Telehealth Encourages Patients with Diabetes in Racial and Ethnic Minority Groups to Return for in-Person Ophthalmic Care During the COVID-19 Pandemic

Factors Associated with Utilization of Teleretinal Imaging in a Hospital-Based Primary Care Setting

Regular eye examinations to screen for the initial signs of diabetic retinopathy (DR) are crucial for preventing vision loss. Teleretinal imaging (TRI) offered in a primary care setting provides a means to improve adherence to DR screening, particularly for patients who face challenges in visiting eye care providers regularly. The present study evaluates the utilization of TRI to screen for DR in an outpatient, hospital-based primary care clinic. Patients with diabetes mellitus (DM) but without DR were eligible for point-of-care screening facilitated by their primary care provider, utilizing a non-mydriatic, handheld fundus camera. Patient demographics and clinical characteristics were extracted from the electronic medical record. Patients who underwent TRI were more likely to be male, non-White, and have up-to-date monitoring and treatment measures, including hemoglobin A1c (HbA1c), microalbumin, and low-density lipoprotein (LDL) levels, in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. Our findings demonstrate that TRI can reduce screening costs compared to a strategy where all patients are referred for in-person eye examinations. A net present value (NPV) analysis indicates that a screening site reaches the break-even point of operation within one year if an average of two patients are screened per workday.

Diabetic microaneurysms detected by fluorescein angiography spatially correlate with regions of macular ischemia delineated by optical coherence tomography angiography

Purpose

To characterize the relationship between diabetic macular ischemia (DMI) delineated by optical coherence tomography angiography (OCTA) and microaneurysms (MAs) identified by fundus fluorescein angiography (FFA).

Methods

Patients with diabetic retinopathy (DR) who underwent OCTA and FFA were retrospectively identified. FFA images were cropped and aligned with their respective OCTA images using i2k Align Retina software (Dual-Align, Clifton Park, NY, USA). Foveal avascular zone (FAZ) and ischemic areas were manually delineated on OCTA images, and MAs were marked on the corresponding FFA images before overlaying paired scans for analysis (ImageJ; National Institutes of Health, Bethesda, MD, USA).

Results

Twenty-eight eyes of 20 patients were included. The average number of MAs identified in cropped FFA images was 127 ± 42. More DMI was noted in the superficial capillary plexus (SCP; 36 ± 13%) compared to the deep capillary plexus (DCP; 28 ± 14%, P < 0.001). Similarly, more MAs were associated with ischemic areas in SCP compared to DCP (92.0 ± 35.0 vs. 76.8 ± 36.5, P < 0.001). Most MAs bordered ischemic areas; fewer than 10% localized inside these regions. As DMI area increased, so did associated MAs (SCP: r = 0.695, P < 0.001; DCP: r = 0.726, P < 0.001). Density of MAs surrounding FAZ (7.7 ± 6.0 MAs/mm2) was similar to other DMI areas (SCP: 7.0 ± 4.0 MAs/mm2, P = 0.478; DCP: 9.2 ± 10.9 MAs/mm2, P = 0.394).

Conclusion

MAs identified in FFA strongly associate with, and border areas of, DMI delineated by OCTA. Although more MAs are localized to SCP ischemia, the concentration of MAs associated with DCP ischemia is greater. By contrast, few MAs are present inside low-flow regions, likely because capillary loss is associated with their regression.

Effectiveness and Financial Viability of Telehealth Physician Extenders for Re-Engagement of Patients with Diabetic Retinopathy

Purpose: To assess the effectiveness and financial implications of employing a telehealth physician extender program to re-engage patients with diabetic retinopathy (DR) who are lost to follow-up (LTF). Methods: Established patients with DR unevaluated in the prior 12 months were identified as LTF, and randomized to receive a recall intervention or standard operating procedure (SOP). For the intervention, a telehealth physician extender performed outbound calls, offering each patient a symptom screening questionnaire following a physician-directed escalation pathway and assistance in scheduling a return appointment. All patients retained the ability to schedule an appointment by means of SOP. Appointment schedule and adherence rates were assessed 30 days after a 6-week intervention period. Call times were digitally measured to estimate intervention labor cost. Results: Four hundred twenty-five of 2,514 established patients with DR were LTF (17%). One hundred fifty-seven patients were assigned to the intervention group; the remaining 268 formed the SOP group. Sixty-six outbound calls reached patients (42%). At the time of program assessment, the intervention group demonstrated a higher rate of appointment scheduling (31% vs. 14%, p < 0.001) and adherence (14% vs. 7%, p = 0.020). The measured call duration was 2.3 ± 1.9 min, yielding an estimated cost of US$4.70 per appointment scheduled. Conclusion: Re-engagement by a telehealth physician extender improves the rate at which patients with DR return for eye care, and can be done at a reasonable cost. This method of improving adherence with follow-up should be readily translatable to other health care settings.

Missing Care: the Initial Impact of the COVID-19 Pandemic on CKD Care Delivery

BACKGROUND

Chronic kidney disease (CKD) is a common condition with adverse health outcomes addressable by early disease management. The impact of the COVID-19 pandemic on care utilization for the CKD population is unknown.

OBJECTIVE

To examine pandemic CKD care and identify factors associated with a high care deficit.

DESIGN

Retrospective observational study PARTICIPANTS: 248,898 insured individuals (95% Medicare Advantage, 5% commercial) with stage G3-G4 CKD in 2018 MAIN MEASURES: Predicted (based on the pre-pandemic period of January 1, 2019-February 28, 2020) to observed per-member monthly face-to-face and telehealth encounters, laboratory testing, and proportion of days covered (PDC) for medications, evaluated during the early (March 1, 2020-June 30, 2020), pre-vaccine (July 1, 2020-December 31, 2020), and late (January 2021-August 2021) periods and overall.

KEY RESULTS

In-person encounters fell by 24.1% during the pandemic overall; this was mitigated by a 14.2% increase in telehealth encounters, resulting in a cumulative observed utilization deficit of 10% relative to predicted. These reductions were greatest in the early pandemic period, with a 19.8% cumulative deficit. PDC progressively decreased during the pandemic (range 9-20% overall reduction), with the greatest reductions in hypertension and diabetes medicines. CKD laboratory monitoring was also reduced (range 11.8-43.3%). Individuals of younger age (OR 1.63, 95% CI 1.16, 2.28), with commercial insurance (1.43, 95% CI 1.25, 1.63), residing in the Southern US (OR 1.17, 95% CI 1.14, 1.21), and with stage G4 CKD (OR 1.21, 95% CI 1.17, 1.26) had greater odds of a higher care deficit overall.

CONCLUSIONS

The early COVID-19 pandemic resulted in a marked decline of healthcare services for individuals with CKD, with an incomplete recovery during the later pandemic. Increased telehealth use partially compensated for this deficit. The downstream impact of CKD care reduction on health outcomes requires further study, as does evaluation of effective care delivery models for this population.