a population at risk, these findings suggest that such patients typically should be encouraged to undergo ophthalmic examination regularly, regardless of any results of Amsler grid self-assessment.

Real-Time Mobile Teleophthalmology for the Detection of Eye Disease in Minorities and Low Socioeconomics At-Risk Populations

PURPOSE

To examine the benefits and feasibility of a mobile, real-time, community-based, teleophthalmology program for detecting eye diseases in the New York metro area.

DESIGN

Single site, nonrandomized, cross-sectional, teleophthalmologic study.

METHODS

Participants underwent a comprehensive evaluation in a Wi-Fi-equipped teleophthalmology mobile unit. The evaluation consisted of a basic anamnesis with a questionnaire form, brief systemic evaluations and an ophthalmologic evaluation that included visual field, intraocular pressure, pachymetry, anterior segment optical coherence tomography, posterior segment optical coherence tomography, and nonmydriatic fundus photography. The results were evaluated in real-time and follow-up calls were scheduled to complete a secondary questionnaire form. Risk factors were calculated for different types of ophthalmological referrals.

RESULTS

A total of 957 participants were screened. Out of 458 (48%) participants that have been referred, 305 (32%) had glaucoma, 136 (14%) had narrow-angle, 124 (13%) had cataract, 29 had (3%) diabetic retinopathy, 9 (1%) had macular degeneration, and 97 (10%) had other eye disease findings. Significant risk factors for ophthalmological referral consisted of older age, history of high blood pressure, diabetes mellitus, Hemoglobin A1c measurement of ≥6.5, and stage 2 hypertension. As for the ocular parameters, all but central corneal thickness were found to be significant, including having an intraocular pressure >21 mm Hg, vertical cup-to-disc ratio ≥0.5, visual field abnormalities, and retinal nerve fiber layer thinning.

CONCLUSIONS

Mobile, real-time teleophthalmology is both workable and effective in increasing access to care and identifying the most common causes of blindness and their risk factors.