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Patil SA, Guttha SP, Nair AA, Pandit S, Parikh R, Lee TF, Hu J, Mehta N, Modi YS. Investigating the Utility of Near-Infrared Reflectance Imaging for Diabetic Retinopathy Screening. Ophthalmic Surg Lasers Imaging Retina 2024; 55:318-325. [PMID: 38530988 DOI: 10.3928/23258160-20240205-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
BACKGROUND AND OBJECTIVE We investigated the reliability of near-infrared reflectance (NIR) imaging as a method of assessing severity of diabetic retinopathy (DR). PATIENTS AND METHODS One hundred ninety-five NIR images were reviewed by two graders for the number of hyporeflective foci, presence or absence of vascular abnormalities, and presumptive DR stage; these were correlated to fundus photography-defined DR stage. Interrater reliability was confirmed via one-way random effects model of intraclass correlation coefficients. Analysis of variance was used in subgroup analysis, receiver operating characteristic (ROC) curves were created to validate reliability of the model, and logistic regression was used to model foci and vascular abnormalities as predictors for moderate or worse disease. RESULTS A statistically significant difference in mean number of hyporeflective foci was found between no DR and moderate non-proliferative DR (NPDR; P < 0.0001), no DR and severe NPDR (P < 0.001), no DR and proliferative DR (PDR; P < 0.0001), mild and moderate NPDR (P = 0.008), mild and severe NPDR (P < 0.001), and mild NPDR and PDR (P < 0.001). The area under the ROC curve was 0.849 (CI: 0.792 to 0.905). The threshold for detection of moderate NPDR or worse was 4.75 foci, with a sensitivity of 79.0% and a false positive rate of 20.0%. Multivariate logistic regression model incorporating hyporeflective foci with vascular abnormalities (odds ratio [OR] = 1.592, 95% CI: 1.381 to 1.835; P < 0.001) was able to accurately predict moderate disease or worse, just moderate disease (OR = 1.045, 95% CI: 1.003 to 1.089; P = 0.035), severe disease (OR = 1.050, 95% CI: 1.006 to 1.096; P = 0.027), and proliferative disease (OR = 1.050, 95% CI: 1.008 to 1.095; P = 0.018). CONCLUSIONS NIR imaging may be an adjunct tool in screening for DR. [Ophthalmic Surg Lasers Imaging Retina 2024;55:318-325.].
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Luo S, Lock LJ, Xing B, Wingelaar M, Channa R, Liu Y. Factors Associated with Follow-Up Adherence After Teleophthalmology for Diabetic Eye Screening Before and During the COVID-19 Pandemic. Telemed J E Health 2023; 29:1171-1178. [PMID: 36576981 PMCID: PMC10440654 DOI: 10.1089/tmj.2022.0391] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/16/2022] [Indexed: 12/29/2022] Open
Abstract
Abstract Background: Follow-up adherence with in-person care is critical for achieving improved clinical outcomes in telemedicine screening programs. We sought to quantify the impact of the COVID-19 pandemic upon follow-up adherence and factors associated with follow-up adherence after teleophthalmology for diabetic eye screening. Methods: We retrospectively reviewed medical records of adults screened in a clinical teleophthalmology program at urban and rural primary care clinics between May 2015 and December 2020. We defined follow-up adherence as medical record documentation of an in-person eye exam within 1 year among patients referred for further care. Regression models were used to identify factors associated with follow-up adherence. Results: Among 948 patients, 925 (97.6%) had health insurance and 170 (17.9%) were referred for follow-up. Follow-up adherence declined from 62.7% (n = 52) prepandemic to 46.0% (n = 40) during the pandemic (p = 0.04). There was a significant decline in follow-up adherence among patients from rural (p < 0.001), but not urban (p = 0.72) primary care clinics. Higher median household income (odds ratio [OR] 1.68, 95% confidence interval [CI]: 1.19-2.36) and obtaining care from an urban clinic (OR 5.29, 95% CI: 2.09-13.43) were associated with greater likelihood of follow-up during the pandemic. Discussion: Follow-up adherence remains limited after teleophthalmology screening even in a highly insured patient population, with a further decline observed during the COVID-19 pandemic. Our results suggest that rural patients and those with lower socioeconomic status experienced greater barriers to follow-up eye care during the COVID-19 pandemic. Conclusions: Addressing barriers to in-person follow-up care is needed to effectively improve clinical outcomes after teleophthalmology screening.
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Affiliation(s)
- Susan Luo
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Loren J. Lock
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Bohan Xing
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Maxwell Wingelaar
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Schofield T, Patel A, Palko J, Ghorayeb G, Laxson LC. Diabetic retinopathy screenings in West Virginia: an assessment of teleophthalmology implementation. BMC Ophthalmol 2023; 23:93. [PMID: 36899342 PMCID: PMC9999538 DOI: 10.1186/s12886-023-02833-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/27/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND The prevalence of diabetes in the state of West Virginia (WV) is amongst the highest in the United States, making diabetic retinopathy (DR) and diabetic macular edema (DME) a major epidemiological concern within the state. Several challenges exist regarding access to eye care specialists for DR screening in this rural population. A statewide teleophthalmology program has been implemented. We analyzed real-world data acquired via these systems to explore the concordance between image findings and subsequent comprehensive eye exams and explore the impact of age on image gradeability and patient distance from the West Virginia University (WVU) Eye Institute on follow-up. METHODS Nonmydriatic fundus images of diabetic eyes acquired at primary care clinics throughout WV were reviewed by retina specialists at the WVU Eye Institute. Analysis included the concordance between image interpretations and dilated examination findings, hemoglobin A1c (HbA1c) levels and DR presence, image gradeability and patient age, and distance from the WVU Eye Institute and follow-up compliance. RESULTS From the 5,512 fundus images attempted, we found that 4,267 (77.41%) were deemed gradable. Out of the 289 patients whose image results suggested DR, 152 patients (52.6%) followed up with comprehensive eye exams-finding 101 of these patients to truly have DR/DME and allowing us to determine a positive predictive value of 66.4%. Patients within the HbA1c range of 9.1-14.0% demonstrated significantly greater prevalence of DR/DME (p < 0.01). We also found a statistically significant decrease in image gradeability with increased age. When considering distance from the WVU Eye Institute, it was found that patients who resided within 25 miles demonstrated significantly greater compliance to follow-up (60% versus 43%, p < 0.01). CONCLUSIONS The statewide implementation of a telemedicine program intended to tackle the growing burden of DR in WV appears to successfully bring concerning patient cases to the forefront of provider attention. Teleophthalmology addresses the unique rural challenges of WV, but there is suboptimal compliance to essential follow-up with comprehensive eye exams. Obstacles remain to be addressed if these systems are to effectively improve outcomes in DR/DME patients and diabetic patients at risk of developing these sight-threatening pathologies.
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Affiliation(s)
- Travis Schofield
- Department of Ophthalmology and Visual Sciences, West Virginia University School of Medicine, Morgantown, WV, 26506, USA.
| | - Ami Patel
- Department of Ophthalmology and Visual Sciences, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Joel Palko
- Department of Ophthalmology and Visual Sciences, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Ghassan Ghorayeb
- Department of Ophthalmology and Visual Sciences, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - L Carol Laxson
- Department of Ophthalmology and Visual Sciences, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
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Patil SA, Sanchez VJ, Bank G, Nair AA, Pandit S, Schuman JS, Dedania V, Parikh R, Mehta N, Colby K, Modi YS. Follow-up Rates After Teleretinal Screening for Diabetic Retinopathy: Assessing Patient Barriers to Care. JOURNAL OF VITREORETINAL DISEASES 2023; 7:125-131. [PMID: 37006661 PMCID: PMC10037748 DOI: 10.1177/24741264221147103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Purpose: To study patient follow-up after they engage in a teleretinal screening program and to understand potential barriers to care. Methods: This was a retrospective analysis and a prospective study of telephone-based patient interviews of outpatients screened for diabetic retinopathy (DR) through a teleretinal referral system. Results: Of 2761 patients screened through a teleretinal referral program, 123 (4.5%) had moderate nonproliferative DR (NPDR), 83 (3.0%) had severe NPDR, and 31 (1.1%) had proliferative DR. Of the 114 patients with severe NPDR or worse, 67 (58.8%) saw an ophthalmologist within 3 months of referral. Eighty percent of interviewed patients reported they were not aware of the need for follow-up eye appointments. Conclusions: Of patients with severe retinopathy or worse, 58.8% presented for in-person evaluation and treatment within 3 months of screening. Although this result was negatively affected by factors related to the COVID-19 pandemic, key elements of patient education and improved referral strategies to facilitate in-person treatment are essential to improving follow-up after patients engage in telescreening.
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Affiliation(s)
- Sachi A. Patil
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
| | - Victor J. Sanchez
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
| | - Georgia Bank
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
| | - Archana A. Nair
- Vanderbilt University Department of
Ophthalmology, Nashville, TN, USA
| | - Saagar Pandit
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
| | - Joel S. Schuman
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
- Departments of Biomedical Engineering
and Electrical and Computer Engineering, New York University Tandon School of
Engineering, Brooklyn, New York, USA
- Department of Physiology and
Neuroscience, NYU Grossman School of Medicine, NYU Langone Health, New York
University, New York, NY, USA
- Center for Neural Science, College of
Arts and Science, New York University, New York, NY, USA
| | - Vaidehi Dedania
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
| | - Ravi Parikh
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
- Manhattan Retina and Eye, New York, NY,
USA
| | - Nitish Mehta
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
| | - Kathryn Colby
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
| | - Yasha S. Modi
- New York University Department of
Ophthalmology, NYU Langone Health, New York, NY, USA
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Garcia JF, Peters AL, Raymond JK, Fogel J, Orrange S. Equity in Medical Care for People Living With Diabetes. Diabetes Spectr 2022; 35:266-275. [PMID: 36082008 PMCID: PMC9396720 DOI: 10.2337/dsi22-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Disparities and inequities exist for individuals with diabetes in marginalized communities of color, especially among people with low socioeconomic status. Although these barriers are apparent, only a few care models have been designed for and examined in racially and ethnically diverse individuals. This article reviews models that have been developed and examined in a variety of different populations and focuses on how to implement elements from these programs in clinical practice. Health equity-promoting ideas and approaches that can be applied throughout the life span (children to seniors) are also included. As diabetes health care providers, researchers, educators, policymakers, and advocates, we must now combine our efforts and focus on historically excluded populations to bridge the gap to essential diabetes care.
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Affiliation(s)
| | | | | | | | - Sharon Orrange
- University of Southern California, Los Angeles, CA
- Corresponding author: Sharon Orrange,
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Ramchandran RS, Yousefi-Nooraie R, Dadgostar P, Yilmaz S, Basant J, Dozier AM. Clinical staff impressions on implementation of a teleophthalmology program to improve diabetic retinopathy surveillance informed by implementation science frameworks (Preprint). JMIR Diabetes 2021; 7:e32162. [PMID: 35353038 PMCID: PMC9008535 DOI: 10.2196/32162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/04/2021] [Accepted: 01/01/2022] [Indexed: 01/23/2023] Open
Abstract
Background The store-and-forward camera-based evaluation of the eye, or teleophthalmology, is an effective way to identify diabetic retinopathy, the leading cause of blindness in the United States, but uptake has been slow. Understanding the barriers to and facilitators of implementing teleophthalmology programs from those actively adopting, running, and sustaining such programs is important for widespread adoption. Objective This study aims to understand the factors that are important in introducing teleophthalmology to improve access to diagnostic eye care for patients with diabetes in primary care clinics by using implementation science. Methods This qualitative study in 3 urban, low-income, largely racial and ethnic minority–serving safety-net primary care clinics in Rochester, New York, interviewed nurses and physicians on implementing a teleophthalmology program by using questions informed by the Practical, Robust Implementation and Sustainability Model and the Consolidated Framework for Implementation Research. Results Primary care nurses operationalizing the program in their clinics saw increased work burden and a lack of self-efficacy as barriers. Continuous training on the teleophthalmology process for nurses, physicians, and administrative staff through in-service and peer training by champions and superusers were identified by interviewees as needs. Facilitators included the perceived convenience for the patient and a perceived educational advantage to the program, as it gave an opportunity for providers to discuss the importance of eye care with patients. Concerns in making and tracking referrals to ophthalmology because of challenges related to care coordination were highlighted. The financial aspects of the program (eg, patient coverage and care provider reimbursement) were unclear to many staff members, influencing adoption and sustainability. Conclusions Streamlining processes and workflows, training and assigning adequate staff, effectively coordinating care between primary care and eye care to improve follow-ups, and ensuring financial viability can all help streamline the adoption of teleophthalmology.
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Affiliation(s)
- Rajeev S Ramchandran
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY, United States
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
| | - Reza Yousefi-Nooraie
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
| | - Porooshat Dadgostar
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
| | - Sule Yilmaz
- Division of Supportive Care in Cancer, Department of Surgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Jesica Basant
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Ann M Dozier
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
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